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Aim
The aim of this article, the eighth in the care maps series, is to describe a care map that enables healthcare professionals, especially community mental health nurses, and patients to manage extrapyramidal side effects associated with atypical antipsychotic drugs.
Atypical antipsychotics with a low risk of extrapyramidal side effects are identified. The care map expands and elaborates on the assessment and management options for extrapyramidal side effects outlined in the flow chart (Figure 1). The evidence base that has informed the care map is also included.
Background
Although the risk of extrapyramidal, or abnormal, involuntary movement-related side effects with all atypical antipsychotic drugs is lower than with first generation antipsychotics, it remains a concern. For example, several cases of severe akathisia have been reported by researchers in connection with olanzapine, one of the most commonly used atypical agents (Jauss et al 1998).
Extrapyramidal side effects are perhaps the most difficult side effects to live with. They are a source of stigma, with the common misconception that movement disorders are part of the disease, rather than the treatment (Neppe and Ward 1990). They are also considered to be a significant factor in nonconcordance with medication regimens (Fleischhaker et al 1994).
Atypical antipsychotics with a low risk of extrapyramidal side effects are olanzapine, amisulpride and risperidone (dose related) (Taylor et al 2003).
Care map
1.1 Whenever a new antipsychotic is being considered for treatment a risk assessment for extrapyramidal side effects will be needed. Evidence shows that certain groups of patients are more at risk of developing these side effects even with the novel antipsychotic drugs. These include patients experiencing first episodes of schizophrenia, women (Woerner et al 1991), older people (Avorn et al 1994, Sweet and Pollock 1998) and patients with affective symptoms, for example lowered or raised mood. The prescriber will need to exercise caution with drug selection when one or more of these factors is present.
1.2 The recommended frequency of monitoring for all atypical antipsychotics for extrapyramidal side effects and tardive dyskinesia is before initiation of the medication - and then annually or biannually provided that no symptoms have emerged (Marder et al 2002). In this case they need to be assessed during every patient visit for as long as the symptoms...