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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 176-178

Probable respiratory dyskinesia in an elderly patient after sudden stoppage of antipsychotics


Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Date of Web Publication13-Dec-2016

Correspondence Address:
Avinash Desousa
Carmel, 18, St. Francis Road, Off S.V. Road, Santacruz West, Mumbai - 400 054, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-9995.195681

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  Abstract 

Antipsychotic drugs are widely used in the management of schizophrenia in the elderly. Extrapyramidal reactions to these drugs and tardive dyskinesia are a dreaded side effect of these drugs that may be seen in the elderly. We present herewith, a case of probable respiratory dyskinesia, a rare but important variant of tardive dyskinesia seen in an elderly patient with schizophrenia after the sudden stoppage of antipsychotic medication.

Keywords: Antipsychotics, dyskinesia, extrapyramidal reaction, respiratory dyskinesia, schizophrenia, tardive dyskinesia


How to cite this article:
Vaidya V, Shah N, Desousa A. Probable respiratory dyskinesia in an elderly patient after sudden stoppage of antipsychotics. J Geriatr Ment Health 2016;3:176-8

How to cite this URL:
Vaidya V, Shah N, Desousa A. Probable respiratory dyskinesia in an elderly patient after sudden stoppage of antipsychotics. J Geriatr Ment Health [serial online] 2016 [cited 2020 Aug 13];3:176-8. Available from: http://www.jgmh.org/text.asp?2016/3/2/176/195681


  Introduction Top


Typical and atypical antipsychotic drugs are widely used in the management of schizophrenia in the elderly. [1] The chronic use of these drugs does take its toll on the dopamine pathway and may result in extrapyramidal symptoms or reaction which is often a common and dreaded complication of this group of drugs. [2] The most gravest of the extrapyramidal side effects is the occurrence of tardive dyskinesia which is commonly seen with increasing age and may be seen within 3 months to over years of antipsychotic usage and sudden withdrawal. [3] Respiratory dyskinesia is a rare variant of tardive dyskinesia and is an ill-understood phenomenon. [4] It may mimic cardiac distress and panic attack such as symptoms in its presentation and is often misdiagnosed in clinics and emergency settings. [5] Here, we present a case of an elderly patient with schizophrenia that developed probable respiratory dyskinesia due to a sudden withdrawal of antipsychotic therapy that had been continuing for many years.


  Case report Top


A 66-year-old man who had been diagnosed with schizophrenia for the past 30 years presented to the outpatient department after having stopped his medication for 4 weeks before presentation. He had received antipsychotic medication for the past 30 years and had been regularly on medication with a few days without medication off and on. His last prescription was that of trifluoperazine 10 mg/day, aripiprazole 10 mg/day, and trihexyphenidyl 4 mg/day (all in divided doses). The patient had been symptom-free for the last 5 years but had been told by his doctor that he shall have to take medication lifelong considering the chronic nature of his illness. The patient had visited his village and fell short on medication. Hence, all medication was stopped for 4 weeks before visiting us. Within 3 weeks of stopping all medication, the patient remained symptom-free (with regard to schizophrenia) but developed breathlessness, difficulty in breathing, had grunting movements during breathing, and would have little difficulty in swallowing food. He was shown to the local doctor in his village and when no respite was seen, he was brought to our department. The patient on presentation appeared breathless and had grunts that coordinated with inspiration. The patient was a known case of hypertension and was on regular medication (telmisartan 40 mg/day). There was no history of any cardiac disease in the past and no history of smoking or chewing tobacco was noted. The patient also did not have any family history suggestive of movement disorders.

On a clinical examination, he had a pulse rate of 99/min and blood pressure was 130/90 mmHg. He was given clonazepam 1.5 mg/day in divided doses by his doctor in the village, and that caused no relief for the patient. The relatives however noted that all these symptoms were absent in sleep. The patient showed stereotypic movements of the face, mouth, tongue, and neck. His oral cavity on examination showed involuntary movements of the pharynx and soft palate. We considered respiratory dyskinesia as a diagnosis and made a medical as well as a neurological referral. The physician advised sending an arterial blood gas analysis. We wanted to admit the patient and observe him in the ward, but the relatives refused admission. His X-ray chest done a few days before, his visit was normal and his electrocardiogram too was within normal limits. He did complain that he would feel fatigued after these movements and at the end of the day would get sleep due to the tiredness itself. He also mentioned that when he developed any anxiety thinking about his illness, the movements became faster. The neurologist wanted to carry out a deglutition study and diagnosis oropharyngeal movement disorders if any. The neurologist agreed with our presumptive diagnosis of respiratory dyskinesia. The patient was advised admission, but the relatives refused and decided to take treatment elsewhere. The patient has not followed up since, and the current status is unknown. Because of a lack of follow-up, no electromyography confirmation was possible along with spirometry and other parameters.


  Discussion Top


Tardive dyskinesia is often related to respiratory dyskinesia, and advanced age is a well-known risk factor for the same as seen in our case. [6] The total duration of antipsychotic medication use and the total cumulative dosage of drug used have also been linked to this form of dyskinesia. [7] Usually, the arterial blood gas analysis in respiratory dyskinesia would show a respiratory alkalosis pattern, [8] but our patient refused the investigation, and we could not have a confirmation in this regard. Both voluntary and involuntary neurological pathways manage the control of respiration. [9] The respiratory center in the brainstem controls the automaticity of breathing and is not under our control. Voluntary control of the respiratory muscles is linked to the motor cortex in the frontal lobes. These neurons work via the pyramidal tracts and receive some modulation via the basal ganglia, thalamus, and cortex. [9] These areas are also linked to the presence of dopamine receptors, and sudden withdrawal of antipsychotic treatment may cause dopamine-related changes in these regions. [10] Various agents such as tetrabenazine, [11] lorazepam, [12] bromocriptine, [13] Vitamin E [14] and calcium channel blockers [15] with propranolol [16] have been used in the management of these dyskinesias, but data in elderly subjects are much less than that in adult subjects. Neuroleptic-induced respiratory dyskinesia has been reported in literature and clinicians must be vigilant about the same. The risk factors for the same include older age, history of dyskinesia, and extrapyramidal reactions as well as sensitivity to antipsychotics. [17],[18] Our patient did not wait for treatment and hence we could not manage the condition. It is important that clinicians working with patients on long-term antipsychotic therapy be aware of this rare yet important complication that may result when patient abruptly stop years or months of antipsychotic treatment suddenly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jeste DV, Blazer D, Casey D, Meeks T, Salzman C, Schneider L, et al. ACNP White Paper: Update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology 2008;33:957-70.  Back to cited text no. 1
    
2.
Gareri P, De Fazio P, De Fazio S, Marigliano N, Ferreri Ibbadu G, De Sarro G. Adverse effects of atypical antipsychotics in the elderly: A review. Drugs Aging 2006;23:937-56.  Back to cited text no. 2
    
3.
Aquino CC, Lang AE. Tardive dyskinesia syndromes: Current concepts. Parkinsonism Relat Disord 2014;20 Suppl 1:S113-7.  Back to cited text no. 3
    
4.
Rich MW, Radwany SM. Respiratory dyskinesia. An underrecognized phenomenon. Chest 1994;105:1826-32.  Back to cited text no. 4
    
5.
Rice JE, Antic R, Thompson PD. Disordered respiration as a levodopa-induced dyskinesia in Parkinson′s disease. Mov Disord 2002;17:524-7.  Back to cited text no. 5
    
6.
Kinon BJ, Kollack-Walker S, Jeste D, Gupta S, Chen L, Case M, et al. Incidence of tardive dyskinesia in older adult patients treated with olanzapine or conventional antipsychotics. J Geriatr Psychiatry Neurol 2015;28:67-79.  Back to cited text no. 6
    
7.
Gopal S, Xu H, Bossie C, Burón JA, Fu DJ, Savitz A, et al. Incidence of tardive dyskinesia: A comparison of long-acting injectable and oral paliperidone clinical trial databases. Int J Clin Pract 2014;68:1514-22.  Back to cited text no. 7
    
8.
Komatsu S, Kirino E, Inoue Y, Arai H. Risperidone withdrawal-related respiratory dyskinesia: A case diagnosed by spirography and fibroscopy. Clin Neuropharmacol 2005;28:90-3.  Back to cited text no. 8
    
9.
Mehanna R, Jankovic J. Respiratory problems in neurologic movement disorders. Parkinsonism Relat Disord 2010;16:628-38.  Back to cited text no. 9
    
10.
Godlee FN, Brooks DJ, Impallomeni M. Dyskinesia in the elderly presenting as respiratory disorder. Postgrad Med J 1989;65:830-1.  Back to cited text no. 10
    
11.
Leung JG, Breden EL. Tetrabenazine for the treatment of tardive dyskinesia. Ann Pharmacother 2011;45:525-31.  Back to cited text no. 11
    
12.
Alabed S, Latifeh Y, Mohammad HA, Rifai A. Gamma-aminobutyric acid agonists for neuroleptic-induced tardive dyskinesia. Cochrane Database Syst Rev 2011;4:CD000203.  Back to cited text no. 12
    
13.
Aia PG, Revuelta GJ, Cloud LJ, Factor SA. Tardive dyskinesia. Curr Treat Options Neurol 2011;13:231-41.  Back to cited text no. 13
    
14.
Howland RH. Drug therapies for tardive dyskinesia: Part 1. J Psychosoc Nurs Ment Health Serv 2011;49:13-6.  Back to cited text no. 14
    
15.
Cloud LJ, Zutshi D, Factor SA. Tardive dyskinesia: Therapeutic options for an increasingly common disorder. Neurotherapeutics 2014;11:166-76.  Back to cited text no. 15
    
16.
Mejia NI, Jankovic J. Tardive dyskinesia and withdrawal emergent syndrome in children. Expert Rev Neurother 2010;10:893-901.  Back to cited text no. 16
    
17.
Bhimanil MM, Khan MM, Khan MF, Waris MS. Respiratory dyskinesia - An under-recognized side-effect of neuroleptic medications. J Pak Med Assoc 2011;61:930-2.  Back to cited text no. 17
    
18.
Kruk J, Sachdev P, Singh S. Neuroleptic-induced respiratory dyskinesia. J Neuropsychiatry Clin Neurosci 1995;7:223-9.  Back to cited text no. 18
    




 

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