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Annual training and reliable new tools can help physicians improve tardive dyskinesia screening and symptom measurement.
An annual, one-hour training session on using the Abnormal Involuntary Movement Score (AIMS) significantly increased tardive dyskinesia (TD) screening at an outpatient clinic, according to findings published in Cureus.1
“Between October 2016 and September 2017, only one patient seen at the clinic prescribed an antipsychotic medication had an AIMS score documented in their electronic health record,” wrote lead author Arindam C. Chakrabarty, MD, affiliated with Southern Illinois University School of Medicine, and coauthors. “A large number of patients seen in the psychiatry clinic are on medications that may cause tardive dyskinesia. AIMS should ideally be administered and documented to each patient on these medications at least every six months.”
Third-year psychiatric residents, led by a hospital-based Lean Six Sigma black belt mentor, conducted the quality improvement project. Their goal was to achieve an AIMS documentation rate of 100%.
“Given the high risk of developing tardive dyskinesia following the use of psychiatric medications and the recent approval for medications to treat tardive dyskinesia, this is an important intervention,” Dr. Chakrabarty and coauthors wrote.
Documentation Challenges & Effective Interventions
According to the study, several factors may have contributed to the clinic’s low AIMS screening rate, including limited time during appointments, barriers to accessing information on patient charts, and gaps in provider knowledge about AIMS. In addition, the clinic reportedly switched to a new electronic health record that did not automatically alert providers to conduct AIMS screening.
Twenty-six residents and five attending physicians were surveyed to identify areas of need. Of these, only one-third of residents said they had screened patients on antipsychotics with AIMS, and only one physician screened every patient receiving antipsychotics.
“When asked, ‘What prevents you from using the AIMS Screening Tool?’ among residents surveyed, the most common response was ‘no formal training,’” Dr. Chakrabarty and coauthors wrote.
The researchers designed and tested 11 interventions. The study team identified six interventions as low effort and high impact, termed “quick wins.” Of these “quick win” interventions, three prioritized physician training.
“Reminders given in a monthly clinic operations meeting” had the lowest effort and highest impact. However, residents’ most highly ranked intervention was a one-hour educational session that included video instruction on completing and documenting AIMS.
Three-month follow-up data was collected in February 2020 and showed the rate of AIMS documentation increased significantly after the education session intervention, from 3% to 87% (P<0.001). Six-month follow-up could not be conducted due to pandemic-related disruptions.
“The study shows that changes in electronic health records, time constraints, and limited exposure to TD screening education can be overcome with continuing education efforts,” Dr. Chakrabarty and coauthors concluded. “This has high clinical importance as it allows for earlier diagnosis and management of TD especially in light of recent advances in therapeutics for TD improving quality of care.”
A New Tool for Measuring Tardive Dyskinesia
In another study published recently in The Journal of Clinical Psychiatry,2 researchers evaluated a new tool, the Clinician’s Tardive Inventory (CTI), designed to improve TD symptom measurement. Their findings suggest the CTI is reliable for assessing the signs and functional impacts of TD.
The CTI assesses abnormal anatomical movements and vocalizations. These include movements of the eye, eyelid, and face; tongue and mouth; jaw; and limbs and trunk. The CTI also measures complex movements, which the study team defined as “complicated movements different from simple patterned movements or postures.” The frequency of each sign is rated from 0-3, with 0 indicating the sign is absent and 3 indicating the sign presents constantly.
Additionally, the CTI measures functional impairments such as disruptions in activities of daily living, social impairment, symptom distress, and physical harm, with a score of 0 representing unawareness and a score of 3 indicating severe impact.
For the study, the CTI underwent interrater and test-retest reliability testing based on videos. Movement disorder specialists and clinicians reviewed the videos and their accompanying vignettes.
“Interrater agreement was analyzed via 2-way random-effects intraclass correlation (ICC), and test-retest agreement was assessed utilizing the Kendall tau-b,” wrote lead author Richard M. Trosch, MD, and coinvestigators.
The researchers evaluated 45 videos and vignettes for interrater reliability and 16 for test-retest reliability. Tongue and mouth movements were the most prevalent signs (77.8%), followed by jaw movements (55.6%).
Findings indicate the following ICCs for anatomic signs:
- anatomic symptom summary score: 0.92
- abnormal eye movement: 0.89
- abnormal tongue/mouth movement: 0.91
- abnormal jaw movement: 0.89
- abnormal limb movement: 0.76
- complex movement: 0.87
- abnormal vocalization: 0.77
In addition, the following ICCs were reported for functional impairments:
- total impairment score: 0.92
- physical harm: 0.82
- social embarrassment: 0.88
- activities of daily living: 0.83
- symptom bother: 0.92
“Retests were conducted a mean (SD) of 15 (3) days later with correlation coefficients ranging from 0.66 to 0.87,” Dr. Trosch and his team reported.
Researchers concluded the CTI was reliable in assessing TD signs and functional impacts but added that further study is needed to validate their findings.
