TD: Commonly impairing, often untreated^1,2

Voiceover:

Welcome to TD Talks and today’s installment: The need to assess and manage tardive dyskinesia, or TD.

Amber Hoberg:

Hi, I’m Amber Hoberg. I’ve been a psychiatric nurse practitioner treating people with TD for more than 10 years.

As a known complication of antipsychotic drugs, TD affects about 500,000 patients in the United States.

Yet, many of these patients may not tell us about their symptoms or may minimize the impact that TD is having on their lives. It’s therefore critical that we do not make assumptions and do everything we can to uncover the true impact of TD. That way, we can ensure that patients receive the quality care they need.

So, if patients aren’t complaining about their TD symptoms, why are they still so important to assess and manage?

TD can have a profound impact on everyday life for these patients, including the way it affects their primary condition and treatment with antipsychotic drugs, or APDs. This often manifests in the cycle you see here.

Patients with TD can experience a significantly more severe and refractory course of their primary condition. This can include a poor response to care and an increased risk of relapse or readmission.

In addition, patients have said that involuntary movements affect their physical health and can make everyday activities a challenge.

Despite this, between 20 and 30 percent of patients may not be aware that they are experiencing TD symptoms. It is for these very important reasons that we need to be sure we’re assessing our patients for TD—even if they’re not bringing up the subject themselves.

Whether minor or very apparent, the symptoms of TD can affect every patient, and those who care for them, differently. That is why it is so important not only to talk to the patient, but to also involve the patient’s family or caregivers in your assessment.

For example, I often engage a patient’s spouse or partner to see the impact the symptoms might be having on their everyday lives and relationships at home.

We can start by asking about symptoms across these 3 categories: psychosocial, functional, and physical. These questions can help identify the presence of TD and evaluate the severity of each patient’s symptoms.

To see TD symptoms more clearly, you can ask your patient to perform activation maneuvers, as shown onscreen. Activation maneuvers can help reveal any underlying TD symptoms or highlight symptoms that may initially be less apparent. If any involuntary movements are noted, a thorough workup should be done.

Although asking patients about the impact of symptoms on their life is the first step in our evaluation, it is also important to consider the objective severity of TD symptoms and how they may affect functioning.

Therefore, it is best practice to also use standardized measures such as the AIMS scale. By using the AIMS scale, we have a consistent way to evaluate patients’ TD symptoms and response to management over time.

Remember, it is not just the more severe scores that require further evaluation—any score above zero should trigger a deeper qualitative assessment on how those functions may be affecting their daily life.

AIMS can be performed in both in-person or telehealth settings. However, virtual assessments should be intermixed with live exams when possible.

The APA recommends clinical assessment of abnormal involuntary movements prior to initiating APD therapy and at follow-up visits. The exact frequency of AIMS follow-up is driven by APD history and level of risk.

If assessments are scheduled virtually, there are a few considerations to keep in mind.

Be sure to work out the appropriate camera angle with your patient prior to initiating the exam. I recommend activating your patients by mimicking their maneuvers on your end of the screen—so make sure they can see you, too.

If you cannot see your patient clearly onscreen, you may need to rely on patient commentary or a caregiver’s observation to evaluate certain body locations. If the platform doesn’t work at all, request to switch to a different program so you’re able to view your patient more clearly.

As rigidity cannot be formally assessed remotely, observe the arms while the patient is walking. Absence of arm swing can be a clinical sign of rigidity.

Lastly, be aware of the limitations that may be encountered during the assessment, including the inability to observe lower limbs, midline structures, and upper limbs. Inability to assess rigidity associated with parkinsonism; and technological limitations that may affect the test.

In summary, it’s critical to identify and address TD in order to minimize the effects that it can have on patients’ well-being.

Do so by leveraging established assessment criteria, and ask further questions to reveal the true impact that their symptoms may be having on their life.

Remember, by assessing the impact of TD and managing symptoms, you can make a tremendous difference in a patient’s life.

Thanks for watching this installment of TD Talks.