Clinical Geriatrics

CASE PRESENTATION
An 82-year-old woman was referred for psychiatric evaluation by her primary care physician. Mrs. C was accompanied by her 86-year-old husband. She has suffered from dementia of the Alzheimer’s type for the past six years. Her husband has been her primary caregiver, with some assistance from the couple’s son and daughter-in-law, who live nearby. Mrs. C sat quietly next to her husband in the waiting room, but on observation displayed prominent movements of her lips and jaw, as well as restless and jerky movement in her arms and legs.

Mr. C is a very reliable historian, who has kept detailed notes regarding his wife’s condition. Mrs. C was very hostile and suspicious early in the course of her dementia, and refused to bathe or change clothing. Perphenazine 2 mg 3 times per day was prescribed with marked improvement in her paranoia and behavior. She continued on this medication for two years, until she developed a tremor in her hands, unsteady gait, and suffered several falls. The perphenazine was discontinued after she saw a neurologist who diagnosed drug-induced parkinsonism. Mrs. C was stable for four months, but became aggressive toward her daughter-in-law and refused to allow a home aide into the house. Risperidone 1 mg twice per day was started by the neurologist. Improvement was noted in her physical aggression, and she allowed their housekeeper to come in to help with cleaning and cooking.

Mrs. C continued on risperidone for the next three years. Mr. C grew concerned when she started to show some lip-smacking movements during the second year, but they appeared to improve after her dentures were adjusted. The movements began to worsen over the past six months. The neurologist who initially prescribed the risperidone retired, so Mr. C consulted with their primary care physician. Mrs. C has no active medical problems, and takes no medications other than risperidone. The primary care physician noted movements of her tongue and jaw, and found that she appeared rather restless. He suggested tapering the risperidone to 0.5 mg twice daily, prescribed vitamin E 400 IU twice daily, and referred Mrs. C to a psychiatrist.

Mr. C stopped giving his wife the risperidone. He noted that Mrs. C was initially very restless, but later calmed down. Her facial and hand movements continued. Due to family problems (the couple’s son and daughter-in-law were severely injured in a car accident), it was several months before they could schedule an appointment with a psychiatrist.

On examination by the psychiatrist, Mrs. C was alert and able to maintain eye contact. She responded to her name, but was unable to answer any questions. Her score on a Mini-Mental State Examination was 0/30. She scored 22 of 28 on the Abnormal Involuntary Movement Scale (AIMS), suggestive of moderate-to-severe tardive dyskinesia. Mrs. C appeared to have no distress or awareness related to the constant movements. She periodically stood up during the interview, and sat back down, several times.

Mr. C noted that his wife was cooperative with care and usually calm. She often wandered around the house at night, but he had installed safety locks on the doors and kitchen cabinets and placed nightlights throughout the home. Mr. C was very concerned that his wife was suffering as a result of her mouth movements, as she had difficulty chewing and required soft food. He was reluctant to give her any medication, but wanted to know if something could be done to help her.

DISCUSSION
Tardive dyskinesia is a movement disorder that results from treatment with antipsychotic agents. It is characterized by involuntary movements of the face, tongue, jaw, or extremities that have repetitive, choreiform, or athetoid qualities (Table I).1-5 Older adults are at particular risk for tardive dyskinesia and may develop this syndrome after as little as one month of continuous treatment with an antipsychotic agent.