Download - Tardive Diskensia 18.10
-
7/31/2019 Tardive Diskensia 18.10
1/46
TARDIVE DYSKINESIA
CHAIRPERSONDr.DENZIL A PINTO
PRESENTER Dr.D.ARCHANAA
O
-
7/31/2019 Tardive Diskensia 18.10
2/46
-
7/31/2019 Tardive Diskensia 18.10
3/46
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
-
7/31/2019 Tardive Diskensia 18.10
4/46
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)
-
7/31/2019 Tardive Diskensia 18.10
5/46
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
-
7/31/2019 Tardive Diskensia 18.10
6/46
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)
-
7/31/2019 Tardive Diskensia 18.10
7/46
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%
-
7/31/2019 Tardive Diskensia 18.10
8/46
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..
-
7/31/2019 Tardive Diskensia 18.10
9/46
GP, SNr
StriatumMotorCortex
VA-VLcomplex
- GABA
-
GABA
+
glutamate ?
glutamate
+
glutamate
+
Basal Ganglia (Microcircuitary)Connections
-
7/31/2019 Tardive Diskensia 18.10
10/46
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
-
7/31/2019 Tardive Diskensia 18.10
11/46
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
-
7/31/2019 Tardive Diskensia 18.10
12/46
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
-
7/31/2019 Tardive Diskensia 18.10
13/46
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
-
7/31/2019 Tardive Diskensia 18.10
14/46
-
7/31/2019 Tardive Diskensia 18.10
15/46
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)
-
7/31/2019 Tardive Diskensia 18.10
16/46
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 -
7/31/2019 Tardive Diskensia 18.10
17/46
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
-
7/31/2019 Tardive Diskensia 18.10
18/46
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
-
7/31/2019 Tardive Diskensia 18.10
19/46
RISK FACTORS
Old ageDiabetes
Depression
ParkinsonismAkathisia
Negative symptoms,
Cognitive impairments,
Premorbid substance abuse ( Sachdev 2005)
Traumatic head injury
encephalitis
-
7/31/2019 Tardive Diskensia 18.10
20/46
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
-
7/31/2019 Tardive Diskensia 18.10
21/46
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)
-
7/31/2019 Tardive Diskensia 18.10
22/46
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?
-
7/31/2019 Tardive Diskensia 18.10
23/46
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.
-
7/31/2019 Tardive Diskensia 18.10
24/46
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.)
-
7/31/2019 Tardive Diskensia 18.10
25/46
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.
-
7/31/2019 Tardive Diskensia 18.10
26/46
Worseningpsychostimulants,short-term withdrawal of antipsychotic
medication,
anticholinergic medication,
emotional arousal,
stress,
voluntary movements of other parts ofthe body.
-
7/31/2019 Tardive Diskensia 18.10
27/46
Improved
relaxation,
Voluntary movements of the involvedparts of the body
sleep
increased dose of antipsychotics(temporarily)
-
7/31/2019 Tardive Diskensia 18.10
28/46
D/D
neuroleptic-inducedparkinsonism,
rabbit syndrome,
Wilsons disease
cerebellar disease
anxiety states,
alcoholism,
hyperthyroidism
Acute dystonias,
myoclonus,
tics,mannerisms,
compulsions,
akathisia
Withdrawaldyskinesia
-
7/31/2019 Tardive Diskensia 18.10
29/46
metoclopramide, antiemetics,amoxapine levodopa,amantadine,bromocriptine
Sydenhams chorea
Conversion disorder
MalingeringHuntingtons disease
-
7/31/2019 Tardive Diskensia 18.10
30/46
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.
-
7/31/2019 Tardive Diskensia 18.10
31/46
-
7/31/2019 Tardive Diskensia 18.10
32/46
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 ).
-
7/31/2019 Tardive Diskensia 18.10
33/46
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,
-
7/31/2019 Tardive Diskensia 18.10
34/46
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
-
7/31/2019 Tardive Diskensia 18.10
35/46
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
-
7/31/2019 Tardive Diskensia 18.10
36/46
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
-
7/31/2019 Tardive Diskensia 18.10
37/46
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)
-
7/31/2019 Tardive Diskensia 18.10
38/46
IMPORTANCE
Common and disabling side-effect
At times life-threatening
Potentially irreversible May be increased or decreased by stopping
the offending drug
Legal issues
-
7/31/2019 Tardive Diskensia 18.10
39/46
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.
-
7/31/2019 Tardive Diskensia 18.10
40/46
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.
-
7/31/2019 Tardive Diskensia 18.10
41/46
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)
-
7/31/2019 Tardive Diskensia 18.10
42/46
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
-
7/31/2019 Tardive Diskensia 18.10
43/46
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
-
7/31/2019 Tardive Diskensia 18.10
44/46
CONCLUSIONS
The need for continued antipsychotictherapy needs to be evaluated
Emphasis on prevention; as treatment isdifficult
Switching to atypical antipsychotics maybe considered
-
7/31/2019 Tardive Diskensia 18.10
45/46
CONCLUSIONS
Clozapine is the gold standard oftreatment.
Periodic evaluation with a standardmovement
Atypical Antipsychotics havent beenaround long enough.
-
7/31/2019 Tardive Diskensia 18.10
46/46
Thank u