Extrapyramidal side effect of donepezil hydrochloride in an elderly patient: A case report.

INTRODUCTION: Alzheimer disease (AD) is a neurodegenerative disease characterized by progressive cognitive dysfunction, which is mainly manifested as memory impairment and a reduced ability to self-care, often accompanied by neuropsychiatric and behavioral disorders. Donepezil is the second drug to be approved by the US FDA for the treatment of AD. Of the five FDA-approved drugs for AD treatment, donepezil is currently the most widely used. Here, we report an extrapyramidal adverse reaction to donepezil in an elderly patient with AD. PATIENT CONCERNS: An 87-year-old woman presented with a 1-year history of forgetfulness that was aggravated since the past 2 months. She had a long-term history of multiple major conditions, including hypertension, diabetes, osteoporosis, and arterial plaques. Brain imaging showed age-related changes, and her Mini Mental State Examination score was 20. Other tests revealed no abnormalities apart from multiple thyroid nodules on ultrasonography. DIAGNOSIS: She was diagnosed with AD, hypertension, type 2 diabetes mellitus, diabetic neuropathy, osteoporosis, carotid and lower-extremity arterial plaques, thyroid nodules. INTERVENTIONS: She was treated with donepezil (5 mg/day), amlodipine besylate (5 mg/day), glimepiride (4 mg/day), methylcobalamin (1.5 mg/day), calcium carbonate D3 (600 mg/day), simvastatin (20 mg/day) and enteric-coated aspirin (100 mg/day). OUTCOMES: Four days later, she experienced fatigue, panic, sweating, and one episode of vomiting. On the 5th day, she developed increased muscle tension, speech difficulty, and involuntary tremors. Imaging and blood tests revealed no obvious abnormality, and the patient was not receiving psychotropic drugs. An extrapyramidal adverse reaction to donepezil was considered, and the drug was discontinued, after which the symptoms gradually disappeared. CONCLUSION: Serious adverse reactions to donepezil can occur in elderly patients, who typically require multiple medications for a variety of comorbidities. In particular, extrapyramidal reactions have occurred when donepezil is administered in combination with psychotropic drugs. However, in our patient, an extrapyramidal adverse reaction occurred in the absence of psychotropic drugs. Thus, clinicians must be aware of inter-individual differences in drug actions and possible serious adverse reactions, and carefully monitor these patients to ensure the timely detection of adverse events and their safe treatment.

[Analysis of energy balance and risk factors on clinical outcomes in patients with severe traumatic brain injury].

OBJECTIVE: To observe the energy expenditure in severe traumatic brain injury patients, and to assess the impact of cumulative energy balance on clinical outcomes. METHODS: Using prospective self-controlled study, the change in energy expenditure of 42 patients with severe traumatic brain injury was measured by indirect calorimetry (IC). Daily energy intake was recorded. Afterwards, energy balance was calculated. The levels of nutritional biochemical indicators were compared. Logistic regression analysis was used to analyze the correlation of cumulative energy balance with clinical outcomes. RESULTS: Mean practical energy intake of all patients was (6787 ± 1848) kJ/d, and mean negative energy balance was (913 ± 285) kJ/d. The negative energy balance was most crucial in first 3 days after admission. Meanwhile, practical energy intake was significantly lower than target energy intake (kJ: 2859 ± 1370 vs. 6027 ± 899, P < 0.01). The practical energy intake was increased with time, and it was found that the first 14 days were crucial for development of negative energy balance. On 7th day after admission, albumin (g/L) level in plasma was lowest compared with that on 3rd day (29.5 ± 5.0 vs. 35.9 ± 3.8, P < 0.01), and then it was increased gradually returning to normal level on 28 days (34.1 ± 2.8). Three days after admission, prealbumin (mg/L: 122.5 ± 23.3) was obviously lower than normal level, but it rapidly elevated on 7th day (214.3 ± 38.6, P < 0.01) and continued to rise till 28th day (257.7 ± 25.2). On the 3rd day after admission, C-reactive protein (mg/L: 139.5 ± 54.4) was obviously higher than normal level. However, it significantly fell on 7th day (108.4 ± 42.2, P < 0.01), and it continued to fall. Logistic regression analysis showed a strong association of cumulative negative energy balance with infection and upper gastrointestinal bleeding [odds ratio (OR) of infection was 2.130, 95% confidence interval (95%CI) 1.540 to 29.661, P = 0.023; OR of upper gastrointestinal bleeding was 0.083, 95%CI 0.013 to 0.542, P = 0.009]. CONCLUSIONS: Cumulative negative energy balance may be correlated with the occurrence of complications in patients with severe traumatic brain injury. On the basis of the measurements of changes in energy by IC, early supply of sufficient energy may improve the outcome of patients.

[Comparison of measuring energy expenditure with indirect calorimetry and traditional estimation of energy expenditure in patients in intensive care unit].

OBJECTIVE: To compare measurement of energy expenditure (MEE) by indirect calorimetry (IC) with traditional estimation of energy expenditure (EEE), to provide a basis for energy supplementary for critically ill patients. METHODS: Using self-controlled study,the energy expenditure of 57 intensive care unit (ICU) patients was measured by IC. Meanwhile, EEE was also calculated using the following equations : Harris-Benedict (HB), HB×factor , or 104.6 kJ/kg. Body weight were calculated using actual body weight (ABW) or ideal body weight (IBW). If body mass index (BMI)<18.4 kg/m(2) it was considered as underweight , and the IBW was selected from the IBW table. The potential adequacy of estimated energy was assayed by ratio of EEE/MEE. RESULTS: There was significant difference in MEE by IC and EEE by HB, HB×factor and 104.6 kJ/kg [(6 335 ± 1 004) kJ, (9 125 ± 1 795) kJ, (7 188 ± 1 029) kJ vs. (7 753 ± 1 439) kJ ,P<0.05 or P<0.01]. There was significant difference between EEE by HB×factor and 104.6 kJ/kg (P<0.01) , and EEE by 104.6 kJ/kg×ABW , and the latter was closer to MEE. Underfeeding would occur in most ICU patients if HB equation was used [100% (4/4) in underweight patients and 73.59% (39/53) in normal weight (BMI 18.5-23.9 kg/m(2))]. EEE as calculated by 104.6 kJ/kg×IBW was reasonable in the underweight patients 100% ( 4/4 ), but EEE in the patients with normal weight by using HB×factor or 104.6 kJ/kg×ABW resulted in significant underfeeding [39.62% (21/53) and 43.39% (23/53)] or overfeeding [24.53% (13/53) and 13.22% (7/53)]. CONCLUSION: EEE derived from the equations was extremely inaccurate and may result in significant underfeeding or overfeeding in individuals. On the basis of this study we would recommend IC for measuring energy expenditure in ICU patients. Otherwise , the equations of 104.6 kJ/kg×IBW in underweight and 104.6 kJ/kg×ABW in normal weight patients may be reasonable.