Patient-Centered Tools to Implement When Screening for Tardive Dyskinesia

While on-site at the recent Inaugural 2023 Psych Congress NP Institute In-Person conference in Boston, Massachusetts, Psych Congress Network's Tardive Dyskinesia Section Editor, Amber Hoberg, MSN, APRN, PMHNP-BC, discussed why tardive dyskinesia (TD) continues to be underdiagnosed and what screening tools should be used to identify and diagnose the disorder with patient needs in mind.

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Read the transcript:

Hi, I'm Amber Hoberg. I'm a psychiatric mental health nurse practitioner from San Antonio, Texas, and I at work at Morningstar Family Medicine.

Question: In your experience, is tardive dyskinesia (TD) underdiagnosed, and if so, why?

TD is very underdiagnosed currently. I think a lot of it is because this disease state has been around for 60 years, so since the first antipsychotic came out, Tardive dyskinesia has been around, and I think what the problem is that we, for so long, haven't had any really good treatment to treat tardive dyskinesia. It wasn't until 2017 when the VMAT2 inhibitors came out that we actually had treatment to be able to treat it in its entirety. I do believe that it's underdiagnosed. It's still getting the word out there, talking to people about tardive dyskinesia, getting the education, and really making sure that we're talking to our patients about it, and then treating it as we see this occur in our patients.

Question: What TD screening tools should be used, and how does the patient's personal experience play into those screeners?

The screening tools that should be used to treat tardive dyskinesia is, of course, the abnormal involuntary movement scale (AIMS). This is the standard of care in regards to assessing for the severity of TD and also quantifying the level at which the patient's TD is. But, I don't just stop at doing the AIMS scale. I also talk to my patients because another part that's super important is talking about impact.

There is a new impact TD scale that is out that actually lets you assess the 4 domains that TD causes impact in. The way you score it is: 0 there is no impact, 1 is mild, 2 is moderate, and 3 is severe. And whatever the highest score you give in any one of those four domains is actually the answer for the scale. It really helps you really quantify that impact piece, which, for me, is more important sometimes than even the number on the scale in regards to the AIMS total score.

Also, semi-structured scales can be used. This is where you can look at the patient's profile, that they have an antipsychotic on their regimen. Then what you definitely want to do is talk to your patient about that they've been on 'XYZ antipsychotic for this amount of time.'

One of the things that can come out of this is they can develop a movement disorder. I ask my patients, "Has anybody ever talked to them about this?" Sometimes you'll get the answer, "Yes" and sometimes you'll get the answer, "No." But, then I go a step further to explain what these movement disorders may look like. And then I ask them a simple question, "Do you have any unwanted movements in your body at this time?" If my patient says, "Yes," then we talk about where they're having this unwanted movement.

I do a focused exam in that area. If it's problematic, then I go through and do a complete AIMS. If they tell me, "No," I'll go a little bit step further, explain to them what some of these movements may look like. And then talk to them about if they notice these things in between visits that they can call me so that we can get an earlier appointment. I also talk to them about telling the people who they live with, because sometimes they're the first ones to identify these movements, sometimes even before the patient. And then I let them know that every visit that they come to see me, we're going to have this discussion.

These are the things that have been very highly successful in my practice in helping implement tardive dyskinesia care.

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.