Patient-Centered Strategies and Treatment Approaches in Tardive Dyskinesia Care

Key Takeaways

• Treatment of tardive dyskinesia (TD) should be individualized, with decisions guided primarily by the patient’s perceived impact on quality of life rather than exam findings alone.
• First-line management includes assessing symptom burden, addressing triggers, and using VMAT2 inhibitors when symptoms are bothersome, with choice often influenced by insurance coverage.
• Ongoing monitoring relies on both Abnormal Involuntary Movement Scale (AIMS) assessments and patient/caregiver input, with routine screening recommended for all patients on dopamine antagonists.

Adam Margolius, MD, a movement disorders neurologist at Cleveland Clinic, discusses his approach to managing TD with a focus on individualized, patient-centered care. He shares insights on treatment decision-making, the role of patient-reported outcomes, and practical strategies for improving detection and long-term management in clinical settings.

Welcome to Annals of Long-Term Care. My name is Juliet Gallagher, and today I'll be interviewing Dr Adam Margolius. Could you please introduce yourself, Dr Margolius?

Adam Margolius, MD: My name is Dr Adam Margolius. I'm a movement disorders neurologist at Cleveland Clinic.

How do you ensure a patient-centric approach in the treatment of TD? Are there particular strategies or models you've implemented to promote individualized care that address both motor and non-motor symptoms?

Dr Margolius: The most important thing with TD is getting a sense for how the symptoms are affecting the patient's quality of life. Generally, the treatment is going to be different for each patient. It really depends on whether the movements are bothersome to the patient, if they're affecting the patient's ability to do normal activities, or if they're causing the patient suffering in any way.

Have you incorporated any technology-enabled tools or digital platforms to aid in the monitoring or management of TD symptoms? And if so, how have these tools improved treatment adherence or symptom tracking?

Dr Margolius: I often see patients in follow-up virtually or through telehealth visits. A lot of my patients live far away, so it's more convenient for them to see me from the comfort of their own home rather than always having to come back in person. So, that is the main way  I use technology in my practice for TD follow-ups.

Can you walk us through your typical treatment protocol for TD? What pharmacologic and non-pharmacologic interventions do you find most effective? And how do you tailor these approaches based on patient characteristics?

Dr Margolius: First, after a diagnosis is made, if the movements aren't bothersome to the patient or aren't affecting their quality of life at all, we don't have to do anything for treatment. We could just monitor clinically. The next question is, if the movements are bothersome or affect quality of life, what can we do about it? Sometimes we try and see if there are any triggers, things like anxiety, stress, or lack of sleep that could be making symptoms worse.

Once all these questions are addressed, then we think about medications, pharmacotherapy. My main 2 treatment options are Austedo (deutetrabenazine)  or Ingrezza (valbenazine). Either medicine works well for most patients, so I don't have a strong preference between them. The decision often comes down to which one insurance is going to cover better and which will have less out-of-pocket costs for the patient.

What metrics or patient-reported outcomes do you use to assess the effectiveness of your TD treatment strategy? And how do you manage progress, adjust interventions, and ensure continued quality of life for your patients?

Dr Margolius: There is a physical exam scale that we often use in TD called AIMS. The scale looks at movements primarily around different facial muscles, but also the torso and extremities. I often follow these symptoms in my patients.

However, the patient's perception of how the medicine is working for them is important because when I examine them it’s just a snapshot every few months. So, I'm more interested in hearing from them how they feel the medicine has worked and if it's helped their quality of life.

Even if the movements look about the same to me, if the patient says they're worse, I'll take that seriously. This could potentially lead to an increase in the dose of medication. If the patient tells me they're doing great—even if the medicines seem a little worse right in that moment—then we wouldn't necessarily make a change.

Can you share how you address safety and quality concerns when managing TD in patients who are often frail, cognitively impaired, or on complex medication regimens?

Dr Margolius: Well, we rely a lot on help from caregivers. Not all patients are able to give all details of their history. Often we also ask their loved ones (eg, spouse or adult children) how they've been doing and how the medicine is affecting them. Generally, I ask all my patients whether they've had any falls, been in the hospital for any reason, or if they have any new medical symptoms that other doctors are working up, things of that nature.

What advice do you have for long-term care clinicians or medical professionals looking to improve detection, documentation, and management of TD in their facilities?

Dr Margolius: I would say that every patient that is chronically on a dopamine antagonist should be screened for TD in some way. Ideally, that would include a brief exam to look for movement disorders, typically around the face, but other areas can be affected too. It is something that should be on the radar for every patient who is on a dopamine antagonist, not just psychiatric medicines, but some antinausea medicines too can cause TD.