TD Management

Screening, Diagnosis, & Assessment

Use AIMS to monitor for and assess tardive dyskinesia (TD) symptoms

Guidelines for screening and routine monitoring of patients on antipsychotic drugs (APDs)1

The American Psychiatric Association (APA) recommends1:

  • Clinical assessment for TD at each visit1
  • Assessment with a structured instrument, such as AIMS (Abnormal Involuntary Movement Scale)1:
  • 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

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

Abnormal Involuntary Movement Scale

Movement Ratings
Score
Facial & Oral
Movements
1.Muscles of facial expression
0 1 2 3 4
2.Lips and perioral area
0 1 2 3 4
3.Jaw
0 1 2 3 4
4.Tongue
0 1 2 3 4
Extremity
Movements
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
movements
0 1 2 3 4
10.Patient's awareness of abnormal
movements
0 1 2 3 4
Dental Status
11.Current problems with teeth and/or
dentures?
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

Use the TD Estimator Tool to see how many patients in your practice may have TD

Semistructured assessments may be used in between formal AIMS assessments1,8

Semistructured assessments may include1,8:

  • Patient recognition of abnormal movements when reviewing APD side effects
  • Visual observations during examination
  • Patient or carepartner report of abnormal movements
  • Patient complaints of movements being distressful or interfering with daily life

If the semistructured assessment reveals abnormal movements, a full AIMS assessment should be performed.1,8​

Screening for abnormal movements can be accomplished by observation of cognitive and physical activation maneuvers2,9

A man sitting on a chair with arms held out front of him.

Ask the patient to:

Extend arms in front of the body and count backwards from 100

Observe:

Hands and arms

  • Cognitive activation maneuvers help to distract the patient and reveal abnormal movements2,10,11
  • These mental tasks should be adapted based on the patient’s cognitive abilities and knowledge
  • Additional cognitive activation maneuvers can include counting backwards by serial 7’s (eg, 100, 93, 86, etc.), reciting the alphabet backwards, and naming the months in reverse order
Two hands in different positions.

Ask the patient to2,9:

Hold mouth open and stick tongue out while tapping thumb to forefinger with both hands

Observe:

Tongue and face

Feet in midwalk.

Ask the patient to2,9:

Walk in a straight line with usual gait and posture

Observe:

Hands, arms, tongue, and face

Assessing TD quickly, efficiently, and accurately in the telehealth setting10,12,13

Benefits of evaluating patients in the telehealth setting include14-16:

  • Observing patients in their own environments
  • Bringing family members into the conversations
  • Reducing no-show rates

Before the telehealth visit10,17,18

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.13,19

  • Assessing 6 of 7 AIMS items can be done with the patient seated, and all 7 AIMS items may be assessed with additional camera positioning3,4,12
  • Ask questions to uncover TD and determine its impact on the patient’s daily life10,20
  • 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 rigidity15,17

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.

Differentiating between TD and drug-induced parkinsonism (DIP) matters

The wrong treatment could lead to a worsening of symptoms21

Considerations for differential diagnosis
TD DIP

Nature of movements

Movements are irregular, unpredictable, jerky and twitchy21,22

Movements are rhythmic21,22

Degree of movements

Movements are excessive and continuous23

Overall paucity of movements24

Degree of muscle tone

Despite movements, patients have normal muscle tone10

Movement can be accompanied by rigidity10

Mechanism

Dopamine blockage upregulates dopamine receptors and increases the potential for erratic dopamine signaling21

Dopamine blockage reduces dopamine signaling21

Timing of onset

Delayed-usually occurs months or years following administration of APD therapy21

Acute-usually occurs within days or weeks following administration of APD therapy or increase of dose21

See DSM-5 diagnostic criteria and interventions:

For tardive dyskinesia

Involuntary athetoid or choreiform movements, generally of the tongue, lower face and jaw, and extremities21

After using an APD for at least a few months:

  • Elderly patients may develop TD symptoms in a shorter period of time21
  • In some patients, movements may appear after discontinuation or after a change or reduction in dosage. If symptoms persist for longer than 4 to 8 weeks, it is considered TD22

Interventions

  • APD reduction/withdrawal may fail to improve or may induce withdrawal dyskinesia21,22
  • VMAT2 inhibitors are indicated in adults for the treatment of TD21
  • VMAT2 inhibitors may cause or further worsen parkinsonism21
For drug-induced parkinsonism

Within a few weeks of:

  • Starting an APD21
  • Increasing the dosage of an APD21
  • Reducing the dosage of a medication used to treat EPS, such as an anticholinergic22
 

Patient may develop one or more of the following:

  • Parkinsonian tremor (rhythmic and faster than TD movements)22
  • Muscular rigidity22
  • Akinesia22
  • Bradykinesia22

Interventions

  • APD reduction/withdrawal may improve or resolve DIP21
  • Anticholinergics are indicated for the treatment of parkinsonism21,22,25
  • Anticholinergics may worsen TD symptoms and are not recommended in patients with TD21,22,25

Visit the YouTube page to view Demystifying EPS, a 3-part series on the importance of differential diagnosis.YouTube play icon

Assessing the impact of TD is imperative for optimal management

  • The overall impact of TD on key functional domains—social, physical, vocational, and psychological/psychiatric—should be assessed at every patient visit20
  • The degree of impact helps determine the urgency with which symptoms should be addressed20

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

Find treatment guidelines

Download the IMPACT-TD Scale, which was developed by a consensus panel to evaluate how TD affects patients’ lives

No clinical trials have been conducted to demonstrate that treating TD affects the outcomes on this page.

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. ECDEUAssessment 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. https://provider.medmutual.com/pdf/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. https://www.ohsu.edu/sites/default/files/2019-10/%28AIMS%29%20Abnormal%20Involuntary%20Movement%20Scale.pdf 7. AUSTEDO® XR (deutetrabenazine) extended-release tablets and AUSTEDO® current Prescribing Information. Parsippany, NJ: Teva Neuroscience, Inc. 8. Caroff SN, Citrome L, Meyer J, et al. A modified Delphi consensus study of the screening, diagnosis, and treatment of tardive dyskinesia. J Clin Psychiatry. 2020;81(2):19cs12983. doi:10.4088/JCP.19cs12983 9. Abdo WF, van de Warrenburg BPC, Burn DJ, Quinn NP, Bloem BR. The clinical approach to movement disorders. Nat Rev Neurol. 2010;6(1):29-37. 10. Data on file. Parsippany, NJ: Teva Neuroscience, Inc. 11. Tardive Dyskinesia: Tips on Conducting Patient-Focused Exams - Tardive Dyskinesia: Contemporary Approaches. www.medpagetoday.com. Accessed December 2, 2022. https://www.medpagetoday.com/resource-centers/tardive-dyskinesia-contemporary-approaches/tardive-dyskinesia-tips-conducting-patient-focused-exams/3347 12. Jain R. Can the AIMS exam be conducted via telepsychiatry? Psych Congress Network. Published December 9, 2019. Accessed June 9, 2022. https://www.hmpgloballearningnetwork.com/site/pcn/article/can-aims-exam-be-conducted-telepsychiatry 13. 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. 14. McEvoy JP. The assessment of tardive dyskinesia via telepsychiatry. Published May 4, 2021. Accessed June 9, 2022. https://www.clinicaloptions.com/neurology-psychiatry/programs/2021/tardive-dyskinesia/clinicalthought/ct1/page-1 15. 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. https://www.movementdisorders.org/MDS/Scientific-Issues-Committee-Blog/cwmandtpdbt.htm#:~:text=Over%2040%25%20of%20people%20with,counseling%20by%20telemedicine%20remains%20unanswered 16. 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 17. Citrome L. Treating TD in the COVID-19 era: 5 steps to success. Published June 8, 2020. Accessed June 9,2022. https://www.hmpgloballearningnetwork.com/site/pcn/multimedia/treating-td-covid-19-era-5-steps-success 18. Cubo E, Mari Z. Telemedicine in your movement disorders practice: how does the COVID-19 crisis affect us. Accessed June 9, 2022. https://www.movementdisorders.org/MDS-Files1/Education/Webinars/Webinar_FINAL2.pdf 19. 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. 20. Jackson R, Brams MN, Citrome L, et al. Assessment of the impact of tardive dyskinesia in clinical practice: consensus panel recommendations. Neuropsychiatr Dis Treat. 2021;17:1589-1597. 21. Ward KM, Citrome L. Antipsychotic-related movement disorders: drug-induced parkinsonism vs. tardive dyskinesia—key differences in pathophysiology and clinical management. Neurol Ther. Published online July 19, 2018. doi:10.1007/s40120-018-0105-0 22. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. 23. Caroff SN. Overcoming barriers to effective management of tardive dyskinesia. Neuropsychiatr Dis Treat. 2019;15:785-794. 24. Patel T, Chang F. Practice recommendations for Parkinson’s disease: assessment and management by community pharmacists. Can Pharm J (Ott). 2015;148(3):142-149. 25. 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