Anticholinergic syndrome

Hall RC, Popkin MK, Mchenry LE. (1977). Angel s trumpet psychosis a central nervous system anticholinergic syndrome. Am J Psychiatry. 134(3) 312-14. 

Holland MS. (1992). Central anticholinergic syndrome in a pediatric patient following transdermal scopolamine patch placement. Nurse Anesth. 3(3) 121-24. 

Duvoison RC, Katz R. Reversal of central anticholinergic syndrome. JAMA. 1968 206 1963. 

Although atropine and scopolamine share many properties, an important difference is the easier entry of scopolamine into the CNS. Typical doses of atropine (0.2-2 mg) have minimal central effects, while larger doses can produce a constellation of responses collectively termed the central anticholinergic syndrome. At intermediate doses (2-10 mg), memory and concentration may be impaired, and the patient may be drowsy. If doses of 10 mg or more are used, the patient may exhibit confusion, excitement, hallucinations, ataxia, asyn-ergia, and possibly coma. 

Central anticholinergic syndrome due to the potent muscarinic-cholinergic effects of many psychotropics... 

Some of the expected changes with age, such as the reduction in cholinergic neurons or the presence of Alzheimer s dementia, may accentuate the anticholinergic effects of many antipsychotics and antidepressants. Thus, elderly patients have increased sensitivity to these properties, often resulting in a central anticholinergic syndrome (267). This condition is characterized by the loss of immediate memory, confusion, disorientation, and florid visual hallucinations, at times superimposed on other psychoses, such as schizophrenia or psychotic depression. 

The classic anticholinergic syndrome is remembered as "red as a beet" (skin flushed), "hot as a hare" (hyperthermia), "dry as a bone" (dry mucous membranes, no sweating), "blind as a bat" (blurred vision), and "mad as a hatter" (confusion, delirium). Patients usually have sinus tachycardia, and the pupils are usually dilated (see Chapter 8 Cholinoceptor-Blocking Drugs). There may be agitated delirium or coma. Muscle twitching is common, but seizures are unusual unless the patient has ingested an antihistamine or a tricyclic antidepressant. Urinary retention is common, especially in older men. 

A central anticholinergic syndrome with psychotic symptoms in a 9-year-old boy on therapeutic doses has also been described (218). 

Watemberg NM, Roth KS, Alehan FK, Epstein CE. Central anticholinergic syndrome on therapeutic doses of cyproheptadine. Pediatrics 1999 103(l) 158-60. 

Speich R, Haller A. Central anticholinergic syndrome with the antimalarial drag mefloquine. N Engl J Med 1994 331(l) 57-8. 

The antidotal effect of 7-MEOTA on the anticholinergic syndrome was potentiated by nootropics, by diazepam, and especially by opioid peptides (Fusek, 1977). 

Qulnuelldlnyl-benzllate on Spontaneous Motor Activity In Rats and Management of the Anticholinergic Syndrome by Some Psychotropic Drugs. Actlv. Nerv. Sup. 14 161-162. 

Prendergast MD, Nasca TJ. Anticholinergic syndrome with procainamide toxicity. JAMA 1984 251(22) 2926-7. 

Seizure disorder (myoclonus) psychobiological reaction (serotonin syndrome, anticholinergic syndrome) tremor extrapyramidal syndrome (dyskinesia)... 

Note Physostigmine is used to reverse the effect upon the nervous system caused by clinical or toxic dosages of drugs and herbs capable of producing the anticholinergic syndrome. 

Some of the drugs responsible are amitriptyline, amoxapine, atropine, benztropine, biperiden, didinium, cyclobenzaprine, desipramine, doxepin, hyoscyamine, imipramine, lorazepam, maprotiline, nortriptyline, protriptyline, propantheline, scopolamine, trimipramine. Some herbals that can elicit the anticholinergic syndrome are black henbane, deadly nightshade, Devil s apple, Jimson weed, Loco seeds or weeds, Matrimony vine, night blooming jessamine, stinkweed. 

Hall, R. et al 1977. Angel s trumpet psychosis A central nervous system anticholinergic syndrome AmericanJournal of Psychiatry 134 312-314. 

Modified and reproduced, with permission, from Mikolich JR. Paulson GW. Cross CJ Acute anticholinergic syndrome due to Jim-son seed ingestion clinical and laboratory observation in six cases. Ann Intern Med 1975 83 321. 

III. Clinical presentation. The anticholinergic syndrome is characterized by warm, dry, flushed skin dry mouth mydriasis delirium tachycardia ileus and urinary retention. Jerky myoclonic movements and choreoathetosis are common, and... 

IV. Diagnosis is generally based on the history of ingestion and can usually be readily confirmed by the presence of typical anticholinergic syndrome. Comprehensive urine toxicology screening will detect most common antihistamines. 

Anticholinergic syndrome Ibotenic acid, muscimol Amanita muscaria, A pantherina, others. Onset 30 mln-2 h vomiting, followed by drowsiness, muscular jerking, hallucinations, delirium, psychosis. (See Anticholinergics, p 84). 

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