Evaluating and Managing Tardive Dyskinesia in the Older Adult

Purpose of Review Tardive dyskinesia is an iatrogenic hyperkinetic movement disorder caused by chronic exposure to antidopaminergic agents. The older adult population is particularly vulnerable to developing TD. It is also more difficult to discern the condition given the confounding medical comorbidities that may present at this age including Parkinson's and other movement disorders that may mimic TD. Recent Findings This paper reviews the most common risk factors, including both modifiable and non-modifiable risk factors. Additionally, the possible causes and proposed pathways of TD and how to correctly diagnose and evaluate TD are discussed. We then focus on how to prevent and manage TD given the current and evolving body of knowledge and evidence. Our stepwise management approach starts by frequent monitoring, discontinuing the culprit antipsychotic, decreasing the dose otherwise; followed by switching to less potent antipsychotics and prescribing VMAT-2 inhibitors. VMAT-2 inhibitors, initially approved for management of Huntington's disease, have been recently showing favorable results in treating other hyperkinetic movement disorders like Tourette's disease, quickly becoming the first line in the treatment of tardive dyskinesia. The properties of the three different agents belonging to this class: tetrabenazine, deutetrabenazine, and valbenazine will be examined, including side-effect profiles. Finally, recent investigational agents and treatment modalities, including neuromodulation (TMS and DBS) will be reviewed that can be considered when conventional treatment fails or is not tolerated. Summary Older adults treated with antidopaminergic medications are at greatest risk for development of tardive dyskinesia. It is important to recognize risk factors and accurately diagnose TD early. New FDA-approved treatments and investigational agents are now available to manage the condition, however further research to optimally prevent and manage TD in the older adult population remains necessary.