Study: AIMS Should Not Be Sole Basis of Tardive Dyskinesia Care

John Kane, MD

The Abnormal Involuntary Movement Scale (AIMS) can be an effective tool in tardive dyskinesia (TD) care, however a multidisciplinary analysis approach is recommended, according to a recent assessment.

Led by John Kane, MD, vice president for Behavioral Health Services of Northwell Health and chairman of Psychiatry at the Zucker Hillside Hospital, researchers from New York gathered 7 psychiatrists and a neurologist to participate in a workshop in order to provide an historic overview of AIMS in clinical TD trials. They also outlined some of the challenges translating clinical trial results into clinical practice, discussed the various approaches to analyzing and interpreting AIMS data, and provided a consensus statement on these areas.

The participants were selected based on their clinical expertise as well as their research experience, the study authors said, and reached their conclusions after reading over studies that employed AIMS to evaluate tardive dyskinesia treatments between January 1970 and August 2017.

In examining the structure and scoring of AIMS, the workshop concluded that global and distress measures, plus dental pathology measures, have not been standardized. These may not be reliable or patients may not be aware of them, they said, and this area is important to further develop in the future. The rest of the workshop’s conclusions focused solely on the first seven items of AIMS: orofacial region, upper and lower extremities, and trunk.

The use of AIMS in TD studies seems to be primarily used to monitor its prognosis of patients who are receiving antipsychotics. When AIMS is used as an efficacy measure in clinical trials focused on improving TD, AIMS may indicate when a clinician should try a new treatment in practice. But AIMS results and their interpretation seem to differ across trials. For example, the workshop found that the rating method, training background or personal experience could all influence AIMS interpretations. Thus, researchers noted these types of controls are “expected to become the new standard for evaluating tardive dyskinesia therapies.”

In clinical practice, AIMS should be administered at regular intervals during antipsychosis medication continuance. But, the workshop warned, TD symptoms could develop at points between these intervals. In that case, self examination is advised as well as additional information and education provided to patients and their caregivers.

The workshop also noted that changes in AIMS scores from baseline and severity of TD needs to be reported, and is currently missing from most of the meta-analyses in the current literature. This missing data could be potentially confusing, and when discussing different mathematical approaches to AIMS scores (either arithmetic mean, geometric mean, or median, or analysis or covariance, missed-effects models, nonlinear machine learning algorithms) authors should include case-based reporting.

The best way to score AIMS in clinical trials is by viewing standardized video recordings or two-way live examinations. However, differences may still be present among the clinicians. A clinician who has only seen a handful of cases might see TD as severe, whereas a clinician who has seen hundreds of cases may not see it that way, the workshop concluded.

“Renewed education and training in use of the AIMS are necessary to ensure reliability of ratings,” researchers wrote. “Such methods could include instructional videos, in-house training by an experienced clinician, and/or participation in continuing medical education activities.”

The application of AIMS analyses may also need to be limited in terms of what the study’s original purpose was, be it well controlled studies examining efficacy or something else. Treatment effect sizes is one example of standardizing mean score changes in AIMS, as well as minimal clinically important differences, percent change from baseline, complete response or symptomatic remission, and functional remission or recovery.

No single analysis can be considered the singularly most important clinical method for using AIMS data, the workshop said; different analysis must be used to draw conclusions.

“Tardive dyskinesia researchers and clinicians may need to start thinking about optimal ways to adopt new technologies, such as wearable sensors, computerized video-based ratings, and smartphone-based monitoring of abnormal movements and other symptoms,” researchers concluded.

The study, “Revisiting the Abnormal Involuntary Movement Scale: Proceedings from the Tardive Dyskinesia Assessment Workshop,” was published online in The Journal of Clinical Psychiatry.