Drug-induced secondary parkinsonism

Neurology

Clinicals - History

Fact Explanation
Features of Parkinsonism Blockage of postsynaptic dopaminergic receptors in the basal ganglia motor circuit manifest the clinical symptoms of parkinsonism. Symptoms begin after the use of the offending drug and usually resolve after the drug is being withdrawn. Features of Parkinsonism
Blockage of postsynaptic dopaminergic receptors in the basal ganglia motor circuit manifest the clinical symptoms of parkinsonism. Symptoms begin after the use of the offending drug and usually resolve after the drug is being withdrawn.
Bradykinesia Patients often experience bradykinesia, which is one of the cardinal feature of parkinsonism. Bradykinesia develops due to the involvement of basal ganglia. Fine motor tasks like buttoning and writing are impaired initially. Bradykinesia
Patients often experience bradykinesia, which is one of the cardinal feature of parkinsonism. Bradykinesia develops due to the involvement of basal ganglia. Fine motor tasks like buttoning and writing are impaired initially.
Finger tremor Tremor is usually absent in drug induced parkinsonism (DIP), however 30-50% of patients may present with asymmetrical resting tremor. Those patients usually shows postural tremor as well. However patients with DIP usually present with symmetrical tremor. Finger tremor
Tremor is usually absent in drug induced parkinsonism (DIP), however 30-50% of patients may present with asymmetrical resting tremor. Those patients usually shows postural tremor as well. However patients with DIP usually present with symmetrical tremor.
Recurrent falls PD causes postural instability and recurrent falls. Recurrent falls
PD causes postural instability and recurrent falls.
Freezing Patients with PD often develop "freezing", so called motor block. Suddenly the patient stops what he or she was doing for some time and restart. Freezing
Patients with PD often develop "freezing", so called motor block. Suddenly the patient stops what he or she was doing for some time and restart.
Expressionless face Patients develop expressionless face due to bradykinesia. Expressionless face
Patients develop expressionless face due to bradykinesia.
Abnormal gait PD causes reduced arm swinging while walking. Abnormal gait
PD causes reduced arm swinging while walking.
Joint pain Patients with PD can develop joint pain due to muscle rigidity. Joint pain
Patients with PD can develop joint pain due to muscle rigidity.
Postural deformities As the disease progresses patients develop postural deformities. These are due to rigidity of the muscles. Neck and the truck is flexed so as the elbows and the knees. Postural deformities
As the disease progresses patients develop postural deformities. These are due to rigidity of the muscles. Neck and the truck is flexed so as the elbows and the knees.
Drug history Typical antipsychotics (Chlorpromazine, phenothiazine, prochloroperazine, perphenazine, fluphenazine, promethazine, pimozide) is the commonest cause of DIP. Atypical antipsychotics (risperidone, olanzapine), gastrointestinal prokinetics (metoclopramide, levosulpiride, clebopride, itopride, domperidone), antidepressants, calcium channel blockers (flunarizine and cinnarizine) and antiepileptic drugs can also cause DIP. Drug history
Typical antipsychotics (Chlorpromazine, phenothiazine, prochloroperazine, perphenazine, fluphenazine, promethazine, pimozide) is the commonest cause of DIP. Atypical antipsychotics (risperidone, olanzapine), gastrointestinal prokinetics (metoclopramide, levosulpiride, clebopride, itopride, domperidone), antidepressants, calcium channel blockers (flunarizine and cinnarizine) and antiepileptic drugs can also cause DIP.
Past medical history Antipsychotics are usually prescribed for psychotic disorders (schizophrenia, bipolar effective disorders). So patients may have delusions, hallucinations, or disordered thought. Headache, dizziness, diarrhea
and anxiety are other side effects of antipsychotics.
Gastrointestinal prokinetics are prescribed for abdominal discomfort, bloating, constipation, heart burn, nausea, and vomiting.
Calcium channel blockers are prescribed for hypertension, angina and arrhythmia.
Past medical history
Antipsychotics are usually prescribed for psychotic disorders (schizophrenia, bipolar effective disorders). So patients may have delusions, hallucinations, or disordered thought. Headache, dizziness, diarrhea
and anxiety are other side effects of antipsychotics.
Gastrointestinal prokinetics are prescribed for abdominal discomfort, bloating, constipation, heart burn, nausea, and vomiting.
Calcium channel blockers are prescribed for hypertension, angina and arrhythmia.

Clinicals - Examination

Fact Explanation
Features of Parkinsonism Most of the examination findings of DIP are similar to Parkinson's disease. Bilateral and symmetrical parkinsonism without resting tremor is the differentiating feature of DIP and primary Parkinson's disease. Features of Parkinsonism
Most of the examination findings of DIP are similar to Parkinson's disease. Bilateral and symmetrical parkinsonism without resting tremor is the differentiating feature of DIP and primary Parkinson's disease.
Rigidity Rigidity is a cardinal feature of PD. “Cogwheel” rigidity is commonly elicited. As rigidity worsens patient adopt a posture where the neck, truck, elbows and the knees are flexed. Rigidity
Rigidity is a cardinal feature of PD. “Cogwheel” rigidity is commonly elicited. As rigidity worsens patient adopt a posture where the neck, truck, elbows and the knees are flexed.
Tremor Absence of resting tremor enables the differentiation of DIP from Parkinson's disease. However around 50% of the affected patients may have resting tremor. Tremor
Absence of resting tremor enables the differentiation of DIP from Parkinson's disease. However around 50% of the affected patients may have resting tremor.
Bradykinesia Patients with PD demonstrate difficulties in planning, initiating and executing motor tasks. When the patient is asked to do repetitive finger taps, hand grips, hand pronation–supination and heel taps the amplitude of the movements reduces and they become progressively slow.
However if the patient is excited he will be able to do quick tasks which is called "kinesia paradoxica".
Bradykinesia
Patients with PD demonstrate difficulties in planning, initiating and executing motor tasks. When the patient is asked to do repetitive finger taps, hand grips, hand pronation–supination and heel taps the amplitude of the movements reduces and they become progressively slow.
However if the patient is excited he will be able to do quick tasks which is called "kinesia paradoxica".
Expressionless face (hypomimia) Patients with PD have "mask face" and reduced or absent eye blinking as bradykinesia progresses. Expressionless face (hypomimia)
Patients with PD have "mask face" and reduced or absent eye blinking as bradykinesia progresses.
Reduced arm swinging Reduced arm swinging is another manifestation of bradykinesia. This is also asymmetrical. Reduced arm swinging
Reduced arm swinging is another manifestation of bradykinesia. This is also asymmetrical.

Investigations - Diagnosis

Fact Explanation
Clinical diagnosis DIP is mainly a clinical diagnosis. Diagnostic criteria include presence of parkinsonism, absence of history of parkinsonism before the use of the offending drug, and onset of parkinsonian symptoms during use of the offending drug. Imaging is indicated to exclude possible organic etiology. Clinical diagnosis
DIP is mainly a clinical diagnosis. Diagnostic criteria include presence of parkinsonism, absence of history of parkinsonism before the use of the offending drug, and onset of parkinsonian symptoms during use of the offending drug. Imaging is indicated to exclude possible organic etiology.
PET scan or Single-photon-emission computed tomography (SPECT) Brain imaging is indicated to exclude possible degenerative causes for parkinsonism. PET scan or Single-photon-emission computed tomography (SPECT)
Brain imaging is indicated to exclude possible degenerative causes for parkinsonism.
MRI MRI of the brain is useful to detect the presence of degenerative changes. MRI
MRI of the brain is useful to detect the presence of degenerative changes.
CT scan Similarly CT scan of the head is useful to exclude degenerative changes. CT scan
Similarly CT scan of the head is useful to exclude degenerative changes.

Management - Supportive

Fact Explanation
Health education Patients should be reassured about the fact that DIP usually reverses with the cessation of the offending drug.
If the patient should be prescribed a drug which is known to cause DIP patient should be educated about the possibility of DIP and they should also be educated about the possible alternative treatment options which have lower risk of DIP (prescription of atypical antipsychotics instead of typical antipsychotics).
Health education
Patients should be reassured about the fact that DIP usually reverses with the cessation of the offending drug.
If the patient should be prescribed a drug which is known to cause DIP patient should be educated about the possibility of DIP and they should also be educated about the possible alternative treatment options which have lower risk of DIP (prescription of atypical antipsychotics instead of typical antipsychotics).

Management - Specific

Fact Explanation
Cessation of the offending drug Once the offending drug is withdrawn, the symptoms usually reverse within few weeks to months. If the typical antipsychotics can not be stopped it is indicated to use an atypical antipsychotic instead of typical antipsychotic, because it has less risk of DIP. About 10 to 50% of patients may worsen or may continue to have symptoms even after cessation of the offending drug. Cessation of the offending drug
Once the offending drug is withdrawn, the symptoms usually reverse within few weeks to months. If the typical antipsychotics can not be stopped it is indicated to use an atypical antipsychotic instead of typical antipsychotic, because it has less risk of DIP. About 10 to 50% of patients may worsen or may continue to have symptoms even after cessation of the offending drug.
Levodopa Levodopa is prescribed for a short period of time till the resolution of symptoms. Levodopa
Levodopa is prescribed for a short period of time till the resolution of symptoms.
Anticholinergic agents Similarly anticholinergic agents can be used for symptom relief. Anticholinergic drugs are effective in relieving motor symptoms. Anticholinergic agents
Similarly anticholinergic agents can be used for symptom relief. Anticholinergic drugs are effective in relieving motor symptoms.
Dopamine agonists Dopamine agonists are indicated for symptom relief. Dopamine agonists act directly on dopamine receptors and mimick the endogenous neurotransmitter. Dopamine agonists
Dopamine agonists are indicated for symptom relief. Dopamine agonists act directly on dopamine receptors and mimick the endogenous neurotransmitter.

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