Transcription
(bright music) - Hello, my name is Kevin Williams, and I'm excited to be a psychiatric PA and serve as the CEO and lead clinician at OnPoint Behavioral Health in Tampa, Florida. Today I'm gonna be discussing how we as PAs can help to manage individuals who struggle with tardive dyskinesia.
Now, to better understand why we treat the way we treat, it's actually a good thing for us to look at some of the pathophysiology that comes behind it. Now, the most widely accepted hypothesis is that there's an increase postsynaptically with the dopamine D2 receptors in the striatum. That's really in response to dopamine receptor blocking agents, such as antipsychotics and antiemetics.
Now, this hypothesis really results in hypersensitivity to dopamine, and then there's a subsequent cascade with motor impairment, and that's those involuntary movements that are hyperkinetic and constant in nature. So how do we treat and what is the thought pattern that we have as clinicians?
Well, a school of thought when I originally started treating patients was that, well, we had anticholinergics such as Benztropine that we know and understand from school that helps to treat movement disorders. But when you look at the package insert of Benztropine, it says while it does help with treating movement disorders, it can actually worsen TD symptoms. So we shouldn't use in individuals who are diagnosed with tardive dyskinesia.
A second school of thought is that, well, and this is commonly asked of me by my patients is, well, Kevin, why don't we just stop the offending agent? Well, oftentimes in psychiatry, and I'm sure in other practices as well, I don't get the option of reducing an antipsychotic that's improved an individual's mental health disorder, such as mood disorder or even in schizophrenia. And then in those individuals who are either no longer on the causing agent or were unable to reduce that agent, what we see is that when we make attempts, as I've commonly seen individuals try to reduce that medication, it actually worsens the TD symptoms because it unmasks those symptoms. Then vice versa, raising the dose of antipsychotic can actually mask TD symptoms.
Well, I'm really excited to share that the best way to treat tardive dyskinesia is with FDA approved VMAT2 inhibitors. Now, we really should consider this because individuals who have moderate to severe TD can see improvement, but even for those who have mild symptoms, studies show that we can even use it on individuals with mild symptoms and find some level of improvement.
Now, our ultimate goal is to cause and drive TD into remission with an AIM score of zero. However, we are really looking for a reduction in AIMs over a period of time. And that's truly what we have seen, and I've seen that in my clinical practice continuously time and time with using the VMAT2 inhibitors.
So the big question that is commonly asked, and really what has me standing before you today is so why aren't we treating it? Well, first, I really think there's a level of underdiagnosis or misdiagnosis that we see. In a recent study in the long-term care facility, what we saw was that patients were often misdiagnosed and then 25% were actually left untreated. They have the diagnosis, but they were left untreated. Then 50% were actually not even on a VMAT2 inhibitor. So it shows that there's a level of under-diagnosis, misdiagnosis, but honestly, what I see is really a lack of confidence. I truly believe we're missing the mark here.
My dear colleagues, I'm urging us to really consider evaluating, screening, and treating patients early who present with these dyskinetic and delayed movements. But we really should feel empowered to identify and treat patients because we have the power to really move the needle and help patients lower the disabling impact that they can feel from having this condition. And hopefully you are able to truly understand that you as a PA can treat this and that you'll start treating tomorrow and assessing your patients.
Now, in our next video, we'll talk about the personal side of caring for patients with TD. Thank you so much for tuning in. I'll see you at the next video. (bright music)