Documentation of extrapyramidal symptoms

Kuruvilla et al (Psychiatric Bulletin, August 2006, 30, 300–303) reported that a high percentage of respondents in their survey had not received formal training in the assessment (52%) or management (36%) of drug-induced movement disorders and mean levels of confidence in these skills were relatively low. We studied the documentation of extrapyramidal symptoms (EPS) in patients’ notes at a Manchester teaching hospital.

A psychiatrist (S.M.) conducted a standardised neurological examination on a representative group of 25 psychiatric in-patients and out-patients aged 18–65 years with schizophrenia and under several consultants. Extrapyramidal symptoms were rated on standard rating scales and parkinsonism, akathisia and tardive dyskinesia were diagnosed using predefined scores. Twelve of the 18 patients (67%) prescribed an atypical antipsychotic and 6 of the 7 patients (86%) prescribed a conventional antipsychotic fulfilled criteria for an extrapyramidal syndrome. A subsequent review of the clinical notes for the preceding 12 months showed that only half of the patients with an extra-pyramidal syndrome (9 of 18) had documented evidence of a management plan to treat the disorder and that only 1 of the 25 patients had a documented physical examination that recorded the presence or absence of extrapyramidal signs.

Our study indicates that EPS remain common in clinical practice despite the widespread use of atypical agents, that half of extrapyramidal syndromes are untreated and that screening for EPS is not routine. Possible explanations are that clinicians lack the knowledge, skills and confidence to assess and manage EPS or that they lack the time to address this aspect of care. We agree with Kuruvilla et al that clinicians need better education and training in this area.