Treating Beyond AIMS Scores: Tracking Functional Outcomes in Tardive Dyskinesia

While the Abnormal Involuntary Movement Scale (AIMS) is a valuable tool for detecting and monitoring tardive dyskinesia (TD), it is not the only way to measure treatment impact, says Craig Chepke, MD, DFAPA, Chief Medical Officer, Psych Congress. In this video, Dr Chepke discusses the pitfalls of evaluating TD treatment progress by an AIMS score alone. He explores how functional impact and quality of life measures may offer a more complete picture of patients’ impairment due to TD. He also reviews the risks of overtreatment and offers insight into choosing a vesicular monoamine transporter 2 (VMAT2) inhibitor that is best suited to a patient’s needs.

• The Abnormal Involuntary Movement Scale (AIMS) is recommended by the American Psychiatric Association (APA) but is limited because motor items (1–7) are not linear and total scores may not reflect true severity or disfigurement.
• Treatment success should be defined by improvement in functional impairment and quality of life rather than achieving an AIMS score of 0, while avoiding overtreatment risks such as drug-induced parkinsonism and sedation.
• There are no clear predictors for choosing between VMAT2 inhibitors, so clinicians should use shared decision-making and longitudinal clinical interviews to assess real-world impact.

Craig Chepke, MD, DFAPA: Hi, my name is Craig Chepke. I’m a psychiatrist in private practice at Excel Psychiatric Associates in Huntersville, North Carolina. I’m also an adjunct associate professor of psychiatry for Atrium Health in Charlotte, North Carolina, and the [Chief Medical Officer] of Psych Congress.

Psych Congress Network: How can clinicians decide which vesicular monoamine transporter 2 (VMAT2) inhibitor may be more effective for a patient with TD, and how should success be measured throughout treatment?

Chepke: When I think about how to measure treatment success in tardive dyskinesia, it is not at all by an AIMS score. Like I always say, AIMS ain't nothing but a number. It's nice to do an AIMS. It's good to do an AIMS. The APA recommends it, so we should do them. 

But it's just tracking the movements themselves, and what’s really important to the treatment of TD is what's important to the person living with it, and that's the functional impairment or quality of life disturbances that TD can and does cause for virtually all individuals. 

That is not measured well at all by the AIMS, and not by the AIMS motor score, which is what we usually think about—items 1 through 7, summed together. And that's what we usually say is this is what their AIMS score is. Now the AIMS goes to 12 on different questions, but after 7, it gets down to the overall severity, the person's impairment from the TD and their awareness of it. Then 2 questions are about their dental status and if they wear dentures. 

We usually think about 1 through 7, but it's not a linear scale, so it doesn't tell us how severe the TD is in general for one. If a patient has a 7, but there's a 1 in all 7 body parts, that is equivocal on all 7 body regions, it could be the extreme end of normal or it could be potentially the involuntary movements. 

But if they have a 4 in their lips and then the other 3 points are distributed, that 4 in the lips is completely disfiguring. These 2 individuals [both] have a total AIMS score of a 7, but one is disfigured more or less and the other we may not even notice unless we are a trained clinician looking for it. So, it’s about the impact. 

As I said, there is a question on the AIMS about the impairment, but I think really it's better to not use that, but just ask questions. Psychiatric interviewing one-on-one, how is this affecting your life? 

It may take a little bit of time to get there with the individual because they may not be able to draw that line from A to B that this medication they started maybe years or decades ago could be responsible for these symptoms they're having here and now today. That’s our job as clinicians, to bridge that gap. 

But in my experience, I've been able to find with every person who's ever had TD that's walked through my doors in my practice, I found the impact eventually. Not always in the first session, not always the second, third, fourth. Sometimes it's 6 months or more, but eventually they'll say something that, because I have my listening ears on, I am able to connect those two. 

“Oh, that thing that's bothering you, I think I can fix that with a VMAT2 inhibitor.” That's not exactly how I say it, but, “I think I can fix that thing that's going on. Are you interested in that? It's because it's related to the TD.” 

For patients who are hesitant, find the impact. No one wants to take an extra pill if they don't think they have an extra problem. But if you can connect the problem with the condition of TD, and then connect the treatment with the condition, then you've got a recipe for [the patient] being more likely to accept treatment. 

So we treat to not the number of the AIMs, and certainly not the number of AIMs being 0, we treat to the impairment or the functionality difficulties. When those have gone away, whatever the AIMS score is, then that's when I stop titrating up the medication or switch from one to the other, whatever it may be.

Again, that's not always 0 because if we over-treat with any VMAT2 inhibitor, we run the risk of causing drug-induced parkinsonism, sedation, other things. If the person is still having movements that are noticeable—again, remember they're noticeable to us as trained clinicians, even if they're sometimes not noticeable to the patient. I have many patients who, with all sorts of movement disorders—TD, Parkinson's disease—that they are very concerned about movements that their family members will come in and say, “I didn't even notice that they had that going on.” And we don't want to over-treat them. Treat to when the functional impact goes away and nothing more. 

In terms of which VMAT2 inhibitors to select for what person, I wish I could give you a cut and dry, clear-cut answer, but there isn't one. These are both safe, efficacious, well-tolerated medications on average. Yes, some people do better on one than the other. but there's not a great way to tell beforehand. 

What I've seen is that it's very much like the situation with certain selective serotonin reuptake inhibitors (SSRIs). I think of it in terms of escitalopram and sertraline. Escitalopram, there's only a couple dose options, so it's very simple that, okay, you're going to get this dose or that dose, more or less. Whereas with sertraline, you titrate through some doses. It's got a wide dose range. I use both of those medications a lot. 

Similarly, I use both VMAT2 inhibitors a lot. But there are some people that only use sertraline or they only use escitalopram as a first-line option, and they will always go with that first. There are some people who, as clinicians, seem to always go to valbenazine or always go to deutetrabenazine. 

But I think just presenting both options for patients with the pros and the cons of each and then saying, “I believe strongly in both of these being good options. What do you think?” And let them guide the way.

Craig Chepke, MD, DFAPA, is a board-certified psychiatrist in clinical practice as the medical director of Excel Psychiatric Associates in Huntersville, NC. He serves as an Adjunct Associate Professor of Psychiatry for the Atrium Health Psychiatry Residency Program and is the Chief Medical Officer of the Psych Congress portfolio of Continuing Education conferences. Dr. Chepke earned his medical degree from NYU School of Medicine and completed his psychiatry residency at Duke University. Dr Chepke has been recognized as a Distinguished Fellow of the American Psychiatric Association and is a recipient of the NAMI Exemplary Psychiatrist Award.

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