Notably, a significant improvement was observed in the ability to stand upright in the levodopa treated group. However, no effects were observed in the other endpoints, including tandem walking and normal gait. In addition, an average improvement of three points on the visual analog scale was recorded over a period of eight weeks 12. Therefore, there is limited scientific literature on parasomnias and SRMD induced by medications, although this is a common and challenging clinical scenario (Kierlin & Littner, 2011). Furthermore, due to the complexity of the mechanisms and neurotransmitters involved in sleep, it is important to study which medications can trigger parasomnias and SRMD. A deeper understanding of these adverse events could assist clinicians in their practices and prescriptions.
A complete list of the medications you’re taking will be extremely helpful during diagnosis. Telling your doctor how often you’re having tremors can help aid in your diagnosis. The speed of your tremors can also help your doctor determine their cause. Rarely a medicine like propranolol, used to treat essential tremor, may be prescribed to control a medication-induced tremor. Treatments like deep brain stimulation and surgery are usually reserved for severe tremors that do not respond to other therapies.
Medical Risk Factors
This pronounced development of tolerance was not previously shown in patients taking perampanel due to epilepsy. Given that the tremor study was neither blinded nor randomized and did not include a crossover design, the conclusions regarding clinical applicability are limited. To achieve more generalizable results, controlled studies with larger cohorts would be necessary. Tardive dyskinesia is a late-onset movement disorder that affects around 20-30% of patients who have been on long-term antipsychotic medications. It is characterized by repetitive, involuntary movements, particularly of the face, such as lip-smacking, tongue movements, or grimacing. Tardive dyskinesia is thought to result from long-term dopamine receptor blockade, which causes the brain to become hypersensitive to dopamine.
Manage Movement Symptoms Today
Ms A was admitted to the hospital medicine service with ongoing consultation from the rheumatology and psychiatry departments. She was diagnosed with an acute dystonic reaction due to administration of haloperidol, and an adverse reaction warning was entered into her electronic medical record. She was started on oral benztropine 1 mg 3 times/day for 3 days as prophylaxis against the return of acute dystonia. Ms A was also diagnosed with a substance-induced mood disorder (bipolar disorder with psychotic features triggered by use of corticosteroids).
Subsequently, the same procedure was applied to the full text of eligible studies. We aimed to supplement the search by including terms such as nocturnal enuresis, sleep‐related eating disorder, sleep sex, nightmares, and catathrenia, as these terms were not covered in the MeSH Term Parasomnia index. Tremors or Drug-Induced Movement Disorders (DIMD) may harm your quality of life and general well-being. You may find it challenging to perform easy tasks, which may, in turn, affect your social functioning and interpersonal communication.
Talk to your doctor about the medications you’re taking, and consult them before adding any new over-the-counter medications. Stimulant medications and drugs containing theophylline should be used with caution. Your doctor might want to rule out other potential causes of tremors by performing blood tests to check for abnormal levels of certain chemicals in your blood.
Insights into Pathophysiology from Medication-induced Tremor
Other drugs can cause tremor, presumably by blockade of dopamine receptors in the basal ganglia (dopamine-blocking agents), by secondary effects such as causing hyperthyroidism (amiodarone), or by other mechanisms. We will attempt to discuss what is known and unknown about the pathophysiology of the most common MITs. It is symmetrical and occurs acutely following drug ingestion or dose escalation. Exceptions include tremor secondary to valproate, which can appear at therapeutic or during stable treatment, or, rarely, tardive tremor. Tremor can occur secondary to many drugs, including SSRIs, lithium, tricyclic antidepressants, antiepileptics (particularly valproate), bronchodilators, amiodarone and immunosuppressives. Another underlying aetiology, such as Parkinson’s disease, essential tremor or hyperthyroidism, needs to be excluded.
Alcohol tremors primarily affect the hands, but they affect the legs and arms in some circumstances. The tremors manifest approximately 8 hours after you stop drinking and peak about 30 hours after your last drink. Alcohol abuse may result in alcohol shakes, also called jitters or tremors. Often, the tremors occur when a person dependent on alcohol stops taking alcohol. On the other hand, hypokinetic disorders are characterized by lack or absence of movement due to weakness.
Abnormal Gait
- Rodrigues et al. 9, described the efficacy of gabapentin in a non-blinded, uncontrolled study involving six patients, focusing on postural instability, electromyogram activity, and quality of life, as assessed by using the PDQ-39.
- Over the next 30 minutes, her tremor, rigidity, eye movement deviation, and torticollis gradually resolved.
- For example, smoking can affect how the body metabolizes certain medications, potentially increasing the risk of side effects like movement disorders.
- Myoclonus can affect any muscle group and may occur spontaneously or in response to stimuli such as light or sound.
- Both therapeutic and illicit drugs can cause neurological adverse effects, including movement disorders.
In the study, first an open-label administration of ascending doses of gabapentin was performed in all patients to establish the individual maximal effective doses, ranging from 600 to 2700 mg per day. Thereafter, three patients each were assigned to treatment with either the maximal effective dose of gabapentin or a placebo. Measurement criteria included postural instability and tremor, as well as the patients’ self-assessment using a modified PDQ-39. All patients reported benefits, which persisted throughout an average follow-up period of 19 months. The functional improvements were statistically significant, while only the aspect of emotional well-being showed a significant improvement in the patients’ assessments 10.
Antidepressant drugs
A report by the National Institute on Drug Abuse revealed that in 2020, approximately 92,000 U.S citizens died from a drug-related overdose of both illegal drugs and prescription opioids. Bromocriptine should therefore be continued for several weeks to ensure the syndrome has completely subsided. Consideration about restarting an antipsychotic requires a specialist psychiatric opinion.
Evidente et al. 8, reported on seven patients who were included in an open-label study, which was not placebo-controlled. The patients received daily doses of gabapentin ranging from 300 to 1800 mg per day. The initial dosage was set to 300 mg per day, with increments of 300 mg every three to five days until a positive therapeutic effect was achieved. The outcome was measured using a subjective scale assessing improvement in symptoms from 0 to 100%. Furthermore, four patients also improved in both the severity of symptoms and the time required to experience unsteadiness upon standing. Two patients underwent subsequent electrophysiological examinations, which showed no improvement compared to baseline values prior to the study drug induced tremors 8.
Mechanisms of Medication-induced Tremor for More Common Offending Agents
Even though antihypertensive agents are not the most concerning drug class when it comes to tremors, some medications used to treat high blood pressure, such as aliskiren and amlodipine, have been linked to drug-induced tremors. Talk to your doctor if you notice symptoms of tremors while on medication for high blood pressure. Rodrigues et al. 9, described the efficacy of gabapentin in a non-blinded, uncontrolled study involving six patients, focusing on postural instability, electromyogram activity, and quality of life, as assessed by using the PDQ-39.
Gabapentin therapy was started with three doses of 300 mg per day and the parameters mentioned above were measured after three weeks. Three of the patients improved their postural instability by up to 70%.Neither adverse drug reactions were recorded, nor an improvement in electrophysiological values. Nevertheless, all patients who completed the questionnaire described a subjective improvement of symptoms. RLS was the most commonly reported in the scientific literature, accounting for 62 records or 36% of the included records. Periodic limb movement disorders were the second most reported sleep‐related movement disorders, with nine records representing 5% of the included records, followed by sleep‐related bruxism with four records, comprising 2% of the included records. Some instances of these can manifest in people addicted to drugs or those who are experiencing withdrawal symptoms when they stop using drugs.
Recommended treatments for each type of AIM are summarized in Table 21,20–30 and described below. Some of these treatments are within the scope of practice of primary care physicians; others will require referral to specialists. The altered mental status, autonomic instability, and spasticity or rigidity with raised creatine kinase, overlap with neuroleptic malignant syndrome. In serotonin syndrome the onset is hyperacute, within hours rather than days, and the signs of central nervous system hyperexcitability are more prominent. If your drug-induced tremor is not severe and does not interfere with daily activities, you may not need any treatment. However, if there are possible complications, such as problems with eating, drinking, and other daily activities, stopping the causative medicine or treatment with additional medication may be necessary.
Both therapeutic and illicit drugs can cause neurological adverse effects, including movement disorders. The most common causes of drug-induced movement disorders are dopamine receptor blocking drugs, including antipsychotics and antiemetics (Table 1). Drug-induced movement disorders can range from tremors to life-threatening syndromes.
In rare instances where clinically appropriate, deep brain stimulation surgery may be necessary to ameliorate the tremor. This systematic review highlights the associations between drugs and induced parasomnias/SRMD. Nervous system drugs were found to be the main drug classes reported in association with parasomnias or SRMD.
Telemedicine offers a convenient way to manage medication-induced movement disorders. Virtual consultations provide timely medical advice, prescription adjustments, and follow-up care without the need for in-person visits, which is especially helpful for those with mobility issues or living in remote areas. Tremors can occur in the setting of withdrawal states, especially with benzodiazepines, ethanol, and opiates.
In terms of drug‐induced SRMD, restless legs syndrome, periodic limb movement disorders (PLMD), and sleep‐related bruxism were most frequent. Medications that inhibit noradrenergic, serotonergic, or orexin transmission could induce REM sleep (e.g., nightmares). Regarding sleepwalking, dysregulation of serotoninergic neurone activity is implicated. Antipsychotics are mentioned, as well as medications involved in the gamma‐aminobutyric acid (GABA) pathway. A mechanism of desensitisation‐autoregulation of GABA receptors on serotoninergic neurones is a hypothesis. SRMD and PLMD could involve medications disrupting the dopamine pathway (e.g., antipsychotics or opioids).