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Free socks? How to increase patients’ cooperation with the AIMS exam

Vol. 1, No. 6 / June 2002

Properly performing the examination for the abnormal involuntary movement scale (AIMS) is, in my view, crucial to detecting antipsychotic-induced tardive dyskinesia and other movement disorders. Yet I’ve found that many psychiatrists perform this examination either improperly or not at all.

The problem sometimes lies in getting psychiatric patients to follow directions during the exam. Patient cooperation is absolutely critical to doing the exam correctly.

The following are common problems encountered during the AIMS exam:

  • The patient refuses to remove his or her shoes. You cannot visualize the feet and accurately assess for movement disorders while the patient is wearing shoes.
  • The patient is tense. For part of the exam, patients must sit in a chair with their arms relaxed and hanging down at the sides. Too often, though, patients hold their arms rigid, thus masking involuntary movement.
  • The patient’s tongue is improperly positioned. The tongue should be relaxed in the bottom of the mouth, with the tip touching the back of the bottom teeth or lower lip. Sometimes patients deliberately curl up their tongues or raise them to the roofs of their mouths.
  • The patient is not familiar with the exam. Many patients either have never heard of the AIMS exam or—in the case of some patients with schizophrenia—do not remember that they previously received the exam.
  • The patient cannot—or will not—follow directions. For example, some cognitively impaired patients find it difficult to touch their thumbs to their fingertips while keeping their mouths open. Sometimes it is easier for them to do rapid alternating hand movements instead.

The following advice can help you surmount these obstacles:

Describe the exam. Start by explaining to the patient, “Your medication places you at risk of developing a movement disorder, so I need to monitor you for involuntary movement. This exam will take less than 10 minutes. It won’t hurt, but you will need to take off your socks and shoes.”

Make sure you are facing the patient. I find that having the patient’s chair aligned directly opposite mine makes it easier to relate to patients and improves their ability to follow directions.

Offer an incentive. I dispense a free pair of socks to patients who complete the exam. Although some affluent patients refuse the free socks, most patients (especially poorer ones) are happy to accept them.

For some patients, I use the socks as a “bribe” (“If you take off your shoes, I’ll give you these socks.”) For others, the socks are a reward for compliance.

Get the patient to relax. If any part of the patient is tense, use a favorite relaxation technique. I tell the patient to breathe deeply and “make believe you’re a pillow.”

Reinforce compliance. Make sure the patient knows you appreciate his or her cooperation. Praise the patient who follows your directions.

Reschedule the exam if necessary. If you cannot get the patient to cooperate that day, stop the exam and try it again during the next visit or as soon as the patient presents in a better mood. Consider having a counselor discuss the exam with the patient in the interim.

Suggested reading

1. Tardive dyskinesia: a task force report of the American Psychiatric Association. Washington, DC: American Psychiatric Association, 1992.

Dr. Szeeley is an associate professor of psychiatry at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Camden, NJ, and is head of the psychiatry department’s Division of Community Psychiatry.

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