Search
tardive dyskinesia
Etiology:
1) late complication of antipsychotic therapy or treatment with dopamine receptor antagonist (haloperidol, chlorpromazine, thiothixine))
a) generally noted after > 5 years of antipsychotic therapy
b) isolated incidences after 1-3 months have been reported
c) first generation antipsychotics with highest risk
2) anti-emetics:
- metoclopramide [7]
- prochlorperazine
3) antidepressants
- risk associated with SSRI & tricyclic antidepressants much lower than with antipsychotics [6]
- phenelzine, trazodone [7,8]
4) anticonvulsants
- carbamazepine, ethosuximide, phenobarbital, phenytoin [7,8]
5) levodopa, bromocryptine [7,8]
6) amisulpride [7]
7) lithium carbonate [8]
8) estrogens [8]
9) amphetamine, methylphenidate [8]
4) longstanding psychosis
5) idiopathic on some elderly individuals, especially if edentulous
Epidemiology:
- may be 20-30% with long-term use of antipsychotic
Pathology:
- dopamine receptor sensitivity in the basal ganglia
Clinical manifestations:
1) choreiform & dystonic craniofacial movements
2) rhythmic, repetitive, bizarre movements largely involving the face, mouth, jaw & tongue
3) grimacing, pursing of the lips, protrusions of the tongue, opening & closing of the mouth, & deviations of the jaw also occur
4) the extremities & trunk are less frequently involved
5) generally occurs at rest
- abnormal movements lessen with activation or touch
6) the condition is often unrecognized by the patient
7) symptoms may take months to resolve of become permanent.
Diagnostic criteria:
- neuroleptic-induced tardive dyskinea requires symptoms that persist for 1 month after exposure to neuroleptics for >= 3 months
- at least 1 month of exposure is required if patient is > 60 years [7]
Differential diagnosis:
- Wilson's disease
- Huntington disease
- brain lesion
Management:
1) consider reducing or discontinuing offending antipsychotic agent
- upon discontinuation of offending agent, symptoms may take months to resolve
- condition may be permanent [3]
- dose reduction preferable in the elderly [8]
2) switch offending antipsychotic to clozapine (Clozaril)
- reduce dose of offending agent in elderly prior to switch to clozapine [8]
3) VMAT2 inhibitors
a) valbenazine (Ingrezza) FDA-approved 2017 tolerated > 1 year [5]
b) deutetrabenazine (Austedo) also FDA-approved
4) dose reduction preferable to VMAT2 inhibitor in the elderly [8]
5) clonazepam, 0.25-4 mg per day, is probably effective [6]
6) Gingko biloba, 80-240 mg per day, is probably effective [6]
7) amantadine is possibly effective [6]
General
dyskinesia
References
- Guide to Physical Examination & History Taking, 6th edition,
Bates B, JB Lippincott, Philadelphia, 1995, pg 544
- UCLA Intensive Course in Geriatric Medicine & Board Review,
Marina Del Ray, CA, Sept 12-15, 2001
- Medical Knowledge Self Assessment Program (MKSAP) 17, 18.
American College of Physicians, Philadelphia 2015, 2018.
- van Harten PN, Tenback DE.
Tardive dyskinesia: clinical presentation and treatment.
Int Rev Neurobiol. 2011;98:187-210
PMID: 21907088
- Visk D
Valbenazine for Tardive Dyskinesia Tolerated Long-Term -
Only 15% of patients discontinued tx over 1 year due to
adverse events.
MedPage Today. May 28, 2017
https://www.medpagetoday.com/MeetingCoverage/APA/65645
- Josiassen RC, et al
Long-term safety and tolerability of valbenazine in subjects
with tardive dyskinesia and a diagnosis of schizophrenia or
mood disorders.
American Psychiatric Association (APA) 2017.
- Swan M
Fast Five Quiz: How Much Do You Know About Tardive Dyskinesia?
Medscape 2021. May 21
https://reference.medscape.com/viewarticle/910550_2
- Lutsep HL
Fast Five Quiz: Movement Disorders.
Medscape 2021. July 8
https://reference.medscape.com/viewarticle/954124
- Geriatric Review Syllabus, 11th edition (GRS11)
Harper GM, Lyons WL, Potter JF (eds)
American Geriatrics Society, 2022
- MedlinePlus
Tardive dyskinesia
https://medlineplus.gov/ency/article/000685.htm
- NINDS Tardive Dyskinesia Information Page
https://www.ninds.nih.gov/Disorders/All-Disorders/Tardive-Dyskinesia-Information-Page