Activation Maneuvers' Can Help Identify Mild to Moderate TD

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.