How is the Abnormal Involuntary Movement Scale (AIMS) questionnaire used to monitor and manage tardive dyskinesia in patients taking antipsychotic medication, such as quetiapine (quetiapine) or clozapine (clozapine)?

Using the AIMS Questionnaire for Monitoring Tardive Dyskinesia in Patients on Antipsychotics

The Abnormal Involuntary Movement Scale (AIMS) should be administered every 3-6 months to all patients on antipsychotic medications to monitor for tardive dyskinesia, with more frequent monitoring for high-risk patients. 1

Understanding Tardive Dyskinesia

Tardive dyskinesia (TD) is a potentially irreversible movement disorder characterized by involuntary, repetitive movements primarily affecting the:

• Orofacial region: tongue movements, tongue protrusion, chewing movements, facial grimacing, excessive blinking, lip puckering
• Extremities: choreic movements of fingers and hands, athetoid movements of limbs 1

TD develops in patients on long-term antipsychotic therapy, with risk increasing with duration of treatment and cumulative dose. The syndrome can develop after relatively brief treatment periods at low doses or even after discontinuation of treatment 2, 3.

AIMS Implementation Protocol

When to Perform AIMS Assessment

• Baseline: Before starting any antipsychotic medication 1
• Regular monitoring: Every 3-6 months during treatment 1, 4
• More frequent monitoring for high-risk patients:
  • Elderly patients (especially women)
  • Patients with higher baseline AIMS scores
  • Patients with intellectual impairment 1

Risk Factors to Consider

• Older age (up to 50% risk after 2 years in elderly patients)
• Female gender
• Higher baseline AIMS scores
• Intellectual impairment
• Duration of treatment
• Cumulative antipsychotic dose 1

Conducting the AIMS Assessment

1. Patient positioning: Seated in a chair with hands on knees, legs slightly apart, feet flat on floor

2. Observation sequence:

   • Observe patient at rest
   • Ask patient to open mouth and protrude tongue twice
   • Ask patient to tap thumb against each finger for 15 seconds with each hand
   • Ask patient to extend arms in front with palms down
   • Ask patient to stand and walk a few paces

3. Rating movements on a 0-4 scale:

   • 0 = None
   • 1 = Minimal, may be normal
   • 2 = Mild
   • 3 = Moderate
   • 4 = Severe

4. Areas to assess:

   • Facial and oral movements (muscles of facial expression, lips, perioral area, jaw, tongue)
   • Extremity movements (upper and lower limbs)
   • Trunk movements
   • Global judgment of severity
   • Patient's awareness and distress from movements 4

Management Based on AIMS Findings

For Positive AIMS Findings

1. Consider VMAT2 inhibitors as first-line treatment:

   • Valbenazine (Ingrezza): Starting dose 40 mg daily, target dose 80 mg once daily
   • Deutetrabenazine (Austedo): Effective doses 24-36 mg/day, twice-daily with food 1

2. Medication adjustments:

   • Consider switching to an atypical antipsychotic with lower TD risk if patient is on a typical antipsychotic
   • Among atypicals, quetiapine and clozapine have shown better profiles for managing existing TD 5, 6
   • Avoid anticholinergics (benztropine, trihexyphenidyl) as they may worsen TD symptoms 1

3. For mild cases: Continue monitoring with serial AIMS assessments 7

Prevention Strategies

1. Limit exposure to dopamine receptor blocking agents when possible
2. Use minimum effective doses of antipsychotics
3. Consider atypical antipsychotics over typical ones when appropriate
4. Avoid unnecessary anticholinergic medications 1

Special Considerations

For Quetiapine and Clozapine

• Both medications carry FDA warnings about TD risk, but clinical evidence suggests they may have lower TD risk compared to typical antipsychotics 2, 3
• Some case reports show improvement in pre-existing TD symptoms when switching to these agents 5, 6
• Clozapine requires additional monitoring for agranulocytosis with regular blood tests 2

Documentation Requirements

• Document baseline abnormal movements before starting antipsychotics
• Record AIMS scores at each assessment
• Document discussion of TD risk with patients as part of informed consent 8

Common Pitfalls to Avoid

1. False sense of security with atypical antipsychotics - they still carry TD risk 8
2. Confusing TD with other movement disorders like drug-induced parkinsonism, akathisia, or withdrawal dyskinesia 1
3. Abrupt discontinuation of antipsychotics or anticholinergics, which can worsen symptoms 1
4. Failure to differentiate between acute and tardive movement disorders, which require different management approaches
5. Inconsistent monitoring - pharmacist-driven screening programs have shown to increase detection rates 4

Remember that early detection through consistent AIMS monitoring is crucial, as the risk of TD persistence increases with time. The goal is to identify TD early when it may still be reversible with appropriate intervention.