Tardive Diskensia 18.10

7/31/2019 Tardive Diskensia 18.10

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TARDIVE DYSKINESIA

CHAIRPERSONDr.DENZIL A PINTO

PRESENTER Dr.D.ARCHANAA

O


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Medication-Induced

Movement Disorders Neuroleptic-Induced Acute Dystonia

Neuroleptic-Induced Parkinsonism

Neuroleptic-Induced Acute Akathisia

Neuroleptic-Induced Tardive Dyskinesia

Neuroleptic Malignant Syndrome

Medication-Induced Postural Tremor


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bucco-linguo-masticatory syndrome,

orofacial dyskinesia, terminal extra pyramidal insufficiency

syndrome

The term tardive dyskinesia (TD) wasintroduced by Faurbye and Rasch toemphasise the delayed or tardive onset

of the syndrome secondary toneuroleptic drug

Tardivelate onset atleast after 4weeks (DSM IV)


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Neuroleptic-induced tardive

sub syndromes Movement disorders

Tardive dyskinesiaOro-buccal-lingual-facial syndrome

Limb-truncal syndrome

Mixed

Tardive akathisia Tardive dystonia

Tardive tics and Tourettes syndrome

Tardive myoclonus

Tardive tremor

Tardive parkinsonism

*Behavioural syndrome

Supersensitivity psychosis

Tardive dysmentia

Tardive dysbehaviour


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Time of Emergence of Neuroleptic-InducedMovement Disorders

Condition Highest Risk of Emergence

Acute dystonia Days 07

Neuroleptic malignant Days 07 (continues at lesser degree syndromeuntil end of first mo)

Akathisia Days 714 (continues at lesser degree until 2.5mo)

Parkinsonism Days 1430 (continues at lesser degree until 2.5

mo)

Tardive dyskinesia Month 3* onward (risk increaseswith increasing time on neuroleptic)


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EPIDEMIOLOGY Preliminary 1-year incidence rates of TD

with atypical antipsychotics- 0.4 to 2.6%(35% with typical agents) (Nasrallah06).

Gender (female) was thought to be a riskfactor

Indian study

Doongaji et al (1982) : 9.6% Prevalence

Dutta et al (1994) : 25.5%

Bhatia et al (2004) : 28.7%


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ETIOLOGY & PATHOPHYSIOLOGY

Striatal dopamine receptor supersensitivity confirmedby PET among TD patients (Margolese et al. 2005 )

GABA; chronic neuroleptic treatment decreasesGABA turnover and increases GABA receptors,which can be explained on the basis of reducedGABA release or a loss of GABA terminals

Gunne and Andren proposed that the degenerationoccurred in the GABAergic neurons projecting fromthe globus pallidum to the thalamus..


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GP, SNr

StriatumMotorCortex

VA-VLcomplex

- GABA

-

GABA

+

glutamate ?

glutamate

+

glutamate

+

Basal Ganglia (Microcircuitary)Connections


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Contd..

Degeneration of striatal cholinergicinterneuron's and the resulting dopamineacetylcholine imbalance play a role in TD

pathogenesis (Jeste et al. 1992 , Margoleseet al. 2005 ).

Lohr and Jeste ( 1988b ) suggested thatlong-term antipsychotic use may producetoxic free radicals that damage striatalneurons


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Contd..

Antipsychotics may increase dopamineturnover, elevating levels of hydrogenperoxide and consequently free radicals, andantipsychotics may also generate free

radicals via inhibition of the mitochondrialrespiratory chain (Margolese et al. 2005)

Neuroleptics accumulation of iron in thebasal ganglia neurotoxic through freeradical mechanisms


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Contd..

EXCITOTOXICITY

Dopamine has an inhibitory effect on therelease of excitatory neurotransmitters, and

dopamine D2 blockade leads to an increaseof glutamate (Glu) and aspartate release inthe striatum

Higher concentrations of N-acetylaspartate,N-aspartylglutamate and aspartate in thecerebrospinal fluid of TD patients


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Contd..

reduced levels of brain-derivedneurotrophic factor (BDNF) andelevated serum homocysteine (Lerneret al. 2005 , Tan et al. 2005 ).

several candidate genes

Related to neurobiology of schizophrenia

itself


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DSM IV TR (333.82) A. Involuntary movements of the tongue, jaw, trunk, or

extremities have developed in association with the use ofneuroleptic medication.

B. The involuntary movements are present over a period of atleast 4 weeks and occur in any of the following patterns:

(1) choreiform movements (i.e., rapid, jerky, nonrepetitive)

(2) athetoid movements (i.e., slow, sinuous, continual)

(3) rhythmic movements (i.e., stereotypies)

C. The signs or symptoms in criteria A and B develop during

exposure to a neuroleptic medication or within 4 weeks ofwithdrawal from an oral (or within 8 weeks of withdrawal fromdepot) neuroleptic medication.

D. There has been exposure to neuroleptic medication for atleast 3 months (1 month if age 60 years or older)


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ICD 10

Diseases of the nervous system G00-G99

Extrapyramidal and movement disorders G20-G26

Dystonia G24-

ICD-10-CM Diagnosis Code G24.01 Drug induced subacute dyskinesia

Applicable To

Drug induced blepharospasm Drug induced orofacial dyskinesia

Neuroleptic induced tardive dyskinesia

Tardive dyskinesia
http://www.icd10data.com/ICD10CM/Codes/G00-G99http://www.icd10data.com/ICD10CM/Codes/G00-G99/G20-G26http://www.icd10data.com/ICD10CM/Codes/G00-G99/G20-G26/G24-http://www.icd10data.com/ICD10CM/Codes/G00-G99/G20-G26/G24-http://www.icd10data.com/ICD10CM/Codes/G00-G99/G20-G26/G24-http://www.icd10data.com/ICD10CM/Codes/G00-G99/G20-G26http://www.icd10data.com/ICD10CM/Codes/G00-G99/G20-G26http://www.icd10data.com/ICD10CM/Codes/G00-G99/G20-G26http://www.icd10data.com/ICD10CM/Codes/G00-G99http://www.icd10data.com/ICD10CM/Codes/G00-G99http://www.icd10data.com/ICD10CM/Codes/G00-G99


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Clinical features

Fine vermicular movements of the tongue while it issitting at the base of the oral cavity is a common andearly feature

Dyskinetic blinking may be another early sign of TD.

Lip smacking, puckering or pouting, chewing, jawclenching or mouth opening, facial grimacing,blowing, blepharospasm and frowning are alsocommon features

Extremities & trunk movement is common in youngpatients, orofacial movements is common in olderindividuals


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Associated features Some neurological, behavioural and cognitive

features have been described as associatedwith TD.

These include saccadic eye movementabnormalities neurological soft signs andventricular enlargement

Tardive dyskinesia, when it occurs in

patients with schizophrenia, is more likely tobe associated with negative symptoms andcognitive impairment


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RISK FACTORS

Old ageDiabetes

Depression

ParkinsonismAkathisia

Negative symptoms,

Cognitive impairments,

Premorbid substance abuse ( Sachdev 2005)

Traumatic head injury

encephalitis


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Assessment

Involuntary movements of the tongue,face, and neck muscles upper andlower extremities

trunk.

Most rare of all are involuntarymovements of the muscle groupsinvolved with breathing and swallowing.

earliest symptoms typically involvebuccolingualmasticatory movements


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SCALES

AIMS (Guy 1976)

SMITH TD SCALE (Smith et al. 1977)

SIMPSON TD RATING SCALE(Simpson et al 1979)

TD VIDEOTAPE RATING

TECHNIQUE (Barnes & Trauer 1982)


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AIMS

1. Muscles of Facial Expression

2. Lips and Perioral Area 3. Jaw 4. Tongue

5. Upper (arms, wrists, hands, fingers)

6. Lower (legs, knees, ankles, toes)

7. Neck, shoulders, hips

8. Severity of Abnormal Movements

9. Incapacitation Due to Abnormal Movements 10. Patient's Awareness of Abnormal Movements

11. Current Problems with Teeth and/or Dentures

12. Does Patient Usually Wear Dentures?


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How to assess T D Ask patient to remove shoes and socks if there is anything in his/her mouth (eg, gum,

candy); if there is, to remove it.

Ask patient about the current condition ofhis/her teeth. Ask patient if he/she wearsdentures. Do teeth or dentures bother thepatient now?

Ask patient whether he/she notices anymovements in mouth, face, hands, or feet. Ifyes, ask to describe and to what extent theycurrently bother patient or interfere with

his/her activities.


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Have patient sit in chair with hands on knees,legs slightly apart and feet flat on floor. (Look atentire body for movements while in this position.)

Ask patient to sit with hands hangingunsupported. If male, between legs, if female andwearing a dress, hanging over knees. (Observehands and other body areas.) Ask patient to

open mouth. (Observe tongue at rest in mouth.)Do this twice

Ask patient to protrude tongue. (Observeabnormalities of tongue movement.) Do this

twice.

Ask patient to tap thumb, with each finger, asrapidly as possible for 10 to 15 seconds;separately with right hand, then with left hand.

(Observe facial and leg movements.)


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Flex and extend patient's left and right

arms (one at a time). (Note any rigidity) Ask patient to stand up. (Observe in

profile. Observe all body areas again,

hips included.) Ask patient to extend both arms

outstretched in front with palms down.(Observe trunk, legs, and mouth.)

Have patient walk a few paces, turnand walk back to chair. (Observe handsand gait.) Do this twice.


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Worseningpsychostimulants,short-term withdrawal of antipsychotic

medication,

anticholinergic medication,

emotional arousal,

stress,

voluntary movements of other parts ofthe body.


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Improved

relaxation,

Voluntary movements of the involvedparts of the body

sleep

increased dose of antipsychotics(temporarily)


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D/D

neuroleptic-inducedparkinsonism,

rabbit syndrome,

Wilsons disease

cerebellar disease

anxiety states,

alcoholism,

hyperthyroidism

Acute dystonias,

myoclonus,

tics,mannerisms,

compulsions,

akathisia

Withdrawaldyskinesia


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metoclopramide, antiemetics,amoxapine levodopa,amantadine,bromocriptine

Sydenhams chorea

Conversion disorder

MalingeringHuntingtons disease


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Course

TD seems to stabilize in 50%, worsen in25%, and improve in 25%

Onset of the disorder may be gradual,occurring over a period of months toyears.


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Treatment

Patients with nonpsychotic mood or other disorderswho need antipsychotics should receive the minimalnecessary amounts of antipsychotic treatment andshould have the medication tapered and then

stopped once the clinical need is no longer present Atypical antipsychotics appear to offer some

advantage compared to older agents in terms of TDrisk

increase in dosage of a conventional agent usually(in approximately 66% of patients) results in aclinically significant but temporary reduction in TDsymptoms (Jeste et al. 1988 ).


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TREATMENT

Clozapine may be effective in reducing TD in patientswith existing TD (Lieberman et al. 1991 , Small et al.1987 ); however, side effects such asagranulocytosis, seizures, and anticholinergic

symptoms limit its use

studies have noted a beneficial effect of otheratypical agents (i.e., risperidone and olanzapine) onpreexisting TD (Jeste et al. 1997 , Littrellet al. 1998 )

Zhang et al. ( 2004 ) showed an improvement in TDwith vitamin E compared to placebo,


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TREATMENT Neuroleptic to be used only for appropriate

indications

Education and informed consent of patients

before initiation of neuroleptic Prevention of TD by

1. Lowest dose of medication

2. Shortest possible time of treatment3. Routine assessment

TD is suspected or diagnosed Medicalworkup to rule out other cases of dyskinesia


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TREATMENT

Perform riskbenefit analysis to decide

whether to continue neuroleptic or attempttaper

Taper any anticholinergic medications, ifpossible

Consider switch from neuroleptic to anotherneuroleptic, especially to an atypicalantipsychotic.

Also consider vitamin E as adjunctive therapy


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TREATMENT

VITAMIN B6 ( Am J Psy, Sep 2001)

TETRABENZINE(Am J Psy 1999) MELATONIN

Damier and coworkers ( 2007 ) recentlyreported promising benefits of deepbrain stimulation of the globus pallidusfor recalcitrant TD

Ca Channel Blockers

Beta blockers


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Results: Incidence of TD was: Atypicals: 19%

Nave: 5 %

Typicals for 5 years : 42% When TD cases were classified according to duration

of exposure, most were associated with typicalexposure (82%)

When severe TD was examined, those with atypicalsdid not appear to have a better profile.

(de Leon,2006)


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IMPORTANCE

Common and disabling side-effect

At times life-threatening

Potentially irreversible May be increased or decreased by stopping

the offending drug

Legal issues


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ComplicationTD may lead to numerous physical

complications and psychosocial problems

Ulcerations of the tongue, cheeks, and lips

Hyperkinetic dysarthria and swallowing

disordersshortness of breath at rest, irregularities in

respiration, and various grunts, snorts, andgasps

vomiting and dysphagia

Emotional distress may accompany severedyskinesia.


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Complications

Social embarrassment

Suicidal ideation

mild dyskinesia may lead to anxiety, guilt,shame,andanger.

TD is largely an aesthetic problem, but may impairsocial relationships and be an impediment toemployment.

About 510% of TD patients suffer impairment from

the dyskinesia. Orofacial movements may lead todifficulty in eating or retaining dentures, and weightloss or cachexia may develop.


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COMPLICATIONS

Pharyngeal involvement may rarely causeaspiration pneumonia. Involvement of thelimbs and trunk may interfere withambulation.

Diaphragmatic involvement may lead torespiratory dysfunction and even failure.

These occurrences of potentially lifethreatening complications have placedmedicolegal spotlight for justification of useof neuroleptics (Psychopharmacology 1993)


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APA TASK FORCE RECOMMENDATIONS

(1997, 2004)

Establish objective evidence that antipsychotics

are effective for an individual

Using the lowest effective dose

Cautious use in children, the elderly and in mooddisorders

Regular examination of patients for TD

Consider alternatives, obtain informed consent,and consider dosage reduction if TD present

If worsening, consider (a) stopping the drug, (b)

change to another drug, (c) clozapine


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Is dyskinesia a feature of

schizophrenia? The occurrence of peculiar, sprawling, irregular,

choreiform, outspreading movements in

schizophrenic patients were noted by Kraepelin

Many studies have investigated neuroleptic-naiveschizophrenic patients and reported rates ofdyskinesia that vary from nil to as high as 53%

These findings have raised the argument that

dyskinesias may be intrinsic to the pathophysiologyof schizophrenia, and that neuroleptics serve toenhance the process


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CONCLUSIONS

The need for continued antipsychotictherapy needs to be evaluated

Emphasis on prevention; as treatment isdifficult

Switching to atypical antipsychotics maybe considered


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CONCLUSIONS

Clozapine is the gold standard oftreatment.

Periodic evaluation with a standardmovement

Atypical Antipsychotics havent beenaround long enough.


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Thank u

Tardive Diskensia 18.10

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