Also known as pseudoparkinsonism, these drug-induced symptoms mimic those of Parkinson’s disease: ⦁ Tremor (especially apparent in the hands as a resting, “pill rolling” tremor). ⦁ Rigidity (cog-wheel rigidity). ⦁ Bradykinesia (slow movement), decreased arm swing. ⦁ Shuffling gait. ⦁ Slurred speech. ⦁ Mask-like facies, stooped posture, drooling. ⦁ Psychological side effects, such as cognitive dulling (bradyphrenia), worse negative symptoms (neuroleptic-induced deficit syndrome), worse depression (neuroleptic dysphoria). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Donepezil is the cholinesterase inhibitor with the longest track record and with which we have the most experience. It is generally considered the first-line agent for dementia. Though not a cure, it delays dementia progression by six to 12 months. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Armodafinil is an effective wake-promoting agent with some potential for abuse and for drug interactions. It lasts a bit longer than modafinil. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Diazepam has a long history of use with good efficacy for anxiety. Its long half-life makes it a particularly effective anxiolytic for some patients, and it is a good alternative to chlordiazepoxide for alcohol withdrawal. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Pimavanserin is the only antipsychotic with virtually no effect on dopamine receptors. It is the only approved medication for psychosis in Parkinson’s disease, but we do not yet know if it has any efficacy advantages over quetiapine, which has generally been the go-to antipsychotic for this syndrome. Its lack of weight gain is a side effect advantage, but there are some concerns about increases in hospitalization and higher mortality in patients with Parkinson’s disease psychosis. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Duloxetine is the main SNRI alternative to venlafaxine/desvenlafaxine. It has a niche for depressed patients with various comorbid pain syndromes. However, you should balance this advantage against its potentially serious (though rare) hepatic side effects. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Molindone is an effective, well-tolerated first-generation antipsychotic of medium potency—a solid medication that some clinicians have gained experience with and favor for select patients. Recently it has been reintroduced into the market, and is still generic and inexpensive. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Guanfacine is an alpha-2 agonist that has no abuse potential, does not worsen tics, and does not cause insomnia. However, it is less effective than stimulants and has a delayed onset of effect (two to four weeks). Guanfacine ER is now available in generic and is easier to use than IR. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Amantadine is a dopaminergic medication used primarily in Parkinson’s disease, but it is also helpful in drug-induced parkinsonism and has fewer anticholinergic side effects (eg, cognitive impairment, dry mouth, constipation) than other meds used to combat extrapyramidal symptoms (EPS), like benztropine. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Buspirone is a reasonable option in anxious patients for whom benzodiazepines are not appropriate. Don’t expect as robust a response, and make sure patients know it may take a week or two to kick in. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).