Tardive Dyskinesia: An Older Man With Bipolar Disorder

Stephen R. Saklad, PharmD, BCPP | Director and Clinical Professor, Psychiatric Pharmacy, The University of Texas at Austin

A 68-year-old man with bipolar disorder presented to your office for his annual examination. He has been taking a variety of antipsychotic medications, including lithium, valproate, and lamotrigine, at different times since he was diagnosed with bipolar disorder at age 29 years. Currently, he is taking oral aripiprazole, 15 mg, in the morning and oral lamotrigine, 200 mg, twice daily.

He had worked as a civil engineer until 2 years ago when he retired.

Three months prior to presentation, the patient had seen his psychiatric provider for routine follow-up and reported unusual movements, including lip smacking. His Abnormal Involuntary Movement Scale (AIMS) examination at that time revealed a rating of 2 (mild) for lips and perioral area. At the present visit 3 months later, he was quite distressed because his abnormal movements had worsened. 

The abnormal movements in his facial area had increased to an AIMS score of 3 (moderate) for lips and perioral area and 2 (mild) for tongue. Additionally, his upper extremities were involved with a rating of 3 (moderate) for his upper arms with choreic movements in his fingers. Therefore, his total score on items 1 through 7 of the AIMS examination is 8, and his global rating is a 3 (moderate).

For the AIMS examination global judgments, he is rated as follows. Severity of abnormal movements (Item 8) would be 3, which by convention is the highest rating assigned to any individual AIMS Item 1 to 7. His incapacitation due to abnormal movements (Item 9) was rated as 1 (mild), caused by a minimal difficulty with eating because of his hand and mouth movements. However, his awareness (and distress) of abnormal movements (Item 10) is rated as 3 (moderate) since it has caused him to avoid eating in public and visiting his friends.

His incapacitation was rated as 1 (mild), caused by a minimal difficulty with eating because of his hand and mouth movements. However, his awareness and distress because of his abnormal movements is currently rated as 3 (moderate) and has caused him to avoid eating in public and visiting his friends. 

He has no dental problems or dental appliances, which are final questions on the AIMS examination.

Based on the patient’s AIMS scores, his level of distress, his current medication use and history, and standard diagnostic criteria, a diagnosis of tardive dyskinesia was made.