Tardive dyskinesia assessment and diagnosis

Make screening a part of your routine for all patients on antipsychotics

2020 American Psychiatric Association guidelines recommend1:

1

Screening for TD before starting or changing patients’ dopamine receptor blocking agent (DRBA) treatment

2

Monitoring for signs of TD at each visit

3

Conducting a structured TD assessment every 6 to 12 months, depending on patient’s risk, and if new or worsening movements are detected at any visit

The involuntary and uncontrollable movements from TD may
not only impact your patients physically, but also emotionally2

When assessing the signs of tardive dyskinesia, ask about how it is affecting their everyday lives.

Tardive dyskinesia (TD) doesn’t just present in the face and mouth—involuntary movements may impact upper and lower limbs, the neck, and trunk3,4

UPPER LIMBS

A man with TD and his chest to knees facing forward with his fingers moving, swaying, having 'piano fingers'

Asymmetrical movements, swaying, “piano fingers,” grabbing of clothing3,4

LOWER LIMBS

Feet of a woman with TD with toes gripping and hyperextending

Splayed or hyperextended toes, gripping, ankle twisting3,4

TORSO

Man with TD sitting in chair with upper body moving in a rocking motion, jerking or thrusting shoulders

Hyperextension, shifting, rocking3,4

TONGUE

Man with TD facing forward with his tongue moving inside his mouth

“Bonbon” sign, protrusion, darting3,4

EYES

Woman with TD facing forward blinking her eyes and raising her eyebrows up and down

Excessive blinking and squinting3,4

LIPS

Woman with TD facing forward with her top and bottom lips puckering and pursing

Smacking, puckering, pursing3,4

JAW

Woman with TD facing forward with her jaw clenching and moving side to side

Biting, clenching, lateral movements, chewing3,4

Actor portrayals

Magnifying glass on brain icon

Take the TD Challenge: Assessment and diagnosis

Can you differentiate tardive dyskinesia from drug-induced parkinsonism and other acute extrapyramidal symptoms?
Put your knowledge to the test.

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Take the TD Challenge:
Assessment and diagnosis

Question 1 of 5

TD Challenge

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Assessment and diagnosis

Question 1 of 5

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QUESTION

TRUE OR FALSE:

The movements in this video show tardive dyskinesia (TD).

Actor portrayal

THE CORRECT RESPONSE IS FALSE.

These are parkinsonian jaw tremors.

Parkinsonian jaw tremors are characterized as rhythmic jaw movements that can be of high amplitude.1-3

In contrast, jaw movements associated with TD may include biting, clenching, and lateral jaw movements.2,4

ASSESSMENT TIP

Ask patients to remove any gum or candy before assessing for TD movements.5

REFERENCES

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1. Task Force on Tardive Dyskinesia. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 1992. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 3. Gupta R, Bhatia MS. Drug induced parkinsonism presenting as isolated jaw tremors. Online J Health Allied Scs. 2005;4(3):1-3. 4. Guy W. ECDEU Assessment Manual for Psychopharmacology. Revised 1976. Rockville, MD: National Institute of Mental Health; 1976. 5. Munetz MR, Benjamin S. How to examine patients using the Abnormal Involuntary Movement Scale. Hosp Community Psychiatry. 1988;39(11):1172-1177.

Take the TD Challenge:
Assessment and diagnosis

Question 2 of 5

TD Challenge

Take the TD Challenge:
Assessment and diagnosis

Question 2 of 5

NEXT
QUESTION

TRUE OR FALSE:

The movements in this video show tardive dyskinesia (TD).

Actor portrayal

THE CORRECT RESPONSE IS TRUE.

This is TD.

Lower-limb movements associated with TD may include splayed or hyperextended toes, gripping, and ankle twisting.1-3

These movements can be more challenging to recognize than TD movements of the face and mouth.1

ASSESSMENT TIP

To help identify lower-limb movements associated with TD, ask patients to remove their shoes and socks before you begin the assessment.4,5

REFERENCES

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1. Task Force on Tardive Dyskinesia. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 1992. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 3. Guy W. ECDEU Assessment Manual for Psychopharmacology. Revised 1976. Rockville, MD: National Institute of Mental Health; 1976. 4. Munetz MR, Benjamin S. How to examine patients using the Abnormal Involuntary Movement Scale. Hosp Community Psychiatry. 1988;39(11):1172-1177. 5. Saltz BL, Robinson DG, Woerner MG. Recognizing and managing antipsychotic drug treatment side effects in the elderly. Prim Care Companion J Clin Psychiatry. 2004;6(2):14-19.

Take the TD Challenge:
Assessment and diagnosis

Question 3 of 5

TD Challenge

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Assessment and diagnosis

Question 3 of 5

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QUESTION

TRUE OR FALSE:

Tardive dyskinesia (TD) and acute extrapyramidal symptoms (EPS) (eg, drug-induced parkinsonism) never coexist.

THE CORRECT RESPONSE IS FALSE.

TD and acute EPS may coexist as different and distinct drug-induced movement disorders, each requiring specific identification and management.1-3

ASSESSMENT TIP

It is important to consider the time between the initiation of antipsychotic treatment and the onset of involuntary movements to differentiate TD from acute EPS.4

REFERENCES

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1. Task Force on Tardive Dyskinesia. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 1992. 2. Caroff SN, Huford I, Lybrand J, et al. Movement disorders induced by antipsychotic drugs: implications of the CATIE schizophrenia trial. Neurol Clin. 2011;29(1):127-148. 3. Guy W. ECDEU Assessment Manual for Psychopharmacology. Revised 1976. Rockville, MD: National Institute of Mental Health; 1976. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

Take the TD Challenge:
Assessment and diagnosis

Question 4 of 5

TD Challenge

Take the TD Challenge:
Assessment and diagnosis

Question 4 of 5

NEXT
QUESTION

TRUE OR FALSE:

The movements in this video show tardive dyskinesia (TD).

Actor portrayal

THE CORRECT RESPONSE IS FALSE.

These are parkinsonian hand tremors.

Parkinsonian hand tremors are characterized as rhythmic movements that can be of high amplitude and typically occur when the patient is at rest.1-4

TD hand movements may include grabbing of clothing and “piano fingers.”1,2,5

ASSESSMENT TIP

Activation techniques, such as asking patients to tap their thumb to another finger rapidly for 15 seconds, can help identify suppressed TD movements.6

REFERENCES

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1. Task Force on Tardive Dyskinesia. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 1992. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 3. Saltz BL, Robinson DG, Woerner MG. Recognizing and managing antipsychotic drug treatment side effects in the elderly. Prim Care Companion J Clin Psychiatry. 2004;6(2):14-19. 4. Thenganatt MA, Louis ED. Distinguishing essential tremor from Parkinson’s disease: bedside tests and laboratory evaluations. Expert Rev Neurother. 2012;12(6):687-696. 5. Guy W. ECDEU Assessment Manual for Psychopharmacology. Revised 1976. Rockville, MD: National Institute of Mental Health; 1976. 6. Munetz MR, Benjamin S. How to examine patients using the Abnormal Involuntary Movement Scale. Hosp Community Psychiatry. 1988;39(11):1172-1177.

Take the TD Challenge:
Assessment and diagnosis

Question 5 of 5

TD Challenge

Take the TD Challenge:
Assessment and diagnosis

Question 5 of 5

GET YOUR
SCORE

TRUE OR FALSE:

The movements in this video show tardive dyskinesia (TD).

Actor portrayal

THE CORRECT RESPONSE IS TRUE.

This is TD.

Movements of the eyes and face associated with TD may include excessive blinking and squinting.1-3

ASSESSMENT TIP

Remember, TD may affect more than one area of the body—not just the face. A comprehensive full body assessment may help you identify abnormal involuntary movements.1-3

REFERENCES

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1. Task Force on Tardive Dyskinesia. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 1992. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 3. Guy W. ECDEU Assessment Manual for Psychopharmacology. Revised 1976. Rockville, MD: National Institute of Mental Health; 1976.

X/X correct

You’ve completed the TD Challenge: Assessment and diagnosis

HELP YOUR TD PATIENTS TAKE CONTROL6

Explore how INGREZZA reduced TD severity in both short- and long-term studies of adult patients with TD

REVIEW EFFICACY

TREAT FIRST LINE WITH VMAT2 INHIBITORS

VMAT2 inhibitors, like INGREZZA, are recommended as first-line treatment for TD1,7,8

TD GUIDELINES

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EXPERT PERSPECTIVES:

Tardive dyskinesia (TD) is clinically distinct

Dr. Laxman Bahroo, from Georgetown University’s Neurology Department, discusses the clinical distinctions between TD and acute extrapyramidal symptoms (EPS) and what to look for.

Dr laxman facing forward

REFERENCES: 1. Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. 3rd ed. American Psychiatric Association Publishing, 2020. 2. McEvoy J, Gandhi SK, Rizio AA, et al. Effect of tardive dyskinesia on quality of life in patients with bipolar disorder, major depressive disorder, and schizophrenia. Qual Life Res. 2019;28(12):3303-3312. 3. Guy W. ECDEU Assessment Manual for Psychopharmacology. Revised 1976. Rockville, MD: National Institute of Mental Health; 1976. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 5. Task Force on Tardive Dyskinesia. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 1992. 6. INGREZZA [package insert]. San Diego, CA: Neurocrine Biosciences, Inc. 7. Bhidayasiri R, Jitkritsadakul O, Friedman JH, Fahn S. Updating the recommendations for treatment of tardive syndromes: a systematic review of new evidence and practical treatment algorithm. J Neurol Sci. 2018;389:67-75. 8. Caroff SN, Citrome L, Meyer J, et al. A modified Delphi consensus study of the screening, diagnosis, and treatment of tardive dyskinesia. J Clin Psychiatry. 2020;81(2):19cs12983.

Important Information

INDICATION & USAGE

INGREZZA® (valbenazine) capsules is indicated for the treatment of adults with tardive dyskinesia.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any components of INGREZZA. Rash, urticaria, and reactions consistent with angioedema (e.g., swelling of the face, lips, and mouth) have been reported.

WARNINGS & PRECAUTIONS

Somnolence

INGREZZA can cause somnolence. Patients should not perform activities requiring mental alertness such as operating a motor vehicle or operating hazardous machinery until they know how they will be affected by INGREZZA.

QT Prolongation

INGREZZA may prolong the QT interval, although the degree of QT prolongation is not clinically significant at concentrations expected with recommended dosing. INGREZZA should be avoided in patients with congenital long QT syndrome or with arrhythmias associated with a prolonged QT interval. For patients at increased risk of a prolonged QT interval, assess the QT interval before increasing the dosage.

Parkinsonism

INGREZZA may cause parkinsonism in patients with tardive dyskinesia. Parkinsonism has also been observed with other VMAT2 inhibitors. Reduce the dose or discontinue INGREZZA treatment in patients who develop clinically significant parkinson-like signs or symptoms.

ADVERSE REACTIONS

The most common adverse reaction (≥5% and twice the rate of placebo) is somnolence. Other adverse reactions (≥2% and >Placebo) include: anticholinergic effects, balance disorders/falls, headache, akathisia, vomiting, nausea, and arthralgia.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit MedWatch at www.fda.gov/medwatch or call 1-800-FDA-1088.

Please see INGREZZA full Prescribing Information

Indication and Important Safety Information

INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any components of INGREZZA.

+Expand-Collapse

Rash, urticaria, and reactions consistent with angioedema (e.g., swelling of the face, lips, and mouth) have been reported.

INDICATION & USAGE

INGREZZA® (valbenazine) capsules is indicated for the treatment of adults with tardive dyskinesia.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any components of INGREZZA. Rash, urticaria, and reactions consistent with angioedema (e.g., swelling of the face, lips, and mouth) have been reported.

Important Information

INDICATION & USAGE

INGREZZA® (valbenazine) capsules is indicated for the treatment of adults with tardive dyskinesia.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any components of INGREZZA. Rash, urticaria, and reactions consistent with angioedema (e.g., swelling of the face, lips, and mouth) have been reported.

WARNINGS & PRECAUTIONS

Somnolence

INGREZZA can cause somnolence. Patients should not perform activities requiring mental alertness such as operating a motor vehicle or operating hazardous machinery until they know how they will be affected by INGREZZA.

QT Prolongation

INGREZZA may prolong the QT interval, although the degree of QT prolongation is not clinically significant at concentrations expected with recommended dosing. INGREZZA should be avoided in patients with congenital long QT syndrome or with arrhythmias associated with a prolonged QT interval. For patients at increased risk of a prolonged QT interval, assess the QT interval before increasing the dosage.

Parkinsonism

INGREZZA may cause parkinsonism in patients with tardive dyskinesia. Parkinsonism has also been observed with other VMAT2 inhibitors. Reduce the dose or discontinue INGREZZA treatment in patients who develop clinically significant parkinson-like signs or symptoms.

ADVERSE REACTIONS

The most common adverse reaction (≥5% and twice the rate of placebo) is somnolence. Other adverse reactions (≥2% and >Placebo) include: anticholinergic effects, balance disorders/falls, headache, akathisia, vomiting, nausea, and arthralgia.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit MedWatch at www.fda.gov/medwatch or call 1-800-FDA-1088.

Please see INGREZZA full Prescribing Information

EXPAND FOR
GUIDELINES

INGREZZA is a recommended first-line TD treatment option.

See guidelines and recommendations