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Treating TD in the COVID-19 Era: 5 Steps to Success

June 08, 2020

logoIn this video, Leslie Citrome, MD, MPH, details 5 steps to success for clinicians treating patients who have tardive dyskinesia or are at risk of the disorder. Dr. Citrome is Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla.

Read the transcript:

Hello, I'm Dr. Leslie Citrome, Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York. Today we're going to talk about tardive dyskinesia, 5 steps to success, and coping during the COVID‑19 era.

We're going to talk about what has changed, what's different with COVID‑19, and then we're going to drill down to our 5 steps to success for tardive dyskinesia, talk about the need for differential diagnosis, assessment, harm reduction, interventions, and follow‑up as well.

So what has changed with COVID‑19? For one thing, office visits have been reduced or eliminated, and patients aren't getting the usual screening.

You can no longer observe patients in the waiting room, additional staff can no longer report to you their observations, and the team approach is challenging to do with this environment. Some clinics, unfortunately, have shut down, and stopped administering long‑acting injectables, and patients are suffering the consequences.

There is a general reluctance in some instances to change therapies or add on therapies. There is an attitude of "just hang in there until the office reopens" and care is left unoptimized. Those are several negatives. However, we can do several different things and what has changed is telehealth.

Telehealth has become more mainstream and may make health care actually more accessible to more people, provided they can deal with the equipment. Assessment for motor movements such as for tardive dyskinesia is very feasible with video. Actually, video ratings were used as the primary outcome for the studies of the treatments approved for tardive dyskinesia.

We can continue to screen, and evaluate, and initiate treatment when it's necessary. Moreover, barriers have been removed regarding HIPAA‑certified solutions as well as obstacles to billing and reimbursement. It's now a lot easier.

In fact, our local ACT team, Assertive Community Treatment team, actually is doing better in accessing care for their patients. They're able to get in touch with patients actually more easily. There are no shows anymore, so to speak, because phone calls are taking place. Actually, that was a bit of a surprise.

It turns out that actually more long‑acting injectable antipsychotic use is being seen in that environment because patients are reluctant to go to the pharmacy. So actually, things that we were worried about turned out not to be the case and we were pleasantly surprised.

I'd like to share with you some video best practices, though to make this actually happen and so that you can be successful. Looking at the patient on the phone really is not good enough when you're assessing movements, and you need to use a laptop or tablet so that you can see better. On the patient side, a propped‑up tablet or the use of a laptop is better than the patient holding the phone.

If a companion is available, this extra pair of hands will make it a lot easier to keep the patient in the view of the camera when asking the patient to move their arm, stand, or walk and let you look at their head, face, mouth, tongue, trunk, arms, hands, fingers, legs, feet, toes. You can do it all if someone else is holding that camera.

Actually, this is made a lot easier with the phone call and the person’s living at home or in a supportive environment with other people there. They can have other people help them with that call. It may be useful for you to record movements on the call to allow you to review them and also zoom in on the hands, feet, tongue, as needed when you're assessing the movements.

You still need to be prepared to model what you want the patient to do so as you remember those activation maneuvers that are necessary when evaluating tardive dyskinesia, like asking the patient to touch their fingers to their thumb as quickly as possible, you need to show them what you want them to do.

If you want them to open their mouth and stick out their tongue, you need to still show them what to do, and allow the patient to actually do that. It is still helpful to have the patient sit in a chair without arms, that's what we usually do when assessing abnormal movements in the clinic, and it's helpful if they can find such a chair where they are.

With that out of the way, those are the best practices I can share with you, let's go through the 5 steps to success and first answer the question, why do we need to do a careful differential diagnosis?

The key issue here is, are we dealing with drug‑induced parkinsonism or tardive dyskinesia? They're both stigmatizing movement disorders associated with exposure to antipsychotics, but they're very different.

Anticholinergic treatments such as benztropine or Cogentin is used to treat acute EPS but can worsen the dyskinetic movements with TD. That's an important consideration. VMAT2 inhibitors that we use to treat tardive dyskinesia can actually worsen drug‑induced parkinsonism. So treatments for one can worsen the other.

We do have examples in psychiatry that drives this home. We've all been taught that antidepressant monotherapy can effectively treat major depressive disorder, that is unipolar depression, but we now know it can make bipolar depression worse, so we spend a lot of time and effort to distinguish between unipolar from bipolar depression.

That same amount of care and effort is required for us to distinguish between drug‑induced parkinsonism and tardive dyskinesia. Fortunately, they look different and they also resolve differently.

Let me share with you some hints that I use in day‑to‑day practice when evaluating patients. With drug‑induced parkinsonism, the tremor is rhythmic. It worsens when we increase the antipsychotic dose and is often accompanied by rigidity. The arm swing when they're walking is less.

TD movements are jerky, they're not rhythmic. They get better with higher antipsychotic dose at least temporarily, and they're not usually accompanied by rigidity. Then lastly, drug‑induced parkinsonism often resolves by stopping the causative agent, but TD may be permanent.

Drug‑induced parkinsonism and tardive dyskinesia are treated differently and fortunately, they look different and resolve differently.

How do we assess? Well, the good old AIMS, Abnormal Involuntary Movement Scale examination. We've all learned it over the years, at least most of us. It's an observer‑rated 12‑item scale that takes about 5 to 10 minutes to do. It's adopted by many agencies for routine clinical use and is used as a primary outcome measure in research of drugs for tardive dyskinesia.

The first 7 items of this 12‑item scale refer to the movements that we observe, and record, and basically rate, but the remainder of the items are just as helpful. Global assessments of how bad the movements are, patient's awareness and level of distress, as well as impact on function.

The instructions for the AIMS also tell us that we should assess rigidity by flexing and extending the patient's left and right arms. We don't actually rate that on the form, but the instructions tell us to do that. That's difficult to do with telemedicine, but we can observe the gait and that's also suggested that this be done.

By observing the gait, watching the patient walk in front of the camera, will help us detect whether or not there's some rigidity by watching for that arm swing. If you don't see arm swing, think some degree of rigidity and some degree of drug‑induced parkinsonism may be possible. I use that arm swing as a clinical sign that I may be dealing with rigidity.

Harm reduction is step 3 of our 5‑step process of dealing with TD. Harm reduction means just minimizing the risk of TD. We'll make sure that we have an appropriate indication for using the antipsychotic, we'll use conservative doses, and we'll try to use second‑generation antipsychotics as much as possible because they have a lower risk for extrapyramidal side effects and potentially tardive dyskinesia.

Second‑generation antipsychotics are preferable with regard to movement problems. We want to make sure that we inform patients and caregivers of the risk and we'll assess for incipient signs, so early signs of TD, and we can do that by keeping in mind the Abnormal Involuntary Movement Scale examination, or abbreviated versions as you see fit, even when using telehealth.

Step 4, our interventions. I want to warn you about something, something very important to consider, and that is, anticholinergic medicines. They can increase the risk of developing tardive dyskinesia, can worsen comorbid tardive dyskinesia, and can negatively impact cognition. These are problems.

We use Cogentin a lot. When we read the product label, it's useful to treat drug‑induced parkinsonism, for example, but the product label actually tells us it is not for TD and can make TD worse.

In the elderly, anticholinergic medication is especially problematic. There's an increased risk of delirium, especially if they're receiving other medicines that have anticholinergic‑induced adverse effects.

In addition to altered cognition, there may be peripheral side effects such as blurred vision, dry mouth, constipation, and urinary retention. Once we start an anticholinergic, it's not so easy to stop. We can't stop it abruptly. We have to taper it. Anticholinergics come with a lot of baggage and if I can avoid using them, I will.

What do we do with the tardive dyskinesia? The interventions there, as approved by the FDA, are VMAT2 inhibitors. They decrease dopamine release and lead to reduction in dyskinetic movements. There are other potential strategies for treatment of tardive dyskinesia, but they're not approved. They're out there, but I like to stick with agents that have actually a good basis in terms of clinical trials that have established their efficacy and tolerability, as well as their safety.

What's the last step, step 5, in our journey to success? Follow‑up. We need to follow up. When treatment is initiated, you already have or you should have, a baseline assessment using the AIMS. Follow‑up assessments uses, guess what, the AIMS, and you can see how patients have improved or not on various dyskinetic movements using the scale that you've used.

Don't worry too much about inter‑rater reliability. It's you who's doing the assessment. You probably are doing it in a very similar way from exam to exam, and you can rely on your own ratings. If you don't see improvement, then we need to ask, are there problems with adherence? Are there unidentified drug‑drug interactions? That will help inform decisions on, do we do something about the dose or change the intervention?

Measuring the AIMS dyskinesia items alone is inadequate. We'll still need in follow‑up to ask about functional impairments. So if a patient had difficulty with eating, drinking, speaking, breathing, dressing oneself, writing, working, leisure activities, being with others, we want to address those and we want to follow up in order to ensure success. Fortunately, the AIMS actually contains items that remind us to ask about this.

Let's summarize our journey, 5 steps to success in the COVID era. First, we must assume that TD still exists in our practice, even if it's a telemedicine practice at present. TD is still common and will continue to be because of the increasing use of antipsychotic medicines.

We'll still want to prevent if possible using harm reduction. We'll minimize drug‑induced parkinsonian symptoms by selecting agents with lower risk for this problem. We'll avoid first‑generation antipsychotics. We’ll want to minimize the use of anticholinergic medications. We'll taper them if we can.

We're going to continue screening with scheduled AIMS examinations, especially in the older population. Young or old with telehealth, it's still going to be important to have someone there with the patient, allowing for the virtual AIMS to effectively occur.

You may miss TD unless you use a larger video screen than your phone and you also want to see the patient's arms or legs and look at the feet, too. Actually, looking at the feet remotely is easy and doesn't expose you to the problems of looking at the feet in person. That's an advantage.

You want to treat it as quickly as possible after it appears. There's now reliable, effective, and well‑tolerated treatments for persistent tardive dyskinesia. I hope this has been helpful to you and I wish you good luck and ongoing success in treating your patients with tardive dyskinesia.

MORE: Guidance From Dr. Rakesh Jain on Treating TD During the Pandemic  

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