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TD Care in Elders
Assessment, Diagnosis, and Treatment of Tardive Dyskinesia in Elders

Released: December 31, 2025

Susan Scanland
Susan Scanland, MSN, CRNP, GNP-BC, CDP
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Key Takeaways
  • An alarming rate of 95% under/missed diagnoses in tardive dyskinesia (TD) emphasize the need for proactive screening, diagnosis, and awareness of TD across clinical settings.
  • The Abnormal Involuntary Movement Scale (AIMS) and the Impact-TD Scale should both be used to guide healthcare professionals in assessing severity and impact of tardive movements.
  • Anticholinergic agents, especially benztropine, should not be used for TD, as they are not indicated and will likely worsen the symptoms.
  • The American Psychiatric Association recommends use of VMAT2 inhibitors for TD, as they are the only FDA-approved medications for this condition.
  • Differences exist between valbenazine and deutetrabenazine in dosing titrations, formulation, and hepatic metabolism, but both VMAT2 inhibitors are effective in decreasing AIMS score to a clinically significant level.

A 2025 publication of a retrospective 22-year electronic health record analysis revealed that only 5% of patients with evidence of abnormal movements indicating TD, or specific mention of TD during a mental status exam, had an ICD-TD diagnosis. Restricting analysis to those specifically mentioning TD on mental status exam, the ICD-TD diagnosis rate was less than 10%.

Tardive dyskinesia (TD) presents as uncontrollable, involuntary movements in the face, trunk, and extremities most frequently observed in the oro-bucco-lingual area. It is due to exposure to dopamine receptor–blocking agents. TD risk is estimated at 30% for persons currently on first-generation “typical” antipsychotics (FGA), 7.2% for treatment-naive second-generation “atypical” (SGA) antipsychotic use and 23.4% for current SGA treatment with a past history of FGA use. TD results from an increase in synaptic dopamine release due to postsynaptic D2 receptor blockade. Less frequently, gastrointestinal motility agents (eg, metoclopramide) or antiemetic medications may cause TD.

Who is at the highest risk for TD? Age, female sex, mood disorders, and longer duration of antipsychotic use are leading risk factors. Consider relevant demographics: two thirds of 85-year-olds are women. Women also have higher rates of depression; atypicals are prescribed to augment antidepressant effect and for treatment-resistant depression. Women occupy the majority of nursing home beds; 14.4% of long-term care residents are prescribed an antipsychotic, and antipsychotics which may be prescribed off-label for behaviors such as agitation and psychosis in patients with Alzheimer’s disease or other dementias.

TD screening should begin by questioning the patient/resident about whether they are experiencing movements they cannot control and the impact of these movements in the following areas:

  1. Psychological: New or increasing levels of anxiety and depression frequently occur with TD. Healthcare professionals (HCPs) need to assess sleep patterns, appetite, self-worth, suicidality and self-deprecation. Have new or increased doses of antidepressant, antianxiety, or hypnotic meds been prescribed when emotional changes are actually caused or aggravated by TD without staff being aware that TD is the culprit?  Polypharmacy is often the outcome. Elders with TD and depression may exhibit increased irritability and verbal outbursts. Those with Alzheimer’s disease or other dementias may exhibit new or worsening behaviors.
  2. Physical: Analgesics or narcotics may be prescribed for muscular pain without cuing in to TD as the cause. Constant involuntary jerking movements increase caloric needs, often leading to weight loss and frailty. Orofacial TD affects chewing, swallowing, dentition, buccal and tongue lesions, choking and aspiration risk. How are movements specifically affecting gait and ambulation? Truncal, leg, or foot TD may put an elder at risk for falls. It may seriously impede progress in physical or occupational therapy. Other activities of daily living (ADLs) such as eating with utensils, bathing, dressing, toileting, and transferring take longer for both patient and caregiver(s).
  3. Social: Isolation often results from embarrassment. Has a long-term care resident been ridiculed? Do they “no show” to a nursing home dining area or recreational activity? Do families visit less frequently? If the person lives at home, do they avoid inviting/accepting visitors? Do they limit outside activities?

TD is best measured using 2 different scales. The first is the Abnormal Involuntary Movement Scale (AIMS). The HCP performs a focused assessment in each of 7 body regions, 1 at a time, determining a score for each area. The total AIMS range is 1-28; the higher the number, the greater the severity. A second, more recently developed scale is the Impact-TD scale. This measures the subjective effect of the patient’s movements in 4 domains: social, physical, psychological/psychiatric, and vocational/educational/recreational. Use of both scales can identify persons with mild TD experiencing severe impact of symptoms and someone with a high AIMS score who is less concerned or aware (lower Impact-TD score). 

For decades, TD treatment was “managed” using benztropine or other anticholinergics. The American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults stresses the dangers of anticholinergics in elders. Benztropine is used for treatment of drug-induced parkinsonism (DIP).  Prescribing information states benztropine should not be used for TD and may worsen it. HCPs often confuse DIP symptoms with TD, resulting in inappropriate treatment of TD with benztropine or amantadine.

Differential diagnosis between TD and DIP is made by history, observation, and physical exam. Physical exam differences exist: TD exhibits choreiform, flaccid movements with varying/unpredictable cadence, whereas DIP motor signs (similar to those seen in Parkinsons’ disease) include stiffness, rigidity (cogwheeling), blank stare, and parkinsonian gait. 

Two vesicular monoamine transporter (VMAT2) inhibitors, deutetrabenazine and valbenazine, are the only FDA-approved agents for TD. Both are recommended by the American Psychiatric Association. No head-to-head studies exist comparing deutetrabenazine and valbenazine.

Deutetrabenazine trials compared the AIMS score from baseline to 12 weeks. A flexible-dose study revealed the mean dose of 38.8 was significantly superior to placebo. In a fixed-dose study, both 24 and 36 mg were superior to placebo in the AIMS score over 12 weeks. 

AIMS was also the primary outcome in valbenazine trials. A flexible-dose study showed a greater proportion of individuals much or very much improved. The fixed-dose study revealed a dose-dependent effect with 80 mg offering the greatest AIMS score decrease.

Similarities in deutetrabenazine and valbenazine existed in the trials mentioned above. Both VMAT2 inhibitors decreased the AIMS score between 3.0 and 3.3 points. Both medications had open-label studies (48 weeks with valbenazine and 145 weeks with deutetrabenazine) with continual progressive decreases in AIMS scores. Safety and tolerability for extended use was established.  

Both agents are dosed daily, but differences exist. The number of titrations with deutetrabenazine XR is 7 (between 12 and 48 mg), allowing more choices to balance effectiveness and toleration. Valbenazine has 3 doses: 40, 60 and 80 mg, offering simpler titration.

Differences in metabolism exist. Deutetrabenazine, when prescribed with strong CYP3A4/5 inducers and inhibitors, has no dose restrictions for maximum daily therapeutic dose. Valbenazine use is not recommended with strong CYP3A4 inducers. Its 40 mg starting dose is the recommended maximum dose with 3A4 inhibitors.  Valbenazine’s 40 mg dose is the highest recommended for both strong CYP2D6 inhibitors and poor CYP2D6 metabolizers, whereas deutetrabenazine’s is 36 mg.

Differences in formulations exist. The deutetrabenazine XR tablet must be swallowed whole. Valbenazine has both capsules and sprinkle capsules that can be opened and sprinkled on food or in GI tubing.

Optimal treatment of TD offers the potential to improve the Centers for Medicare and Medicaid Services quality measures and long-term care facility star ratings. Examples are: falls with major injury (hence hospitalizations and ER visits), ability to walk worsening, increasing ADL assistance, depression symptoms (hence weight loss), and antianxiety/hypnotic use.

A 95% lack of TD diagnosis in persons with abnormal movements associated with TD is a wake-up call for all primary and specialty care clinicians. VMAT2 inhibitors valbenazine or deutetrabenazine should be prescribed for moderate to severe tardive dyskinesia, as well as for mild tardive dyskinesia symptoms negatively impacting the patient.

 

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