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Tardive Dyskinesia in Special Populations
Expert Opinion on the Impact and Management of Tardive Dyskinesia in Special Populations

Released: August 03, 2023

Stuart Isaacson
Stuart Isaacson, MD
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Key Takeaways
  • The impact of tardive dyskinesia (TD) on a patient can be variable depending on how the movements affect an individual’s daily activities including socially, psychologically, and physically.
  • Minor movements or minor changes in movement can have a significant impact on a patient’s daily activities. There are many areas—such as an individual’s hobbies, social activities, work, or schooling—that should be taken into consideration when assessing the impact of TD.
  • Although TD is largely irreversible, VMAT2 inhibitors are safe, effective, and tolerable first-line therapies that reduce TD movements and can improve a patient’s quality of life.

Dr Stuart Isaacson of the Boca Raton Institute for Neurogenerative Disorders answers questions regarding Tardive dyskinesia (TD) in special populations and discusses whether certain patient populations are at higher risk, the variable effect of TD on certain populations, what factors must be taken into consideration when assessing the impact of TD on an individual, and what management options are available.

Who should be screened for TD?

Stuart Isaacson, MD:
Tardive dyskinesia (TD) is a highly prevalent condition that is underrecognized and often undertreated. We should screen any patient who has been exposed to or is currently taking a medication that blocks the postsynaptic dopamine D2 receptor. These include antipsychotics and some gastric motility agents.

Are certain patient populations at higher risk?

Stuart Isaacson, MD:
Although we should screen all patients who have been exposed to antipsychotics and similar drugs for TD, certain populations are at higher risk of developing TD and should be screened more frequently. These include women, elderly patients (especially elderly women), patients who have been exposed to certain medications such as stimulants, and patients that are using illicit drugs. In addition, patients who have mood disorders and have been exposed to an antipsychotic are at increased risk compared to other populations. 

Does TD impact certain populations differently?

Stuart Isaacson, MD:
The impact of TD on a patient can vary significantly. In some patients it may not have a large impact, but in many patients the impact is greater than we realize. Considering how TD impacts certain activities is crucial to understanding its impact on a patient’s life. For instance, an elderly person whose TD movements affect their legs while they’re standing or walking could be at increased risk of falling. If TD movements affect a patient’s arms, they may have difficulty buttoning their shirt or grooming and may require assistance at home. Younger patients could be at risk of losing their job or having their job curtailed if their TD interferes with their ability to use a pen or mouse, or their ability to use their fingers. Furthermore, TD can affect a patient's hobbies and social activities regardless of age by making it difficult to perform certain tasks, such as shuffling a deck of cards.

Whenever we assess a patient for TD we should also be assessing the impact TD is having on their lives. TD can also exacerbate underlying psychiatric conditions, such as depression. Studies have suggested that patients with schizophrenia and TD experience worse outcomes compared to those without TD. At work or school, TD may make an individual appear unfocused or distracted or can cause individuals to become isolated due to social embarrassment. There are many different areas where we must query patients to understand if they’re aware of the movements, and how these movements are affecting them socially, psychologically, physically, and in relation to their jobs and schooling.

Do specific comorbidities result in a poorer outcome?

Stuart Isaacson, MD:
Patients who take stimulants or use illicit drugs have a higher risk of developing TD and may experience accentuated TD movements when they have these medications in their body. People who have mood disorders are at higher risk of developing TD, and having TD may likewise exacerbate their mood disorders. TD may also result in poorer outcomes in people using multiple medications simultaneously—particularly the elderly—if their TD movements make it difficult to handle pills, leading to missed doses. There are many conditions in individual patients that can influence TD and that TD can influence correspondingly.

What management options are available for TD?

Stuart Isaacson, MD:
Unfortunately, until 5 or 7 years ago, we had very few options for our patients with TD. There were no approved treatments so we would most commonly either ask our patients to live with their movements despite the impact on their daily lives, switch to a less potent dopamine receptor blocking agent, or lower their current dose. However, for patients with mental illness, these medications are often life-changing, if not life-saving, despite their side effects, including TD. In these cases, it may be best not to change the underlying medication, but to treat the movement. Fortunately, with the advent of VMAT2 inhibitors, we now have a way of managing our patients. VMAT2 inhibitors are first‑line medications that reduce TD movements and allow patients to mitigate the effects of those movements on their daily lives, often without significant side effects.

When would you consider using a VMAT2 inhibitor?

Stuart Isaacson, MD:
I think most patients should consider trying a VMAT2 inhibitor to see how they could benefit from treatment, as this condition is largely irreversible. It may wax and wane, but it’s going to persist. Luckily, the VMAT2 inhibitors that have been approved for the treatment of TD have demonstrated tolerability and are now first‑line therapy.  They are reversible, so they can be tried for a few months if someone is hesitant to commit to long‑term therapy. After a few months, the patient can assess the improvement in their daily activities, taking into consideration the social, psychological, and effects on their job or hobbies before making a decision on whether to continue this therapy in the long term. Most patients do choose to continue these medications because of the benefits.

Are there differences between VMAT2 inhibitors?

Stuart Isaacson, MD:
I think it is good that we have choices now to treat TD that have been approved by the FDA. The 2 approved agents are different molecules and may exhibit differential efficacy or tolerability for individual patients. The agents that are taken once a day are preferable to ones taken multiple times a day. In addition, for some patients a simpler dose titration can be effective, while other patients may find it more helpful to have the option of flexible doses where they have efficacy balanced with tolerability.

Any further comments?

Stuart Isaacson, MD:
Assessing TD can be difficult. Recently, a scale was proposed that considers how TD movements can impact different areas of patients’ lives. Hopefully, we’ll soon have tools that help us better recognize patients with this highly prevalent condition. This will help us assess the impact of TD on the daily lives of individuals, facilitate shared decision-making on using VMAT2 inhibitors to treat these symptoms, and further enable us to assess how to lessen the impact of TD.

Your Thoughts?
How has the impact of TD differed across your patient populations? What are challenges do you face in assessing the impact of TD on an individual? Answer the polling question and leave a comment to join the discussion.

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