Monitoring for Tardive Dyskinesia: Who Is at Greatest Risk?

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Tardive dyskinesia (TD) is an involuntary movement disorder characterized by repetitive, stereotyped movements, most commonly affecting the face, lips, tongue, and limbs. It is typically caused by long-term use of dopamine receptor–blocking agents, including antipsychotics.

While TD can affect anyone exposed to these medications, certain groups are at greater risk. Recognizing high-risk patients, implementing effective monitoring strategies, and understanding treatment options are crucial for minimizing the impact of TD, according to the authors of a recent paper in Primary Care Companion for CNS Disorders.

Who is at the Greatest Risk for Developing TD?

The authors listed several risk factors for developing TD (Table). Older adults are particularly vulnerable to developing TD because age-related decreases in dopaminergic neurons in the substantia nigra increase susceptibility. Women are also more susceptible, especially post-menopausal women.

Long-term use of first-generation antipsychotics (FGAs), such as haloperidol, is associated with a higher risk due to their greater propensity for dopamine blockade. Underlying psychiatric conditions, including schizophrenia and mood disorders, often require long-term antipsychotic treatment, further increasing the risk of TD.

“I always consider the risks of treating or not treating, and the benefit for the patient,” explains Howard R. Weeks, MD. “However, the risk of TD is quite low on normal doses of the newer medications we typically use.”

Additionally, comorbidities like diabetes mellitus can elevate the risk for TD due to complex metabolic interactions with antipsychotic medications.

Monitoring Considerations for TD

“Unfortunately, TD is often irreversible; thus, it is critical to detect TD early in its course and change medications to those that are less likely to cause TD,” the article’s authors wrote.

The Abnormal Involuntary Movement Scale (AIMS) is the gold standard for monitoring TD symptoms. It is recommended to screen patients at the start of antipsychotic treatment, annually for most patients, and every six months for high-risk groups, including older adults and those on FGAs.

In addition, Alex Dimitriu, MD, advises clinicians to “regularly review medications for TD potential by checking for dopamine-blocking agents.”

“To receive a diagnosis of TD secondary to antipsychotic use, patients must have symptoms for at least 1 month and must have been exposed to a neuroleptic for at least 3 months,” the article authors wrote.