TD is both underdiagnosed and undertreated, making it essential to screen for movements and systematically and objectively assess their severity and impact.
It is important to screen for TD at every encounter because TD can have a profound impact on many aspects of patients’ lives and can affect the course of the underlying mental health disorder.
About 8.7 million patients were taking APDs in 2022. In a 2020 consensus statement, an expert panel of clinical neurologists and psychiatrists recommended that all patients taking APDs be screened for abnormal movements and assessed for TD at every clinical encounter, regardless of the risk of TD.
There are 4 barriers that fall into 2 categories.
Watch to see how you can build confidence in recognizing TD.
Screening for abnormal movements and assessing for TD at every clinical encounter, regardless of the risk of TD, can be achieved by utilizing a combination of structured assessments, such as the AIMS, and semi-structured assessments.
(Abnormal Involuntary Movement Scale)
AIMS is a structured exam widely used to screen for and identify abnormal movements, including TD.
Conducting an AIMS exam
at regular intervals is considered to be the standard of care
Observe
Ask
The American Psychiatric Association (APA) recommends performing a structured assessment:
Upon initiation of an APD if abnormal involuntary movements are detected during clinical assessment
If a new onset or exacerbation of preexisting movements is detected
A minimum of every 6 months in patients at high risk, including
At least every 12 months in other patients
Which patients are at increased risk?
Patients at increased risk for developing abnormal involuntary movements include people with any of the following characteristics:
A semistructured examination using the concepts of ASK and OBSERVE is the practical approach to ensure that patients receiving APDs are screened for abnormal movements at every clinical encounter. The semistructured approach is informed by the AIMS that is completed when the patient starts on an APD.
Observe the patient in the waiting room and during the exam
“Have you been noticing any abnormal movements?”
Activation is used to distract the patient and help reveal abnormal movements in areas not being activated. Activation can be both physical and cognitive. Explore the differences by clicking below.
Extend their arms straight out in front of their body and count backward from 100
Hands and arms
Patient images used with permission.
Tap thumb to forefinger with both hands, first with the mouth closed, then open
Face and tongue
Patient images used with permission.
Walk in a straight line with their usual gait and posture
Hands, arms, tongue, and face
Patient images used with permission.
Question 1 of
What do you think is the estimated prevalence of TD among patients treated with typical and atypical APDs?
Answer: 30% typical and 7% atypical
The prevalence of TD among patients treated with typical APDs is estimated to be 30% and with atypical APDs is 7%.
True or False: It is a standard of care to use a structured exam like AIMS every 12 months in all patients.
Answer: False
The APA recommends that an exam like the AIMS should be done a minimum of every 6 months in patients at high risk and every 12 months in other patients.
The standard of care is to ask about and observe movements at every clinical encounter, using a combination of semistructured exam and the AIMS at APA-recommended intervals.
What can AIMS be used for? (Select every answer that applies)
Answer: Screen for and assess the severity of abnormal movements and formally document and monitor abnormal movements over time
AIMS is used to screen for, assess the severity of, and monitor abnormal movements.
Although TD can impact the underlying mental health disorder, AIMS does not provide an indication of treatment efficacy and does not identify side effect of APDs other than abnormal movements.
Thank you for completing
Screening and Assessment: Chapter 1
Screening
Summary:
All patients receiving APDs should be screened for abnormal movements at every encounter.
Chapter 1 references
American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia. 3rd ed. Washington, DC: American Psychiatric Association; 2021.
Ascher-Svanum H et al. J Clin Psychiatry. 2008;69(10):1580-1588.
Carbon M et al. J Clin Psychiatry. 2017;78(3):e264-e278.
Caroff SN. Neuropsychiatr Dis Treat. 2019;15:785-794.
Caroff SN et al. J Clin Psychiatry. 2011;72(3):295-303.
Caroff SN et al. J Clin Psychiatry. 2020;81(2):19cs12983.
Caroff SN et al. J Clin Psychopharmacol. 2020;40(3):259-268.
Data on file. Teva Neuroscience, Inc.
Gulko C. Medpage Today. https://www.medpagetoday.com/resource-centers/tardive-dyskinesia-contemporary-approaches/tardive-dyskinesia-tips-conducting-patient-focused-exams/3347.
Guy W. ECDEU Assessment Manual for Psychopharmacology: Revised. Rockville, MD; 1976:534-537.
Jackson R et al. Neuropsychiatr Dis Treat. 2021;17:1589-1597.
Munetz MR, Benjamin S. Hosp Community Psychiatry. 1988;39(11):1172-1177.
AUSTEDO® XR (deutetrabenazine) extended-release tablets and AUSTEDO® (deutetrabenazine) tablets are indicated in adults for the treatment of chorea associated with Huntington’s disease and for the treatment of tardive dyskinesia.
Depression and Suicidality in Patients with Huntington’s Disease: AUSTEDO XR and AUSTEDO can increase the risk of depression and suicidal thoughts and behavior (suicidality) in patients with Huntington’s disease. Balance the risks of depression and suicidality with the clinical need for treatment of chorea. Closely monitor patients for the emergence or worsening of depression, suicidality, or unusual changes in behavior. Inform patients, their caregivers, and families of the risk of depression and suicidality and instruct them to report behaviors of concern promptly to the treating physician. Exercise caution when treating patients with a history of depression or prior suicide attempts or ideation. AUSTEDO XR and AUSTEDO are contraindicated in patients who are suicidal, and in patients with untreated or inadequately treated depression.
Contraindications: AUSTEDO XR and AUSTEDO are contraindicated in patients with Huntington’s disease who are suicidal, or have untreated or inadequately treated depression. AUSTEDO XR and AUSTEDO are also contraindicated in: patients with hepatic impairment; patients taking reserpine or within 20 days of discontinuing reserpine; patients taking monoamine oxidase inhibitors (MAOIs), or within 14 days of discontinuing MAOI therapy; and patients taking tetrabenazine or valbenazine.
Clinical Worsening and Adverse Events in Patients with Huntington’s Disease: AUSTEDO XR and AUSTEDO may cause a worsening in mood, cognition, rigidity, and functional capacity. Prescribers should periodically re-evaluate the need for AUSTEDO XR or AUSTEDO in their patients by assessing the effect on chorea and possible adverse effects.
QTc Prolongation: AUSTEDO XR and AUSTEDO may prolong the QT interval, but the degree of QT prolongation is not clinically significant when AUSTEDO XR or AUSTEDO is administered within the recommended dosage range. AUSTEDO XR and AUSTEDO should be avoided in patients with congenital long QT syndrome and in patients with a history of cardiac arrhythmias.
Neuroleptic Malignant Syndrome (NMS), a potentially fatal symptom complex reported in association with drugs that reduce dopaminergic transmission, has been observed in patients receiving tetrabenazine. The risk may be increased by concomitant use of dopamine antagonists or antipsychotics. The management of NMS should include immediate discontinuation of AUSTEDO XR and AUSTEDO; intensive symptomatic treatment and medical monitoring; and treatment of any concomitant serious medical problems.
Akathisia, Agitation, and Restlessness: AUSTEDO XR and AUSTEDO may increase the risk of akathisia, agitation, and restlessness. The risk of akathisia may be increased by concomitant use of dopamine antagonists or antipsychotics. If a patient develops akathisia, the AUSTEDO XR or AUSTEDO dose should be reduced; some patients may require discontinuation of therapy.
Parkinsonism: AUSTEDO XR and AUSTEDO may cause parkinsonism in patients with Huntington’s disease or tardive dyskinesia. Parkinsonism has also been observed with other VMAT2 inhibitors. The risk of parkinsonism may be increased by concomitant use of dopamine antagonists or antipsychotics. If a patient develops parkinsonism, the AUSTEDO XR or AUSTEDO dose should be reduced; some patients may require discontinuation of therapy.
Sedation and Somnolence: Sedation is a common dose-limiting adverse reaction of AUSTEDO XR and AUSTEDO. Patients should not perform activities requiring mental alertness, such as operating a motor vehicle or hazardous machinery, until they are on a maintenance dose of AUSTEDO XR or AUSTEDO and know how the drug affects them. Concomitant use of alcohol or other sedating drugs may have additive effects and worsen sedation and somnolence.
Hyperprolactinemia: Tetrabenazine elevates serum prolactin concentrations in humans. If there is a clinical suspicion of symptomatic hyperprolactinemia, appropriate laboratory testing should be done and consideration should be given to discontinuation of AUSTEDO XR and AUSTEDO.
Binding to Melanin-Containing Tissues: Deutetrabenazine or its metabolites bind to melanin-containing tissues and could accumulate in these tissues over time. Prescribers should be aware of the possibility of long-term ophthalmologic effects.
Common Adverse Reactions: The most common adverse reactions for AUSTEDO (>8% and greater than placebo) in a controlled clinical study in patients with Huntington’s disease were somnolence, diarrhea, dry mouth, and fatigue. The most common adverse reactions for AUSTEDO (4% and greater than placebo) in controlled clinical studies in patients with tardive dyskinesia were nasopharyngitis and insomnia. Adverse reactions with AUSTEDO XR extended-release tablets are expected to be similar to AUSTEDO tablets.
Please see accompanying full Prescribing Information, including Boxed Warning.