Tardive Dyskinesia¶

DIAGNOSIS: Tardive Dyskinesia ICD-10: G24.01 (Drug-induced tardive dyskinesia); G24.02 (Drug-induced acute dystonia); G24.09 (Drug-induced dystonia, unspecified)

CPT CODES: 80053 (CMP), 85025 (CBC with differential), 84443 (TSH), 82525 (24-hour urine copper), 82550 (CK), 80299 (Antipsychotic drug level), 81401 (Huntington disease genetic testing, HTT CAG repeats), 85060 (Acanthocyte smear), 86255 (Paraneoplastic antibody panel), 81479 (SLC6A3 genetic testing), 96127 (AIMS — Abnormal Involuntary Movement Scale), 70553 (MRI Brain), 78607 (DaTscan, ioflupane I-123), 78816 (PET scan, FDG or dopamine receptor imaging), 92012 (Slit lamp examination), 95886 (EMG) SYNONYMS: TD, tardive syndrome, tardive movement disorder, persistent tardive syndrome SCOPE: Diagnosis confirmation, severity assessment using AIMS, identification of causative agents, risk factor evaluation, FDA-approved VMAT2 inhibitor therapy, antipsychotic management strategies, prevention, and psychiatric coordination. Covers classic orofacial-lingual TD, tardive dystonia, tardive akathisia, and tardive stereotypy.

VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026

STATUS: Approved

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

SECTION A: ACTION ITEMS¶

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
CMP (80053)	STAT	ROUTINE	ROUTINE	STAT	Baseline renal/hepatic function before VMAT2 inhibitor therapy; electrolyte abnormalities can worsen movements	Normal
CBC with differential (85025)	STAT	ROUTINE	ROUTINE	STAT	Baseline for medication monitoring; rule out infection if acute change	Normal
TSH (84443)	URGENT	ROUTINE	ROUTINE	-	Thyroid dysfunction can cause or exacerbate movement disorders	Normal (0.4-4.0 mIU/L)
Medication and dose history review	STAT	ROUTINE	ROUTINE	-	Identify causative agent(s): antipsychotics, metoclopramide, prochlorperazine, other dopamine blockers	Document agent, duration, cumulative dose

1B. Extended Workup (Second-line)¶

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
Ceruloplasmin, serum copper (82390/82525)	-	EXT	ROUTINE	-	Rule out Wilson's disease if age <50 or atypical presentation	Normal
24-hour urine copper (82525)	-	-	EXT	-	Wilson's disease confirmation if ceruloplasmin low or borderline	<100 μg/24hr
Vitamin B12, folate (82607/82746)	-	ROUTINE	ROUTINE	-	Deficiency can cause movement disorders	Normal
Iron studies: ferritin, serum iron, TIBC (82728/83540/83550)	-	EXT	ROUTINE	-	Rule out brain iron accumulation disorders	Normal
CK (82550)	STAT	STAT	-	STAT	If concern for neuroleptic malignant syndrome or severe dystonia	Normal
Antipsychotic drug level (80299)	-	ROUTINE	ROUTINE	-	Assess compliance and toxicity if indicated	Therapeutic range

1C. Rare/Specialized (Refractory or Atypical)¶

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
Huntington disease genetic testing, HTT CAG repeats (81401)	-	-	EXT	-	Chorea with psychiatric history; family history	<36 CAG repeats (normal)
Acanthocyte smear (85060)	-	-	EXT	-	Neuroacanthocytosis if orofacial dyskinesia with chorea	Negative
Paraneoplastic antibody panel (86255)	-	EXT	EXT	-	Atypical movement disorder; occult malignancy; autoimmune chorea	Negative
Anti-NMDA receptor antibodies (86255)	-	EXT	EXT	-	Young patient; psychiatric symptoms; orofacial dyskinesia	Negative
SLC6A3 genetic testing (81479)	-	-	EXT	-	Research; consider if dopamine transporter dysfunction suspected	Normal

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
AIMS — Abnormal Involuntary Movement Scale (96127)	URGENT	ROUTINE	ROUTINE	-	At evaluation; before treatment; q3-6 months on antipsychotics	Document baseline severity (0-4 scale per item; total score)	None
Clinical examination: orofacial, trunk, limbs	STAT	ROUTINE	ROUTINE	-	At evaluation	Characterize movement type, distribution, severity	None
Video documentation	-	ROUTINE	ROUTINE	-	At baseline and follow-up	Record for comparison; share with psychiatry	Patient consent

2B. Extended¶

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain (70553)	URGENT	ROUTINE	ROUTINE	-	Atypical presentation; focal findings; rule out structural lesion	Normal or chronic dopaminergic medication changes	MRI-incompatible devices
DaTscan, ioflupane I-123 (78607)	-	-	EXT	-	Differentiate from Parkinson's disease or Huntington's if uncertain	Normal or mild reduction (dopamine blockers can affect)	Iodine hypersensitivity

2C. Rare/Specialized¶

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain with SWI sequence (70553)	-	EXT	EXT	-	Suspected brain iron accumulation (NBIA)	No abnormal iron deposition	MRI contraindications
PET scan, FDG or dopamine receptor imaging (78816)	-	-	EXT	-	Research; atypical cases	Variable	None
Slit lamp examination (92012)	-	EXT	EXT	-	Wilson's disease evaluation	No Kayser-Fleischer rings	None
EMG (95886)	-	-	EXT	-	Characterize tremor vs dystonic movements	Define movement characteristics	None

3. TREATMENT¶

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Discontinue or reduce causative agent	N/A	First step if psychiatrically safe; requires psychiatry coordination	N/A :: N/A :: N/A :: Collaborate with psychiatry; gradual taper preferred if stopping; dose reduction may help	Cannot discontinue if psychosis relapse risk too high	Monitor for psychiatric decompensation	URGENT	URGENT	ROUTINE	URGENT
Switch to clozapine	PO	Lowest TD risk; for patients requiring continued antipsychotic	12.5 mg :: PO :: qHS :: Start 12.5-25 mg/day; titrate by 25-50 mg q3-7d; target 200-450 mg/day; requires REMS	Agranulocytosis history; severe neutropenia; seizure disorder (relative)	ANC weekly x 6mo, q2wk x 6mo, then monthly; seizures; myocarditis	URGENT	URGENT	ROUTINE	-
Switch to quetiapine	PO	Lower TD risk; for patients requiring continued antipsychotic	25 mg :: PO :: BID :: Start 25-50 mg BID; titrate by 50-100 mg/day q2-3d; target 300-800 mg/day	QT prolongation; severe hepatic impairment	QTc, sedation, metabolic parameters	URGENT	URGENT	ROUTINE	-
Benzodiazepine (severe distress)	PO/IV	Severe anxiety/distress from TD movements; temporary relief	0.5 mg :: PO :: TID PRN :: Lorazepam 0.5-1 mg TID PRN for acute distress; short-term only	Respiratory depression; substance use disorder	Sedation, respiratory status	URGENT	URGENT	-	URGENT

3B. Symptomatic Treatments (FDA-Approved for TD)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Valbenazine (Ingrezza)	PO	FDA-approved first-line for TD; VMAT2 inhibitor	40 mg :: PO :: daily :: Start 40 mg once daily; increase to 80 mg daily after 1 week if tolerated; take with or without food	Congenital long QT; strong CYP2D6 inhibitors at higher dose; severe hepatic impairment	QTc (baseline, after dose increase); somnolence; depression	-	ROUTINE	ROUTINE	-
Deutetrabenazine (Austedo)	PO	FDA-approved first-line for TD; VMAT2 inhibitor	6 mg :: PO :: BID :: Start 6 mg BID (12 mg/day); increase by 6 mg/day weekly; max 48 mg/day; take with food	Depression/suicidality; MAO-I use; hepatic impairment; reserpine use within 20 days	Depression (PHQ-9); parkinsonism; QTc; akathisia	-	ROUTINE	ROUTINE	-
Tetrabenazine (Xenazine)	PO	VMAT2 inhibitor; older agent with more side effects	12.5 mg :: PO :: daily :: Start 12.5 mg daily; increase by 12.5 mg q1wk; max 50 mg/day (100 mg if CYP2D6 extensive metabolizer); require CYP2D6 genotyping >50 mg	Depression/suicidality; untreated or inadequately treated depression	Depression (PHQ-9); parkinsonism; akathisia; sedation; requires CYP2D6 genotyping	-	ROUTINE	ROUTINE	-

3C. Second-line/Refractory¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Clonazepam	PO	Adjunct for TD; limited evidence; reduces choreiform movements	0.25 mg :: PO :: BID :: Start 0.25 mg BID; titrate slowly; typical 0.5-4 mg/day divided	Respiratory depression; substance use disorder	Sedation, dependence, falls	-	ROUTINE	ROUTINE	-
Amantadine	PO	Limited evidence; may reduce TD severity; antiglutamatergic	100 mg :: PO :: BID :: Start 100 mg BID; may increase to 300-400 mg/day divided; adjust for renal function	Severe renal impairment; seizure history (relative)	Livedo reticularis; edema; hallucinations; confusion (elderly)	-	ROUTINE	ROUTINE	-
Ginkgo biloba	PO	Limited evidence; antioxidant mechanism; modest benefit in trials	120 mg :: PO :: BID :: 240 mg/day divided; EGb 761 extract standardized	Bleeding disorders; anticoagulant use	Bleeding risk	-	-	ROUTINE	-
Vitamin E	PO	Limited evidence; may prevent progression; minimal therapeutic effect	400 IU :: PO :: daily :: 400-1600 IU daily; better evidence for prevention than treatment	Coagulopathy; vitamin K deficiency	Bleeding risk at high doses	-	-	ROUTINE	-
Vitamin B6 (pyridoxine)	PO	Limited evidence; some trials show benefit	100 mg :: PO :: daily :: 100-400 mg daily; monitor for neuropathy at high doses	Peripheral neuropathy	Neuropathy with chronic high dose (>200 mg)	-	-	EXT	-
Levetiracetam	PO	Limited evidence; case reports of benefit	500 mg :: PO :: BID :: Start 500 mg BID; titrate to 1500-3000 mg/day; adjust for renal function	Severe renal impairment without adjustment	Mood changes; sedation	-	-	EXT	-
Propranolol	PO	For tardive akathisia component	10 mg :: PO :: TID :: Start 10 mg TID; titrate to 30-120 mg/day divided	Asthma; bradycardia; heart block	HR, BP	-	ROUTINE	ROUTINE	-

3D. Interventional/Advanced Therapies¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Botulinum toxin (focal TD)	IM	Focal tardive dystonia (e.g., cervical, blepharospasm)	Per target :: IM :: q3mo :: Cervical: 100-300 units; blepharospasm: 25-50 units per eye; repeat q3mo	EMG guidance recommended for some targets	Active infection at site; myasthenia gravis	Dysphagia (cervical); ptosis (periocular); local weakness	-	-	ROUTINE	-
Deep brain stimulation (DBS)	Surgical	Severe, disabling, medication-refractory TD	GPi target :: Surgical :: per protocol :: Bilateral GPi most common; programming optimization over months	MRI; neuropsychological testing; multidisciplinary evaluation; psychiatry clearance	Untreated psychiatric instability; cognitive impairment; coagulopathy	Programming; psychiatric monitoring; speech/swallowing	-	-	EXT	-
Pallidal lesioning	Surgical	Alternative to DBS if not candidate; irreversible	Unilateral pallidotomy :: Surgical :: per protocol :: Stereotactic lesion of GPi; reserved for DBS failures or contraindications	Same as DBS	Same as DBS	Permanent side effect risk higher than DBS	-	-	EXT	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Psychiatry consultation for antipsychotic management, dose reduction, or switch to lower-risk agent (ESSENTIAL - requires collaborative decision-making)	URGENT	URGENT	ROUTINE	URGENT
Movement disorders neurology for diagnosis confirmation, AIMS scoring, and VMAT2 inhibitor initiation	-	ROUTINE	ROUTINE	-
Neurosurgery consultation for DBS evaluation if medication-refractory disabling TD	-	-	EXT	-
Speech therapy for dysphagia evaluation if oropharyngeal involvement	-	ROUTINE	ROUTINE	-
Occupational therapy for adaptive strategies if hand involvement affects function	-	ROUTINE	ROUTINE	-
Social work for disability evaluation and resources if TD causes functional impairment	-	-	ROUTINE	-
Dentistry for oral health evaluation with orofacial TD (tooth damage, denture issues)	-	-	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Report any worsening movements, difficulty swallowing, or breathing problems immediately (may indicate progression)	ROUTINE	ROUTINE	ROUTINE
Do not stop antipsychotic medications without psychiatry guidance as this can worsen psychosis or cause withdrawal dyskinesia	ROUTINE	ROUTINE	ROUTINE
Report any new or worsening depression, suicidal thoughts, or mood changes on VMAT2 inhibitors (boxed warning)	-	ROUTINE	ROUTINE
Movements may temporarily worsen after stopping causative drug before improving (withdrawal dyskinesia)	ROUTINE	ROUTINE	ROUTINE
VMAT2 inhibitors may take 2-6 weeks to show maximum benefit; continue as prescribed	-	ROUTINE	ROUTINE
Avoid caffeine and stimulants which may worsen involuntary movements	-	ROUTINE	ROUTINE
Maintain regular dental visits for oral health if orofacial TD present (prevents tooth damage, ulceration)	-	-	ROUTINE
Consider support groups and counseling for coping with visible movement disorder	-	-	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Use lowest effective antipsychotic dose for shortest duration needed (primary prevention)	-	ROUTINE	ROUTINE
Perform AIMS examination at baseline, 3 months, 6 months, then q6-12 months on dopamine-blocking agents	-	ROUTINE	ROUTINE
Prefer second-generation antipsychotics over first-generation when clinically appropriate (lower TD risk)	-	ROUTINE	ROUTINE
Avoid metoclopramide for >12 weeks; use domperidone or other alternatives when possible (not available in US)	-	ROUTINE	ROUTINE
Document informed consent regarding TD risk when starting dopamine-blocking agents	-	ROUTINE	ROUTINE
Identify and monitor high-risk patients more frequently: elderly, female, mood disorders, diabetes, longer exposure, higher cumulative dose	-	ROUTINE	ROUTINE
Consider early intervention with VMAT2 inhibitors before TD becomes severe and irreversible	-	-	ROUTINE
Stress management and adequate sleep may help reduce movement severity	-	ROUTINE	ROUTINE

SECTION B: REFERENCE¶

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Huntington disease	Family history; cognitive decline; chorea; CAG expansion	Genetic testing for HTT CAG repeats
Sydenham chorea	History of rheumatic fever; anti-streptolysin O; younger patients	ASO titer; echocardiogram
Withdrawal dyskinesia	Occurs immediately after stopping dopamine blocker; self-limited (<3 months)	History; timeline (TD persists >3 months)
Spontaneous orofacial dyskinesia (elderly)	Elderly without antipsychotic exposure; edentulous	Careful medication history; dental exam
Wilson disease	Age <50; Kayser-Fleischer rings; liver disease; psychiatric symptoms	Ceruloplasmin; 24h urine copper; slit lamp
Neuroacanthocytosis	Orofacial dyskinesia; chorea; self-mutilation; elevated CK; acanthocytes	Acanthocyte smear; CK; genetic testing
Autoimmune chorea (anti-NMDA, anti-LGI1)	Subacute onset; psychiatric symptoms; seizures; encephalopathy	Autoimmune antibody panels; CSF
Meige syndrome (primary cranial dystonia)	Blepharospasm and oromandibular dystonia without antipsychotic exposure	Clinical history; no dopamine blocker use
Tourette syndrome	Childhood onset; tics (brief, suppressible); premonitory urge	Clinical criteria; onset <18 years
Drug-induced acute dystonia	Occurs within days of drug exposure; not persistent	Timeline (acute dystonia is immediate, TD delayed)
Parkinson disease dyskinesia	History of Parkinson's; peak-dose or diphasic dyskinesia on levodopa	Clear PD diagnosis; levodopa relationship
Hyperthyroidism	Tremor predominant; tachycardia; weight loss; heat intolerance	TSH, free T4

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
AIMS score	Baseline, 3mo, 6mo, then q6-12mo on antipsychotics	Improvement from baseline (decrease of 2+ points clinically meaningful)	Adjust treatment; consider VMAT2 inhibitor	-	ROUTINE	ROUTINE	-
AIMS score on VMAT2 inhibitor	q4-8 weeks until stable, then q3-6mo	50%+ improvement goal; any improvement beneficial	Optimize dose; consider second agent	-	ROUTINE	ROUTINE	-
Depression screen (PHQ-9)	Baseline, 2wk, 4wk, then q3mo on VMAT2 inhibitors	PHQ-9 <5	Hold VMAT2 inhibitor; psychiatry consultation; consider switch	-	ROUTINE	ROUTINE	-
Suicidality assessment	Each visit on VMAT2 inhibitors	No suicidal ideation	Immediate psychiatry referral; hold medication	-	ROUTINE	ROUTINE	-
QTc interval	Baseline, after dose increase (valbenazine/deutetrabenazine)	<500 msec	Reduce dose; evaluate medications; electrolytes	-	ROUTINE	ROUTINE	-
ANC (if on clozapine)	Weekly x 6mo, q2wk x 6mo, then monthly	ANC >1500/mm3	Follow REMS protocol for neutropenia	-	ROUTINE	ROUTINE	-
Parkinsonism symptoms	Each visit on VMAT2 inhibitors	No new bradykinesia, rigidity, rest tremor	Reduce VMAT2 dose	-	ROUTINE	ROUTINE	-
Akathisia	Each visit on VMAT2 inhibitors	No subjective restlessness	Reduce dose; consider propranolol	-	ROUTINE	ROUTINE	-
Swallowing function	Each visit with orofacial TD	Normal swallowing	Speech therapy referral; modify diet	-	ROUTINE	ROUTINE	-
Functional status	Each visit	Acceptable ADL function	OT referral; treatment intensification	-	ROUTINE	ROUTINE	-
Weight and metabolic parameters	q3-6mo on antipsychotics	Stable weight; glucose <126 fasting	Lifestyle modification; consider antipsychotic switch	-	ROUTINE	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Mild-moderate TD; able to manage oral medications; follow-up with neurology and psychiatry arranged; no psychiatric instability
Admit to floor	New severe TD with swallowing/respiratory involvement; psychiatric decompensation from medication change; severe dystonic component causing pain/disability; need for expedited workup (suspect alternative diagnosis)
Admit to ICU	Respiratory compromise from severe oropharyngeal/laryngeal TD; neuroleptic malignant syndrome; severe tardive dystonia with rhabdomyolysis
Outpatient follow-up	Initial: 4-6 weeks for medication titration; Stable: q3-6 months for AIMS monitoring; More frequent if depression risk on VMAT2 inhibitors

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Valbenazine FDA-approved for TD (KINECT 3)	Class I, Level A	Hauser et al. Am J Psychiatry 2017
Valbenazine efficacy and safety (KINECT 4)	Class I, Level A	Factor et al. J Clin Psychiatry 2017
Deutetrabenazine FDA-approved for TD (ARM-TD/AIM-TD)	Class I, Level A	Anderson et al. JAMA Neurol 2017
Tetrabenazine efficacy for TD	Class II, Level B	Kenney et al. Expert Rev Neurother 2006
AIMS as standard TD assessment	Class II, Level B	Guy W. ECDEU Assessment Manual 1976
Clozapine lowest TD risk	Class II, Level B	Correll et al. J Clin Psychiatry 2004
Second-generation antipsychotics lower TD risk than first-generation	Class I, Level A	Carbon et al. World Psychiatry 2017
Risk factors for TD (age, duration, dose, diabetes)	Class II, Level B	Woerner et al. J Clin Psychopharmacol 1998
AAN evidence-based guideline for TD treatment	Class I-IV, Level A-U	Bhidayasiri et al. Mov Disord 2018
DBS for medication-refractory TD	Class IV, Level C	Macerollo et al. J Neurol 2020
Ginkgo biloba modest benefit in TD	Class II, Level B	Zhang et al. J Clin Psychiatry 2011
Vitamin E for TD prevention (not treatment)	Class II, Level U	Soares-Weiser et al. Cochrane 2018
Clonazepam for TD	Class IV, Level U	Thaker et al. Acta Psychiatr Scand 1990
Metoclopramide black box warning (>12 weeks increases TD risk)	Regulatory guidance	FDA Drug Safety Communication 2009

CHANGE LOG¶

v1.1 (January 30, 2026) - Standardized lab tables: reordered columns to Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding - Added CPT codes to all lab tests (1A: 4 rows, 1B: 6 rows, 1C: 5 rows) - Standardized imaging tables: reordered columns to Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications - Added CPT codes to all imaging studies (2A: 3 rows, 2B: 2 rows, 2C: 4 rows) - Fixed structured dosing first fields across all treatment sections (3A-3D): starting dose only in first field - Added VERSION/CREATED/REVISED header block

v1.0 (January 27, 2026) - Initial template creation - Comprehensive coverage of VMAT2 inhibitors (valbenazine, deutetrabenazine, tetrabenazine) - AIMS scoring guidance for monitoring - Risk factor identification and prevention strategies - Psychiatry coordination emphasized throughout - Causative agent documentation (antipsychotics, metoclopramide, prochlorperazine) - Structured dosing format for order sentence generation - Advanced interventions (DBS, botulinum toxin)

APPENDIX A: AIMS (Abnormal Involuntary Movement Scale) Examination¶

Examination Procedure¶

Patient Preparation:
Patient seated in hard chair without arms
Observe at rest, then during activation maneuvers
Examine with dentures in and out (if applicable)
Rating Scale:
0 = None
1 = Minimal, may be extreme normal
2 = Mild
3 = Moderate
4 = Severe
Body Areas Assessed:

Item	Body Area	Observation
1	Muscles of facial expression	Forehead, eyebrows, periorbital area, cheeks
2	Lips and perioral area	Puckering, pouting, smacking
3	Jaw	Lateral movement, clenching, chewing, opening
4	Tongue	Protrusion, tremor, choreoathetoid movement
5	Upper extremities	Arms, wrists, hands, fingers
6	Lower extremities	Legs, knees, ankles, toes
7	Trunk	Neck, shoulders, hips

Global Judgments:

Item	Assessment
8	Severity of abnormal movements overall
9	Incapacitation due to abnormal movements
10	Patient's awareness of abnormal movements

Dental Status:
Current dental problems (Y/N)
Dentures used (Y/N)

Interpretation¶

Total Score (Items 1-7)	Interpretation
0-1	No or minimal TD
2-4	Mild TD
5-9	Moderate TD
10-28	Severe TD

Monitoring Schedule¶

Context	AIMS Frequency
Starting antipsychotic	Baseline, 3 months, 6 months
Stable on antipsychotic	Every 6-12 months
On VMAT2 inhibitor	Every 4-8 weeks until stable, then every 3-6 months
High-risk patient	Every 3 months

APPENDIX B: Causative Agents and Risk Factors¶

High-Risk Dopamine-Blocking Agents¶

Agent Class	Examples	TD Risk Level
First-generation antipsychotics (typical)	Haloperidol, fluphenazine, perphenazine, chlorpromazine	HIGH
Metoclopramide	Reglan	HIGH (especially >12 weeks)
Prochlorperazine	Compazine	HIGH
Promethazine	Phenergan	MODERATE

Lower-Risk Antipsychotics¶

Agent	TD Risk Level	Notes
Clozapine	LOWEST	REMS required; consider for refractory TD
Quetiapine	LOW	Good alternative; sedation may be limiting
Aripiprazole	LOW	Partial agonist; may worsen TD in some
Ziprasidone	LOW	QTc monitoring required
Olanzapine	MODERATE	Metabolic concerns
Risperidone	MODERATE	Higher than other SGAs

Risk Factors for TD Development¶

Risk Factor	Relative Risk	Notes
Age >55 years	HIGH	Most important risk factor
Female sex	MODERATE	Especially postmenopausal
African American ancestry	MODERATE	Higher incidence observed
Mood disorder (vs schizophrenia)	MODERATE	Higher risk in bipolar/depression
Diabetes mellitus	MODERATE	Metabolic dysfunction
Longer duration of exposure	HIGH	Cumulative risk
Higher cumulative dose	HIGH	Dose-dependent
Intermittent antipsychotic use	MODERATE	Drug holidays may increase risk
Early extrapyramidal symptoms	MODERATE	Predictor of TD susceptibility
Cognitive impairment	MODERATE	May mask early symptoms
Substance use disorder	MODERATE	Especially alcohol