Using AIMS to Monitor Tardive Dyskinesia

In this video, Rakesh Jain, MD, MPH, Psych Congress steering committee member and clinical psychiatrist, discusses tardive dyskinesia focusing on how to modify the Abnormal Involuntary Movement Scale, or AIMS, to fit your clinical practice.

Read the transcript:

Dr. Rakesh Jain:  Hello, there. This is Rakesh Jain. A proud member of the Steering Committee at Psych Congress. I'm a psychiatrist and very much looking forward to having a conversation with you about tardive dyskinesia. The focus topic today will be on modifying the AIMS to fit our busy clinical practices.

As we already know, DSM has weighed in and offered us very good advice on what tardive dyskinesia is. The presence of involuntary athetoid or choreiform activities, sometimes stereotypies, that are often derived as a result of chronic blockade from D2 blocking medications, which in psychiatry, often are, of course, atypical and typical antipsychotics.

It doesn't tell us exactly how to look for it, how to assess it. The Schooler-Kane criteria really forwarded the field by telling us some specifics. There must be at least a three-month exposure to neuroleptics. There should be at least moderate dyskinetic movements in one body region at the very least or mild dyskinetic movements in two body regions.

All very helpful, but how do we go about measuring it? That's where the conversation today will lead us to. I would like to remind you that this particular publication that I was part of, the Caroff publication, the Modified Delphi Panel Guidelines, do make a appropriately big deal about the need for TD screening.

Look what we recommended. That the screening should be performed at every clinical encounter in all patients regardless of how long they had been on an antipsychotic medication, and regardless of the risk for TD. This, therefore, put some pressure on us to be able to do it formally at specific intervals, but also informally at every clinical encounter.

Why don't we visit the gold standard before we switch into the quick, efficient ways of conducting an examination for the presence of tardive dyskinesia? The gold standard examination for TD, of course, is the, yes, the well-known, AIMS.

In this big red box, I have put the top seven items, which are indeed the seven body regions that are involved in the assessment for dyskinetic movements in the AIMS. Those are muscles of facial expression, lips and perioral region, jaw, tongue, upper and lower extremities, and of course, the torso, which includes neck, shoulders, and hip.

Please note this is a Likert scale goes from zero, one, two, three, four. The AIMS is actually rapid. We can get the AIMS done in five to seven minutes, depending on the patient. There are sometimes where even this is too much. It needs to be far more rapid than this. Before we go on to talking about that, allow me to remind you, AIMS is indeed the gold standard.

It is very appropriate to conduct a full AIMS at regular intervals. It could be once a year, depending on the patient and the medication they're on and the risk factors, or every six months, every three months, and in occasional patients, every single month.

One more time, let me restate the obvious. AIMS is the gold standard, but there is a need for quick and formal assessment for abnormal movements at every visit. I would like to propose to you a rather pragmatic three-step approach to getting it done. Just remember, this is the semiformal movement disorder assessment process. It does not replace the AIMS. It should not replace the gold standard.

We often have encounters with patients on such a regular basis that it would be such a waste not to conduct some semiformal assessment for an abnormal movement disorder. The first step is, don't put the entire burden on just your shoulders.

For example, if you are a clinician, a prescriber who works in a partial hospital program, and you see the patients every few weeks, but you know for a fact that your staff members see them three times a week or five times a week, would it not be great to involve the entire treatment team in noticing involuntary movements.

Please advise and instruct them and educate them on unobstructively watching the patients while they're doing things, such as sitting in the waiting room, such as filling out the paperwork, such as even walking into the waiting room. In a few minutes, I'll tell you how we can do this, even with telepsychiatry.

Step number two is the following. We should involve others. We should involve others, such as family members, such as a spouse, such as children, such as parents. In particular, the semi-structured interview focuses on a few areas of the body that seem to be particularly prone to the development of tardive dyskinesia, such as the face, the tongue at rest, perhaps even speech.

In particular, with this semi-structured interview, you may want to do a quick physical activation. I'll show you two right now. One could be, have the patient put their hand out, close their eyes, and have them count backwards from 20 or whatever the case might be. By doing this, you're activating and potentially revealing the presence of any abnormal movement.

The other could be as simple as asking the patient to raise their hand and then touch the tips of their fingers with the thumb as rapidly as they can. While they're doing that, please observe the face for any activation maneuvers. See, easy stuff. This would be step two.

Step three is, if you do see something, even if you're not certain what you saw was an area of concern, but something did alert you, if you did get alerted to the presence of a challenge, go for the full AIMS. The full AIMS is not that long. It's five to seven minutes long. It is the gold standard.

It protects the patient, but also protects the clinician and the health system they are in because we fulfill the obligations that we have in this patient-clinician relationship.

Now telepsychiatry. Very often nowadays we're doing telepsychiatry, and I do think it's here to stay. It is possible to do an informal assessment even during a telepsychiatry visit. In fact, right now. You're looking at me. You're actually observing me from my shoulders up, and you're able to observe my hands, too. You know what? That's six out of seven body regions that we've already covered.

If you do activation maneuvers, then you are able to detect a great deal of any challenges that patient might have with these abnormal movements. It's not a good idea to feel pessimistic or nihilistic about our ability to detect TD just because telepsychiatry may be the only law of the land in your clinic, or with very many patients. That's their choice and your choice going forward.

Having a support system member would be very helpful. If you are doing an exam on me, and somebody was to be present, the camera could be held further away, so you could perhaps even watch my lower extremities.

Having said all that, telepsychiatry may not be perfect, but it's still is incredibly valuable tool for the informal assessment of TD. I hope I've whetted your appetite, and you want to perhaps know even more so about TD.

We have created a lovely website, a resource for you on tardive dyskinesia, www.td-360.com. I sincerely invite you to come, visit that website, and avail yourself of any and all educational opportunities. With that, thank you very much for your kind attention. I wish you and your patients the very best. Goodbye for now.