Ways to Assess TD

Purple silhouette of person. Light purple icon of person with zigzag lines on each side.

In-person is the ideal scenario for assessing abnormal movements; however, screening for, diagnosing, and assessing tardive dyskinesia (TD) can all be readily done virtually

Blue icon of person with zigzag lines on each side inside a computer screen.

Expert analysis of video recordings of the Abnormal Involuntary Movement Scale (AIMS) have been used as the primary means of measurement in clinical trials

Virtual visit

The need to assess TD is not diminished in the virtual setting

  • Assessing 6 of 7 AIMS items can be readily done during a video call when the patient is seated
  • With additional camera positioning, examination of all 7 AIMS items is possible

Benefits of virtual visits include:

  • You can observe the patient in their own environment
  • You can bring the family members into the conversation
  • Patients may be less likely to miss appointments

FACIAL & ORAL MOVEMENTS

Sketch of head showing 3 sites for movement ratings as areas shaded in purple, with a callout line between the number 1 and the muscles of facial expression, a callout line between the number 2 and the lips and perioral area, and a callout line between the number 3 and the jaw. Sketch of head with tongue protruded and shaded in purple with a callout line between the number 4 and the tongue.

1. Muscles of facial expression

2. Lips and perioral area

3. Jaw

4. Tongue

EXTREMITY MOVEMENTS

Sketch of body with arms and legs highlighted, with a callout line between the number 5 and the right arm and another between the number 6 and the left leg.

5. Upper (arms, wrists, hands, fingers)

6. Lower (legs, knees, ankles, toes)

TRUNK
MOVEMENTS

Sketch of body with neck, shoulders, and torso highlighted in light blue, with a callout line between the number 7 and the shaded area.

7. Neck, shoulders, hips

 
 
 

Telephone calls are not ideal; however, assessment for abnormal movements still needs to be done

  • Focus on asking patients whether they or others around them notice any abnormal movements; if there are movements, ask about impact
  • Start the conversation and, if you suspect TD, follow up in person or via video call
  • Consider asking the patient to have a caregiver record a video, which can be sent for you to review
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PerfecTD:

Pencil and open spiral notebook with √TD written in it.

Question 1 of  

True or False: A patient’s movements can only be assessed during an in-person visit.

 
 
 

Answer: False

You can assess a patient’s movements on a virtual visit, and you can probe about movements on a telephone call.

True or False: Assessing 6 of 7 AIMS items can be readily done during a video call.

 
 
 

Answer: True

Assessing 6 of 7 AIMS items can be readily done during a video call when the patient is seated. With additional camera positioning, examination of all 7 AIMS items is possible.

Thank you for completing

Screening and Assessment: Chapter 4

Virtual Screening and Assessment of TD

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Summary:

Video assessments are widely used to screen for and diagnose TD.

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Hear From the Expert

Visit the overview page to access a video of
Dr Rakesh Jain discussing the critical importance of screening for and assessing TD.

WATCH
Explore the Learning Unit
DIP vs TD

Chapter 4 references

American Psychological Association. https://www.apa.org/practice/guidelines/telepsychology.

Caroff SN et al. J Clin Psychiatry. 2020;81(2):19c12983.

Citrome L. Psychiatry & Behavioral Health Learning Network. https://www.hmpgloballearningnetwork.com/site/pcn/multimedia/treating-td-covid-19-era-5-steps-success.

Dorfman S, Henault F. CMI/Compas. 2020.

Dorsey R et al. International Parkinson and Movement Disorder Society. https://www.movementdisorders.org/MDS/Scientific-Issues-Committee-Blog/cwmandtpdbt.htm.

Fernandez HH et al. Neurology. 2017;88(21):2003-2010.

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.

Jain R. Psych Congress Network. https://www.hmpgloballearningnetwork.com/site/pcn/article/can-aims-exam-be-conducted-telepsychiatry.

Kopelovich SL et al. Community Ment Health J. 2021;57(3):405-415.

McEvoy JP. Clinical Care Options Neurology/Psychiatry. https://www.clinicaloptions.com/neurology-psychiatry/programs/2021/tardive-
dyskinesia/clinicalthought/ct1/page-1.

Srinivasan R. Tremor Other Hyperkinet Mov (N Y). 2020;10.

STABLE National Coordinating Council Resource Toolkit Workgroup. https://provider.medmutual.com/pdf/STABLE_toolkit.pdf.

INDICATIONS AND USAGE

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.

IMPORTANT SAFETY INFORMATION

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.