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TD 2024 CT2
Tardive Dyskinesia: How to Help Your Patients Manage an Aging-Related Risk

Released: July 16, 2024

Expiration: July 15, 2025

Martha Sajatovic
Martha Sajatovic, MD
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Key Takeaways
  • Aging trends and growing use of antipsychotic medications are rapidly increasing the number of patients at risk for developing tardive dyskinesia (TD).
  • TD can lead to an increased risk of falls or other medical complications in older patients, as well as social stigma and decreased quality of life.
  • VMAT2 inhibitors in crushed or sprinkled form provide treatment options for TD in patients with difficulty swallowing.

Tardive dyskinesia (TD) is a challenging health condition usually caused by prolonged exposure to dopamine receptor–blocking agents (DRBAs), particularly antipsychotic medications used for the management of schizophrenia and other psychiatric disorders. Use of antipsychotic medications has grown fairly rapidly in the last 2 decades due to the wide availability of second-generation antipsychotic drugs (SGAs) and increasing use of antipsychotics for management of mood disorders such as bipolar disorder and major depressive disorder (as adjunctive treatment combined with antidepressant medication).

TD in Older Populations

In tandem with the broader use of SGAs, the US population is at a greater risk of developing TD given overall aging trends and a burgeoning population of older people. With the “baby boomer” generation now hitting their senior years, America is rapidly growing older, and older age is one of several key risk factors for the development of TD. Modifiable risk factors for TD include diabetes, smoking, alcohol/substance abuse, use of DRBAs, higher cumulative and current antipsychotic dose or plasma levels, early parkinsonian side effects, treatment-emergent akathisia, and anticholinergic cotreatment.

It has been estimated that TD affects at least 600,000 Americans. In addition, TD prevalence numbers by age paint a sobering picture: 5.9% in young people aged 7 to 21 years receiving DRBA treatment for 3 months, 20% to 29% in elderly patients receiving DRBA treatment for 3 months, and 26% to 67% in patients undergoing long-term treatment. TD can lead to increased risk of accidents and medical complications such as falls and fall-related injuries as well as social complications such as stigma and social isolation. In general, patients with TD have worse health-related quality of life than those without, especially in domains of physical symptoms, and in reduced health-related quality of life resulting from social withdrawal.

Identifying TD in Your Patients

Assessing and diagnosing TD, especially in older people who are prone to other neurologic side effects related to DRBAs, can be challenging for clinicians. A common “mimic” of TD in older people is drug-induced Parkinsonism, which is characterized by a general slowing of movements (bradykinesia), focal tremor, and rigidity. All of these can contribute to greater fall risk in older people, which clinicians need to be aware of and address. A careful history and neurologic examination can help to parse out TD vs other movement disorders. Critical differential diagnostic considerations include chronicity/timing as well as clinical features. For example, onset that is days to weeks after DRBA exposure is more likely acute dystonia or akathisia, while drug-induced parkinsonism and TD typically occur with weeks to months of exposure.

Treatment Considerations for Older Patients

A variety of treatment approaches are available for patients with TD, with varying degrees of success and evidence. One approach involves discontinuing or reducing the dose of antipsychotic medication or switching to another less associated with TD, but this may not be feasible for many patients due to the worsening of their underlying psychiatric disorder. A recent review of treatments for TD identified a moderate level of evidence for clozapine and a high level of evidence for vesicular monoamine transporter 2 (VMAT2) inhibitors. The American Psychiatric Association treatment guidelines also recommend that patients who have moderate to severe or disabling TD associated with antipsychotic therapy be treated with a VMAT2 inhibitor. Valbenazine and deutetrabenazine are 2 reversible VMAT2 inhibitors that are FDA approved for treatment of people with TD. Particularly relevant to older adults with TD, in 2023, the FDA approved a once-daily/XR formulation of deutetrabenazine that can be taken with or without food. In 2024, the FDA approved an oral granule sprinkle formulation of valbenazine intended to be sprinkled on soft food. In addition, a recent publication of in vitro studies indicated the potential viability of the crushed valbenazine formulation that can be delivered via gastronomy tube. However, specific treatment needs for older individuals and those who have problems with swallowing should be considered in the selection and implementation of VMAT2 inhibitors.

Conclusions

In conclusion, TD is a challenging clinical problem that is becoming more prevalent due to aging of the population and broader use of SGAs for a variety of chronic psychiatric conditions. It is critical that clinicians be aware of available care approaches, including VMAT2 inhibitors, that can help to minimize some of the physical and mental health complications related to TD and have potential to advance care for people with living with psychiatric illness.

Join us live at GAPNA!

For more in-depth discussion on how to best identify and treat TD in older individuals, please join us in person or virtually for a live, 1-hour, CME-CE-certified symposium at the 2024 Gerontological Advanced Practice Nurses Association (GAPNA) Annual Conference, October 11, 2014, in San Antonio. Register now using this link!

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