Despite the impact the COVID-19 pandemic has had on psychiatry practice, a proactive, routine, and systematic assessment for tardive dyskinesia (TD) in patients taking atypical and typical antipsychotics is a mandate for all clinicians, Rakesh Jain, MD, MPH, reminded colleagues during his session at the virtual Psych Congress Elevate conference.
“Let’s not let the pandemic situation be a reason for our abdicating responsibility to assess for tardive dyskinesia,” said Dr. Jain, a Psych Congress Steering Committee member and clinical professor in the department of psychiatry at Texas Tech Health Sciences Center School of Medicine in Austin.
Untreated TD impacts the lives of patients beyond involuntary movement, the speaker emphasized. The disorder can wreak emotional, physical, social, financial, relationship, and employment consequences as well.
Living With TD
To illustrate the psychosocial effect of TD symptoms, Dr. Jain shared video clips of actual patients with the disorder reflecting on their experiences. Patients described difficulty swallowing, stares from others, baffled family members (“Why is Dad nuts?” one patient reflected), and marital challenges.
“People have stopped talking to us, and we lost a lot of friends,” said a woman whose husband has difficulty speaking because of tardive dyskinesia. “And that’s been hard. It’s taken a lot of work and therapy for both of us to be OK and accept what we have.”
Dr. Jain was present during the filming of the clips, which he described as powerful.
“As I sat across from individuals and their family member, hearing their plights, it became quite clear that tardive dyskinesia is not just a movement disorder,” he said. “It’s also conditioned with a huge amount of suffering, psychosocial impairment. And it’s common.”
With first-generation antipsychotics, the annualized tardive dyskinesia rate was 6.5% in a 2018 meta-analysis of 57 randomized controlled trials published in World Psychiatry. With second-generation antipsychotics, the annualized incidence was 2.6%.
“The problem is, we’re using a lot of these medications,” Dr. Jain said. “So there’s no running away from tardive dyskinesia. We’re going to have to stand our ground and deal with it.”
Identifying TD With the AIMS Scale
Dr. Jain highlighted the Abnormal Involuntary Movement Scale (AIMS) as a gold-standard tool for identifying tardive dyskinesia. The assessment examines 7 body regions: muscles of facial expression, lips and perioral region, tongue, jaw, upper extremity, the trunk, and the lower extremities. Before conducting the exam, clinicians should be sure to ask patients to remove any gum or candy in the mouth, whether their teeth or dentures are bothering them, and whether they have noticed any movements in their mouth, face, hands, or feet since their last appointment.
“This is a rather important point because we’ve been trained to think of the AIMS as all objective,” Dr. Jain said. “But it’s actually a combination of objective and subjective exams.”
Although telepsychiatry due to COVID-19 may make to harder to complete a full AIMS assessment, it does not render it impossible, Dr. Jain clarified. Having a member of the patient’s family or support system present during telepsychiatry vastly improves the quality of the assessment, he shared.
Most, though perhaps not all, of the AIMS exam should be able to be conducted via video.
“A suboptimal AIMS,” Dr. Jain said, “is better than no AIMS.”
— Jolynn Tumolo
“Achieving and maintaining improved quality of life in patients with tardive dyskinesia.” Presented at Psych Congress Elevate: Virtual; July 25, 2020.