Navigating and Optimizing Movement Disorder Diagnosis, Treatment

In this excerpt from a recent Psych Congress Regionals live Q&A session, Psych Congress Network’s Tardive Dyskinesia Section Editor Amber Hoberg, MSN, APRN, PMHNP-BC, answers audience questions presented by moderator Saundra Jain, MA, PSYD, LPC, Psych Congress steering committee member, and explores the complexities of movement disorders including tardive dyskinesia (TD). Hoberg clarifies the distinctions between drug-induced parkinsonism (DIP) and extrapyramidal symptoms (EPS), explores TD’s persistence even after discontinuing antipsychotic medications, and the importance of trying different VMAT-2 inhibitors for optimal results. 

In responding to these questions from clinicians, Nurse Hoberg sheds light on rare presentations of movement disorders as well as in-person and virtual treatment challenges.

Read the Transcript: 

Saundra Jain, MA, PSYD, LPC: Welcome back, everyone. Hey, Amber. It's super nice to see you. We're super glad to have you with us. We've got some really, really good questions. So, are you ready to get started?

Amber Hoberg, MSN, APRN, PMHNP-BC: I'm ready.

Dr Jain: All right, here we go. Our most popular question this afternoon, a group of clinicians is asking, can you please elaborate on DIP versus EPS symptom presentation?

Nurse Hoberg: This is one of my favorite questions to be asked. The first thing I have to do is talk about EPS or extrapyramidal symptoms. This is an old definition, it's actually a medical definition that's an umbrella term for actually all movement disorders. Truly drug-induced parkinsonism is lumped under the EPS umbrella. When you use the word extrapyramidal symptoms, you're saying that the patient has drug-induced parkinsonism, tardive dyskinesia, dystonia, akathisia, and other movement disorders. I really am trying to dispel the myth of using that term, “extrapyramidal symptoms,” because what we really want to do is call each movement disorder what it is.

For drug-induced parkinsonism, this is a hypokinetic movement disorder. The only thing that makes it rhythmic is that they have arrhythmic tremors, but otherwise, every part of the movement is hypokinetic. So, very slow-moving in nature. When it comes to the treatment for this particular movement disorder, we can use anticholinergic medications to treat this, versus tardive dyskinesia is very different, where it's a hyperkinetic movement disorder. It's very fast-moving and irregular and jerky looking in nature and it's constant. So, what we use to treat that is VMAT-2 inhibitors. Really for each one of these movement disorders, we have to call it what it is for each patient because each one has a different treatment approach that we must use.

Dr Jain: That's a really important distinction, Amber. I'm so glad you walked us through how they're different and really how we should be using them. All right, another really good question. Does TD persist for years after a person stops their antipsychotic medications?

Nurse Hoberg: Yes, TD is a persistent disorder. It's permanent. Once a patient has tardive dyskinesia, no matter if they remain on the offending agent or you remove the offending agent, which you're going to see is that tardive dyskinesia is going to persist. In my own practice, I've had patients off of antipsychotic medications for 25 years and they still had persistent tardive dyskinesia for that full time until we came in and got them treated. But of course, yes, it can persist because it's a permanent involuntary movement and no matter, like I said, if they're on that offending agent, you stop that offending agent, you switch it to something different, that TD is going to continue to be a persistent problem.

Dr Jain: Another medication question. Does a higher dose of an antipsychotic increase the risk of developing TD versus using the same medication but at a lower dose? And then they give an example like quetiapine 25 milligrams versus 400 milligrams.

Nurse Hoberg: This is kind of a loaded question, and the reason why is because, yes, when you actually do look at one of the risk factors of tardive dyskinesia, when you look at the medication itself, the length of time a patient has been on it as well as the potency and the dose, does increase the risk for tardive dyskinesia. So, yes, I would say in general, dosing can increase the risk unless you're taking care of a patient of an older age, like a patient over the age of 60. For them, because that age is one of the bigger risk factors regardless of dose, sometimes you're going to see that TD can present itself. 

It's kind of a yes/no question depending on the patient. Younger patients, again, length of time, potency, dosing is important. But an older patient, because age a lot of times supersede potency and dosing regardless of dose, sometimes you can see that a little more prevalent in an older patient regardless of the dosing of the medicine.
Dr Jain: Amber, you said that age marker is 60 and older?
Nurse Hoberg: Yes, ma'am. Sixty and older is kind of that age marker. They carry a 5 times greater risk factor for developing tardive dyskinesia.

Dr Jain: Got it. All right. If a patient fails one of the VMAT-2 inhibitors, what do you think, Amber, is it worthwhile to try the other one?

Nurse Hoberg: I would say absolutely. Both of them are different enough in that the way kind of their makeup is as far as their isomers and their profiles, that if a patient gets onto the max dose of one of the VMAT-2 inhibitors and those movements are not improving or you feel like the patient is not where they need to be, absolutely I would transition them to the other VMAT-2 inhibitor and then get them titrated up to see if they can have more improvement. In my own practice, I've had this happen where I've started them on one of the VMAT-2 inhibitors, we've gotten it up to adequate dosing and the patient is still not improving.

I have switched them to the other agent and lo and behold, the patient does improve with their TD movement. Each one is different enough that, yes, please don't stop and just leave them on something that's not working, try the other VMAT-2 inhibitor because it's different enough that they may be able to improve and get some results with the other one.

Dr Jain: Great advice. It must be extremely rare for a patient to have movements in the lower body with none in the upper body, and the clinician wants to know why then is it necessary to score movements of the lower body, which may be inconvenient and inaccurate, particularly by teleconferencing in the absence of movements in the upper body?

Nurse Hoberg: Okay, well, that's a great question, and I can definitely tell you that I have actually had patients that have had no movement in the upper body but have had movements in the lower body. I mean if you think about tardive dyskinesia in general, it's going to present different in every single patient. I mean, if I sit there and look at all my patients with tardive dyskinesia, I have some that have it in the face, some that have it in the upper extremities, some that just have it in the lower extremities, some that have it in the trunk. It's just so different for every patient that that is the reason why we have to screen every single part of the aim to make sure we're not missing something.

I do have one patient in particular in my practice that she has no movements in the face. She has no movements in the upper extremities, but when it came to the lower extremities, she has chronic toe movements as if they're playing a piano. Also, she has some leg movements that look very abnormal in regards to the TD, and she has no movements anywhere else. So that is the reason why it is important to address those lower extremity movements because it's not uncommon to see that patients can have lower movements in the absence of upper body movements.

When you're doing telehealth, which I do a lot of my patients by telehealth, and if you can't really assess it by looking at it, one of the things you can do is ask the patient questions. So you can ask them, do you have movements in your toes where they're constantly moving like they're playing a piano? Do your legs go in and out and move constantly where you can't control it, but they're constantly moving in and out or rocking back and forth with your legs or feel like your sides are jumping or your lower part of your leg is rolling in and out? Do you notice any of those things?

Because what I find is that asking those questions, patients sometimes will say yes or no. If they say no, say, "Okay, well, next time I see you on telehealth, we'll maybe have a helper there so that we're able to really assess that area by having somebody hold the bone down or be able to look at it." If they say yes, then you can say, "Well, look, would you mind coming into the office at our next visit so I can get a little bit closer look at what these lower extremity movements are looking like?"

So for me, yes, I would definitely still assess the lower body, but telehealth, I understand there's nuances into really looking at that area, but ask a lot of questions to your patients or get them to have somebody in the home help them so that you can try to assess it the best you can and the next visit, bring them into the office that you can really assess it a little bit better.

Dr Jain: Great suggestions, Amber. Well, we are out of time. Never seems to be enough time for Q&A, but what we covered really so important and relevant for us in clinical practice. Thank you, Amber, for joining us this afternoon. I want to thank our attendees. Excellent questions. We'll see you very soon.

Nurse Hoberg: Thank you.

Saundra Jain, MA, PsyD, LPC, is an adjunct clinical affiliate, school of nursing, at The University of Texas at Austin. In 1992, she launched a private practice of psychotherapy where she currently provides services for a wide range of mental health issues. Dr Jain is a co-founder of the WILD 5 Wellness Program and a member of the Psych Congress Steering Committee. Dr Jain obtained her master's degree from the University of Houston-Clear Lake and a doctoral degree from Southern California University for Professional Studies; she is a Licensed Professional Counselor. She has an MBA from Texas Woman's University. She was selected for a Postgraduate Clinical Fellowship at the University of Texas Medical Branch, Galveston, Texas where she trained in the Division of Child and Adolescent Psychiatry.

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.