Does tardive dyskinesia (TD) typically present with symptoms at rest, and can it be associated with a shuffling gait in an adult or elderly patient with a history of neurological or psychiatric conditions?

Tardive Dyskinesia Does NOT Typically Present at Rest and Does NOT Cause Shuffling Gait

Tardive dyskinesia (TD) is characterized by rapid, involuntary choreiform and athetoid movements—not symptoms at rest or shuffling gait, which are hallmarks of parkinsonism, not TD. 1

Clinical Presentation of TD

TD manifests as hyperkinetic involuntary movements that are present during wakefulness and typically worsen with voluntary movement or stress, not at rest 2, 3:

• Orofacial region most commonly affected: rapid involuntary facial movements including blinking, grimacing, chewing, or tongue movements 1
• Choreiform and athetoid movements: rhythmic, repetitive, stereotypic movements of the face, mouth, tongue, trunk, and extremities 3, 4
• Not tremor as a primary feature: TD involves chorea and athetosis, distinctly different from resting tremor 1

Shuffling Gait is NOT a Feature of TD

A shuffling gait indicates drug-induced parkinsonism or Parkinson's disease, not tardive dyskinesia 1:

• Shuffling gait is a cardinal motor feature of parkinsonism (bradykinesia with rigidity), which represents a separate drug-induced movement disorder 5
• Rule out drug-induced parkinsonism when evaluating abnormal movements, as it requires different management than TD 1
• Dopaminergic imaging may assist in differentiating drug-induced parkinsonism from neurodegenerative causes when diagnostic uncertainty exists 5

Critical Differential Diagnosis

When evaluating movement disorders in patients on dopamine receptor-blocking agents, distinguish between 1, 2:

• Tardive dyskinesia: choreiform/athetoid hyperkinetic movements
• Drug-induced parkinsonism: bradykinesia, rigidity, resting tremor, shuffling gait
• Acute dystonia: sustained muscle spasms
• Akathisia: inner restlessness with pacing

Common Pitfall to Avoid

Do not confuse TD with parkinsonism—they are phenomenologically distinct tardive syndromes that may occur simultaneously in the same patient but require different treatment approaches 2. TD involves excessive involuntary movements, while parkinsonism involves reduced movement and rigidity 1.

If TD is Confirmed

For moderate to severe TD, treat with a VMAT2 inhibitor (valbenazine or deutetrabenazine) as first-line pharmacotherapy 1, 6:

• Gradually withdraw the offending antipsychotic if clinically feasible 1, 6
• Never use anticholinergic medications (benztropine, trihexyphenidyl) for TD—they are contraindicated and may worsen the condition 6
• Consider switching to clozapine if continued antipsychotic therapy is necessary, as it has the lowest risk profile for movement disorders 1, 6

If Parkinsonism is Present Instead

For drug-induced parkinsonism with shuffling gait 5:

• Reduce antipsychotic dose if psychiatric condition allows
• Consider switching to an atypical antipsychotic with lower D2 affinity
• Dopaminergic imaging may help differentiate from early-onset Parkinson's disease, which has increased prevalence in certain populations 5