Tardive Dyskinesia?

rncopper · Oct 15, 2003

Unfortunately, sometimes TD does not go away.

Good place to ask this question is under the Psych nurses forum. Many, many psych pts get tardive dyskinesia.

PlanetCaroline · Oct 15, 2003

Disclaimer: This is only my opinion. I am not qualified (nor smart enough) to diagnose diddly-squat. With that said...

I think your pt needs to be carefully evaluated to identify the cause of the new symptoms. Never heard of TD with Neurontin (an anticonvulsant), but my drug book talks about twitching & anxiety. TD happens with neuroleptics including the ones that aren't supposed to have that effect (eg. Risperdal, Seroquel). Also, people who are older are more likely to get TD.

Your pt might have a dystonia, which while disturbing is usually reversible. Cogentin, an anticholinergic medication, is often given for dystonia.

What I find alarming is that you said that in the 1 1/2 years you worked with him, you never saw him like this. I'd say your patient needs an examination and tests to r/o something more serious than a drug reaction.

Just my two cents. Caroline

sharann, BSN, RN · Oct 15, 2003

This is interesting. Today our outpatient surgery dept had a pt who developed an intesne restless need to leave "now", an a feeling of having to crawl out of her skin. This followed her being medicated with Reglan for unremitting nausea. I wonder. Compazine did this to me, with a horrible feeling of my legs having a mind of thei own.

I agree with Caroline. This patients needs a full evaluation with someone very familiar with his meds and symptoms. I feel bad for him, he must be exausted from all the movement...

Anniekins · Oct 15, 2003

I am a senior nursing student, currently in Psych Nursing...we just learned about this!!!!!!!!!!! I know that it is usually a side effect of long term use of Typical Antipsychotics, and sometimes atypical. And, is usually irreversable, and currently there is no TX for it.

I hope that helps....

:roll annie

nurseygrrl, LPN · Oct 16, 2003

Thanks for the replies. I feel so sorry for this man and it's hard because the docs at my facility are so into 'easy' cases. Anything that poses a challenge, they just push to the side and I feel that it's now my duty to try and help him.

sharann...I had the exact same thing happen to me with Compazine. It was the most awful feeling. I went to the ER totally nauseated with lower R quadrant pain. Turned out to be an ovarian cyst so they gave me compazine for the nausea and tylenol for the pain and told me I could go home once they got the paperwork straight and I got my IV D/Cd. After about 20 minutes I was ready to pull my own IV and run out the door. Then when I got home I was so tired but I couldn't lie still. This lasted for a good 24 hours!

PlanetCaroline...any advice on causes of dystonia?

plumrn, BSN, RN · Oct 16, 2003

My mother received Reglan IV while in ER once for intractable n/v. She developed restless legs right away; wanted to just crawl out of her skin, she said. The GI doc and the ER doc blamed it on the Reglan. She also had the problem when she took it po, but it was relieved when she went down from QID to BID. Some years ago she had taken Reglan for a long while, and she developed a fine tremor of the hands which was blamed on Reglan.

sjoe · Oct 16, 2003

"the docs at my facility are so into 'easy' cases. Anything that poses a challenge, they just push to the side "

One of the advantages of teaching hospitals is that they often LOVE the unusual cases. If he is eligible for VA benefits, I'd see if a VA medical center would be of help.

Otherwise, given the combination of chemicals this person is taking in, and the re-combinations they might be creating among themselves, and the interacting brain effects of all this chaos--it's a wonder he can still communicate, IMHO.

Would he really be worse off if ALL his medications were stopped?

NICU_Nurse, BSN, RN · Oct 16, 2003

Well, I don't know squat about this- I had to do a search (so take this with a grain of salt), but I looked up "antipsychotics and sore tongue" (tried antipsychotics and glossitis but I didn't come up with any good sources) and found this site (for dentists) on side effects of antipsychotics (scroll down to the table at the bottom):

http://www.nrchc.com.au/oralhealth/info_kit_dental_pros.pdf

which lists sore tongue/glossitis as a side effect. Try a google search...I didn't look too long on this. This was one of the first sites I found.

Based on that, I also looked up "neurontin and sore tongue" and came up with the neurontin page on http://www.rxlist.com which not only lists glossitis but also pharyngitis, laryngitis, and esophogitis as (infrequent) side effects. This is at: http://www.rxlist.com under the side effects/adverse reaction section of each drug.

Also on rxlist, laryngitis and glossitis were listed as (infrequent) side effects of Celexa.

I'm just taking a wild, wild stab here (I'm with Caroline- I don't know diddly squat. ), but knowing that these medications can enhance each other's side effects, perhaps this could lead you to discovering what the problem is?

I'd be looking at the Celexa, Xanax, and Neurontin very closely. When was the Xanax upped?

NICU_Nurse, BSN, RN · Oct 16, 2003

Why was he on the Neurontin?

glascow · Oct 16, 2003

A side effect of Reglan is:

restlessness, involuntary movements, facial grimacing, rigidity, or tremors. Extrapyramidal symptoms are most likely to occur in children, young adults, and the older adult.

An older person can take the same meds for years and then suddenly develop adverse reactions. This is due to pharmakokinetics (what your body does to the drug). There are so many factors affecting pharmacokinetics, it is truely amazing!

Four basic pharmacokinetic processes:

Absorption

Distribution

Metabolism

Excretion

A change in any of these can cause someone who once tolerated meds to suddenly react differently to them.

Things that I would question are:

Has he had a recent weight change? Has he had lab work recently?

Lab values that may affect how his body reacts to drugs would include: albumin, liver and renal function.

I doubt there is one quick, simple answer to your question. Drug therapy, esp. in the elderly, is very complex and I know that is something I have not appreciated in the past 13 yrs of my nsg career.

Now that I am in school for NP and taking advanced pharmacology (gee..could you tell I'm taking pharm), I realize it's amazing we don't harm more people with all the meds we give them! (We probably do, its just not documented).

Shamrock, BSN, RN · Oct 16, 2003

Elderly people often react to medications atypically. As said above, a complete eval. is in order. Keep advocating for your patient.