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Psych Congress Network: What clinical pearls can you offer to our audience to help optimize tardive dyskinesia treatment in their practices?

Amber Hoberg, MSN, APRN, PMHNP-BC: Some clinical pearls I'd like to leave you with on how to really address tardive dyskinesia are, first: talk to your patients. Really make them talk about how this is impacting them. If I can't hit anything enough, it's really to talk about impact. Like I said, I do the AIMS scale for formality. I get the number on the scale—yes,this assessment is important. It meets the standard of care. But, that's not what drives me to treat patients. What drives me to treat patients is what they're saying behind that. Really try to uncover what this disease robbing from your patients. What is this taking away from them? How is this impacting their everyday life? What is this keeping them from doing? That, to me, is way more important and necessary to plan treatment, even more so sometimes than the number on the scale. That's clinical pearl number 1.

Clinical pearl number 2 is look at your patient's regimens. Before they come into your office, look at what they're on. If they're on a dopamine receptor blocking agent (i.e. antipsychotic), then make sure you have that  2-minute discussion with your patient. Let them know what antipsychotic they're on. Talk to them about the length of time they've been on it. Explain that movement disorders are something that can happen while on these medications. Ask them, "Do they have any unwanted movements in their body and what does that look like for them?" If they say “no,” educate your patient. Provide that education on what these movements may look like, and use patient words. For example, when I'm looking at muscles of facial expression, I'm looking at the brow. Does your brow ever furrow like you're mad? Or do people ever say you look mad all the time? Or does your nose squinch up and down like a bunny? Or do your eyes blink very rapidly as if you have dry eyes or that you can't control what's going on with your eyes? What about your mouth? Does your mouth ever move as if you're rubbing them, like you have chapped lips? Or that you're puckering and pursing your lips constantly? Really try to use the patient terminology so that they understand the movements you're looking for so that they can say “yes or no” in an appropriate way.

Finally, empower your patient. Lett them know, "okay, we don't see any movement today, but now you know what to look for. Every day I want you to look in the mirror. Let me know if you notice these movements. If you see these between visits, call me so I can get you in sooner so we can address this." Also, tell your family, friends, loved ones, anybody you live with. What kind of movements could occur from you being on this medication and to help you identify it. And lastly, when you come back to me every visit, we are going to have this discussion every time you come in, so I make sure I'm being proactive about identifying it. That's clinical pearl number 2.

Amber Hoberg, MSN, APRN, PMHNP-BC, is a board-certified psychiatric mental health nurse practitioner from the University of Texas Health Science Center, San Antonio. She has been working for the past 12 years with the adult and geriatric populations treating all types of psychiatric conditions. Her background, as a psychiatric advanced practice nurse, includes outpatient, inpatient, group home, and nursing home/ALF settings. She currently works for Med Management Associates and Morning Star Family Medicine PLLC treating the chronically mentally ill in both inpatient and outpatient settings.

Q: Should TD symptoms develop, how can providers reassess their patient's treatment course?

Amber Hoberg: How providers can reassess their treatment course, should tardive dyskinesia develop, if you catch it early, then the way that you definitely would want to address this is you would want to either decrease the dosage, change them to a different agent that's a lower D2 binding agent. Then you could actually prevent tardive dyskinesia from occurring. If the patient has had tardive dyskinesia for a period of time and this disease is permanent and irreversible, so really it doesn't matter if you decrease the drug or change them to a different agent or even take them off of an antipsychotic altogether; this disease is going to continue to be a permanent issue. That is where VMAT2 inhibitors are actually indicated to treat tardive dyskinesia. 

Q: What practices can clinicians incorporate into their TD treatment plans immediately to identify and improve TD management and patient outcomes? 

Hoberg: Some of the things that I do in my clinical practice to help with identifying and also with clinical outcomes is, we're so good as providers at being able to recognize the severe cases of tardive dyskinesia. But, when it comes to mild or moderate cases, sometimes we're not so good at identifying these types of movements. One of the things that I have implemented into my practice is doing something called activation maneuvers.

Always make sure that when you're looking at a patient's tardive dyskinesia movements, that you use these activation maneuvers. They're simple. You can do something as like a physical activation where you ask the patient, on one side, to tap their fingers in a fast pace for 20 or 30 seconds, and then ask them to stop. Then move to the other side. If they can't do the tapping of their fingers, you can ask them to do something called turning the light bulb, where they can turn their arm back and forth. Or something I call spirit fingers, where you ask them to wiggle their fingers back and forth. Or even opening and closing their hand. 

These are all really good physical activation maneuvers that can bring out tardive dyskinesia. The reason why this is important is tardive dyskinesia waxes and wanes throughout the day. When a patient is calm and relaxed, if they have mild or moderate movement, they are probably not going to see it. But, once you stress the patient or put them into an anxiety provoking type of situation, you're going to notice that the movements become more problematic. And that's what these physical tasks do. If you don't see it with physical tasks, you can do mental tasks. Asking the patient to count backwards from a hundred, say the months of the year backwards, tell me 5 things that begin with the letter "C"

I don't really care what it is you're asking the patient, it's getting their mind off of controlling these movements and on to answering your question, so then you can see when the movements are the worst for the patient. 

When I'm doing the AIMS scale, I always score it under activation because that's when it's going to be the worst for the patient. This is one thing that I do definitely implement into my practice and has made a huge difference in really recognizing those mild and moderate cases because it is important regardless of the level, even if it's mild, follow it up with questions about impact. I always ask impact questions. Especially on the AIMS. Anything more than zero. Or if I'm doing a semi-structured exam, anything my patient tells me that they're having movement. I do a focus exam, and then I'm going to follow it up with: "How is this affecting them physically, socially, psychologically?" and "How is this affecting you in your job or being able to do your recreational activities?"

Because that is just as important because the APA guidelines do state that if it's moderate, severe disabling, we should treat it, but even if it's mild, if it's impacting the patient, the patient prefers to be treated, then we absolutely should be treating with VMAT2 inhibitors, as well. And in my own clinical practice, I don't really care what the number is on the scale. If it's impacting the patient, it's causing them distress, I absolutely will implement a VMAT2 inhibitor regardless of score.

Amber Hoberg, MSN, APRN, PMHNP-BC is a board-certified psychiatric mental health nurse practitioner from the University of Texas Health Science Center San Antonio. She has been working for the past 12 years with the adult and geriatric populations treating all types of psychiatric conditions. Her background, as a Psychiatric Advanced Practice Nurse, includes outpatient, inpatient, group home, and nursing home/ALF settings. She currently works for Med Management Associates and Morning Star Family Medicine PLLC treating the chronically mentally ill in both inpatient and outpatient settings.

Read the transcript:

Hi, I'm Amber Hoberg. I'm a psychiatric mental health nurse practitioner from San Antonio, Texas, and I at work at Morningstar Family Medicine.

Question: In your experience, is tardive dyskinesia (TD) underdiagnosed, and if so, why?

TD is very underdiagnosed currently. I think a lot of it is because this disease state has been around for 60 years, so since the first antipsychotic came out, Tardive dyskinesia has been around, and I think what the problem is that we, for so long, haven't had any really good treatment to treat tardive dyskinesia. It wasn't until 2017 when the VMAT2 inhibitors came out that we actually had treatment to be able to treat it in its entirety. I do believe that it's underdiagnosed. It's still getting the word out there, talking to people about tardive dyskinesia, getting the education, and really making sure that we're talking to our patients about it, and then treating it as we see this occur in our patients.

Question: What TD screening tools should be used, and how does the patient's personal experience play into those screeners?

The screening tools that should be used to treat tardive dyskinesia is, of course, the abnormal involuntary movement scale (AIMS). This is the standard of care in regards to assessing for the severity of TD and also quantifying the level at which the patient's TD is. But, I don't just stop at doing the AIMS scale. I also talk to my patients because another part that's super important is talking about impact.

There is a new impact TD scale that is out that actually lets you assess the 4 domains that TD causes impact in. The way you score it is: 0 there is no impact, 1 is mild, 2 is moderate, and 3 is severe. And whatever the highest score you give in any one of those four domains is actually the answer for the scale. It really helps you really quantify that impact piece, which, for me, is more important sometimes than even the number on the scale in regards to the AIMS total score.

Also, semi-structured scales can be used. This is where you can look at the patient's profile, that they have an antipsychotic on their regimen. Then what you definitely want to do is talk to your patient about that they've been on 'XYZ antipsychotic for this amount of time.'

One of the things that can come out of this is they can develop a movement disorder. I ask my patients, "Has anybody ever talked to them about this?" Sometimes you'll get the answer, "Yes" and sometimes you'll get the answer, "No." But, then I go a step further to explain what these movement disorders may look like. And then I ask them a simple question, "Do you have any unwanted movements in your body at this time?" If my patient says, "Yes," then we talk about where they're having this unwanted movement.

I do a focused exam in that area. If it's problematic, then I go through and do a complete AIMS. If they tell me, "No," I'll go a little bit step further, explain to them what some of these movements may look like. And then talk to them about if they notice these things in between visits that they can call me so that we can get an earlier appointment. I also talk to them about telling the people who they live with, because sometimes they're the first ones to identify these movements, sometimes even before the patient. And then I let them know that every visit that they come to see me, we're going to have this discussion.

These are the things that have been very highly successful in my practice in helping implement tardive dyskinesia care.

Amber Hoberg, MSN, APRN, PMHNP-BC is a board-certified psychiatric mental health nurse practitioner from the University of Texas Health Science Center San Antonio. She has been working for the past 12 years with the adult and geriatric populations treating all types of psychiatric conditions. Her background, as a Psychiatric Advanced Practice Nurse, includes outpatient, inpatient, group home, and nursing home/ALF settings. She currently works for Med Management Associates and Morning Star Family Medicine PLLC treating the chronically mentally ill in both inpatient and outpatient settings.