Tardive Dyskinesia (TD):
Screening Is Crucial for Patients
Taking APDs

All patients taking APDs—both typical and atypical—are at risk of developing TD. In fact, TD occurs in as many as 1 in 3 patients taking typical APDs and 1 in 5 patients taking atypical APDs.

 

However, TD remains both underdiagnosed and undertreated, making it essential to screen for movements systematically and objectively assess their severity and impact.

 

It is important to screen for TD at every encounter in patients taking APDs because TD can have a profound impact on many aspects of patients’ lives and can affect the course of the underlying mental health disorder.

Undiagnosed or misdiagnosed ~ 85% Diagnosed ~ 15% Receive VMAT2 inhibitors < 6%

VMAT2, vesicular monoamine transporter 2.

Screen for TD at Every
Clinical Encounter

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.

patients were taking APDs in 2022 ~8.7 million

Clinicians May Fail to Appreciate Subtle Presentations of Symptoms

Psychiatry providers are often focused on listening to their patients, rather than carefully observing them.

Click to listen to a patient with TD

 

If the clinician is focused on listening, they may fail to identify subtle movements in their patients.

Click to see and hear the patient

 

Even very subtle movements can have a significant impact on patients.

Click to observe the patient

 

It is important to OBSERVE and ASK ABOUT movements in all patients taking APDs at every clinical encounter

Structured and Semistructured Exams Can Be Used
to Screen for Movements

Screening for abnormal movements and assessing TD at every clinical encounter, regardless of the risk of TD, can be achieved through a combination of structured assessments, such as the AIMS, and semi-structured assessments. Visual assessment of movements is sufficient for the clinician to diagnose TD.

AIMS

(Abnormal Involuntary Movement Scale)

AIMS is a structured exam widely used to screen for and identify abnormal movements, including TD.

  • Screen for and identify abnormal movements systematically
  • Assess the severity of abnormal movements
  • Monitor change in movements over time or with treatment

Conducting an AIMS exam
at regular intervals is considered to be the standard of care

Download AIMs

Semistructured exams

Blue icon of an eye inside a blue circle.

Observe

Two purple speech bubbles, one with a question mark inside, surrounded by a purple circle.

Ask

When to Perform an AIMS Assessment

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

6 mo

A minimum of every 6 months in patients at high risk

  • High cumulative exposure to APDs
  • Age >55 years
  • Mood disorder
  • Other movement disorders, including drug-induced parkinsonism
12 mo

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:

  • High cumulative exposure to antipsychotic medications, particularly high-potency dopamine D2 receptor antagonists
  • Older than 55 years of age
  • Women
  • Mood disorder, substance abuse disorder, intellectual disability, and/or central nervous system injury
  • Acute dystonic reactions, clinically significant parkinsonism, and/or akathisia

Performing a Semistructured Exam

A semistructured examination using the concepts of OBSERVE and ASK 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. If a semistructured exam suggests TD, a full AIMS exam may be warranted.

OBSERVE

Blue icon of an eye inside a blue circle.

Observe the patient in the waiting room and during the exam

  • Have them open their mouth and stick their tongue out
  • Use activation maneuvers to unmask movements

ASK

Two purple speech bubbles, one with a question mark inside, surrounded by a purple circle.

“Have you been noticing any abnormal movements?”

  • Ask this of the patient as well as their family, caregivers, and friends. Patients may not be aware of their abnormal movements

Physical or Cognitive Activation Maneuvers Can Unmask TD

Activation is used to distract the patient and help reveal abnormal movements in areas not being activated. Activation can be accomplished using physical and/or cognitive tasks. Explore the different activation maneuvers by clicking below.

ASK THE PATIENT TO . . .

Extend their arms straight out in front of their body and count backward from 100

OBSERVE THEIR . . .

Hands and arms

 

Patient images used with permission.

ASK THE PATIENT TO . . .

Tap thumb to fingertips with both hands, first with the mouth closed, then open

OBSERVE THEIR . . .

Face and tongue

 

Patient images used with permission.

ASK THE PATIENT TO . . .

Walk in a straight line with their usual gait and posture

OBSERVE THEIR . . .

Hands, arms, tongue, and face

 

Patient images used with permission.

Overcoming Barriers to the Screening and Assessment of TD

Understanding the need to screen for TD at every clinical encounter and building a degree of confidence in the assessment of TD is a critical step toward improving care for patients.

 
White play video icon inside blue circle.

Watch to see how you can build confidence in recognizing TD.

Orange globe icon inside an orange circle.

PerfecTD:

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

Question 1 of  

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 observe and ask about 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 effects of APDs other than abnormal movements.

Thank you for completing

Screening and Assessment: Chapter 1

Screening

Orange clipboard with checkmarks next to 3 lines, surrounded by an orange circle.

Summary:

All patients receiving APDs should be screened for TD at every encounter.

Explore the Next Chapter
AIMS

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. Parsippany, NJ.

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.

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.