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Tardive Dyskinesia Parkinson’s Disease

Dystonia Vs Dyskinesia In Parkinson’s Disease

Ask the MD: Dyskinesia and Parkinson’s Disease

Dystonia and dyskinesia are movement problems that commonly occur in Parkinsons disease . You may experience one or both of them, particularly in late-stage PD. Dystonia is muscle stiffening caused by PD, while dyskinesia is a type of muscle twisting caused by some PD medications.

Dystonia and dyskinesia can both cause distress, and they are distinguished from each other based on their visible features. They can be managed with medication or surgery, typically with a moderate improvement of symptoms.

PD is characterized by four primary symptoms:

  • Postural instability

While they can fluctuate in severity, the primary symptoms of PD tend to be present most of the time.

Dystonia and dyskinesia are recurrent, abrupt, and short-lived muscle movements. Not everyone who has PD experiences dystonia and dyskinesia. If they do, the symptoms they experience can be telling.

  • Affects large muscle groups

  • Smooth, repetitive movement often described as a rolling or writing motion

  • Can begin suddenly and stop after several minutes

  • Not typically painful

  • More likely to occur when PD medication effects are at their peak

For example, dystonia can cause your toes to curl, making it difficult to walk. Or it may manifest primarily in your neck muscles, causing your head to turn painfully to one side.

With dyskinesia, you may experience a snakelike twisting of your arm or movements of your head and neck that appear like dancing in slow motion.

How Is Tardive Dyskinesia Diagnosed

If youre taking a medication that can cause tardive dyskinesia, your healthcare provider will watch for problems.

If symptoms develop, your healthcare provider may recommend certain tests. These tests can rule out other movement disorders like Parkinsons disease.

These tests include:

  • Physical exam to assess nervous system functions.
  • Blood tests and urinalysis to check for infections, illnesses and other problems.
  • Electroencephalogram to measure electrical activity in your brain.
  • Electromyography to measure communication between muscles and nerves.

What Is The Difference Between Tardive Dyskinesia And Dystonia

Tardive dyskinesia refers to uncontrollable mouthing and lip-smacking grimaces that develop following the long-term use of neuroleptics. Dystonia refers to abnormal muscle tone resulting in muscle spasms or abnormal postures.

Tardive dyskinesia is always caused by the long-term use of neuroleptics. However, various factors such as different drugs, neurodegenerative diseases and traumatic damages to central nervous system can cause dystonia. Moreover, dystonias include a variety of movement disorders that occur due to various reasons while tardive dyskinesia is only a subgroup of primary dystonias.

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Take Additional Medication For Your Parkinson’s Disease

Taking a medication called a dopamine agonist can allow your doctor to reduce your levodopa dosage, which may help ease the symptoms of dyskinesia. However, according to the 2016 review, these drugs can cause similar side effects as those of levodopa for some people and may require you to adjust your dose of levodopa.

Adding amantadine to your treatment regimen may also provide relief of dyskinesia symptoms.

What Are Parkinsons Tremors

Tardive Dyskinesia

A tremor is a rhythmic, back-and-forth movement, says Dr. Herrington. While most tremors tend to occur in the hand, he says that they can also involve other parts of the body, including the thumbs, arms, legs, or head.

Tremors also tend to occur when a person isnt otherwise moving, or is at rest. We call that a resting tremor, says Herrington. In such a case, the tremor isnt as pronounced when the person is using the body part affected by the tremor. However, Herrington says, when the hand comes to rest . . . the tremor emerges.

Tremors are usually more prominent when Parkinsons medications are wearing off, he says. During an off time for example, if a person has stopped taking their medicine they can be slow and stiff or stooped over. When they walk, says Herrington, theyll take very short steps. Theyre moving less, and theyre moving small.

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Rem Sleep Behavior Disorder

In vivid dreaming states most peoples bodies are still. However people with RBD lack muscle paralysis resulting in their acting out their dreams. This can include talking, screaming, shouting, hitting, punching or kicking, even propelling them out of bed. This can be scary and dangerous if they strike their partners or other bedside objects involuntarily. RBD is common in and can begin long before the onset of declining motor function. Fortunately it is also a very treatable condition.

Movement Disorders Clinic Coordinator

Dyskinesia, also known as tardive dyskinesia , is a neurological disorder often caused by the long-term use of neuroleptic drugs. Such drugs are generally prescribed for psychiatric disorders, as well as for some gastrointestinal and neurological disorders.

TD involves involuntary movements of the lips, tongue, mouth and face. These excess movements also may be experienced by people with Parkinsons disease.

The movements can become more diffuse and can resemble generalized jitteriness, chorea or dystonias. Akithisia, a form of restlessness, is often associated with TD and manifests itself as constant fidgeting or a necessity to keep moving.

Elderly women appear to be the most susceptible to developing TD from neuroleptics.

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Measuring Tardive Dyskinesia Against Drug Induced Parkinsonism

The symptoms of tardive dyskinesia and drug-induced parkinsonism can be remarkably similar, but an accurate diagnosis is critical when treatment for one condition may worsen the other.

Kristen M. Ward, PharmD

An accurate diagnosis for patients with either drug-induced parkinsonism or tardive dyskinesia is imperative and can minimize the impact of the symptoms on the patients quality of life, according to a new review of movement related disorders.

Researcher duo Kristen M. Ward, PharmD, and Leslie Citrome, MD, MPH, conducted a literature review of articles published as of the spring of 2018 that related to the presentation, pathophysiology, epidemiology, and management of DIP and TD. The pair found that there was sparse primary literature that supported the use of most medications for treatment of DIP and TD, except for valbenazine and deutetrabenazine.

The study authors wrote that while both DIP and TD are stigmatizing movement disorders associated with exposure to dopamine receptor blocking agents such as antipsychotics they differ in their pathophysiology and clinical management.

The differences in treatment are immensely important, they said, because treatment for one may worsen the other. The treatments are different for DIP and TD and rely on accurate diagnoses.

Leslie Citrome, MD, MPH

The study authors noted that it is possible for patients to have both DIP and TD DIP usually precedes TD. This is not currently understood clearly.

Distinction From Similar Conditions

Dystonia, Akathisia, Parkinsonism, and Tardive Dyskinesia – Antipsychotics Side Effects

Unlike TD, Sydenham chorea is a disorder associated with a history of group A streptococcal infection and rheumatic fever in children. It typically affects children and adolescents 6 months or more after an infection with group A streptococci. Prompt administration of antibiotic therapy for infections with group A streptococci dramatically reduces the incidence of Sydenham chorea. The female-to-male ratio is approximately 2:1.

Sydenham chorea is characterized by the rapid onset of chorea, muscular weakness, hypotonia, dysarthria, obsessions, compulsions, and other behavioral and emotional disturbances. After an abrupt or insidious onset, Sydenham chorea worsens over 2-4 weeks and then resolves over 36 months. Chorea may persist after the episode has ended. One fifth of patients with Sydenham chorea experience a recurrence, typically within 2 years of the initial episode.

Pantothenate kinase-associated neurodegeneration occurs in patients aged 1015 years, a different age group than that of persons with TD. PKAN is an extremely rare, progressive neurogenetic disorder with autosomal recessive inheritance associated with dementia and death . It is characterized by rigidity, dystonia, choreoathetosis, spasticity, foot deformity, and intellectual deterioration. It is associated with excessive iron deposition in the basal ganglia that can be observed on MRI.

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Prevalence And Risk Of Td

The mean prevalence of TD in people treated with APs was 2025% according to meta-analyses of articles published between 1959 and 2015.27,28 A 20-year longitudinal study initiated prior to the widespread use of second-generation APs calculated a yearly cumulative incidence of TD of 4%5%.27 The frequent occurrence of TD and acute extrapyramidal symptoms, such as drug-induced parkinsonism and acute dystonia, encouraged the development of second-generation APs, which were intended to minimize the incidence of adverse neurological effects. Although acute drug-induced parkinsonism and acute dystonia are lessened, TD has not been eliminated. The annual prevalence of TD among patients receiving APs was estimated to be 7.6 to 9.7 per 1000 people according to a large retrospective observational study of electronic health records, with nearly 80% of study participants using second-generation APs.15 A direct comparison of annualized incidence between first- and second-generation APs indicates a reduced but not eliminated risk of TD with use of second-generation APs .6,29

The most important risk factors for the development of TD include older age and cumulative exposure to the DRBA. Other risk factors include the dopamine-receptor binding affinity of the DRBA in question, female sex, mood disorders, dementia, and prior drug-induced parkinsonism.4, Smoking and substance abuse may also be associated with a higher risk of developing TD.33

Know How Treatments Can Affect Both Conditions

Understanding underlying pathophysiology is key to understanding the effects of certain treatments. The treatment approaches for TD and drug-induced parkinsonism are distinct and rely on the accurate identification of the underlying movement disorder.1 In his commentary, Knowing the Difference Can Make a Difference , Dr Nasrallah states that anticholinergic agents are sometimes used for drug-induced parkinsonism because they may increase dopaminergic activity and help reverse the hypodopaminergic state of drug-induced parkinsonism and adds that using anticholinergic agents in TD may further exacerbate the hyperdopaminergic staterather than help it. Table 2 takes a closer look at both drug classes and their effects on patients with either movement disorder.

Finally, it is important to consider that, after waiting for decades, evidence-based treatments for patients with TD were approved in 2017. The American Psychiatric Association recommends that patients with moderate to severe or disabling TD associated with antipsychotic therapy be treated with a reversible inhibitor of vesicular monoamine transporter 2 .3 Treatment with a VMAT2 inhibitor can also be considered for patients with mild TD, based on factors such as the clinical need for ongoing antipsychotic pharmacotherapy, patient preference, associated impairment, or effect on psychosocial functioning.3

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Strategies For Minimizing Td Risk

TD can be irreversible, highlighting the need for preventative strategies. Many clinicians focus primarily on limiting the use of TD-inducing medications and secondarily on detecting TD symptoms early.51,60,61 Considering the pharmacology of individual APs with an understanding of proposed TD pathophysiology informs the selection of therapies that are least likely to induce TD. Use of less potent dopamine receptor blocking second-generation APs instead of first-generation APs may reduce TD risk. Correll and colleagues presented the initial support for a lower risk of TD associated with second-generation APs compared with first-generation APs in a meta-analysis of 11 randomized studies.6 Here, the annual TD risk estimate associated with haloperidol was 5.4% across 3 studies, whereas across 5 studies, the risk estimates associated with olanzapine, risperidone, quetiapine, or amisulpride ranged from 0.5% to 1.5%. In addition, because older people both experience benefit from second-generation APs at low doses and are at greater risk of developing TD after minimal exposure, treatment regimens should reflect these sensitivities and implement the lowest effective AP dose.7,62

Dimd Classification And Symptoms

Tardive dyskinesia info for clinicians in training

The various movement disorderswhich can be confusing to patients and clinicians alikeare classified based on timing and specific symptomatology. There are two major categories of DIMD: acute and chronic . Acute symptoms occur during the early phase of drug therapy and are frequently short-lived. Chronic symptoms commonly arise with prolonged use of the inciting drug. Some thought leaders believe that permanent movement disorders may arise after a single dose of a dopamine receptor antagonist, but the general consensus supports the chronic-use concept.13

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , developed and published by the American Psychiatric Association, includes classifications of all currently recognized mental health disorders. In DSM-5, DIMDs are termed medication-induced movement disorders . The MIMDs listed in DSM-5 include neuroleptic-induced parkinsonism and other medication-induced parkinsonism neuroleptic malignant syndrome medication-induced acute dystonia medication-induced acute akathisia TD tardive dystonia and tardive akathisia medication-induced postural tremor and other medication-induced movement disorders .16

Medication-induced postural tremor is expressed as a fine tremor that occurs when the patient attempts to maintain a posture. The tremor is similar to that seen with anxiety and the use of caffeine and other stimulants.16

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What Causes Dyskinesia And Dystonia

Dyskinesia is a common side effect of the Parkinsons drug levodopa. This drug is used to help increase the level of dopamine in the brain, alleviating symptoms of the disease. However, levodopa is taken intermittently throughout the day, causing dopamine levels to rise and fall over time. These fluctuations are thought to be the cause of dyskinesia. There are two types of dyskinesia:

  • Peak-dose dyskinesia, which occurs when the level of levodopa is at its highest
  • Diphasic dyskinesia, which occurs when levels of levodopa are rising or falling

While dystonia can be a symptom of Parkinsons disease itself, it can also be caused by levodopa treatment, similar to dyskinesia. Dystonia symptoms occur when there is a decrease in brain dopamine levels, which can occur before medication is taken in the mornings or as it is wearing off during the day. This off and on dystonia can be addressed by taking an extended-release form of levodopa or by increasing the number of doses taken per day.

Dystonic dyskinesia can occur when the movements caused by levodopa are more sustained and twisting than in typical dyskinesia. When this occurs, it is important to determine the cause whether the movement occurs at peak-dose levels of dopamine or it is off and on dystonia.

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Uncontrolled Movements In Parkinsons Disease

Parkinsons disease is a disorder that can involve several different kinds of uncontrolled movements. Some are caused by the disease, such as tremor and gait freezing, while dyskinesia uncontrolled jerking or twisting movement is caused by long-term levodopa use. We unpack how dyskinesia affects movement in Parkinsons disease and how its usually treated.

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Impact Of Td In Older People

The impact of TD on an individuals physical, mental, and economic health may intensify with age.3,22 The social and emotional effects of symptoms are highly debilitating for people with TD of all ages, but feelings of isolation and depression may be especially profound for older people.3,16 Older individuals are also uniquely vulnerable to the physical consequences of TD, such as impaired gait and balance, which can lead to falls.16,26 TD in older patients often presents as oro-bucco-lingual dyskinesia, and these movements can interfere with eating and swallowing incidents of choking resulting from respiratory TD have been reported.7,19,46 Further, oro-bucco-lingual TD can cause loosening of natural and artificial teeth and be augmented by edentulousness and denture use edentulousness itself can cause abnormal movements of the mouth in the absence of neurological disorders such as TD.26,46,47 Older patients may also be affected by dyskinesias of the limbs, trunk, and respiratory system, with symptoms such as grunting.7,26,48

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Talk To Your Doctor About Continuous Drug Infusion

Cup for Dyskinesia from Parkinson’s Disease

One way to potentially avoid fluctuations in medication delivery and dopamine levels is through a continuous drug delivery system such as duodenal infusion, in which the medication travels through a tube directly into the intestine. Another option is continuous subcutaneous apomorphine infusion, in which a small device similar to an insulin pump is clipped to the clothing, according to the Parkinsons Foundation. A wire then enters the skin to deliver a steady dose of the medication apomorphine , a dopamine agonist, which may reduce the “off” periods, when levodopa stops working, and may minimize dyskinesia symptoms.

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How Are Tremors And Dyskinesia Treated

We treat these two kinds of movements very differently, says Herrington. Dyskinesias are usually a problem of too much dopamine medication , and tremors are sometimes a problem of not quite enough.

Its therefore important for a neurologist to be able to tell the difference between the two symptoms, he says, and to adjust the medications accordingly.

Herrington points out that not all people are similarly bothered by tremors or dyskinesia. Take tremors, for example. There are some people who have a very small tremor and it bothers them immensely, he says. Other people have quite a substantial tremor and really dont seem to care about it very much.

When it comes to treating Parkinsons-related tremors, doctors may start out by asking people how much the symptom bothers them. As a physician, you can categorize which symptoms people have or the level of severity, says Herrington, but its always really important to ask the person what bothers them. The most objectively severe symptom may not be the one that bothers them the most.

As for dyskinesia, some people dont notice it at all, he says. there is often a divergence between how much they notice and are bothered by it and how much their loved ones notice and are bothered by it.

What Does Tardive Dyskinesia Mean

The medical term tardive dyskinesia means:

  • tardive: delayed or late

  • dyskinesia: involuntary, unusual muscle movements

There are many different types of dyskinesia. Tardive dyskinesia refers to the fact that the involuntary movements appear months, or sometimes years, after a person starts taking certain medications. In other words, theres a delay between the medication and the medication side effect.

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