• Today, I want to discuss a movement disorder on the rise due to increase use of neuroleptics and new indications for dopamine antagonists have increased over the years thus increasing the number of patients at risk. Also because some of the initial symptoms of this condition are acute extrapyramidal symptoms (EPS) like stiffness, slowness, and tremors; if not caught early can lead to full blown tardive dyskenesias (TD) or be inappropriately diagnosed as parkinsonism or Parkinson’s plus syndrome (e.g. multisystem atrophy) causing undue disability and frustration among patients and clinicians alike.

 

The most common symptoms of tardive dyskinesia are: occur after EPS

  • Grimacing
  • Tongue protrusion
  • Lip smacking
  • Puckering and pursing
  • Rapid eye blinking
  • Rapid movements of the arms
  • Rapid movements of the legs
  • Rapid movements of the trunk

First of all, tardive means late dyskinesia’s. These are abnormal involuntary undulating movement s often involving the face but can be seen in other parts of the body such as the extremities and trunk.

Why is it important to know about tardive dyskinesias? These are not to be confused with dyskinesias seen in Parkinson’s as I stated above but rather a secondary effect of long term dopamine replacement.

As the name implies these abnormal movements occur late after a prolonged exposure to dopamine antagonists ( blockers) such as anti -psychotics (particularly older)- e.g. Haldol; anti- nausea medicines- e.g. Reglan; anti-depressants- e.g. respideral. certain groups are already at higher risk like those with mental illnesses such as schizophrenia, cognitive or mood disorders  as well as those who are diabetic, have alcohol use or are immunodeficient, and/or  elderly. The risk goes up from ~13% to 50% with age and prolonged use of these medications.

of note: dyskinesias can appear after stopping medications which cause this and may even disappear weeks later. These are known as withdrawal dyskinesias.

 

Conditions resembling TD:

  • oral movements from ill fitting dentures
  • autism
  • chronic motor tics
  • Huntington’s chorea
  • restless leg syndrome
  • Tourette’s
  • Wilson disease – disorder of copper regulation
  • senile chorea (old age)
  • Meige’s syndrome ( face dystonia )
  • drug induced
  • Sydenham chorea ( associated with rheumatic fever)

 

Even in routine careful examination TD may be difficult to detect early by non specialists especially if a good history not taken. this is due to fact that agents causing problem can also mask the symptoms. doctors use a scale AIMS- abnormal involuntary movement scale

Usually is family that bring movements to attention of doctor!!!

Because in many cases people have been left with life long abnormal movements we must minimize the occurrence by minimizing drugs that are dopamine blockers and if needed using lower doses and shorter periods of time. Treat as quickly after it appears!

Treatments:

  • Tetrabenazine
  • reserpine
  • melatonin
  • donepezil ( Aricept)
  • vitaminB6
  • vitamin E
  • Valbenazine (should be available soon- better efficacy and tolerability than any to date)
  • AMANTADINE has no PLACE here…

Parkinson’s dyskinesias  on the other hand are due to prolonged use and exposure of dopamine agonists.  The best way to treat and diagnose these are keeping a diary of when abnormal involuntary undulating movements occur at peak dose, at onset, or at end of dose.

Time if they are predictable or random? as well as duration? are they painful?

Treatments for PD dyskinesia:

  1. prevent by using smaller doses and multiple mechanisms of action ( i.e. MAO inhibitor + dopamine agonist + levodopa)
  2. adjust medications i.e. shorten/ increase frequency of medications
  3. add amantadine ( shortly should have a new formulation of amantadine available to add to our armamentarium of drugs- Key treatment
  4. DBS  ( deep brain stimulation) is the gold standard treatment- discuss elsewhere in my blog.

When in doubt as to kind of movement disorder you have take a video and go see your MDS/neurologists ASAP many treatments are available.

 

As a side note: I would like to thank all of my readers and followers for making this blog one of your favorites as well as one of the top 50 blogs in topic of PD. could not do it without your love and support. Many blessings and Happy Valentine’s Day! ❤ ❤