Back Back
Tardive Dyskinesia in Long-Term Care
Tardive Dyskinesia in Long-Term Care: Nuances in Detection and Management

Released: April 25, 2024

Expiration: April 24, 2025

Sanjay Gupta
Sanjay Gupta, MD
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • Tardive dyskinesia (TD) in the long-term care (LTC) setting is often missed and not treated. Modification of the AIMS screening tool may be needed to detect TD in LTC residents who are in wheelchairs and unable to ambulate.
  • The use of antipsychotic agents is inevitable in patients with severe mental illnesses such as schizophrenia and bipolar disorder, increasing the risk of TD.
  • Age, along with a history of mood disorder, is a significant risk factor for TD.
  • Exposure to antipsychotics for as little as 1 month may result in TD.

Tardive dyskinesia (TD) is a potentially irreversible movement disorder involving the orofacial region, trunk, and limbs with exposure to antipsychotic agents. The duration of exposure can be as little as 4 weeks, and individuals with mood disorders and neurologic side effects such as extrapyramidal symptoms have increased susceptibility. Tardive dyskinesia was first described by Schonecker in 1957.

The “silver tsunami” of aging baby boomers within the healthcare system has impacted long-term care (LTC) facilities significantly, including an increase in LTC admissions of patients treated with antipsychotic medications for chronic psychiatric disorders such as schizophrenia and bipolar illness. In the US, there has been a sharp increase in the use of second-generation antipsychotics (SGAs) for the treatment of bipolar disorder, while mood stabilizer and lithium use has declined. In addition, SGAs (eg, aripiprazole) have been widely used for augmentation of antidepressants to treat major depressive disorder. Furthermore, psychotic symptoms, agitation, and aggression in residents with major neurocognitive disorders such as dementia have resulted in the prescription of antipsychotic agents.

Until the recent approval of brexpiprazole in May 2023, there were no FDA-approved agents for managing agitation in patients with dementia. However, SGAs are commonly used off-label for this purpose in LTC. The first-generation antipsychotic (FGA) haloperidol is also used due to its familiarity and multiple formulations (tablet, liquid, and parenteral forms). Altogether, many patients in LTC require treatment with these agents, making detection and management of TD essential.

In older adults, TD can result with just 1 month of exposure to an antipsychotic, with a greater risk associated with FGAs vs SGAs (approximately 30% vs 7%, respectively). To address this risk in LTC, the Centers for Medicare and Medicaid Services have strict rules (F-329) regarding antipsychotic prescriptions and the need for gradual dose reduction. Facilities are regularly evaluated, with one of the parameters being off-label antipsychotic use and side effect monitoring. However, there are still areas where LTC homes can improve, both in terms of monitoring for TD and in mitigating TD risk factors.

Coordination of care among multiple physicians and advanced practice providers in the LTC setting coupled with high turnover and frequent shortages of staff often leads to prescription of psychotropic medications without clear documentation or precise algorithm. Judicious use of antipsychotics in LTC must follow a clear rationale, such as the treatment of delusions or aggression/agitation where nonpharmacologic approaches have failed, or indication for long-term treatment of schizophrenia. Often, residents are cognitively impaired and unable to give informed consent, which highlights the need for involvement of the healthcare proxy in shared decision-making.

The gold standard for TD monitoring is the Abnormal Involuntary Movement Scale (AIMS), but a high prevalence of LTC residents cannot ambulate and require use of wheelchairs and Hoyer lifts, resulting in problems completing this assessment. To ensure the AIMS is performed, there is a need to modify the protocols on a case-by-case basis. For example, in the case of a nonambulatory resident, HCPs can omit the walking portion, but should focus on the face, lips, and tongue, which comprise 4 items on the AIMS. In fact, TD is commonly detected in these areas first. In an ambulatory resident, the assessor must also be cognizant of the fall risk when performing the walking task. It is helpful for multiple care team members to be aware of TD and its commonly seen manifestations, so those who spend a significant amount of time with the residents can raise the TD alarm for verification by a formally trained individual. “What the mind does not know, the eyes will not see”.

The 2017 FDA approvals of 2 VMAT2 inhibitors, valbenazine and deutetrabenazine, marked a tremendous accomplishment for the care of patients with TD. Both agents have demonstrated efficacy for the treatment of TD, with no head-to-head comparison studies between the two. The initial titration schedule of valbenazine (1 week to recommended therapeutic dose) is simpler compared to deutetrabenazine, which may require several weeks to reach the therapeutic dose. Both medications are available with once daily dosing, following the recent introduction of an extended-release formulation of deutetrabenazine. Both are costly, but discounted pricing may result in the selection of one over the other in some situations.

Anticholinergic agents (eg, benztropine, trihexyphenidyl) are appropriate for the treatment of some movement disorders associated with antipsychotic exposure, such as parkinsonism and acute dystonia, and are commonly also used to treat TD. However, evidence has shown that these agents can in fact worsen TD, as well as cause cognitive and functional impairment in patients with schizophrenia and increase the risk of delirium in older adults.

In summary, there is a critical need for LTC staff education regarding TD, with a goal of early identification and treatment. Antipsychotic agents should be used judiciously and according to label indications; off-label use should target symptoms and follow gradual dose reduction recommendations. The AIMS should be modified on an individual basis, driven by the resident's debility. Treat TD early with a VMAT2 inhibitor and minimize the total anticholinergic load. Involve healthcare proxies in the shared decision-making process when appropriate.

Your Thoughts?
How do you approach assessment and treatment of TD in your practice? What have been your experiences regarding dosing, adverse events, and adherence with VMAT2 inhibitors? What factors have guided your choice of agent? What questions or concerns do you frequently hear from your patients? Join the discussion by leaving a comment below!

Continue

Poll

1.

How comfortable are you treating patients with TD in LTC settings?

Submit