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Department of Psychiatry and Behavioral Sciences
New York Medical College
Valhalla, New York
Leslie Citrome, MD, MPH: speaker/consultant: AbbVie/Allergan, Acadia, Adamas, Alkermes, Angelini, Astellas, Avanir, Axsome, BioXcel, Boehringer Ingelheim, Cadent, Cerevel, COMPASS, Eisai, Enteris BioPharma, HLS Therapeutics, Impel, INmune Bio, Intra-Cellular Therapies, Janssen, Karuna, Lundbeck, Lyndra, Medavante-ProPhase, Merck, Neurocrine, Novartis, Noven, Otsuka, Ovid, Praxis, Relmada, Reviva, Sage, Sunovion, Supernus, Takeda, Teva; ownership interest: Bristol-Myers Squibb, Johnson & Johnson, Lilly, Merck, Pfizer, Reviva (options only).
Tardive dyskinesia (TD) is not rare. As per the definition in the newly published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Text Revision (DSM-5-TR), TD is manifested by abnormal, involuntary movements of the tongue, jaw, trunk, or extremities that develop in association with the use of medications that block postsynaptic dopamine receptors, such as first-generation and second-generation antipsychotic medications, and other medications such as metoclopramide for gastrointestinal disorders. These movements—which may be choreiform (ie, rapid, jerky, nonrepetitive), athetoid (ie, slow, sinuous, continual), or semirhythmic (ie, stereotypies) in nature—must be present over a period of at least 4 weeks, and there must be at least 3 months of history (or 1 month in individuals aged 60 or older) of the use of the offending agent. The DSM-5-TR spells out that TD movements are distinctly different from the rhythmic (3-6 Hz) tremors commonly seen in drug-induced parkinsonism; however, the 2 can coexist. It is imperative to distinguish drug-induced parkinsonism from TD because the treatments commonly used to manage parkinsonism (ieg, anticholinergic medications) can worsen the abnormal motor movements associated with TD.
When evaluating people with TD, it is helpful to think of the different domains that may be impacted by TD: social, physical, vocational, psychological, and psychiatric. Examples of how each of these domains may be affected are listed below.
The Abnormal Involuntary Movement Scale (AIMS) is foundational in the assessment and treatment of TD. This is an observer-rated 12-item anchored scale that takes 5-10 minutes to complete. Items 1-7 of the AIMS involve measurement of dyskinetic movements, 4 of which are dedicated to the face, lips, jaws, and tongue. The other 3 items are each used to rate observed dyskinetic movements in the upper extremities, lower extremities, and trunk. Each item is scored from 0-4, with 0 equaling no movements, 1 equaling minimal or extreme normal, 2 equaling mild, 3 equaling moderate (and obvious to the untrained eye), and 4 equaling severe. The sum of the scores of these 7 items is the total dyskinesia score; this can range from 0-28, but a score of 28 is theoretical.
Of note, the total dyskinesia score is not as informative a measure of severity as are the individual item scores. For example, a total dyskinesia score of 7 would not be of great concern if all the individual items scored as a 1. However, a total dyskinesia score of 7 that results from one item score of 4 and another item score of 3 would represent a potentially very severe case. To resolve this problem, we need to examine each item individually when assessing and managing patients with TD.
We also can make use of item 8 on the AIMS—the Global Judgment for Severity of Abnormal Movements. This item is based on the highest single score on items 1-7 and could be scored even higher depending on the individual circumstances of the patient.
There are 2 other global ratings: one regarding incapacitation due to abnormal movements (think of the impact on the different domains mentioned above) and another regarding the patient's awareness (and distress level) of the abnormal movements. It is not unusual for persons with schizophrenia to have little or no insight into their dyskinetic movements; however, patients with mood disorders may be better able to articulate their distress.
The last 2 items of the AIMS are yes or no questions regarding dentition status and the use of dentures. Note that people with TD who wear dentures often have problems with them.
The AIMS includes using activating maneuvers such as thumb/finger tapping and walking to elicit abnormal movements in other body areas. An additional activation maneuver that can be used is a cognitive task while the patient is standing with their arms extended, such as asking the patient to count backward from 100 or to recite the months of the year in reverse order. Activated movements are scored in the same way as movements observed without activation. Do not lower the rating for a dyskinetic movement observed only during activation, as was done in the past. Score the highest amplitude or frequency observed in a movement on the 0-4 scale, not the average.
Note that the instructions for the AIMS also include an assessment of upper extremity rigidity by flexing and extending the patient's arms, as well as observation of gait. These 2 assessments are not rated on the AIMS form, but findings from these actions may be helpful when determining if the patient has drug-induced parkinsonism and/or TD.
With the exception of assessing rigidity, we can do most of the above assessments with telehealth platforms. It is useful for the patient to have a helper to angle the camera so that all body parts can be evaluated, including the feet and toes. Obtaining an asynchronous AIMS is also an option; teach the patients how to complete the procedures (and give instruction sheets) so they can record themselves completing these movements and send it to you at a later date. This can be beneficial because TD symptoms are variable and may wax and wane. With an asynchronous approach, patients can catch bad days.
Additional benefits of asynchronous AIMS are that it can save time during routine visits and can overcome technology barriers (ie, low internet speed or poor connection). Completing a remote AIMS examination also may be advantageous in terms of patient and provider comfort. For example, as the provider, you can stare directly at the patient’s face for 10-15 seconds to assess dyskinesia without the awkwardness that may be present in an in-person setting. When asking to observe the patient’s feet without shoes and socks, a remote AIMS may quell patient fear or embarrassment over hygiene or smell. (To mitigate this in live visits, I will warn the patient or caregiver that the patient will need to remove shoes and socks at the next visit as part of the routine motor assessment.)
The bottom line is that TD is common and exists in your practice. Screen for it. The AIMS and questions about functional impact should be used to measure TD at baseline and to guide ongoing treatment and follow-up. We have pharmacologic agents that may be of benefit to patients with TD, but their clinical use is rendered moot if TD goes unrecognized and unmonitored.
What are your thoughts and questions on using the AIMS exam to identify and assess TD? Please answer the polling question and join the conversation by posting a comment in the discussion section below.