Why is age a key risk factor for tardive dyskinesia?

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Leslie Citrome, MD, MPH, Clinical Professor of Psychiatry and Behavioral Sciences, New York Medical College

According to results published in Neuropsychiatric illness and treatment.

Age is a key factor in the development of TD, according to Leslie Citrome, MD, MPH and colleagues. Dr. Citrome and his colleagues reviewed, with particular emphasis on the elderly, the risk of DT, the burden of DT, and disease management.


Prevalence and risk factors

The average prevalence of TD among people treated with APs was 20% to 25%, according to meta-analyses of articles published from 1959 to 2015. Another large retrospective observational study that examined EHRs reported a prevalence estimated annual DT of 7.6 to 9.7 per 1,000 people; nearly 80% of study participants were treated with second-generation APs, according to Dr. Citrome and colleagues.

“A direct comparison of annualized incidence between first- and second-generation APs indicates a reduced but not eliminated risk of TD with use of second-generation APs (range 0.8% to 3% with use second-generation APs versus 5.4% to 7.7% using first-generation APs),” the researchers wrote.

In addition to age and exposure to dopamine receptor blocking agents (DRBAs) – which include first- and second-generation PAs and drugs such as metoclopramide – other risk factors for the development of DT include female gender, mood disorders, dementia, and history of drug-induced parkinsonism. “Smoking and substance abuse may also be associated with a higher risk of developing TD,” Dr. Citrome and colleagues wrote.

The role of age in the development of tardive dyskinesia

In their review of age in relation to the development of TD, the researchers noted that PAs can be used off-label for dementia-related psychosis and aggression. As a result, “TD may be encountered in this population, particularly in institutions caring for the elderly,” they wrote, adding that up to 33% of patients in nursing homes or residences- services are handled with APs, primarily in the form of off-label use.

“A survey of 350,000 nursing home residents in 8 states, representing 40% of residents nationally, found that in 2006, 27.6% of residents had taken APs in the last 7 days , and only 20.7% of these were for the treatment of primary indications of schizophrenia or bipolar disorder,” Dr. Citrome and his team wrote. “The National Nursing Home Survey of 300,000 residents revealed that 23% of respondents had received at least 1 second-generation PA, and 86.3% of these prescriptions were for off-label indications Dementia is one of the most common indications for the use of off-label PAs. MDAs in these settings, despite the bold “black box” warning against the use of PAs in patients with dementia-related psychosis Behavioral problems related to dementia may in part result in the use of PA in this population. »

Additionally, the effect of DT on a person’s physical, mental and economic health may increase with age, according to Dr. Citrome and his colleagues. “The social and emotional effects of symptoms are highly debilitating for people with TD of all ages, but feelings of isolation and depression can be particularly profound for older adults,” they wrote. “Older adults are also particularly vulnerable to the physical consequences of TD, such as impaired gait and balance, which can lead to falls.

Treat Tardive dyskinesia & Minimize risks

The irreversible nature of TD necessitates the use of preventative strategies, the researchers noted. Strategies include restricting the use of drugs known to induce TD and secondarily identifying TD symptoms early. According to Dr. Citrome and colleagues, clinicians can also examine the pharmacology of different PAs to choose therapies that are least likely to induce TD.

Prompt diagnosis is also “the first step” in defining the best treatment approach for DT. Treatment of TD initially involves modifying the use of current PAs if it is clinically possible to do so, although the study team noted that this approach is not often successful.

“Avoiding TD by eliminating exposure to DRBAs may be the best option for the elderly,” Dr. Citrome and colleagues wrote. “Several new agents are being studied for their antipsychotic properties. Alternative mechanisms, including reverse agonism/antagonism of serotonin in the absence of dopamine receptor blockade, agonism of TAAR1 receptors, and modulation of muscarinic cholinergic receptors, may provide different therapeutic approaches for patients requiring a drug with an AP effect [to] avoid contributing to the risk of developing DT. »

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