Recognizing Tardive Dyskinesia and Collaborating In Its Management

Adolfo Ramirez-Zamora, MD

Patients with tardive dyskinesia are often stuck between a rock and a hard place, as the condition, while caused by long-term use of psychiatric treatments, is most easily recognized by neurologists in the movement disorder space.

The complexity between recognition and management of the condition can lead patients to bounce back and forth between providers without much progress. Adding to that challenge is that the condition lacks many treatment options, and is often forgotten altogether, according to some in the field.

To speak to some of these challenges in tardive dyskinesia management, as well as some of the ways they might be addressed, Adolfo Ramirez-Zamora, MD, an associate professor of neurology and the director of clinical trials at the University of Florida’s Center for Movement Disorders and Neurorestoration, spoke with NeurologyLive.

NeurologyLive: What are the biggest challenges in properly diagnosing tardive dyskinesia?

Adolfo Ramirez-Zamora, MD: One of the biggest challenges, when it comes down to it, is just that defining the term has been difficult. When people say, “tardive dyskinesia,” they could be talking about a variety of different things. I think is more appropriate is to really call it a tardive syndrome because when you just have tardive dyskinesia people automatically think, for the most part, about the classic presentation of tardive dyskinesia, which is these abnormal, perioral mouth and tongue movements that can occur when you're taking dopamine-blocking agents for a period of time. But tardive dyskinesia could also refer to a variety of other symptoms that go from symptoms that resemble Parkinson disease, like tardive parkinsonism, tardive tremors, tardive dyskinesia, and, even in rare cases, tardive myoclonus. Most patients actually have a combination of all of them, and unfortunately, that may require detailed assessment by a neurologist.

What may end up happening—what happens commonly—is that if somebody develops any kind of abnormal movements, no matter whether it's tremors or movements in the face or movements in the eyes, psychiatrists feel compelled to prescribe anticholinergics drugs. Very commonly, they put them on Cogentin (benztropine mesylate) or Artane (trihexyphenidyl), which, if you have classic tardive dyskinesia, can exacerbate the problem instead of helping it. Some of these strategies are not helpful with some of the other symptoms that may occur. It may be helpful for dystonia, but it can make classic tardive dyskinesia worse, and it may not help with tardive parkinsonism. Defining the problem instead of using this big umbrella term of tardive dyskinesia is the first step. Education about all the different presentations of tardive syndromes and tardive complications of the use of medications for psychiatric purposes.

How important is the collaboration with the psychiatric field in terms of treating, managing, and diagnosing patients with tardive dyskinesia?

It's critical. That's the biggest gap because if you develop some of these movements, then the diagnostic approach and the treatment approach really depends on what the psychiatrist feels the patient needs from a psychiatric perspective. The selection of therapy really requires close collaboration with psychiatry. Also, psychiatrists need the assistance of the neurologist to manage some of these abnormal movements and potential complications that go beyond just the movements. You can have freezing of gait that leads to falls, problems with balance and posture, but it really requires a close relationship with between the neurologists and psychiatrists to really manage the patient properly.

I may suggest, “Alright, let's use this medication for the movement,” which can, in turn, make the depression worse which is then falls on the psychiatrist, and then the same can happen if I recommend, “Oh, you need to stop all these medications that are causing the problem and watch,” but then their psychiatric symptoms become unstable. It's a tough balance between what you need and the risk of what you are taking, so it is really critical.

What’s the biggest challenge for the neurologist in tardive dyskinesia care?

I think neurologists to do a good job of recognizing the symptoms once the patients get referred to us. I think that we can recognize what the problem may be. The biggest gap, or the biggest challenge, for us is how to coordinate the care for that patient. That's the key. They can provide recommendations, but I ultimately defer a lot of the treatments to the treating psychiatrist because these people have bad psychiatric disease that they are going to need care for, continuously, for the rest of their life. They have been on medications for a long period of time. I think that recognition is, for the most part, good from the neurologist point of view.

Education for psychiatry to help to recognize these movements would be very, very useful, and for neurologists, it’s finding out how can we work together with psychiatrists to really complement the therapy for these patients. These patients feel like they belong to no man’s land. Psychiatrists may say, “Well this is not mine, this is up to a neurologist,” while the neurologists say, “Well, I cannot stop these drugs, you need to talk to your psychiatrist.” They just go back and forth. Being been stuck in the middle, it must be so frustrating for patients. It's difficult.

Transcript edited for clarity.