Announcer:
You’re listening to NeuroFrontiers on ReachMD, and this episode is sponsored by Teva Pharmaceuticals. Here’s your host, Ashley Baker.
Ms. Baker:
This is NeuroFrontiers on ReachMD, and I am psychiatric nurse practitioner Ashley Baker. Here with me today to share best practices for using a clinical tool to assess the impact of tardive dyskinesia is Dr. Richard Jackson, who is the Founder and Owner of Neurobehavioral Medicine Group, which is an outpatient psychiatric treatment center in Bloomfield Hills, Michigan, in addition to being an Associate Clinical Professor at the Oakland Beaumont University School of Medicine and an Assistant Clinical Professor at the University of Michigan School of Medicine. Dr. Jackson, welcome to the program.
Dr. Jackson:
Well, thank you so much. So wonderful to be here with you.
Ms. Baker:
To start us off, Dr. Jackson, can you tell us how tardive dyskinesia can impact patients, physically, psychologically, socially, and even professionally?
Dr. Jackson:
Absolutely. So we know that tardive dyskinesia are involuntary movements following the treatment of antipsychotic medications. We now use antipsychotic medications for so many different types of psychiatric disorders, so we see more and more patients being exposed and unfortunately experiencing abnormal movements, but not necessarily being diagnosed or understanding what you just asked: what is the impact on day-to-day lives for patients? So tardive dyskinesia is typically focused on the face, often lips, tongue, jaw, but also upper extremities and lower extremities in what we call the trunk, things like shoulders, hips, and neck. So you can actually see a variety of movements. It impacts almost every aspect of patients’ lives, which is typically every day, for much of the day, and almost always early on is not recognized, and they don't attribute those abnormal movements to the medications they are taking, and there is often a significant delay. And while that delay is going on, patients are often suffering with significant impacts to their day-to-day life.
Ms. Baker:
With that in mind and the seriousness of what TD can lead to in each of those realms, let's zero in on how we assess those impacts using the IMPACT-TD scale. How is it designed, and how does it work?
Dr. Jackson:
So the IMPACT-TD scale has four domains to actually look at as mild, moderate, and severe. And how do we divide those up? Psychiatric is anytime that a patient has a psychiatric disorder, let's say schizophrenia, bipolar disorder, or depression, which are the typical diagnoses that we treat with typical or atypical antipsychotic medications. If they have TD, it makes that disorder much more difficult to treat. You can imagine, if I have abnormal movements and people actually are staring at me and I have schizophrenia and am often paranoid that people are watching me, it makes that psychosis even worse or the anxiety worse or depression. The idea is that any disorder with TD is more difficult to treat than without TD. So what's the impact on that disorder as well as the psychological symptoms, the contribution of anxiety, depression, and other types of mood symptoms along with this psychological suffering?
And then we move away from psychiatric/psychological to look at social aspects overall. How comfortable do I feel being with others? How comfortable do I feel at work? Meeting others? Dating others? Within my own family? Do I avoid contact even when I'm comfortable with people because I'm concerned what they're thinking or what they're seeing? And sometimes, I don't even know why I have those movements because no one went over the movements with me.
So we move from social to medical. What are some of the medical complications? People often present with broken teeth or inside cuts in their mouth because they're biting and trying to suppress the movements. There's a variety of medical aspects. Activities of daily living. “My hand is shaking or moving, and I can't use my fork. I can't drink out of a glass. I start limiting the way I do things.” The muscle pain that goes along with it. And the other impact is if I start associating this with my medicine. If you look at some clinical reviews and surveys with patients, they stop taking their medications. They stop seeing their clinicians. They actually encourage others not to take their medicines because they may have the same type of adverse events. And then, what's the role as far as my actual occupational or educational activities? How much does it interfere with my day-to-day work? Because you can imagine, depending where the movements are, can impact me much more or much less. But the IMPACT-TD scale gets you to individualize it to that patient, rather than generalizing impact based on specific movement severity.
Ms. Baker:
So as a quick follow-up to that, what role, in your opinion, can the IMPACT-TD scale have in fostering better communication and treatment outcomes?
Dr. Jackson:
I think it's a great way to move from what we do with an AIMS to look at abnormal movements, but how are those movements affecting your day-to-day life? And what would you like to see different? So it's a nice way to talk to the patient. What would you like to see? How can we help you? And then we can look at the treatments. Because for almost my whole career in treating patients with typical or atypical antipsychotics, we had no treatment for tardive dyskinesia. So if I can put it off a little bit, it's just mild, it's maybe not impacting them. It was almost like a don’t ask, don't tell. But even worse, don't look. Don't look because maybe I'll get sued if I identify tardive dyskinesia. As a forensic psychiatrist—I have board certification in forensic psychiatry—it’s often the medical-legal aspects. It's much further below the standard of care to pretend it's not there, not to assess in that treatment, and not treat rather than to identify it early, be on top of it with patients, and become a team. You'll look for it. I'll look for it. You can ask others if you feel comfortable if they see abnormal movements, but we can look at this now as something we can treat, treat early, and hopefully decrease the course because typically, tardive dyskinesia is one that becomes more and more severe as time goes on. We actually change that course so that we don't see more severe impact in day-to-day functioning by good treatment, assessing, looking for every visit, and how is it impacting day-to day lives.
Ms. Baker:
For those just tuning in, you're listening to NeuroFrontiers on ReachMD. I'm psychiatric nurse practitioner Ashley Baker, and I'm speaking with Dr. Richard Jackson about using the IMPACT-TD assessment tool to evaluate the effects of tardive dyskinesia in clinical practice.
And so once we successfully integrate the assessment into our clinical practice and learn how tardive dyskinesia is impacting a patient, what specific counseling techniques can we use to promote shared decision-making with them and address their unique needs?
Dr. Jackson:
I think the first thing is educating them on how those movements potentially are related to their medications, that we can treat the movements, and what do they see as their primary, secondary, tertiary concerns? And what would they like to see happen? We often talk about in therapy, what's your life worth living goal? What would you like to see happen? How are those movements affecting you, and how do we address them? We don't want to just say, “Oh, well, stop doing this and do this because you have the movement,” right. We don't tell someone or a student that can't see, “Well, just sit close to the board so you can see the writing on the board.” We give them glasses. We want to give them the tools that can help them meet their full expectations that they are hoping for.
So if they're on board with us, it's actually obviously a lot easier versus, “Oh, you need to take this. This is something you have to do. Why wouldn't you do this?” It's really joining with the patient. What is this journey we're on and where are we trying to get to? The sicker the patient is, the less judgment they may have, the less insight. So we may have to be a bit more treatment oriented in looking at how we guide them. But really that's individualized for each patient. Because many of the patients, if they're educated, they identify the movements, and they attribute it to their medicines and how it affects their day-to-day lives. We have some patients that have some abnormal movements, and the first thing I see them do, and I just had a woman last week, she told me quickly, “Oh, it's just when I get anxious. It's just when I have dry mouth.” And then the spouse said, “No, actually, that's much of the time. I don't say anything, but it's much of the time, especially when you're driving, your mouth starts clicking,” and they were like, “Oh my God, you've noticed it?” And they have never even talked about it before. So it's really telling how much they are living with trying to hide things or they're not aware of things.
Ms. Baker:
Before we close, Dr. Jackson, are there any final thoughts you'd like to share about the IMPACT-TD Scale or the far-reaching effects of tardive dyskinesia?
Dr. Jackson:
Absolutely. I think we should think about that, for the most part, TD is often missed, even when there's abnormal movements, so we have to address it early. Early meaning initiation of treatment with informed consent, assessment, and do at least some abnormal movement scale or monitoring every time you see the patient. If you can just activate them—we activate by some type of rapid alternating movement, some type of simple cognitive task, counting backwards, or saying the months backwards. Within minutes, you have looked for TD. And if you identify that, speaking to the patient about the day-to-day impact on their lives.
And even if you don't identify it then, ask them if they notice any movements because they may be noticing movements at other times than they're with you, but they don't associate those movements to their medicine, and maybe they're not related. Maybe there's something different. There's a variety of other potential reasons why patients may have movements, but if they don't tell you about it, you're not able to assess it.
And then we look for individualizing that assessment with the IMPACT-TD scale. Simple four domains to look at being mild, moderate, or severe. And are we moving in the right direction? Are we improving their day-to-day functioning? And if we take 3, 4, or 5 minutes of each visit to address that in patients on typical and atypical antipsychotics, we're much less likely to miss that, which is best for our patients and also best for us from a medical-legal standpoint.
Ms. Baker:
With those final thoughts in mind, I'd like to thank our guest, Dr. Richard Jackson, for joining me to share his expert perspective on integrating the IMPACT-TD assessment scale into clinical practice. Dr. Jackson, it was great speaking with you today.
Dr. Jackson:
Thank you so much. Wonderful time.
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You've been listening to NeuroFrontiers, and this episode was sponsored by Teva Pharmaceuticals. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
