Tardive Dyskinesia & Tourette's Syndrome

therefore what is a huge factor for TD

*AGE*

Risk factors for TD

- *OLDER AGE* - *length of neuroleptic use* - the longer you are on it, the more risk you have - Postmenopausal females (hormonal) - Mental retardation - Alcoholism and substance abuse - Extrapyramidal symptoms early in the course of neuroleptic treatment - Presence of other movement disorders (like essential tremor increases the risk) - Diabetes mellitus - Mood disorders (particularly MDD - higher risk factors)

Dopamine Receptor Blocker

- 60-80% improvement - Orap (pimozide) or Tetrabenazine (xenazine) - SE: arrhythmia, hypotension, drowsiness, anorexia

SxS of TD

- 75% of individuals with TD have orofacial dyskinesia (lips sticking out, moving lips) - 50% have limb dyskinesia (moving around, shaking) - 25% have axial dyskinesia (in their body) - 10% have total body involvement (entire body) - typically starts minimal to mild in nature, and progresses in severity with prolonged use.

Prognosis of Tourette's

- Clinically, symptoms wax and wane, and new tics commonly can develop (but only 1 at a time) - Up to 50% of patients show marked improvement during the teenage years. - If tics go away, they do not usually reccur in adulthood. - If tics persist past age 15 years, they tend to remain chronic.

Anti-psychotics

- Haloperidol (Haldol) - Chlorpromazine (Thorazine) - Fluphenazine (Permitil, Prolixin) - Thioridazine (Mellaril) - Perphenazine (Trilafon) - Trifluoperazine (Stelazine) - Pimozide (Orap) - Thiothixene (Navane) - Molindone (Moban)

Tourette's Syndrome

- Hereditary, chronic neurologic disorder consisting of various motor and vocal tics. - Tics are sudden, involuntary, brief, repetitive, stereotypic motor movements.

What is tardive dyskinesia?

- It is a neurologic syndrome that possesses the essential features of abnormal, involuntary movements of the tongue, lips, face, trunk, and extremities.

Alpha-adrenergic

- May help attention deficit disorders as well - *Clonidine (catapres)* and Guanfacine (tenex) - SE: common.. such as sedation and dry mouth; may decrease with time

Tics - many dif types

- Multiple motor tics such as: facial grimacing, blinking, head or neck twitching, tongue protruding, sniffing, or touching - Vocal tics such as: grunts, snorts, throat clearing, or barking

Epidemiology

- Predominant age = CHILDHOOD ONSET - 95% at age 2-15 years - 90% by age 10 years - Average age of onset: 6 years old - None start after age 21, by definition - M>F 3:1 - about 1 mil in the U.S

Other treatment

- Requip (Ropinirole) - Dopamine Agonist - Botox - for the consistent motor tics , stops the firing - (but they have to have the same tic) - Habit reverseal training (psychotherapy- biofeedback and helps them calm down reduce stress- tics can go away)

Fluoxetine (Prozac)

- SSRI - also useful for OCD sxs- (tourette's is NOT the only issue they have) - SE: dizziness, sexual side effects, wt loss, insomnia

how do the tics occur

- Tics occur many times throughout the day and can change over time. - But only 1 tic can occur at a time.

Severity of a tic can change with...

- Tics usually worsen with stress and are most severe during day - When patient is absorbed in a physical activity, tics are less severe or absent* - Also when they sleep - the tic is usually absent

Tics can persist for

- a few months and remit, then reoccur in the form of a NEW motor tic

Tardive dyskinesia is most commonly associated with...

- a long-term treatment of neuroleptic medications. (A lot of times seen from psychiatry & TD needs to be r/o) - TD can begin *during treatment with neuroleptics or within 4 weeks of discontinuing neuroleptics*

Sxs of Tourette's

- begins in childhood - the location, number, frequency, and complexity of tics change over time. - Can only have one type of tic occurring at a time but can have many different types overall

the movements of TD can have...

- choreiform characteristics (rapid, jerky, or nonrepetitive) - athetoid characteristics (slow, sinuous, continual) - rhythmic characteristics

Movements of TD include:

- grimacing, sticking out the tongue, and smacking and sucking the lips.

*<55 years old* Younger patients

- have a 5% risk each year and 50-60% over their lifetime of developing TD due to their neuroleptics (classical antipsychotics)

*>60 year old* Older patients

- have approx. a 20% incidence rate after 1 year of exposure, to 30%, and near 50% at 2- and 3-year exposures from being on a neuroleptic will develop TD

Treatment for Tourette's include:

Dopamine Receptor Blocker = Orap or Tetrabenazine Alpha-Adrenergic = Clonidine or Guanfacine SSRI = Fluoxetine (Prozac) Others = Requip, Botox, Habit reverseal training

Mostly (NOT 100%)

are *reversible* when you stop the meds - (but still can continue up to a month later)

More complex vocal tics are:

echolalia (repeating last words of someone else) palilalia (repeating one's own words) coprolalia (use of obscenities) copropraxia (use of obscene gestures - give you the finger)

key with Tourette's

it starts in *CHILDHOOD* (if someone comes in their 20s saying it started yesterday, if it did it has nothing to do with Tourette's)

Atypical Anti-psychotics

newer. happens less frequent - but still happens. (Cleaner, while the older ones are dirtier) - Quetiapine (Seroquel) - Olanzapine (Zyprexa) - Risperidone (Risperdal)