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Dr. Richard Jackson on Assessing and Monitoring TD Through Telepsychiatry

June 15, 2020

In this video, psychiatrist Richard Jackson, MD, speaks about assessing and monitoring tardive dyskinesia during telepsychiatry visits. Dr. Jackson is a founder and owner of The Neurobehavioral Medicine Group, an outpatient psychiatric treatment center in Bloomfield Hills, Michigan, and a researcher, author, and speaker. 

Read the transcript:

Hello and welcome everyone. I'm Richard Jackson, MD, a psychiatrist practicing both in Michigan and Florida, and serve on a variety of faculties, including associate clinical professor at Wayne State University School of Medicine in Detroit, Michigan, as well as the Oakland University Beaumont Hospital Medical School in Royal Oak, Michigan, and assistant clinical adjunct professor at the University of Michigan School of Medicine, Department of Psychiatry in Ann Arbor, Michigan.

Today, we'll speak to some of the required monitoring and assessment of tardive dyskinesia, which can be difficult during the COVID‑19 telepsychiatry visits that you may be providing to your patients.

One of the first things that is critically important with regards to looking at tardive dyskinesia is that you have appropriate use of the antipsychotic medication that may be putting patients at risk for tardive dyskinesia.

With regards to diagnosis and treatment of the core illness, that the use of the atypical or typical antipsychotic medication would be appropriate with regards to risk and benefits for your individual patient.

Monitoring during COVID‑19 for tardive dyskinesia may be a bit more difficult, especially if you're not used to seeing patients on a video format. Much of the same criteria that we would use on inpatient or outpatient settings when we see patients directly would hold for seeing patients via video. The nice thing is for evaluation of tardive dyskinesia, this is clearly able to be done in just about a complete a fashion as you may do in person without being able to, unfortunately, touch your patient.

First would be identifying with patients the risk of tardive dyskinesia for patients, and that you're going to be monitoring them periodically for abnormal movements. This will stand for your informed consent, and each time you look for movements in patients for abnormal movements, you would again discuss the reason why you're doing this. This helps to assure your patients that you are aware of the potential risks, and that you're monitoring them closely for appropriate treatment and intervention if required.

It's important to do a baseline AIMS exam, because we want to identify any abnormal movements that may be present, either prior to your treatment with the antipsychotic medication, or if they're already on medication prior to you beginning, the continuing of care with whatever medication potentially puts your patient at risk.

Just like we would do baseline labs for liver function test if patients were starting on divalproex, or asking them questions also about abnormal movements, just as you may before prescribing something like lamotrigine that may induce a rash. You want to know if there was any areas of rash or other concerning areas that were present even before starting the medication.

It's important to look for abnormal movements using the AIMS. It's been a standardized way and a baseline AIMS identifying the 7 abnormal areas of movement, but it's also critical to look at the impact of those movements. Certainly, those areas are well able to be completed by your telepsychiatry visit.

When discussing with patients the potential risks, things that they need to look for and can identify for you is any difficulties that they may see related to abnormal movements. When looking for abnormal movements in patients after completing an AIMS, it's really imperative that we continue to look for abnormal movements each time we see patients.

We may ask them to sit up and do some activation maneuvers. We often do activation maneuvers for tardive dyskinesia through rapid alternating movements. Touching each finger to their thumbs, some type of movement of their hands often called the doorknob, moving back and forth, as well as screwing in a light bulb.

These are classic ways to activate movements, and making sure that you look for movements that you may not see otherwise, such as having patients open their mouth and looking at their tongue. Of course, you do that during your AIMS exam.

Each visit doing some quick activation maneuvers will help you to continue to find any early abnormal movements or the worsening of movements that may already be there, as well as providing continued informed consent for your patient as you tell them you're looking for abnormal movements that may be related to the medications, and again, assures them that you are on top of it. You're going to monitor them and offer interventions that may be appropriate.

When completing the AIMS and activation, we are obviously able to see areas to look at for continued monitoring, which is critically important, not only to our patients but also for ourselves from a medical‑legal standpoint.

Back to 1982, in a landmark case, Clites v. Iowa, a court established that the requirements for clinicians are to appropriately use antipsychotic medications what a reasonable physician would do, as well as appropriate monitoring, which does include monitoring and potential treatment, which we now have available for tardive dyskinesia.

When we look at movements that may be apparent to us, and there may be some hidden movements that we can talk to patients about, but in addition to that is really discussing with patients the impact of their movements.

We do that from looking at impact with regards to impairments in functioning. Do they have difficulties putting away glasses? Do they have functioning difficulties with regards to their daily activities, maybe writing, maybe walking, maybe even talking, breathing?

Asking about how it impairs their day‑to‑day functioning. Beyond the physical impairments that you may see from abnormal movements, what is the potential emotional difficulties? Do they feel depressed related to their movements? Do they feel that they're isolated? Do they want to avoid others? Do they feel embarrassed? These are typical type feelings that patients with tardive dyskinesia may experience but not be able to verbalize.

Patients with schizophrenia often minimize or deny having movements or how it may interfere with their functioning. Do we look at patients and see some spills on their clothes? Or not tying their shoes? Even patients that may be shaving cutting their face and asking is that actually related to movements, or may it be part of the core psychiatric illness?

Then other symptoms such as physical pain. Are they biting the insides of their mouth, or clenching their teeth to suppress movements, or that they may not even be aware of? We know that we look for movements through face, upper extremities, lower extremities, and truncal areas, shoulders, hips, and neck. That can cause a variety of physical impairment such as pain. Chronic dystonias, where you have continued contractions of muscles, may cause cervical pain as well as impairments and difficulties in functioning.

The only thing that may be difficult on a telepsychiatry or visit where you are not seeing the patient directly, is differentiating sometimes between tardive dyskinesia and drug‑induced parkinsonism. We know that we can see tremor fairly well, and maybe even slowness, so we want to ask patients to do things that may bring out tremor or slowness. Some of those same rapid alternating movements on one side may bring out tremor in the other.

Stiffness may be a bit difficult. We might have to ask patients about stiffness or ask them to move their extremities and see if you can pick up stiffness, which is generally felt versus visualized.

We might speak to patients that, "Although we're seeing you by telepsychiatry or some type of video visit, we can capture many of the movements, but we may be limited in some areas." Explaining that to patients and helping them to understand that also speaks to the standard of care as to how there may be some limitations with regards to visits during a telepsychiatry visit.

In general, what we want to do is provide information with regards to the medication that we may be using. We document and talk to patients of the appropriate use, what we're treating, why we're treating with this type of disorder, what the potential risks are, including tardive dyskinesia. That's all part of standard informed consent.

Alternatives that may be available, as well as risk of not treating, monitoring for part of the abnormal movements regularly, baseline AIMS exam, periodic AIMS, but always looking for abnormal movements when we see patients.

Following abnormal movements and offering, when appropriate, the available treatments for abnormal movements which are now FDA‑approved and available to us because we are looking to not only decrease movements, but play a role with regards to patients' day‑to‑day functioning and speak to patients about their impairments in their functioning.

Hopefully, these tips will be helpful for you. Good luck during these difficult times. Thank you.


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