This newsletter was sponsored and co-developed by Neurocrine Biosciences. The faculty have been compensated by Neurocrine Biosciences. This newsletter is intended to provide general information about tardive dyskinesia and not medical advice for any particular patient.
Tardive dyskinesia (TD) is a movement disorder caused by prolonged exposure to dopamine receptor blocking agents (DRBAs) and is clinically defined by delayed emergence of persistent abnormal, involuntary, and repetitive movements.1 Although TD affects an estimated 600,000 people in the United States,2,3 published TD prevalence and incidence rates may be inaccurately low.4 There are many patients living with the burden of TD who are not diagnosed accurately—if they are even diagnosed at all, according to faculty members Stuart Isaacson, MD; Daniel E. Kremens, MD, JD, FAAN; and Desiree M. Matthews, PMHNP-BC, who maintain that an accurate diagnosis can help ensure appropriate treatment. In this newsletter, they provide guidance on how to best screen for TD—no matter what the practice setting.
All Patients Receiving Dopamine Receptor Blocking Agents Should Be Screened for TD
TD is associated with prolonged use of DRBAs, including available antipsychotics, used to treat a variety of psychiatric disorders such as schizophrenia,5 bipolar disorder,5 and major depressive disorder (as adjunctive treatment),5 among others. With expanded indications as well as varied off-label DRBA use, the number of people at risk for TD continues to increase.6
In a 2020 consensus statement published by Caroff and colleagues, a panel of experts specializing in psychiatry and neurology unanimously agreed that all patients receiving DRBAs should be screened for TD.6 In fact, it is recommended that clinicians assess all patients who have been prescribed antipsychotics for the development of TD and other associated movement disorders at every clinical encounter (live or remote), regardless of the degree of TD risk.6
The American Psychiatric Association (APA) is in agreement with this consensus statement and clarifies the utility of a structured clinical exam in their latest practice guideline for the treatment of patients with schizophrenia. According to the APA, for patients displaying any abnormal movements, a structured clinical exam using an instrument such as the Abnormal Involuntary Movement Scale (AIMS) should be conducted at least once a year and at least every 6 months in higher-risk patients.7
“For patients who have been taking antipsychotics, I feel that TD can be a ticking time bomb,” noted Ms Matthews. “It can show up at any time and should be screened at each visit.”
“I find that many patients may not spontaneously report TD movements,” adds Dr Isaacson. “Therefore, spending a short time at each clinical encounter to look at the patient for any movements is a good clinical practice.”
Multiple Movement Manifestations of TD1
TD refers to involuntary abnormal movements that emerge in patients who have been taking antipsychotics for a while. The classical oro–buccal–lingual movements are often accompanied by choreic-like movements in other body parts. The typical presentation is a combination of tongue twisting and protrusion, lip smacking and puckering, and chewing movements. TD may affect the limbs, which manifests as piano-playing fingers, grasping, flexion and extension of limbs, and foot tapping. Involvement of diaphragm and respiratory muscles may result in loud breathing, hyperventilation, grunting, groaning, or distorted speech. This latter type of movement can present with or without involvement of the lower face, including the mouth and tongue.
“One of the keys to the successful treatment of TD is accurate diagnosis,” says Dr Kremens. “Routine screening is critical to identify and address TD early. It is therefore crucial for all patients on DRBAs to undergo routine screening for TD.”6,7
As detailed in another newsletter in this series, “360-Degree Impact of Tardive Dyskinesia: Functional, Emotional, and Social Consequences,” TD can have significant adverse effects on quality of life and mental well-being. Although patients may have mild, moderate, or severe symptoms, the same movement severity can be associated with varying impact on different patients.7
TD can be very socially isolating.8 “In my experience, patients with abnormal movements may be shunned or avoided by others; their social interactions may be limited as a result of their abnormal movements, especially those that involve the face, mouth, and tongue,” says Dr Kremens.
Structured Clinical Scales for TD Screening Are Straightforward, Quick to Perform
The APA recommends using a structured clinical exam at least once a year and at least every 6 months in patients at greater risk for TD.7 One such tool is the AIMS, a 12-item, clinician-rated scale used to assess symptom severity in patients with TD (Figure).9 The AIMS takes about 5 minutes to complete and scores patients on a scale from 0 (none) to 4 (severe) on various symptoms: facial and oral movements, extremity movements, trunk movements, and global judgments related to severity, incapacitation, and patient awareness of these movements.9 Additional items, which are related to dental status and sleep, are scored as 0 (no) or 1 (yes).9 Experts agree that no specific score threshold suggests the need for intervention; instead, clinicians should consider the impact of the TD movements on the individual patient.7 Even one rating of mild movements (ie, ≥2 on AIMS) could represent TD that may be amenable to treatment.6
aBased on the highest single score on the above items.
AIMS, Abnormal Involuntary Movement Scale.
Based on: Guy W. ECDEU Assessment Manual for Psychopharmacology: Revised. National Institute for Mental Health, Psychopharmacology Research Branch; 1976:534-537.
Another structural screening tool is the Dyskinesia Identification System: Condensed User Scale (DISCUS).10,11 Clinicians rate 15 behaviors and movements on a scale from 0 to 4, and track scoring over time.10 A DISCUS total score of ≥5 should prompt clinicians to look further into a particular case, and the clinician must remain alert for movements that deviate from baseline levels.11
Although these structured scales play a key role in effective screening, clinicians must dig deeper during evaluations to perform comprehensive TD screening. Specifically, they should ask follow-up questions regarding functional impairments attributable to TD—that is, interference with daily activities such as eating, drinking, speaking, breathing, dressing oneself, writing, working, leisure activities, and socializing.12 In fact, the 2020 APA guideline notes that approved treatment can be considered for patients with mild TD based on factors such as patient preference, associated impairment, or effects on psychosocial functioning.7
“Whenever I encounter a patient on an antipsychotic, I always want to do two main things: one, ask whether the tongue or other parts of the body move spontaneously; and two, look at their face, mouth, trunk, arms, and legs while the patient is counting backwards from 20 (called the ‘activation maneuver'12),” advises Dr Isaacson.
“I would also encourage clinicians to ask specific questions regarding the functional impact of TD. In my experience, the patient may not realize it is their TD that is causing their difficulties with function. They may simply assume they are clumsy or less coordinated for other reasons. They may not appreciate that their movements are a result of their medications and are a treatable condition,” says Dr Kremens.
“I want to find how patients feel about their movements,” adds Ms Matthews. “I had a patient with an AIMS of 3, but her increased rate of blinking was extremely embarrassing as coworkers commented on it at work and she had customers make comments that she needed glasses. Ultimately, this added to her worsening social anxiety,” she describes, noting that clinicians have to dig deeper.