Should I assess for Abnormal Involuntary Movement Scale (AIMS) in a patient on Abilify (aripiprazole)?

Should You Assess for AIMS in This Patient on Abilify?

Yes, you should absolutely assess for abnormal involuntary movements using the AIMS scale in this patient on Abilify (aripiprazole), and this assessment should have been done at baseline before starting the medication and should be repeated at least every 3-6 months. 1, 2, 3

Why AIMS Assessment is Critical for This Patient

Aripiprazole carries a significant risk of tardive dyskinesia (TD), a potentially irreversible movement disorder, despite being marketed as an "atypical" antipsychotic with supposedly lower risk. 4 The FDA label explicitly warns that TD may develop in patients treated with antipsychotic drugs, and the risk increases with duration of treatment and cumulative dose. 4

Key Risk Factors Present in Your Patient

• Chronic antipsychotic exposure: Your patient is on ongoing Abilify treatment, which increases TD risk with cumulative exposure 4
• Multiple psychiatric medications: The combination of prazosin, Abilify, and Vyvanse requires careful monitoring 1

Evidence That Aripiprazole Causes Movement Disorders

Despite earlier beliefs that aripiprazole would have lower movement disorder risk due to its partial D2 agonist mechanism, accumulating evidence demonstrates that aripiprazole frequently causes movement disorders including tardive dyskinesia, parkinsonism, and akathisia. 5, 6, 7, 8

• A case series of 14 patients showed aripiprazole induced parkinsonism, tardive dyskinesia, and akathisia, with tardive phenomena often persisting after drug discontinuation 7
• Multiple case reports document aripiprazole-induced TD in neuroleptic-naïve patients, with movements developing within 2 months and failing to remit despite immediate discontinuation 5
• Aripiprazole is now the atypical antipsychotic most commonly reported with covert dyskinesia (TD appearing after drug discontinuation) 6

Specific AIMS Assessment Protocol

Baseline and regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) is mandatory for all patients on antipsychotics. 1, 2, 3 The assessment should include:

• Baseline assessment: Document any pre-existing abnormal movements before medication initiation to avoid later mislabeling them as medication side effects 9, 3
• Regular monitoring: Repeat AIMS every 3-6 months minimum 1, 2, 3
• Systematic examination: Assess facial movements, oral movements, extremity movements, and trunk movements for choreiform or athetoid movements 3
• Severity rating: Record severity for each body region on a 0-4 scale 3
• Global judgment: Make an overall assessment of severity and functional impairment 3

Clinical Significance of Movement Disorders with Aripiprazole

In controlled trials, aripiprazole caused significantly more movement disorders than placebo:

• Extrapyramidal symptoms (excluding akathisia): 13% vs 12% placebo in adults; 25% vs 7% placebo in adolescents 4
• Akathisia: 8% vs 4% placebo in adults; 9% vs 6% placebo in adolescents 4
• Objective measures showed significant differences on the Barnes Akathisia Scale 4
• Tremor occurred in 9% of pediatric patients vs 1% on placebo 4

Compared to other antipsychotics, aripiprazole causes more movement disorders than expected. At 12 weeks, haloperidol caused more movement disorders than aripiprazole, but aripiprazole still caused significantly more participant-reported akathisia than lithium (RR 2.97,95% CI 1.37 to 6.43). 10

What to Do If AIMS is Abnormal

If you detect tardive dyskinesia on AIMS examination, drug discontinuation should be strongly considered. 4 However, the FDA label acknowledges that some patients may require continued treatment despite TD presence. 4

Management Algorithm if TD Detected:

1. Immediately document findings with specific type, location, and severity of movements 3
2. Consider gradual withdrawal of aripiprazole if clinically feasible 2
3. If antipsychotic must continue, consider switching to an atypical antipsychotic with lower D2 affinity 2
4. Do not increase the dose to suppress movements, as this may mask the underlying process 4
5. Reassess need for continued treatment periodically 4

Common Pitfall to Avoid

Do not assume that because aripiprazole is "atypical" it carries low TD risk. The evidence clearly shows aripiprazole causes movement disorders at rates comparable to or exceeding other atypicals, and TD can develop rapidly (within 2 months) even in neuroleptic-naïve patients. 5, 7, 8 The partial D2 agonist mechanism does not provide the protection originally hypothesized. 7, 8

Additional Monitoring Considerations

Beyond AIMS, also monitor for:

• Acute dystonia: Sudden spastic muscle contractions requiring immediate anticholinergic treatment 1, 3
• Drug-induced parkinsonism: Bradykinesia, tremors, rigidity 3
• Akathisia: Subjective restlessness with pacing or agitation, often misinterpreted as psychiatric symptoms 3

Up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia, emphasizing the critical importance of regular monitoring. 1, 2