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Conn H, Jankovic J. Drug-induced parkinsonism: diagnosis and treatment. Expert Opin Drug Saf 2024. [PMID: 39419777 DOI: 10.1080/14740338.2024.2418950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 10/08/2024] [Accepted: 10/09/2024] [Indexed: 10/19/2024]
Abstract
INTRODUCTION Drug-induced parkinsonism (DIP) is one of the most common iatrogenic movement disorders. It is characterized by tremors, slowness of movement, and shuffling gait with postural instability, clinically indistinguishable from idiopathic Parkinson's disease. Prior exposure to antipsychotic medications or other dopamine receptor blocking agents (DRBAs) is required for the diagnosis. AREAS COVERED This article aims to review the epidemiology, pathophysiology, clinical features, ancillary testing, and treatment of DIP. A literature search was undertaken in PubMed from January 2013 to January 2024. EXPERT OPINION A clinician's suspicion of DIP must always be present when a patient develops acute to subacute onset of parkinsonism while taking a DRBA. As DIP can be indistinguishable from idiopathic PD, ancillary testing, such as DaTscans and skin biopsy searching for alpha-synuclein deposits, are often required to make a definitive diagnosis. When DIP develops, steps should be made to discontinue the offending agent or, in the case of antipsychotics, dose reduction or change to an agent with lower risk for DIP, such as quetiapine or clozapine. Prophylactic treatment with anticholinergics is not indicated.
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Affiliation(s)
- Hannah Conn
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX
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Calzetti S, Negrotti A. Outcome of Drug-Induced Parkinsonism in the Elderly: A Permanent Nonprogressive Parkinsonian Syndrome May Occur Following Discontinuation of Cinnarizine and Flunarizine. Ann Pharmacother 2024:10600280241263592. [PMID: 39054800 DOI: 10.1177/10600280241263592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
Parkinsonism induced by dopamine receptor antagonists, traditionally considered completely reversible following offending drug withdrawal, may unmask a degenerative parkinsonism in the patients with an underlying subclinical disease. In elderly patients, parkinsonism induced by the calcium channel blockers such as piperazine derivates cinnarizine and flunarizine may persist following drug discontinuation resulting in a permanent nonprogressive syndrome fulfilling the criteria for tardive parkinsonism. Whether this outcome occurs also following exposure to dopamine receptor antagonists such as neuroleptics and benzamide derivates or represents a class effect of the voltage-gated L-type calcium channel blockers, such as cinnarizine and flunarizine, due to their complex pharmacodynamic properties remains to be established.
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Affiliation(s)
- Stefano Calzetti
- Neurology Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Anna Negrotti
- Neurology Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
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Robison RD, Singh M, Jiang L, Riester M, Duprey M, McGeary JE, Goyal P, Wu WC, Erqou S, Zullo A, Rudolph JL, Rogus-Pulia N. Acute Antipsychotic Use and Presence of Dysphagia Among Older Veterans with Heart Failure. J Am Med Dir Assoc 2023; 24:1303-1310. [PMID: 37478895 PMCID: PMC10527768 DOI: 10.1016/j.jamda.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Examine whether new antipsychotic (AP) exposure is associated with dysphagia in hospitalized patients with heart failure (HF). DESIGN Retrospective cohort. SETTINGS AND PARTICIPANTS AP-naïve Veterans hospitalized with HF and subsequently discharged to a skilled nursing facility (SNF) between October 1, 2010, and November 30, 2019. METHODS We linked Veterans Health Administration (VHA) electronic medical records with Centers for Medicare & Medicaid (CMS) Minimum Data Set (MDS) version 3.0 assessments and CMS claims. The exposure variable was administration of ≥1 dose of a typical or atypical AP during hospitalization. Our main outcome measure was dysphagia presence defined by (1) inpatient dysphagia diagnosis codes and (2) the SNF admission MDS 3.0 swallowing-related items to examine post-acute care dysphagia status. Inverse probability of treatment weighting was used for risk adjustment. RESULTS The analytic cohort consisted of 29,591 Veterans (mean age 78.5 ± 10.0 years; female 2.9%; n = 865). Acute APs were administered to 9.9% (n = 2941). Those receiving APs had differences in prior dementia [37.1%, n = 1091, vs 22.3%, n = 5942; standardized mean difference (SMD) = 0.33] and hospital delirium diagnoses (7.7%, n = 227 vs 2.8%, n = 754; SMD = 0.22). Acute AP exposure was associated with nearly double the risk for hospital dysphagia diagnosis codes [adjusted (adj.) relative risk (RR) 1.9, 95% CI 1.8, 2.1]. At the SNF admission MDS assessment, acute AP administration during hospitalization was associated with an increased dysphagia risk (adj. RR 1.2, 95% CI 1.0, 1.5) both in the oral (adj. RR 1.7, 95% CI 1.2, 2.0) and pharyngeal phases (adj. RR 1.3, 95% CI 1.0, 1.7). CONCLUSIONS AND IMPLICATIONS In this retrospective study, AP medication exposure was associated with increased dysphagia coding and MDS assessment. Considering other adverse effects, acute AP should be cautiously administered during hospitalization, particularly in those with dementia. Swallowing function is critical to hydration, nutrition, and medical management of HF; therefore, when acute APs are initiated, a swallow evaluation should be considered.
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Affiliation(s)
- Raele Donetha Robison
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health (SMPH), Madison, WI, USA
| | - Mriganka Singh
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA
| | - Melissa Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Matthew Duprey
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA
| | - John E McGeary
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Wen-Chih Wu
- Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Sebhat Erqou
- Warren Alpert Medical School of Brown University, Providence, RI, USA; Division of Cardiology, Providence VA Medical Center, Providence, RI, USA; Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Andrew Zullo
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - James L Rudolph
- Center of Innovation in Long Term Services and Supports (LTSS-COIN), Providence VA Medical Center, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Nicole Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health (SMPH), Madison, WI, USA; Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
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Weng J, Zhang L, Yu W, Zhao N, Zhu B, Ye C, Zhang Z, Ma C, Li Y, Yu Y, Li H. Risk factors, clinical correlates, and social functions of Chinese schizophrenia patients with drug-induced parkinsonism: A cross-sectional analysis of a multicenter, observational, real-world, prospective cohort study. Front Pharmacol 2023; 14:1077607. [PMID: 36937864 PMCID: PMC10020528 DOI: 10.3389/fphar.2023.1077607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Abstract
Background: Drug-induced parkinsonism (DIP) is the most prevalent neurological side effect of antipsychotics in the Chinese population. Early prevention, recognition, and treatment of DIP are important for the improvement of treatment outcomes and medication adherence of schizophrenia patients. However, the risk factors of DIP and the impact on the clinical syndromes of schizophrenia remain unknown. Aim: The goal of this study was to explore the risk factors, clinical correlates, and social functions of DIP in Chinese schizophrenia patients. Methods: A cross-sectional analysis of a multicenter, observational, real-world, prospective cohort study of the Chinese schizophrenia population with a baseline assessment was conducted from the year 2012 to 2018. Participants were recruited from four mental health centers in Shanghai and totaled 969 subjects. Sociodemographic data, drug treatment, and clinical variables were compared between the DIP group and the non-DIP group. Variables that correlated with the induction of DIP, and with p≤ 0.1, were included in the binary logistic model for analyzing the risk factors of DIP. First generation antipsychotics (FGA)/second generation antipsychotics (SGA) model and high and low/medium D2 receptor antipsychotics were analyzed respectively to control the bias of co-linearity. All risk factors derived from the a forementioned models and clinical variables with p≤ 0.1 were included in the multivariate analysis of clinical correlates and social function of DIP patients. The Positive and Negative Syndrome Scale (PANSS) model and the personal and social performance (PSP) model were analyzed separately to control for co-linearity bias. Results: Age (OR = 1.03, p< 0.001), high D2 receptor antagonist antipsychotic dose (OR = 1.08, p = 0.032), and valproate dose (OR = 1.01, p = 0.001) were the risk factors of DIP. FGA doses were not a significant contributor to the induction of DIP. Psychiatric symptoms, including more severe negative symptoms (OR = 1.09, p< 0.001), lower cognition status (OR = 1.08, p = 0.033), and lower excited symptoms (OR = 0.91, p = 0.002), were significantly correlated with DIP induction. Social dysfunction, including reduction in socially useful activities (OR = 1.27, p = 0.004), lower self-care capabilities (OR = 1.53, p< 0.001), and milder disturbing and aggressive behavior (OR = 0.65, p< 0.001), were significantly correlated with induction of DIP. Valproate dose was significantly correlated with social dysfunction (OR = 1.01, p = 0.001) and psychiatric symptoms (OR = 1.01, p = 0.004) of DIP patients. Age may be a profound factor that affects not only the induction of DIP but also the severity of psychiatric symptoms (OR = 1.02, p< 0.001) and social functions (OR = 1.02, p< 0.001) of schizophrenia patients with DIP. Conclusion: Age, high D2 receptor antagonist antipsychotic dose, and valproate dose are risk factors for DIP, and DIP is significantly correlated with psychiatric symptoms and social performance of Chinese schizophrenia patients. The rational application or discontinuation of valproate is necessary. Old age is related to psychotic symptoms and social adaption in Chinese schizophrenic patients, and early intervention and treatment of DIP can improve the prognosis and social performance of schizophrenia patients. Clinical Trial Registration: Identifier: NCT02640911.
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Affiliation(s)
- Jiajun Weng
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Zhongshan Hospital, Shanghai, China
| | - Lei Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjuan Yu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Zhao
- Shanghai Pudong District Mental Health Center, Shanghai, China
| | - Binggen Zhu
- Shanghai Pudong District Mental Health Center, Shanghai, China
| | - Chengyu Ye
- Shanghai Zhongshan Hospital, Shanghai, China
- Shanghai Jiading District Mental Health Center, Shanghai, China
| | - Zhanxing Zhang
- Shanghai Clinical Research Center for Mental Health, Shanghai, China
| | - Changlin Ma
- Shanghai Jiading District Mental Health Center, Shanghai, China
| | - Yan Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiming Yu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Yiming Yu, ; Huafang Li,
| | - Huafang Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Clinical Research Center for Mental Health, Shanghai, China
- *Correspondence: Yiming Yu, ; Huafang Li,
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SLC6A3, HTR2C and HTR6 Gene Polymorphisms and the Risk of Haloperidol-Induced Parkinsonism. Biomedicines 2022; 10:biomedicines10123237. [PMID: 36551993 PMCID: PMC9776373 DOI: 10.3390/biomedicines10123237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022] Open
Abstract
Antipsychotic-induced parkinsonism (AIP) is the most common type of extrapyramidal side effect (EPS), caused by the blockage of dopamine receptors. Since dopamine availability might influence the AIP risk, the dopamine transporter (DAT) and serotonin receptors (5-HTRs), which modulate the dopamine release, may be also involved in the AIP development. As some of the individual differences in the susceptibility to AIP might be due to the genetic background, this study aimed to examine the associations of SLC6A3, HTR2C and HTR6 gene polymorphisms with AIP in haloperidol-treated schizophrenia patients. The Extrapyramidal Symptom Rating Scale (ESRS) was used to evaluate AIP as a separate entity. Genotyping was performed using a PCR, following the extraction of blood DNA. The results revealed significant associations between HTR6 rs1805054 polymorphism and haloperidol-induced tremor and rigidity. Additionally, the findings indicated a combined effect of HTR6 T and SLC6A3 9R alleles on AIP, with their combination associated with significantly lower scores of ESRS subscale II for parkinsonism, ESRS-based tremor or hyperkinesia and ESRS subscales VI and VIII. These genetic predictors of AIP could be helpful in better understanding its pathophysiology, recognizing the individuals at risk of developing AIP and offering personalized therapeutic strategies for the patients suffering from this EPS.
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Guo G, Tang J, Shi M, Yang C, Ou H, Chen W. MK212, a 5-hydroxytryptamine 2C receptor agonist, reverses prepulse inhibition deficits in the medial prefrontal cortex and ventral hippocampus. Prog Neuropsychopharmacol Biol Psychiatry 2022; 113:110441. [PMID: 34560172 DOI: 10.1016/j.pnpbp.2021.110441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/31/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
Prepulse inhibition (PPI) is disrupted in many neuropsychiatric diseases. Molecules such as 5-HT2C receptor agonists alleviate PPI deficits in rodents; however, the precise mechanisms and critical regions of the brain responsible for the reversal effect of these agonists remain inconclusive. The present study aimed to investigate the areas of the brain critical for the reversal effect of 5-HT2C receptor agonists on PPI deficits in mice. The results showed that systemic administration of the 5-HT2C receptor agonist MK212 did not affect normal PPI behavior, but reversed the PPI deficits induced by the N-methyl d-aspartate receptor antagonist MK801 in mice. In addition, the 5-HT2C receptor antagonist SB242084 had no effect on PPI behavior despite MK801 treatment. Moreover, local infusion of MK212 into the medial prefrontal cortex and ventral hippocampus, excluding the nucleus accumbens or ventral tegmental area, rescued the PPI deficits induced by MK801. These data suggest that the medial prefrontal cortex and ventral hippocampus are critical brain areas responsible for the reversal of 5-HT2C agonists on PPI deficits. The results will contribute to our current knowledge on the molecular and neural mechanisms underlying the antipsychotic effects of 5-HT2C receptor agonists, especially the neural circuits modulated by 5-HT2C receptor activity.
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Affiliation(s)
- Guanlong Guo
- Key Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, China; Faculty of Psychology, Southwest University, Chongqing, China
| | - Jiaxin Tang
- Key Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, China; Faculty of Psychology, Southwest University, Chongqing, China
| | - Mengwen Shi
- Key Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, China; Faculty of Psychology, Southwest University, Chongqing, China
| | - Chengmei Yang
- Key Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, China; Faculty of Psychology, Southwest University, Chongqing, China
| | - Huaxing Ou
- Key Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, China; Faculty of Psychology, Southwest University, Chongqing, China
| | - Weihai Chen
- Key Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, China; Faculty of Psychology, Southwest University, Chongqing, China.
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Baumgärtner J, Grohmann R, Bleich S, Glocker C, Seifert J, Toto S, Rüther E, Engel RR, Stübner S. Atypical dyskinesias under treatment with antipsychotic drugs: Report from the AMSP multicenter drug safety project. World J Biol Psychiatry 2022; 23:151-164. [PMID: 34096837 DOI: 10.1080/15622975.2021.1938213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this study was to describe atypical dyskinesias (AtypDs) occurring during treatment with antipsychotic drugs (APDs). AtypDs are dyskinesias showing either an unusual temporal relationship between onset of treatment and start of the adverse drug reaction (ADR) or an unusual presentation of clinical symptoms. METHODS Data on the utilisation of APDs and reports of severe APD-induced AtypDs were collected using data from the observational pharmacovigilance programme - 'Arzneimittelsicherheit in der Psychiatrie (English: drug safety in psychiatry)' (AMSP) - from 1993 to 2016. RESULTS A total of 495,615 patients were monitored, of which 333,175 were treated with APDs. Sixty-seven cases (0.020%) of severe AtypDs under treatment with APDs were registered. The diagnoses of schizophrenic disorders as well as organic mental disorders were related to significantly higher rates of AtypDs. Second-generation antipsychotic drugs (SGAs) showed slightly higher rates of AtypDs (0.024%) than high-potency (0.011%) or low-potency first-generation antipsychotic drugs (FGAs; 0.006%). In 41 cases (61.2%), two or more drugs were found to cause AtypDs. CONCLUSIONS Our study indicates that AtypDs are rare ADRs. SGAs may have a higher risk for the occurrence of AtypDs than FGAs. Clinicians should be aware of this ADR and patients should be monitored and examined carefully.
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Affiliation(s)
- Jessica Baumgärtner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Renate Grohmann
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover, Germany
| | - Catherine Glocker
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany
| | - Johanna Seifert
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover, Germany
| | - Eckart Rüther
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany.,Prosomno, Clinic for Sleep Medicine, Munich, Germany
| | - Rolf R Engel
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany
| | - Susanne Stübner
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany.,Department of Forensic Psychiatry, Bezirksklinikum Ansbach, Ansbach, Germany
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Wisidagama S, Selladurai A, Wu P, Isetta M, Serra-Mestres J. Recognition and Management of Antipsychotic-Induced Parkinsonism in Older Adults: A Narrative Review. MEDICINES 2021; 8:medicines8060024. [PMID: 34073269 PMCID: PMC8227528 DOI: 10.3390/medicines8060024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/19/2021] [Accepted: 05/23/2021] [Indexed: 12/30/2022]
Abstract
Background: Parkinsonism is a common side-effect of antipsychotic drugs especially in older adults, who also present with a higher frequency of neurodegenerative disorders like Idiopathic Parkinson’s disease (IPD). Distinguishing between antipsychotic-induced parkinsonism (AIP) and IPD is challenging due to clinical similarities. Up to 20% of older adults may suffer from persisting parkinsonism months after discontinuation of antipsychotics, suggesting underlying neurodegeneration. A review of the literature on AIP in older adults is presented, focusing on epidemiology, clinical aspects, and management. Methods: A literature search was undertaken on EMBASE, MEDLINE and PsycINFO, for articles on parkinsonism induced by antipsychotic drugs or other dopamine 2 receptor antagonists in subjects aged 65 or older. Results: AIP in older adults is the second most common cause of parkinsonism after IPD. Older age, female gender, exposure to high-potency first generation antipsychotics, and antipsychotic dosage are the main risk factors. The clinical presentation of AIP resembles that of IPD, but is more symmetrical, affects upper limbs more, and tends to have associated motor phenomena such as orofacial dyskinesias and akathisia. Presence of olfactory dysfunction in AIP suggests neurodegeneration. Imaging of striatal dopamine transporters is widely used in IPD diagnosis and could help to distinguish it from AIP. There is little evidence base for recommending pharmacological interventions for AIP, the best options being dose-reduction/withdrawal, or switching to a second-generation drug. Conclusions: AIP is a common occurrence in older adults and it is possible to differentiate it from IPD. Further research is needed into its pathophysiology and on its treatment.
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Affiliation(s)
- Sharadha Wisidagama
- Departments of Psychiatry, Central and North West London NHS Foundation Trust, London NW1 3AX, UK; (S.W.); (A.S.); (P.W.)
| | - Abiram Selladurai
- Departments of Psychiatry, Central and North West London NHS Foundation Trust, London NW1 3AX, UK; (S.W.); (A.S.); (P.W.)
| | - Peter Wu
- Departments of Psychiatry, Central and North West London NHS Foundation Trust, London NW1 3AX, UK; (S.W.); (A.S.); (P.W.)
| | - Marco Isetta
- Knowledge and Library Services, Central and North West London NHS Foundation Trust, London NW1 3AX, UK;
| | - Jordi Serra-Mestres
- Old Age Psychiatry, Central and North West London NHS Foundation Trust, Uxbridge UB8 3NN, UK
- Correspondence: ; Tel.: +44-0-1895-484911
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