Antipsychotic Side Effects: Would Your Staff Recognize the Signs?

Staff who administer, monitor, or document antipsychotic use must be trained to recognize the early warning signs of serious side effects like tardive dyskinesia and other involuntary movement disorders. Under CMS regulation F605 (42 CFR §483.45(e)), facilities are required to ensure routine monitoring for adverse effects of psychotropic medications and to take appropriate action when symptoms arise.

The Abnormal Involuntary Movement Scale (AIMS) is the most widely recognized and used clinical tool to detect early signs of tardive dyskinesia (TD) and other movement disorders caused by certain medications, most notably antipsychotics. In the wake of updated CMS guidance under F605, long-term care providers must document not only justification for psychotropic use, but also regular monitoring for side effects.  

CMS regulations do not specify a required tool by name but expect facilities to have systematic, routine monitoring for adverse effects of psychotropic medications, including TD and EPS, to ensure appropriate care and minimize harm. Other scales can be used if they are part of a facility’s clinical protocol and reliably detect drug-induced movement disorders.

The AIMS is the preferred and most widely accepted instrument because it’s validated, easy to administer, and specifically targets TD.

Other Tests/Scales for Monitoring Drug-Induced Movements

1. Simpson-Angus Scale (SAS)

• Focus: Measures extrapyramidal symptoms (EPS), including Parkinsonism symptoms (rigidity, tremor, bradykinesia).

• Use: Helpful for detecting early EPS but less sensitive for tardive dyskinesia.

• Application: Used mostly in psychiatric settings but can complement AIMS.

2. Barnes Akathisia Rating Scale (BARS)

• Focus: Specifically measures akathisia, a restless movement disorder sometimes induced by antipsychotics.

• Use: Useful alongside AIMS for comprehensive movement side effect monitoring.

3. Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS)

• Focus: Covers a broad spectrum of EPS symptoms, including tardive dystonia, Parkinsonism, and akathisia.

• Use: More detailed, but less commonly used in long-term care due to complexity.

4. Unified Parkinson’s Disease Rating Scale (UPDRS)

• Focus: Used to evaluate Parkinson’s disease symptoms but can assess EPS.

• Use: Less specific to TD but useful in certain clinical contexts.

What is the AIMS Tool? A 12-item scale completed by a clinician in about 10 minutes:

• Items 1–7: Score involuntary movements of face, limbs, and trunk

• Items 8–10: Global clinical judgment and resident awareness

• Items 11–12: Assess dental status, which may impact scoring

Used correctly, AIMS helps facilities detect and intervene in early cases of TD before permanent harm is done.

When Should AIMS Be Used?

• Before starting any antipsychotic or high-risk medication

• At least every 6 months, more often if high risk.

• Any time new abnormal movements are observed

Common Medications That Require AIMS Monitoring

Typical Antipsychotics (High Risk):

• Haloperidol (Haldol), Chlorpromazine (Thorazine), Fluphenazine (Prolixin)

Atypical Antipsychotics (Moderate Risk):

• Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Aripiprazole (Abilify)

Other Meds With EPS/TD Risk:

• Metoclopramide (Reglan), Prochlorperazine (Compazine), Promethazine (Phenergan), Lithium, Valproic Acid

Real-World Example A resident on Haldol begins lip-smacking and repetitive hand movements. AIMS screening shows moderate facial and limb scores. The physician reduces the dose and plans regular reassessments. This timely detection likely prevented permanent TD.

QAPI & Compliance Connection AIMS supports:

• Compliance with F605 (Freedom from Chemical Restraints)

• QAPI tracking for medication-related incidents (F865–F867)

• Documentation for resident-centered care planning and informed consent

Educating your staff on how to recognize, report, and respond to early signs of antipsychotic side effects is essential for protecting resident safety and maintaining regulatory compliance. Staff awareness and timely action are the frontline defense against irreversible harm from medication-related movement disorders.

Polaris training options include:

• On-site or virtual in-service training sessions focused on movement disorder recognition.

• Training modules covering psychotropic side effects and CMS F605 expectations.

• Remote psychotropic audits, action plans, and monitoring techniques.

• Mock Surveys with an extended focus on F605 compliance.

For help customizing staff education plans or to schedule a training session, reach out to your Polaris Consultant.

Sources:

• American Psychiatric Association: AIMS Tool

• CMS State Operations Manual – Appendix PP (April 2025)

• AAPACN Psychotropic Guidance Summary

• CMS Compliance Group

• NEJM, 2019: "Tardive Dyskinesia and Antipsychotics"

• FDA Drug Safety Communications