Pharmacist Practice Examination and Assessment of Drug-Induced Movement Disorders

Pharmacist Practice: Examination and Assessment of Drug-Induced Movement Disorders in an Antipsychotic Long-Acting Injection (LAI) Clinic

Presented by: Mark E. Schneiderhan, PharmD, BCPP, FAAPP
Affiliations: Associate Professor, University of Minnesota, College of Pharmacy, Duluth, MN; Brightwater Health (Human Development Center-HDC), Department of Psychiatry

Objectives

  1. Abnormal Involuntary Movement (AIM) Monitoring
       - Context: Focus on pharmacist-provided Long-Acting Injection (LAI) Antipsychotic Services.

  2. Procedure for Assessing Medication-Related Abnormal Movements
       - Introduction and examination procedure.
       - Observation Techniques:
         - Indirect and structured observations techniques beginning from head to toe.
       - Patient Interaction:
         - Questions aimed at uncovering movements that the patient may consciously or unconsciously try to hide (mask).

  3. Assessment Questions Using AIMS Format
       - Focus on Facial, Oral, Extremity, and Trunk Movements.

  4. Scoring Practice
       - Level of severity of abnormal movements in three body areas along with Overall Severity, Incapacitation, and Patient Awareness.

  5. Utilize AIMS with Case Example Videos
       - Practice scoring based on videos demonstrating various symptoms.

Pharmacist Administration of Long-Acting Injectable Antipsychotics

Objective 1: Understanding the role and effect of LAIs in psychiatric treatments

  • APA Guidelines (2B): Suggests patients receive treatment with LAI antipsychotic medications if they prefer such treatment or have a history of poor adherence to oral medications.

  • Efficacy of LAIs:
      - Improve symptoms in individuals with schizophrenia.
      - Meta-analyses show no significant differences in outcomes when compared to oral antipsychotics.
      - Registry database studies indicate consistent benefits of LAIs compared to oral medications.

Types of Long-Acting Injectable Antipsychotics

  • Aripiprazole Monohydrate (Abilify Maintena®): Intramuscular (IM), 4-week interval

  • Aripiprazole (Abilify Asimtufii®): Intramuscular (IM), 8-week interval

  • Aripiprazole Lauroxil (Aristada®): Intramuscular (IM)

  • Paliperidone Palmitate (Invega Sustenna®): Intramuscular (IM), 1-month interval

  • Olanzapine Pamoate (Zyprexa Reprevv®): Intramuscular (IM)

  • Risperidone (Risperdal Consta®): Intramuscular (IM), 2-week interval

Rationale for Long-Acting Injection (LAI) Therapy

  • **Non-Adherence Rates: **
       - 44% - 75% non-adherence in schizophrenia settings.
       - LAIs increase time latency to relapse effectively.

  • Assumptions of Efficacy:
       - LAIs provide equivalent efficacy to oral antipsychotics when used as prescribed.
       - Not a guarantee of improved adherence.

Barriers to LAI Utilization

  • False Assumptions:
       - Patients will automatically reject LAIs.

  • Side Effect Risks:
       - Neuroleptic Malignant Syndrome (NMS), Tardive Dyskinesia.

  • Complex Dosing Issues:
       - Converting from oral to LAI antipsychotics.

  • Administration Challenges:
       - Site preparation (Deltoid vs. Gluteal injection), needle sizes.

  • Cost Implications:
       - MN Medicaid requires a "buy and bill" process for injectable drugs within clinics.

State Policy Recommendations

Pharmacist Roles:

A. Provide medication expertise through Comprehensive Medication Management (CMM) services.
B. Foster community-based pharmacy access to treatment.
   - Assured convenience, proper storage, and cost management.
C. Coordinate with the patient’s healthcare provider concerning missed doses, side effects (notably abnormal involuntary movements), and treatment symptoms (such as relapse and suicide assessments).

Legal Framework

  • Reference: 2020 Minnesota Statutes 151.01, Subd. 27
       - Drug administration through intramuscular and subcutaneous routes for mental health treatment only permitted under specific conditions.

AIMS Examination Procedure

  • Procedure Overview:
       - Conduct observation either before or after the AIMS completion, unobtrusively at rest (for instance, in a waiting room).
       - Examination chair must be firm and without arms.

Observational Questions:

  1. Ensure the patient has no foreign objects in the mouth.

  2. Inquire about teeth condition and if they wear dentures.

  3. Assess if the patient notices any movements in the mouth, face, hands, or feet and their impact.

  4. Observe posture with hands on knees and feet flat on the floor.

  5. Ask the patient to sit with unsupported hands to observe additional movements.

  6. Request the patient opens their mouth to observe tongue at rest, two times.

  7. Request protruding of the tongue for abnormalities, two times.

  8. Assess thumb tapping with each finger within 10–15 seconds for both hands.

  9. Flex and extend both arms, one at a time.

  10. Observe standing posture and body movements from the side view.

  11. Ask to extend arms forward to observe trunk and mouth.

  12. Have the patient walk short distances and turn back to observe gait.

AIMS Frequency Monitoring Guidelines

  • Assessment Timeline:
      - At Month 0: AIMS exam and semi-formal TD assessments during all visits.
      - At Month 6: AIMS exam if high risk for TD.
      - At Month 12: AIMS exam.

Overview of the Abnormal Involuntary Movement Scale (AIMS)

  • Purpose:
       - Records and monitors tardive dyskinesia (TD) in patients receiving neuroleptic medications.
       - Helps assess the degree of TD severity over time.

  • Scale Structure:
       - 12-item, clinician-administered rating scale.
       - Items 1-10 assess oculofacial movements, extremity dyskinesia, and overall severity with patient awareness.
       - Items 11-12 are yes-no questions addressing dental problems to prevent misdiagnosis.

Scoring Considerations:

  1. Frequency: Rate how often movements occur.

  2. Detectability: Consider if the movements were easily observed.

  3. Intensity: Evaluate duration and forcefulness.

Scoring Guide

  • Five Ratings:
       - 0: Not Present
       - 1: Minimal
       - 2: Mild
       - 3: Moderate
       - 4: Severe

Specific Movement Ratings:

  • Facial & Oral:
      - Assess facial expression, lips movements, jaw actions, and tongue activity.

  • Extremity Movements:
      - Evaluate upper and lower limbs, including choreic and athetoid movements.

  • Trunk Movements:
      - Observe movements of neck, shoulders, and pelvic areas.

Global Judgement:

  1. Overall severity of movements.

  2. Incapacitation from abnormal movements.

  3. Patient awareness of the severity of movements.

    

Interpreting AIMS Ratings

  • Utility: Not a diagnostic tool for TD, but identifies possible symptoms.

  • Indicators of Possible Tardive Dyskinesia (TD):
       - An AIMS score of 2 in two or more body areas or a score of 3/4 in one area.

Practice Videos and Case Discussions

  • Practice Video 1:
      - Patient: 68-year-old woman with mild tardive dyskinesia.
      - Symptoms observed: oro-buccal-lingual stereotypy, hand clasping, and foot fidgeting.
      - Key discussions:
       - Patient’s most bothersome symptom?
       - Awareness of abnormal movements?
       

  • Practice Video 2:
      - Patient: 74-year-old woman displaying both tardive dyskinesia and akathisia.
      - Symptoms Include oro-buccal-lingual stereotypy, subjective restlessness, truncal rocking, and nodding.
      - Key discussions:
       - Effect of movements on the quality of life?
       - Additional antipsychotic side-effects correlated with restlessness?

Conclusion

  • The document concludes with encouragement for participation in the AIMS assessment training, emphasizing the pharmacist's role in administering long-acting injectable antipsychotics and their clinical implications in monitoring and support for patients with tardive dyskinesia.