patient care perspectives

Older Patients With Tardive Dyskinesia

by Leslie Citrome, MD, MPH

Overview

Although tardive dyskinesia (TD) can impair psychosocial and physical functioning in people of all ages, older individuals may be more severely impacted. Optimizing overall functioning is a priority in both younger and older patients, and the consideration of TD treatment is important even in people who have limited insight into their symptoms.

Expert Commentary

Leslie Citrome, MD, MPH

Clinical Professor
Department of Psychiatry and Behavioral Sciences
New York Medical College
Valhalla, NY

TD in an older person may be associated with other impairments that impact function, such as decreased manual dexterity and an increased risk for falls, which older people may be at greater risk for to begin with, so it is not a trivial matter.

Leslie Citrome, MD, MPH

Advanced age and limited insight into TD symptoms are separate issues, although both may apply to the same person. The risk of developing TD is much greater in older individuals than it is in younger individuals, so it is more common in the former patient group. TD in an older person may be associated with other impairments that impact function, such as decreased manual dexterity and an increased risk for falls, which older people may be at greater risk for to begin with, so it is not a trivial matter.

Finger flicking due to TD can make buttoning or tying shoelaces challenging, and movements of the toes can lead to painful abrasions on a patient's toes. TD may not be obvious if the movements remain in the mouth, but it can cause damage to the oral mucosa. An individual’s ability to eat normally or to drink liquids without spilling can also be an issue. These are physical manifestations that sometimes go unappreciated. As with younger age groups, the geriatric population needs to be treated to improve their overall functionality.

Patients may not be aware of their TD, and that level of insight is often dependent on their underlying psychiatric disorder. For example, someone with schizophrenia may have limited insight into their illness, whether it be the emotional components, hallucinations, delusions, or somatic illness. They may not be cognizant of the abnormal movements of TD themselves. However, they are often aware when other people remark on their movements, and that may be upsetting to them and/or they may not quite understand the situation.

On the other hand, someone with a mood disorder may be exquisitely sensitive to their TD symptoms, and this can impact their social behaviors to a great extent. For instance, they may not shop during the daytime because they do not want their neighbors to see them, or they may withdraw from family events, which can lead to social isolation.

Even when patients are unaware of their TD, the need to consider treatment still exists because there are other consequences that go beyond a person’s own insight. There is a stigma attached to having abnormal motor movements. Caregivers, family members, and friends are also affected by these abnormal movements. If they take their loved one with TD to the mall, for example, people might stare at them. Thus, TD impacts everyone associated with the patient, and it can be quite uncomfortable for caregivers, family members, and friends.

Having pronounced TD involving the face (eg, sticking out the tongue, blowing out the cheeks, or grimacing) is very obvious to anyone around. The patient with TD may look strange or unusual to other people. Movements of the hands, feet, and torso can also be stigmatizing, in addition to pelvic thrusting, which can occur in severe TD and can be very embarrassing. People with TD can face alienation in society, as others may not want to sit next to them, talk to them, or employ them. People may not want to be friends with someone with TD. This is a real concern for patients of all age groups, whether the person is aware of their TD or not.

References

Ayyagari R, Goldschmidt D, Mu F, Caroff SN, Carroll B. An experimental study to assess the professional and social consequences of tardive dyskinesia. Clin Psychopharmacol Neurosci. 2022;20(1):154-166. doi:10.9758/cpn.2022.20.1.154

Caroff SN. Overcoming barriers to effective management of tardive dyskinesia. Neuropsychiatr Dis Treat. 2019;15:785-794. doi:10.2147/NDT.S196541

Caroff SN, Yeomans K, Lenderking WR, et al. RE-KINECT: a prospective study of the presence and healthcare burden of tardive dyskinesia in clinical practice settings. J Clin Psychopharmacol. 2020;40(3):259-268. doi:10.1097/JCP.0000000000001201

Citrome L, Isaacson SH, Larson D, Kremens D. Tardive dyskinesia in older persons taking antipsychotics. Neuropsychiatr Dis Treat. 2021;17:3127-3134. doi:10.2147/NDT.S328301

Cutler AJ, Caroff SN, Tanner CM, et al. Caregiver-reported burden in RE-KINECT: data from a prospective real-world tardive dyskinesia screening study. J Am Psychiatr Nurses Assoc. 2021 Jun 22;10783903211023565. doi:10.1177/10783903211023565

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