Journal of Neurology and Neuroscience

To the editor:

Tardive dyskinesia (TD) is one of the most worrisome side effects associated to narcoleptics treatment [1,2]. Repetitive and patterned movement characterizes this condition. The most typical form of TD is oro-lingual-masticatory the movement [3]. We report a patient who developed a TD after 9 month of treatment with rivastigmine (cholinesterase inhibitor). Continuos cholinergic-dopaminergic misbalance could be a factor in the pathophysiology of TD.

A 81-year-old woman presented with a 18 month history of probable Alzheimer’s disease (NINCDS-ADRDA criteria). Because of memory dysfunction, she was given rivastigmine with progressive monthly increase to 3 mg twice a day. After nine months with a dose of 3 mg twice a day memory slowly increase but the patient developed repetitive and involuntary oro-lingual-masticatory movement. The patient was diagnosed of TD and rivastigmine was quickly tapered. She improved, however 3 month later the involuntary movement still persists.

TD has been related to antidopaminergic drugs, however, as other movement disorders could be the expression of a cholinergic-dopaminergic misbalance, as has been propose for the Pisa syndrome [4]. Cholinesterase inhibitor could induce distonia in parkinson disease or worsen parkinsonism symptoms in some cases [5,6], however in a long retrospective analysis there were no exacerbation of motor dysfunction [7]. Theoretically cholinergic stimulation could be a factor in TD and Cholinesterase inhibitor could induce TD in Alzheimer disease.

References

1. Yassa R, Jeste DV: Gender differences in tardive dyskinesia: a critcal review of the literature. Schizophr Bull 1992; 18:701–715.
2. Jeste DV, Okamoto A, Napolitano J. Low Incidence of Persistent Tardive Dyskinesia in Elderly Patients With Dementia Treated With Risperidone. Am J Psychiatry 2000; 157:1150–1155.
3. Jankovic J. Stereotypies. In: Marsden CD, Fahn S (Eds). Movement Disorders 3. Oxford. Butterworth-Heinemann 1994: 503-517.
4. Kwan YT, Han IW, Balk J. Relation between cholinesterase inhibitor and Pisa syndrome. The Lancet 2000; 355: 2222.
5. Pavlis CJ, Kutscher EC, Carnahan RM, Kennedy WK, Van Gerpen S, Schlenker E. Rivastigmine-induced dystonia. Am J Health Syst Pharm. 2007;64:2468-70.
6. No authors listed. Cholinesterase inhibitors: tremor and exacerbation of Parkinson’s disease. Prescrire Int 2007; 16: 197-8.
7. Oertel W, Poewe W, Wolters E et al. Effects of rivastigmine on tremor and other motor symptoms in patients with Parkinson’s disease dementia: a retrospective analysis of a double-blind trial and an open-label extension. Drug Saf. 2008;3:79-94.