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eCase: 3 Patients With TD

CE / CME

Practice-based Simulation: TD Management in 3 Patients

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurses: 1.00 Nursing contact hour, including 1.00 hour of pharmacotherapy credit 

Social Workers: 1.00 ASWB ACE CE Credit

Pharmacists: 1.00 contact hour (0.1 CEUs)

Psychologists: 1.00 APA CE Credit

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™

Released: December 30, 2022

Expiration: December 29, 2023

Stanley N. Caroff
Stanley N. Caroff, MD
CME/CE Information

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Introduction

Tardive dyskinesia (TD) is a heterogeneous, hyperkinetic movement disorder induced by dopamine-receptor blocking agents (DRBA) (commonly, antipsychotics) and manifests with abnormal involuntary movements that range in phenomenology, severity, and impact. TD presents a unique challenge in the treatment of psychosis, schizophrenia, and mood disorders in that anyone prescribed a DRBA—for whatever indication—for a sustained length of time is at risk of developing potentially irreversible TD. Unfortunately, TD is not uncommon; in general, the incidence of new cases of TD annually is reported to be approximately 3% to 5%.1-5 The incidence rises cumulatively at this rate for at least the first 3-5 years of antipsychotic treatment. This is not to be misinterpreted as meaning TD occurs only after DRBA exposure of 1 or more years, as it may occur within a few weeks of beginning a DRBA in vulnerable patients. The prevalence of TD in populations of patients treated with antipsychotics is reported to average approximately 20% to 30%.1-5

Keeping in mind that anyone taking a DRBA is vulnerable to developing TD, there are varying degrees of risk to consider. The strongest predictor of TD development is advancing age, such that antipsychotics should be prescribed cautiously in people aged 45 years or older. The incidence of TD among older adults may reach 15% to 30% annually; prevalence of TD among this population is between 50% and 60%.4-6 Increasing risk has also been ascribed to other patient factors (eg, female sex, race, schizophrenia, mood disorders, medical comorbidities) and treatment factors (eg, first-generation antipsychotics, higher doses for longer durations or intermittent dosing, and adjunctive drugs).

Manifestations of TD range from mild to complex in severity and impact, taking a variety of phenomenological forms (eg, stereotypy, chorea, dystonia, akathisia) (Table 1). Although the symptoms of TD affect the orofacial region in 60% to 80% of cases, they can also affect the trunk and extremities.3,7

Table 1. Clinical Presentations of TD3,7

 

A mild case of TD might present with subtle movements in 1 body area that may be mildly embarrassing and resemble common mannerisms. More severe cases of TD might affect multiple body areas and present as painful, disfiguring, or generalized movements that are stigmatizing, incapacitating and impairing a person’s function and quality of life. The American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients With Schizophrenia recommends assessing patients taking antipsychotics for TD with a structured assessment, such as the Abnormal Involuntary Movement Scale (AIMS), at baseline and at least every 6-12 months, depending on patient risk factors. However, the APA guidelines and a consensus of experts also note that informal screening and clinical assessment for TD should be completed at each visit.8,9 For optimal outcomes, a rational strategy for management includes questioning and visual screening at all clinical visits, documenting abnormal movements, discussion of treatment options with patients and caregivers, modification of psychotropic medications, and consideration of specific antidyskinetic treatment with vesicular monoamine transporter 2 (VMAT2) inhibitors.1

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