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AAGP TD commentary
Tardive Dyskinesia: A Pervasive Concern in Geriatric Psychiatry

Released: March 21, 2025

Expiration: March 20, 2026

Martha Sajatovic
Martha Sajatovic, MD
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As the population ages, prevalence data of aging-related risk for tardive dyskinesia (TD) becomes of great concern. In this ClinicalThought, Martha Sajatovic, MD, provides a brief overview of the pathology and treatment of TD with an emphasis on older patients.

Tardive Dyskinesia Overview
Tardive dyskinesia (TD) is a syndrome that encompasses a constellation of iatrogenic movement disorders usually caused by prolonged exposure to dopamine receptor–blocking agents (DRBAs), particularly antipsychotic medications prescribed for the management of psychiatric disorders such as schizophrenia or bipolar disorder, as well as an augmentation treatment for major depressive disorder. The use of antipsychotic medications has grown rapidly in the past 2 decades with the wide availability of second-generation antipsychotic drugs, and TD has become an issue of substantial concern for healthcare professionals who treat older people, a subgroup that is known to have a greater risk of developing TD compared with younger people. Prevalence data highlight the aging-related risk for TD: 5.9% in young patients aged 7-21 years receiving DRBAs for 3 months, 20% to 29% in older patients receiving DRBAs for 3 months, and 26% to 67% in patients undergoing long-term DRBA treatment. Unfortunately, the effects of TD include serious medical complications, such as falls and fall-related injuries, as well as negative downstream consequences, such as poor quality of life, stigma, and social isolation.

Risk Factors and Diagnosis of TD
TD occurs within the broader umbrella of movement disorders that can include akathisia, dystonia, buccolingual stereotypies, chorea, tics, and other abnormal involuntary movements. In addition to older age being a significant risk factor for developing TD, other risk factors include a history of previous drug-related extrapyramidal symptoms such as akathisia, dystonia, or parkinsonism; having a substance use or mood disorder diagnosis; and being exposed to higher dosage, duration, and potency DRBAs.

Assessing and diagnosing TD, especially in older people who are prone to other neurologic conditions, can be challenging, and it is important for healthcare professionals to be familiar with the TD differential diagnosis as well as with standardized assessment tools that can identify and evaluate patients at risk for TD. TD-like presentations in older patients include spontaneous (nondrug related) dyskinesias, oral movements from ill-fitting dentures or other dental problems, drug-induced dyskinesia from drugs prescribed in some older people (such as antiparkinsonian agents), restless legs syndrome, and senile chorea. A careful history and neurologic examination can help to parse out a diagnosis of TD vs other movement disorders. Critical differential diagnostic considerations include timing as well as clinical features. For example, onset that is days to weeks after DRBA exposure is more likely to be acute dystonia or akathisia, whereas drug-induced parkinsonism and TD typically occur with weeks to months of DRBA exposure. Structured screening and monitoring, such as the use of the Abnormal Involuntary Movement Scale (AIMS), is a standard of care in supporting and treating people with TD.

Treatment Approaches for TD
Regarding development of an individualized treatment plan for older individuals with TD, there is a body of research on an array of treatment approaches with varying degrees of success and evidence. Although reducing antipsychotic dose or discontinuation of medication in some cases can be successful in minimizing further DRBA exposure, this may not be feasible for many patients, and existing TD may not improve in the absence of focused treatment. Both the American Psychiatric Association (APA) and American Academy of Neurology (AAN) treatment guidelines recommend the use of reversible inhibitors of VMAT2 as first-line treatments for TD. Of importance, it has been noted that anticholinergic medications do not improve—and may even worsen—TD, and anticholinergic agents may cause their own complications in older people, such as cognitive impairment and increased risk of delirium or falls. 

Valbenazine and deutetrabenazine are 2 FDA-approved VMAT2 inhibitors indicated for the treatment of people with TD. For older adults, a once-daily/extended-release formulation of deutetrabenazine was approved by the FDA in 2023. Potentially helpful for older patients who may have swallowing difficulties, in 2024, the FDA approved an oral granule sprinkle formulation of valbenazine intended to be sprinkled on soft food. In vitro research studies have supported the viability of crushing valbenazine formulation that can then be delivered via G-tube. It should be noted that valbenazine sprinkles, however, should not be used with G-tubes. Deutetrabenazine can be given with or without food, but the tablets cannot be crushed, chewed, or broken. Specific treatment needs, such as for older individuals and those who have problems with swallowing, should be considered in the selection and implementation of VMAT2 inhibitors.

Conclusion
In conclusion, TD is a burdensome condition that is becoming more prevalent because of the aging population and increased use of second-generation antipsychotic drugs for psychiatric conditions beyond schizophrenia and bipolar disorder. Healthcare professionals need to be aware of best practices in screening for and monitoring TD, the differential diagnosis regarding other aging-related conditions, and available care options, including VMAT2 inhibitors, that can help to reduce physical and social complications related to TD and to advance care for people living with psychiatric illnesses.

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