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

The American Psychiatric Association (APA) recommends1:

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  • 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
    detected
  • 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

APA guidelines recommend VMAT2 inhibitor as first-line treatment for TD, regardless of severity1

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
symptoms1-3

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

AIMS Table that measures tardive dyskinesia (TD) symptom severity. AIMS Table that measures tardive dyskinesia (TD) symptom severity.

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

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

For more TD Talks videos, visit the YouTube page for AUSTEDO

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:

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Social factors

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Biological and physical factors

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Psychological factors

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.

There is no evidence that treating TD affects the outcomes above.

It is possible to assess TD quickly, efficiently, and accurately in the telehealth setting15,16

  • In-person assessments should be utilized when possible15,17
  • Regardless of the setting, the standard of care should be maintained16,18
  • Any assessment-related limitations should be documented
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Before the telehealth visit16,19,20

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
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During the telehealth visit

AIMS may be used to effectively assess your patient in the telehealth setting.17,21

  • AIMS scoring should be used when rating severity of symptoms in a semi-structured assessment, as it is necessary for payer coverage16
  • Document the impact of TD on the patient’s daily life18
  • If a helper is not available to assist in camera positioning or if video resolution is poor, you may need to rely on the patient’s responses to evaluate certain areas of the body16
  • To assess rigidity, observe the patient while they are walking. An absence of arm swing is a clinical sign that there may be rigidity19
FIND TREATMENT GUIDELINES

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.

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: Revised, 1976. Rockville, MD: US Department of Health, Education and Welfare, Public Health
Service, Alcohol, Drug Abuse and Mental Health Administration, NIMH Psychopharmacology Research Branch, Division of Extramural Research Programs; 1976. DHEW publication number ADM 76-338. 4. STABLE Resource Toolkit. STABLE
National Coordinating Council Resource Toolkit Workgroup. https://
provider.medmutual.com/pdf/STABLE_toolkit.pdf Accessed July 8, 2020. 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. https://www.ohsu.edu/sites/default/files/
2019-10/%28AIMS%29%20Abnormal%20Involuntary%20
Movement%20Scale.pdf Accessed October 24, 2020. 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. Caroff SN. Overcoming barriers to effective management of tardive dyskinesia. Neuropsychiatr Dis Treat. 2019;15:785-794. 14. Waln O, Jankovic J. An update on tardive dyskinesia: from phenomenology to treatment. Tremor Other Hyperkinet Mov (NY). 2013;3:tre-03-161-4138-1. 15. Jain R. Can the AIMS exam be conducted via telepsychiatry? https://www.psychcongress.com/article/can-aims-exam-be-conducted-telepsychiatry. Published December 9, 2019. Accessed October 24, 2020. 16. Data on file. Parsippany, NJ: Teva Neuroscience, Inc. 17. 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. 18. Jackson R. Dr. Richard Jackson on assessing and monitoring TD through telepsychiatry. Psychiatry & Behavioral Health Learning Network. June 15, 2020. https://www.psychcongress.com/multimedia/dr-richard-jackson-assessing-and-monitoring-td-through-telepsychiatry. Accessed October 24, 2020. 19. Citrome L. Treating TD in the COVID-19 era: 5 steps to success. https://www.psychcongress.com/multimedia/treating-td-covid-19-era-5-steps-success. Published June 8, 2020. Accessed October 24, 2020. 20. Cubo E, Mari Z. Telemedicine in your movement disorders practice: how does the COVID-19 crisis affect us. https://
www.movementdisorders.org/MDS/Education/
Workshops-Conferences/MDS-Webinars/Telemedicine-for-Movement-Disorders-during-the-COVID-19-crisis-How-does-this-affect-us.htm. Accessed October 24, 2020. 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.