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Understanding Assessment and Treatment in Tardive Dyskinesia: Your Questions Answered

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Released: August 26, 2026

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Tardive dyskinesia presents multiple barriers to diagnosis. It can be easy to miss, particularly when patients are unaware of their involuntary movements, and can often be mistaken for another movement disorder. This expert-led FAQ goes beyond recognition alone and explores practical approaches to AIMS-based screening in complex patients, patient counseling, and real-world treatment decisions, including how VMAT2 inhibitors can be incorporated into individualized tardive dyskinesia management.

Eric Carlon
Eric Carlon, APRN, PMHNP-BC
Tardive Dyskinesia FAQ

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Key Takeaways
  • Tardive dyskinesia movements are involuntary and patients may have limited awareness of their movements and impact.
  • VMAT2 inhibitors are the only FDA-approved pharmacologic treatments for tardive dyskinesia in adults and can often be added without substantially disrupting existing psychiatric treatment.

Do patients experience tardive dyskinesia (TD) movements as an “urge” similar to a tic or are they entirely involuntary?
Movements of TD are completely involuntary and there is no build up or “urge” to move.

Do patients realize they are making the movements? Do they have any control over them?
It is estimated that more than one half of patients do not realize that they have involuntary movements. In my experience, patients with TD do not have any true control over their movements. Some patients can briefly decrease their movements, but this sometimes leads movements to return with more intensity.

Do TD movements occur during sleep?
Like other hyperkinetic movement disorders, movements in TD typically stop during sleep. In some rare cases, orofacial movements may persist during sleep and lead to teeth grinding. On the other hand, lack of sleep often leads to worsening movements during the day.

How can potential TD symptoms be assessed in patients with dementia who cannot follow commands?
Attempting to do as much of an Abnormal Involuntary Movement Scale (AIMS) assessment as possible will be helpful in guiding healthcare professionals (HCPs) in diagnosing TD. In situations where the patient is unable to follow any commands, HCPs will need to rely on collateral information from caregivers. In long-term care and memory care settings, it is sometimes helpful to observe patients while they are eating or performing other activities of daily living. In some situations, I will sit and talk with the patients while they eat to monitor for any involuntary movements.

How can TD screening be performed in a patient with movement symptoms caused by Parkinson’s disease?
Screening for TD in patients with a history of Parkinson’s disease will involve performing an AIMS exam just as one would in a patient without Parkinson’s disease. The other important factor that needs to be considered is the medication history and use of dopamine receptor–blocking agents, both past and present. The movements associated with TD are arrhythmic, jerky, and hyperkinetic compared with patients with Parkinson’s disease, which include rhythmic tremors and hypokinetic movements.

What approach do you recommend for patients who are hesitant to take medication for TD?
I always try to guide patients toward treatment and educate them on how symptoms of TD can affect their lives, without them even knowing it. In many cases, these movements have gradually become more impactful, and during that time, the patients may attempt to cope with the effects without any meaningful benefit.

Do you suggest treatment to patients who exhibit TD symptoms but do not find them bothersome? What is your approach?
If patients show symptoms of TD, I will absolutely suggest treatment, while leaving the final decision to the patients or, in cases of patients with dementia, the family. I make sure to tell them that these movements have the potential to worsen and may not go away, even with treatment. If we can recognize the movements early on, we can better position the patient for successful treatment using VMAT2 Inhibitors. With VMAT2 inhibitors, we have 2 medications that offer effective treatment of TD, both with a friendly adverse effect profile and both able to be given without dramatically altering current psychotropic medications.

Can a “watch-and-wait” strategy be appropriate for patients with TD?
A “watch-and-wait” strategy is certainly possible, but I would reiterate that often, patients with TD are not fully aware of the movements or the impact that they may be having. This is a situation when performing routine AIMS exams will be helpful, not only in catching involuntary movements, but also in monitoring for worsening symptoms.

Are VMAT2 inhibitors for treatment of TD typically covered by insurance?
Yes, both valbenazine and deutetrabenazine are generally covered by insurance. In most cases, HCPs need to fill out prior authorizations. Some insurance companies prefer one medication over the other, but it is important to consider specific reasons when choosing which agent will be better for the patient, such as contraindications, metabolic pathways, drug–drug interactions, or other clinical factors.

Can benztropine be used as a treatment for TD?
Benztropine is not approved for the treatment of TD, and data show that this medication has the potential to worsen symptoms of TD. The use of benztropine for drug-induced movement disorders is not new, and this medication has an indication for drug-induced parkinsonism. The prescribing information for benztropine states that it can be used to treat symptoms of extrapyramidal symptoms, except for TD. If we think back to the pathophysiology of TD, we remember that it is caused by upregulated and hypersensitive dopamine receptors that, when activated, cause hyperkinetic, involuntary movements. The use of VMAT2 inhibitors turns down the signaling at these new receptors to improve the involuntary movements. When we give a patient an anticholinergic medication like benztropine, it will increase dopamine signaling, which could in turn increase the involuntary movements associated with TD.

Can botulinum toxin injections be used as treatment for facial TD symptoms?
Although not approved by the FDA for the treatment of TD, botulinum toxin has shown benefits in addressing movements of TD. This is accomplished by the relaxation of the muscles responsible for the involuntary movements. Other useful benefits of botulinum toxin are targeted treatments to specific body areas that have involuntary movements, most notably, the orofacial area. Off-label treatment of TD symptoms with botulinum toxin usually requires 2-4 equally spread out injections per year.

How can TD be treated in adolescent patients?
Currently, there are no randomized, double-blind, placebo-controlled trials for treatment of TD in adolescents, but we do have the FDA-approved VMAT2 inhibitors for treatment in adults. It is possible to contact the specific medication manufacturers to inquire about any possible data they may have on the use of the medication in the adolescent population. This will allow HCPs to best inform patients and their families of the treatment approach. There is some thought that changing the medication or dose may offer benefit to symptoms of TD, but this method is often fruitless. Consideration of off-label use of pharmacologic agents would need to be done very carefully while weighing risks and possible benefits.

Your Thoughts
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