How to treat Tardive Dyskinesia (TD) in elderly patients?

Management of Tardive Dyskinesia in Elderly Patients

For elderly patients with tardive dyskinesia (TD), VMAT2 inhibitors (valbenazine or deutetrabenazine) are the first-line treatment of choice due to their FDA approval specifically for TD and favorable efficacy and safety profiles. 1, 2

Assessment and Monitoring

• TD is an involuntary movement disorder typically affecting the orofacial region but potentially involving any body part, associated with long-term use of dopamine receptor-blocking agents 3
• Before initiating treatment, perform baseline assessment of abnormal movements using the Abnormal Involuntary Movement Scale (AIMS) to document severity 3, 2
• Regular monitoring should occur at least every 3-6 months using standardized measures like AIMS to track progression and treatment response 3, 4

Treatment Algorithm

First-line: VMAT2 Inhibitors

• Valbenazine (40-80 mg once daily) is FDA-approved for TD treatment with dosage adjustment needed for:

  • CYP2D6 poor metabolizers (reduce dose) 5
  • Moderate to severe hepatic impairment (reduce dose) 5
  • No dosage adjustment needed for renal impairment 5

• Deutetrabenazine is also FDA-approved for TD and offers pharmacokinetic advantages over older VMAT2 inhibitors 1, 2

• VMAT2 inhibitors work by depleting presynaptic dopamine and reducing involuntary movements with minimal off-target binding 1

Second-line Options

• If VMAT2 inhibitors are unavailable or ineffective, consider:
  • Clonazepam: Particularly effective in elderly patients with TD, starting with low doses (0.25-1.0 mg at bedtime) 6, 7
  • Gradual withdrawal of the offending antipsychotic medication if clinically feasible 3
  • Switching to an atypical antipsychotic with lower TD risk if continued antipsychotic treatment is necessary 3, 8

Prevention Strategies

• Use atypical antipsychotics when possible, as they have lower TD risk compared to typical antipsychotics 3, 9
• Use the lowest effective dose of antipsychotic medications 2
• Avoid unnecessary long-term use of dopamine receptor-blocking agents 2
• Provide adequate informed consent regarding TD risk when prescribing antipsychotics 3

Special Considerations for Elderly Patients

• Elderly patients are at higher risk for TD and may require more careful monitoring 9
• When using clonazepam, start with very low doses (0.25 mg) due to increased sensitivity in the elderly and risk of falls 6, 7
• For elderly patients with cognitive impairment or dementia, carefully weigh the risks and benefits of antipsychotic use 9
• Avoid anticholinergic medications for TD as they may worsen symptoms and have adverse cognitive effects in elderly patients 2

Treatment Response Evaluation

• Assess treatment efficacy using AIMS scores to document improvement in involuntary movements 2
• Continue regular monitoring even after symptom improvement to assess for potential worsening or recurrence 3
• If initial treatment is ineffective after an adequate trial (typically 4-8 weeks), consider switching to an alternative agent 1, 2