Telepsychiatry: Assessing Tardive Dyskinesia, AIMS Examination

In Part 1 of this interview, Richard Jackson, MD, founder and owner of The Neurobehavioral Medicine Group, Associate Clinical Professor, Wayne State University School of Medicine, Detroit, Michigan, and the Oakland University Beaumont Hospital Medical School in Royal Oak, Michigan, and Assistant Clinical Adjunct Professor, University of Michigan School of Medicine, Department of Psychiatry in Ann Arbor, Michigan discusses assessment through the use of AIMS for tardive dyskinesia (TD) via telepsychiatry.

In Part 2 of this interview, Dr Jackson will discuss monitoring movements and speaks more about medication usage during a telepsychiatry TD visit.

Dr Jackson:

We'll speak to some of the required monitoring and assessment of tardive dyskinesia (TD), which can be difficult during the COVID-19 telepsychiatry visits that you may be providing to your patients.

One of the first things that is critically important regarding looking at TD is that you have appropriate use of the antipsychotic medication that may be putting patients at risk for TD.

Regarding diagnosis and treatment of the core illness, that the use of the atypical or typical antipsychotic medication would be appropriate with regard to risk and benefits for your individual patient.

Monitoring during COVID-19 for TD may be a bit more difficult, especially if you're not used to seeing patients on a video format. Much of the same criteria that we would use on inpatient or outpatient settings when we see patients directly would hold for seeing patients via video. The nice thing is for evaluation of TD, this is clearly able to be done in just about as complete a fashion as you may do in person without being able to, unfortunately, touch your patient.

First would be identifying the risk of TD for patients, and that you're going to be monitoring them periodically for abnormal movements. This will stand for your informed consent, and each time you look for movements in patients for abnormal movements, you would again discuss the reason why you're doing this. This helps to assure your patients that you are aware of the potential risks, and that you're monitoring them closely for appropriate treatment and intervention if required.

It's important to do a baseline AIMS exam, because we want to identify any abnormal movements that may be present, either before your treatment with the antipsychotic medication, or if they're already on medication before you begin, the continuing of care with whatever medication potentially puts your patient at risk.

Just like we would do baseline labs for liver function test if patients were starting on divalproex, or asking them questions also about abnormal movements, just as you may before prescribing something like lamotrigine that may induce a rash. You want to know if there were any areas of rash or other concerning areas that were present even before starting the medication.

It's important to look for abnormal movements using the AIMS. It's been a standardized way and a baseline AIMS identifying the 7 abnormal areas of movement, but it's also critical to look at the impact of those movements. Certainly, those areas are well able to be completed by your telepsychiatry visit.

When discussing with patients the potential risks, things that they need to look for and can identify for you is any difficulties that they may see related to abnormal movements. When looking for abnormal movements in patients after completing an AIMS, it's imperative that we continue to look for abnormal movements each time we see patients.

We may ask them to sit up and do some activation maneuvers. We often do activation maneuvers for TD through rapid alternating movements. Touching each finger to their thumbs, some type of movement of their hands often called the doorknob, moving back and forth, as well as screwing in a light bulb.

These are classic ways to activate movements and making sure that you look for movements that you may not see otherwise, such as having patients open their mouth and looking at their tongue. Of course, you do that during your AIMS exam.

Each visit doing some quick activation maneuvers will help you to continue to find any early abnormal movements or the worsening of movements that may already be there, as well as providing continued informed consent for your patient as you tell them you're looking for abnormal movements that may be related to the medications, and again, assures them that you are on top of it. You're going to monitor them and offer interventions that may be appropriate.

When completing the AIMS and activation, we are obviously able to see areas to look at for continued monitoring, which is critically important, not only to our patients but also for ourselves from a medical–legal standpoint.