Tardive dyskinesia (TD) is a severe movement disorder that is linked to the use of dopamine receptor–blocking agents (DRBAs). To try to prevent the development of TD, clinicians must understand its modifiable and nonmodifiable risk factors and how to mitigate them.

I think that the first-and-foremost consideration in TD risk management is whether the use of DRBAs is appropriate for the patient. These medications are used for a variety of reasons, and for some uses there may be other treatment options that could also be appropriate for the patient. Preventing TD is important, so if a patient does not need to receive a DRBA, their risk of developing TD will be reduced. Therefore, I always start by considering whether a neuroleptic is appropriate for the patient.

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Sometimes, the transition from a neuroleptic drug to another agent is a time when TD symptoms may appear, and it is somewhat difficult to determine how much of that is related to withdrawal-emergent dyskinesia vs something that could be more permanent. Clinicians should taper neuroleptics gradually and not abruptly discontinue them to help mitigate the risk of a patient developing TD symptoms.

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If the continued treatment with a neuroleptic is appropriate for a patient with TD, there are a few additional considerations. First, there are nonmodifiable risk factors for the development of TD that include older age, female sex, neurologic disorders, cognitive impairment, negative symptoms of schizophrenia, and intellectual disability.

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The choice of neuroleptic is a modifiable risk factor, as first-generation antipsychotics are associated with a higher risk of developing TD than second-generation antipsychotics. In addition, there is evidence that a higher dose of a neuroleptic and a longer duration of treatment increase the risk of developing TD, so the dose should be appropriate for the patient and their symptoms. Another modifiable risk factor is whether a patient is receiving cotreatment with an anticholinergic medication for drug-induced extrapyramidal symptoms (eg, tremors). Anticholinergic agents can increase a person’s risk for TD and may also worsen their TD symptoms. Tapering a patient off an anticholinergic medication may help improve their TD symptoms, but it does not necessarily resolve them. One final modifiable TD risk factor to be mindful of is diabetes.

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Regardless of a patient’s risk factors, clinicians should regularly evaluate them for TD. Several measures can be used for evaluation, but the most common is the Abnormal Involuntary Movement Scale (AIMS). It is also a good tool for documenting the presence or absence of movements that are consistent with TD and tracking them over time.