Differentiating Extrapyramidal Symptoms (EPS) and Tardive Dyskinesia

Key Differences

• The American Academy of Child and Adolescent Psychiatry notes that acute EPS occur early in treatment, typically within the first few days to weeks after starting antipsychotic medication or increasing the dose 1, 2
• Tardive Dyskinesia develops after prolonged use of antipsychotics, typically after months or years of treatment, according to the American Academy of Child and Adolescent Psychiatry 2, 3

Clinical Presentation

• Acute dystonia is characterized by sudden spastic contractions of muscle groups, including the neck, eyes, and torso, and can be life-threatening if laryngeal spasm occurs, as reported by the American Academy of Pediatrics 1, 4
• Drug-induced parkinsonism is marked by bradykinesia, tremors, and rigidity, and can be difficult to distinguish from negative symptoms of schizophrenia, according to the American Academy of Child and Adolescent Psychiatry 1, 2
• Akathisia is a subjective feeling of restlessness that manifests as pacing or physical agitation, and is often misinterpreted as psychotic agitation or anxiety, as noted by the American Academy of Child and Adolescent Psychiatry 1, 4
• Tardive Dyskinesia is characterized by involuntary, rhythmic movements primarily affecting the orofacial region, and can persist even after medication discontinuation, according to the American Academy of Child and Adolescent Psychiatry 2, 3

Risk Factors

• The use of high-potency typical antipsychotics is a common risk factor for both EPS and TD, as reported by the American Academy of Family Physicians 5, 1
• Young age, male gender, and higher doses are specific risk factors for acute EPS, according to the American Academy of Child and Adolescent Psychiatry 1
• Older age, female gender, and prolonged antipsychotic use are specific risk factors for Tardive Dyskinesia, although the evidence is not provided in the given text

Prevention and Management

• The American Academy of Family Physicians recommends using atypical antipsychotics when possible to prevent EPS and TD, as they have a lower risk compared to typical antipsychotics 5
• Regular monitoring for early signs of movement disorders is essential, and baseline and periodic assessment using standardized scales like the Abnormal Involuntary Movement Scale (AIMS) is recommended by the American Academy of Child and Adolescent Psychiatry 3
• Reducing the antipsychotic dose, adding anticholinergic agents, and considering β-blockers or benzodiazepines are management strategies for EPS, as reported by the American Academy of Child and Adolescent Psychiatry 1
• The primary approach to managing Tardive Dyskinesia is prevention through early detection, and continuing medication only if the patient is in full remission and changing medication would risk relapse, according to the American Academy of Child and Adolescent Psychiatry 3

Nurse Assessment for Medication-Related Involuntary Movements

Assessment and Monitoring

• The American Academy of Child and Adolescent Psychiatry recommends using the Abnormal Involuntary Movement Scale (AIMS) to systematically assess for medication-related involuntary movements, with evaluations conducted at baseline and then every 3-6 months for patients on medications with tardive dyskinesia risk 6
• The assessment should include a level of consciousness assessment, with alertness, orientation, and response to commands evaluated on a scale 7
• A motor examination should be conducted, including facial movements, oral movements, extremity movements, and trunk movements, to assess for choreiform or athetoid movements 8, 7
• A severity rating for each body region should be recorded, typically on a 0-4 scale 6, 7
• A global judgment of severity and incapacitation should be made 6

Medication-Induced Movement Disorders

• Atypical antipsychotics have a lower but still present risk of causing movement disorders, according to the American Academy of Pediatrics 8
• The AIMS examination should be used to assess for acute extrapyramidal symptoms, including acute dystonia, drug-induced parkinsonism, and akathisia 8

Documentation and Timing

• The American Academy of Child and Adolescent Psychiatry recommends recording baseline movement status before medication initiation and documenting the specific type, location, and severity of any observed movements 6

Aripiprazole-Induced Movement Disorders

Introduction to AIMS Assessment

• The American Academy of Child and Adolescent Psychiatry recommends baseline assessment using the Abnormal Involuntary Movement Scale (AIMS) before medication initiation to document any pre-existing abnormal movements 9

Evidence for Aripiprazole-Induced Movement Disorders

• Aripiprazole causes movement disorders, including tardive dyskinesia, parkinsonism, and akathisia, with a significant risk of tardive dyskinesia, a potentially irreversible movement disorder 9
• The FDA label explicitly warns that TD may develop in patients treated with antipsychotic drugs, and the risk increases with duration of treatment and cumulative dose, with up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia 9

Clinical Significance of Movement Disorders with Aripiprazole

• In controlled trials, aripiprazole caused significantly more movement disorders than placebo, including extrapyramidal symptoms, akathisia, and tremor, with a relative risk of 2.97 for participant-reported akathisia compared to lithium 9

Management of Tardive Dyskinesia in Patients with Preexisting Movement Disorders

Introduction to Tardive Dyskinesia

• The American Academy of Child and Adolescent Psychiatry recommends gradually withdrawing the offending antipsychotic medication if clinically feasible, and not adding another dopamine-blocking agent like olanzapine, as this will worsen TD 10

Alternative Treatment Options

• Consider non-dopaminergic options first, such as mood stabilizers, benzodiazepines for acute agitation, or behavioral interventions 11

Preferred Antipsychotic Agents

• Aripiprazole is the preferred choice with 0 ms QTc prolongation and partial D2 agonist properties that may be less likely to worsen TD, and should be used at the lowest effective dose with intensive AIMS monitoring 10