Risk Factors in Tardive Dyskinesia

Risk Factors in Tardive Dyskinesia

I think probably the first and foremost consideration when we talk about the risk factors for Tardive Dyskinesia is the use of dopamine receptor blocking medication and whether that’s an appropriate therapy for the patient you’re treating. Prevention is number one. If you don’t have to use the dopamine receptor blocking medication, that obviously dramatically reduces or even eliminates the risk of developing the condition (Smith 2022). So it always starts with that initial consideration: is a neuroleptic appropriate?

If it is, then there are modifiable factors to think about. One is the choice of the neuroleptic. First-generation medications are associated with a higher risk of developing TD, and while it’s not absent, the risk is lower with second-generation antipsychotics (Smith 2022). We’re still learning about some of the newer agents. The third factor is the patient themselves, things like age, diagnosis, and individual characteristics. We know that women tend to have a higher risk than men (Smith 2022). However, underlying neurologic disorders, cognitive impairment, or intellectual disability may also elevate that risk (Smith 2022). Even among psychiatric disorders, patients with schizophrenia who have more negative symptoms are more likely to develop TD (Smith 2022).

Now, why some people develop oral buccal lingual dyskinesias while others have more generalized symptoms or dystonic features is something we don’t really have good insight into. There’s no clear indicator for what specific clinical course a patient might be at risk of developing. From my experience, older females may be more likely to show the stereotypy form, while younger males might develop a dystonia syndrome. But I don’t know of any way to predict or mitigate which form of TD will appear.

Dosing is always a consideration. You want to use a dose that’s appropriate for the patient. There is evidence that dosage and duration of treatment are linked to TD risk (Smith 2022). Another situation where I often see TD symptoms emerge is when patients are transitioning between medications. If you’re switching a patient from one neuroleptic to another due to side effects or insufficient control, that transition can be a time when TD appears. It’s difficult to know if that’s related to withdrawal symptoms or something more permanent. Tapering slowly tends to help. Although we do not have exact guidelines, in my experience, the slower approach is more effective. Long-acting injectables can complicate things too, since the patient stays exposed to the medication for a longer period.

In the past, some tried increasing the neuroleptic dose when TD symptoms began. I don’t think that’s a good idea because it only increases exposure to the likely cause of the problem. I also see patients co-treated with anticholinergics for what’s labeled as extrapyramidal symptoms; however, anticholinergics may worsen TD, especially if the movements are oral buccal lingual or dystonic. Tapering them off can sometimes lead to improvement in symptoms.

One group I forgot to mention is patients with diabetes. For some reason, they also seem to be at elevated risk for TD (Smith 2022). I think it’s important to talk with patients about TD whenever neuroleptic medications are prescribed.

There are no lifestyle changes known to specifically address TD. However, brain health remains important through sleep, exercise, and diet. As prescribers, we also have a responsibility to monitor patients on an ongoing basis. I use the AIM scale to assess and document symptoms over time.