Guidelines for TD screening and routine monitoring of patients on antipsychotic drugs (APDs)

The American Psychiatric Association (APA) recommends1:

  • Clinical assessment for TD at each visit
  • Assessment with a structured instrument, such as AIMS:
  • If a new onset or exacerbation of preexisting movements is
  • At least every 6 months in patients at high risk for TD
  • At least every 12 months in other patients

Improve the assessment process by establishing a collaborative relationship with patients and their carepartners.2

Use AIMS to assess tardive dyskinesia (TD) symptoms

The Abnormal Involuntary Movement Scale (AIMS) is the standard structured assessment for the initial screening and the routine monitoring of TD

The AIMS evaluates symptom severity across 12 items2-6

  • Items 1-7 assess the severity of involuntary movements across body regions
  • Item 8 is based on the highest single score of items 1-7 and may be used independently as an indication of overall severity
  • Items 9 and 10 assess the impact of TD and may be useful in clinical decision-making
  • Items 11 and 12 assess dental issues
Movement Ratings
Facial & Oral
1.Muscles of facial expression
0 1 2 3 4
2.Lips and perioral area
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
5.Upper (arms, wrists, hands, fingers)
0 1 2 3 4
6.Lower (legs, knees, ankles, toes)
0 1 2 3 4
Trunk Movements
7.Neck, shoulders, hips
0 1 2 3 4
Global Judgments
8.Severity of abnormal movements overall
0 1 2 3 4
9.Incapacitation due to abnormal
0 1 2 3 4
10.Patient's awareness of abnormal
0 1 2 3 4
Dental Status
11.Current problems with teeth and/or
No Yes
12.Are dentures usually worn?
No Yes
Scoring items 1-7
Each of the first 7 items is scored on a 0 to 4 scale, rated as6,7:
  • 0: Not present,
  • 1:Minimal, may be extreme normal (abnormal movements occur infrequently and/or are difficult to detect),
  • 2:Mild (abnormal movements occur infrequently and are easy to detect),
  • 3:Moderate (abnormal movements occur frequently and are easy to detect), or
  • 4:Severe (abnormal movements occur almost continuously and/or of extreme intensity)

The sum of items 1-7 is the AIMS total score. This may range from 0 to 28. A decrease in score between visits indicates an improvement in symptoms.7

Ask further questions to identify and evaluate the impact of TD

Beyond the involuntary movements, and regardless of symptom severity, TD can have effects on your patient’s life8-10

Your patient may not even recognize all the ways TD is bothersome in their life, so it’s important to ask them specific questions about symptoms.

An evaluation of impact should include questions related to 3 areas of well-being10-14:

Social factors

Biological and physical factors

Psychological factors

VMAT2 inhibitors—like AUSTEDO—are recommended by the APA as a first-line treatment option for patients impacted by TD1

Watch as patients share the impact of TD on their day-to-day lives

Watch: Social Factors

Patients share how TD has affected their relationships and their interactions with others.

Watch: Biological and Physical Factors

Patients discuss the physical effects of TD.

Watch: Psychological Factors

Patients share how TD symptoms affect their mental state.

No clinical trials have been conducted to demonstrate that treating TD affects the outcomes listed above.

Watch Amber Hoberg, PMHNP-BC, discuss the importance of assessing and managing TD

For more videos, visit the YouTube page for AUSTEDO

It is possible to assess TD quickly, efficiently, and accurately in the telehealth setting14-18

  • Benefits of evaluating patients in the telehealth setting include:
  • Observing patients in their own environments
  • Bringing family members into the conversations
  • Reducing no-show rates

Before the telehealth visit14,19,20

Recommend that a carepartner be present during the visit to assist with camera positioning and other aspects of the examination.

Ask the patient or carepartner to make sure they have the following:

  • A straight-back chair with no arms
  • Enough space to:
  • Sit in a chair for review of movements
  • Walk back and forth while being observed
  • Appropriate lighting
  • Bandwidth to ensure good resolution to see movements

During the telehealth visit

The use of AIMS in the telehealth setting has been validated in a well-constructed reliability study.21,22

  • Assessing 6 of 7 AIMS items can be done with the patient seated, and all 7 AIMS items may be assessed with additional camera positioning5,15
  • Ask questions to uncover TD and determine its impact on the patient’s daily life15,23
  • To assess rigidity, ask the patient if they experience stiffness and observe the patient while they are walking. An absence of arm swing is a clinical sign that there may be rigidity17

Watch Dr. Arvinder Walia demonstrate how to conduct TD virtual assessments

Watch: Long Virtual Assessment

A virtual assessment with full view of the patient’s body.

Watch: Short Virtual Assessment

A virtual assessment without full view of the patient’s body.

VMAT2, vesicular monoamine transporter 2.

REFERENCES: 1. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Schizophrenia. 3rd ed. American Psychiatric Association; 2021. 2. Munetz MR, Benjamin S. How to examine patients using the Abnormal Involuntary Movement Scale. Hosp Community Psychiatry. 1988;39(11):1172-1177. 3. Guy W. ECDEU Assessment Manual for Psychopharmacology. US Department of Health, Education, and Welfare; 1976. 4. STABLE National Coordinating Council Resource Toolkit Workgroup. STABLE Resource Toolkit. Accessed June 9, 2022. STABLE_toolkit.pdf 5. Gharabawi GM, Bossie CA, Lasser RA, Turkoz I, Rodriguez S, Chouinard G. Abnormal Involuntary Movement Scale (AIMS) and Extrapyramidal Symptom Rating Scale (ESRS): cross-scale comparison in assessing tardive dyskinesia. Schizophr Res. 2005;77(2-3):119-128. 6. Abnormal Involuntary Movement Scale (AIMS). Oregon Health & Sciences University website. Accessed June 9, 2022. 7. AUSTEDO® (deutetrabenazine) tablets current Prescribing Information. Parsippany, NJ: Teva Neuroscience, Inc. 8. Aquino CCH, Lang AE. Tardive dyskinesia syndromes: current concepts. Parkinsonism Relat Disord. 2014;20(suppl 1):S113-S117. 9. Cloud LJ, Zutshi D, Factor SA. Tardive dyskinesia: therapeutic options for an increasingly common disorder. Neurotherapeutics. 2014;11(1):166-176. 10. Ascher-Svanum H, Zhu B, Faries D, Peng X, Kinon BJ, Tohen M. Tardive dyskinesia and the 3-year course of schizophrenia: results from a large, prospective, naturalistic study. J Clin Psychiatry. 2008;69(10):1580-1588. 11. Strassnig M, Rosenfeld A, Harvey PD. Tardive dyskinesia: motor system impairments, cognition and everyday functioning. CNS Spectr. 2018;23(6):370-377. 12.Yassa R. Functional impairment in tardive dyskinesia: medical and psychosocial dimensions. Acta Psychiatr Scand. 1989;80(1):64-67. 13. Waln O, Jankovic J. An update on tardive dyskinesia: from phenomenology to treatment. Tremor Other Hyperkinet Mov (N Y). 2013;3:tre-03-161-4138-1. doi:10.7916/D88P5Z71 14. Data on file. Parsippany, NJ: Teva Neuroscience, Inc. 15. Jain R. Can the AIMS exam be conducted via telepsychiatry? Psych Congress Network. Published December 9, 2019. Accessed June 9, 2022. 16. McEvoy JP. The assessment of tardive dyskinesia via telepsychiatry. Published May 4, 2021. Accessed June 9, 2022. 17. Dorsey R, Fahn S, Poplar T. Can we make a new diagnosis and treat Parkinson’s disease by telemedicine? Published March, 2021. Accessed June 9, 2022. cwmandtpdbt.htm#:~:text=Over%2040%25%20of%20people%20with,counseling%20by%20telemedicine%20remains%20unanswered 18. Drerup B, Espenschied J, Wiedemer J, Hamilton L. Reduced no-show rates and sustained patient satisfaction of telehealth during the COVID-19 pandemic. Telemed J E Health. Published online March 5, 2021. doi:10.1089/tmj.2021.0002 19. Citrome L. Treating TD in the COVID-19 era: 5 steps to success. Published June 8, 2020. Accessed June 9, 2022. 20. Cubo E, Mari Z. Telemedicine in your movement disorders practice: how does the COVID-19 crisis affect us. Accessed June 9, 2022. 21. Amarendran V, George A, Gersappe V, Krishnaswamy S, Warren C. The reliability of telepsychiatry for a neuropsychiatric assessment. Telemed J E Health. 2011;17(3):223-225. 22. Shore J, Vo A, Yellowlees P, et al. Antipsychotic-induced movement disorder: screening via telemental health. Telemed J E Health. 2015;21(12):1027-1029. 23. Jackson R. Dr. Richard Jackson on assessing and monitoring TD through telepsychiatry. Psychiatry & Behavioral Health Learning Network. Published June 15, 2020. Accessed June 9, 2022. and-monitoring-td-through-telepsychiatry