Tardive Dyskinesia and Tardive Akathisia

Tardive dyskinesia and tardive akathisia are late complications of long-term antipsychotic drug use. Tardive dyskinesia involves persistent, stereotyped, abnormal involuntary movements; tardive akathisia involves motor restlessness. Diagnosis is by history and physical examination. Treatment includes stopping the causative drug when possible. Severe symptoms can be treated with oral drugs.

Geriatric Essentials

• Tardive dyskinesia and akathisia are common among elderly nursing home residents, usually those who have dementia and have been given antipsychotic drugs to treat behavioral and psychologic symptoms.
• Tardive akathisia should be considered in elderly patients with apparent agitation and restlessness.
• Both disorders can usually be prevented by judicious use of antipsychotic drugs. Drug holidays may help.

Tardive dyskinesia and tardive akathisia differ from movement disorders that result from short-term use of antipsychotics (eg, dystonias). The tardive disorders are long-term sequelae that can appear any time during antipsychotic drug use, most often when a dose is reduced or an anticholinergic drug is added. Symptoms may persist after the antipsychotic drug is stopped. Reinstituting the causative drug may temporarily alleviate tardive symptoms. All traditional antipsychotics can be causative. However, 2nd-generation antipsychotics (eg, clozapine, quetiapine) may be less likely to do so. Higher drug doses and longer-term treatment increase the risk. The incidence in the elderly is about 4 times that in younger adults.

Symptoms and Signs

Tardive dyskinesia typically involves orobuccal dyskinesia (tongue movements and chewing, lip puckering, and lip smacking). Involuntary movements of the extremities, flailing movements, and to-and-fro myoclonic jerks of the spine may also occur. Tardive akathisia is a feeling of motor restlessness or an aversion to being still. This subjective state often results in repetitive movements. Manifestations include repeatedly rubbing or stroking parts of the body, crossing and uncrossing the arms or legs, picking at clothes, pacing, marching in place, swinging the legs, moaning, grunting, and shouting.

Diagnosis

Diagnosis is by history and physical examination. Tardive akathisia is frequently misdiagnosed as agitation, which often leads physicians to increase the dose of the causative drug.

Prevention

When antipsychotics are needed, the lowest effective dose should be used for the shortest time possible, and if possible, 2nd-generation antipsychotics should be used. If long-term antipsychotic therapy is required, drug holidays as tolerated are recommended. Once established, dyskinesia is difficult to control.

Treatment

Treatment includes, if possible, stopping the causative drug. Orobuccal dyskinesia, if significant, can be treated with reserpine (0.25 mg po once/day, gradually increased to 1 to 5 mg po once/day), although this drug is not always effective and may not be tolerated at these high doses. Clozapine (6.25 mg po once/day, gradually increased to 25 to 75 mg po once/day) may be used instead; use of clozapine may result in agranulocytosis. Opioids, propranolol, benzodiazepines, and possibly vitamin B₆ or melatonin may also be helpful.

This topic was last updated June 2006.