Management of Extrapyramidal Symptoms with Antipsychotic Medications

Introduction to EPS Management

Anticholinergic medications like benztropine should be reserved for treatment of EPS after they develop rather than used prophylactically, as recommended by the American Academy of Child and Adolescent Psychiatry 1

Monitor for the development of EPS after administering Acuphase (haloperidol) injections and treat only if symptoms occur, as suggested by the American Academy of Child and Adolescent Psychiatry 2

If EPS is a significant concern, consider using an atypical antipsychotic with lower EPS risk instead of haloperidol when clinically appropriate, according to Praxis Medical Insights 3
From lowest to highest EPS risk, the hierarchy among antipsychotics is: Quetiapine, Aripiprazole, Olanzapine, Risperidone, and typical antipsychotics (like haloperidol), as reported by Praxis Medical Insights 3

Elderly patients are particularly sensitive to anticholinergic effects and require lower doses of both antipsychotics and anticholinergic medications, as noted by Praxis Medical Insights 3
In elderly patients, consider using quetiapine as an alternative to haloperidol when possible, as it has the lowest risk of EPS among commonly used antipsychotics, according to Praxis Medical Insights 3
If haloperidol must be used in elderly patients, use the lowest effective dose and monitor closely for EPS and other adverse effects, as recommended by Praxis Medical Insights 4

The American Family Physician recommends avoiding use of benztropine or trihexyphenidyl when treating haloperidol-induced EPS in elderly patients with Alzheimer's disease, due to heightened sensitivity to anticholinergic effects 5
Olanzapine is generally well tolerated with moderate EPS risk, with a recommended starting dose of 2.5-5 mg daily 6, 7
Risperidone has an increased EPS risk if the dose exceeds 2-6 mg/day, with a recommended starting dose of 0.25-0.5 mg daily in elderly patients 5

The American Family Physician guidelines recommend avoiding benztropine or anticholinergics in elderly patients when possible, due to heightened sensitivity to anticholinergic effects 5
Haloperidol is contraindicated in patients with Parkinson's disease or dementia with Lewy bodies due to severe EPS risk 6, 7

The Annals of Emergency Medicine recommends monitoring for improvement in specific EPS syndromes, such as dystonia, parkinsonism, and akathisia 8
Anticholinergic medications can potentially exacerbate agitation due to their anticholinergic side effects, as noted in the Annals of Emergency Medicine 8

The Centers for Disease Control and Prevention, as reported in MMWR Recommendations and Reports, found that amantadine demonstrated fewer CNS side effects compared to anticholinergics in a controlled study of older persons, with 13% CNS symptoms with amantadine vs higher rates with anticholinergics 9, 10
The American Geriatrics Society, as aligned with MMWR Recommendations and Reports, advises that the daily dose for persons ≥65 years should not exceed 100 mg for treatment with amantadine, as renal function declines with age 11
For elderly women, doses of amantadine may need further reduction below 100 mg daily, as recommended by MMWR Recommendations and Reports 12, 13
Patients should be observed carefully for adverse reactions, with dose reduction or discontinuation if CNS side effects develop, according to MMWR Recommendations and Reports 9, 10
Dose reduction to 100 mg/day is mandatory for creatinine clearance <10 mL/min, as stated in MMWR Recommendations and Reports 11

The MMWR Recommendations and Reports suggest that amantadine 100 mg daily (or less if renal impairment or frailty present) should be the first-line treatment, with monitoring for CNS effects which occur in ~13% of patients 9, 10, 11
Amantadine has anticholinergic effects itself and should not be used in patients with untreated angle closure glaucoma, as warned by MMWR Recommendations and Reports 9, 10
Serious CNS side effects with amantadine have been observed most often in elderly persons with renal insufficiency, seizure disorders, or psychiatric disorders, according to MMWR Recommendations and Reports 9, 10
Hemodialysis contributes minimally to amantadine clearance, so dose adjustment is critical in renal failure, as noted in MMWR Recommendations and Reports 11