treatment of psychosis in a patient with parkinson disease and dementia?

[josehernandez94]

i have a patient with pretty severe parkinson disease +/- dementia (by report of the SNF, though i'm not sure i buy it and there aren't any other records i can find!... gonna work on screening him tomorrow) who has intermittent hallucinations that bugs are crawling on his skin and face. he also has some low grade paranoid delusions that SNF staff is plotting to get him.

any ideas on how to treat his psychotic symptoms? any references you could pass along?

thanks a bunch in advance.

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[masterofmonkeys]

I would consider dialing back on his dopaminergic medications, in particular L-Dopa. Although depending on the severity of rigidity and/or tremor, that may not be possible.

Another thing that comes to mind is if he's on cogentin (benztropine). Pretty commonly used anticholinergic for treating parkinson's, but could be causing delirium which may be presenting as dementia and/or psychosis. If he/she IS on cogentin, DCing this would be the first thing I'd do.

I'm still a student, but it always seemed to me that the intersection of parkinson's, dementia, and psychosis seemed to be one of the hardest issues to deal with in psychiatry. Medications that help one exacerbate others.

Sorry, no citations, but given the radically different receptor affinities of the various antipsychotics, I'm sure that there are some that are more indicated for use in parkinson's patients than in others.

But my gut would still be to look at the parkinson's medications first, before trying antipsychotics given the frequency with which parkinson's meds cause psychosis/MSC and the likelihood of antipsychotics worsening the parkinsons.

Calling Dr. Samson...

 

[erg923]

Hallucinations are common with sinemet and some of the other dopaminergic meds used in parkinsons. So is low grade paranoia. However, they are almost always visual hallucinations in this case. Furthermore, the patient almost always has insight into the fact that they are not real. Does the patient know he is hallucinating the bugs under his skin, or is he convinced this is actually happening when he has the sensation? Does he have insight in other words? If its the latter, it might be a symptom of lewy body dementia, rather than solely a medication effect. How cogntively impaired is the patient? This is a case where a good neuropsychological eval can help you out immensely. I would also try to to assess if he has engaged in any abnormal risk taking behaviors such as gambling, or hypersexuality, as the literature demonstrates that these are common psychiatric complications of sinemet as well. In my experience as a clinical psych Ph.D. student who has seen alot of PD patient for pre-surg neuropsych screening, docs tend to just scale back the sinemet, rather than give antipsychotics. If you do i would think you would want something that has low D2 affinity, but im not sure, as that is not my area really. I have attached a good article worth reviewing.

http://pni.med.jhu.edu/aboutus/art_4900.pdf

 

[Faebinder]

Cutting back on dopamine drugs is likely not an option in severe parkinson, but it's worth exploring. Abilify is your next choice due to it's partial agonistic action and low side effect profile.

 

[billypilgrim37]

i have a patient with pretty severe parkinson disease +/- dementia (by report of the SNF, though i'm not sure i buy it and there aren't any other records i can find!... gonna work on screening him tomorrow) who has intermittent hallucinations that bugs are crawling on his skin and face. he also has some low grade paranoid delusions that SNF staff is plotting to get him.

any ideas on how to treat his psychotic symptoms? any references you could pass along?

thanks a bunch in advance.

The movement disorder folks I talk to all swear by quetiapine, although the trials are mixed. I've heard of some pretty low doses (25-50mg) having substantial benefit. I remember there being some trials with the cholinesterase inhibitors, although those results were mixed too.

 

[Doc Samson]

1) See if you can decrease his dopamine agonists as suggested as above
2) Look for causes of delirium, also as suggested above
3) Seroquel, start low (12.5 mg) proceed with caution.
4) Could try Abilify, failing that Clozaril is an option (probably has the best evidence for efficacy and safety in this population, but no-one wants to do the paperwork)

 

[Still Kickin]

i have a patient with pretty severe parkinson disease +/- dementia (by report of the SNF, though i'm not sure i buy it and there aren't any other records i can find!... gonna work on screening him tomorrow) who has intermittent hallucinations that bugs are crawling on his skin and face. he also has some low grade paranoid delusions that SNF staff is plotting to get him.

any ideas on how to treat his psychotic symptoms? any references you could pass along?

thanks a bunch in advance.

I'm really curious about this case since I recently had a Gero-Psych rotation. (And am rather interested in Gero-Psych.) (Let us know how things turn out!)

(This made a good excuse for me to go back & review some of my Gero-Psych notes as the first thought that came to mind for me was "Dementia with Lewy Bodies", but after reviewing my notes I'm less convinced about that.) (From my notes - in Lewy Body Dementia the *DEMENTIA* occurs way earlier in the disease course vs. in Parkinson's + Dementia - [ie, the dementia is concurrent with or soon after the movement features, sometimes even *preceeding* the Parkinsonian movement features.) But it sounds like the Parkinsonian features have been the most prominent features long-term in your patient's case.
(I would be curious about the long-term evolution of this patient's case. Are the "dementia" and hallucinations recent/acute in onset? Or have they been evolving over time? [And which came first - the movement disorder or the dementia?])

 

[Doc Samson]

I'm really curious about this case since I recently had a Gero-Psych rotation. (And am rather interested in Gero-Psych.) (Let us know how things turn out!)

(This made a good excuse for me to go back & review some of my Gero-Psych notes as the first thought that came to mind for me was "Dementia with Lewy Bodies", but after reviewing my notes I'm less convinced about that.) (From my notes - in Lewy Body Dementia the *DEMENTIA* occurs way earlier in the disease course vs. in Parkinson's + Dementia - [ie, the dementia is concurrent with or soon after the movement features, sometimes even *preceeding* the Parkinsonian movement features.) But it sounds like the Parkinsonian features have been the most prominent features long-term in your patient's case.
(I would be curious about the long-term evolution of this patient's case. Are the "dementia" and hallucinations recent/acute in onset? Or have they been evolving over time? [And which came first - the movement disorder or the dementia?])

All good valid diagnostic questions. Treatment of psychotic symptoms in either setting is the same though.

 

[josehernandez94]

wow, thanks everybody for all the helpful replies.

great thought about dlb, but don't think this is it. the patient has had the parkinsonsian symptoms for quite a long time and the dementia is relatively new (and quite mild). his deficits are primarily visuospatial and he also has memory retrieval problems (which are possibly consistent with dlb), but the timing of parkinsonian features preceding dementia doesn't add up. my understanding is that dlb is usually associated with rapid decline and that has certainly not been this patient's course.

not sure we can really go down on his sinemet. he's incredibly rigid and essentially wheelchair bound and pt is struggling to work with him. we're trying him on low dose seroquel for the time being (though he's not actively psychotic). his real reason for admission was that he was being "combative" at his snf. in all honesty, i think the fact that he's very slowed by the parkinson, combined with the fact that he's incredibly hard of hearing and has reported low frustration tolerance/impatience premorbidly make him a difficult patient to care for and i think he and the staff have a lot of conflicts, particularly when he needs to be transferred from bed to chair, etc. so his primary reason for admission was this combativeness and we're treating his "agitated dementia" with low dose depakote. i'm still not entirely convinced that there's a lot of true organic psychopathology we're treating. it seems like this patient is an (understandably) cranky old man who may have lower reserve due to his dementia and parkinson and we're trying to pacify him and mollify the snf staff.

thanks again for the replies though. very helpful and we are, in fact, using seroquel.

 

[Anasazi23]

I agree with Doc Samson's assessment. Most try Seroquel first in this case, with careful monitoring. Clozaril is probably the next option if the psychosis remains or worsens. Asking a SNF-bound patient about gambling is silly, and it's inaccurate to say that they exclusively have insight into their hallucinations, particularly if the disease is advanced and dementia plays a large part. It's not as easy to decrease as sinemet as some might think, since it could render the patient even more non-functional. Though, it's good to try in theory.

 

[whopper]

Agree with most of the above.

Try to see if reducing dopaminergic meds as an option-if it can be done without worsening the patient's Parkinson's.

The board exam answer is Clozaril--of course that is a board exam question several years old that has not been updated.

In my best clinical opinion--avoid a typical antipsychotic because of the high duration of dopamine blockage. Choose an atypical--which one? Risperdal is low on the list. It has a dopamine blockage duration on the order of typicals.

Use the CATIE trial. According to the CATIE trial Seroquel had the least amount of EPS side effects. You though still have to weigh in the fact that it has several non-EPS side effects to contend with such as weight gain, sedation & hypotension.

All of the atypicals minus Risperdal showed very little increase in prolactin--> indictaing little dopamine blockage effects.

Abilify-well Abilify is the new kid on the block & not on CATIE. Theoretically, I would think it would be a good option because its a partial agonist of dopamine, but all the studies I've seen so far concerning the use of Abilify on a Parkinson's patient, the data is sparse & equivocal.
http://www.ncbi.nlm.nih.gov/pubmed/17013906

While some patients had a favorable response, aripiprazole was associated with an exacerbation of motor symptoms. In this small study on psychosis in PD, aripiprazole did not appear promising. Copyright 2006 Movement Disorder Society.

I would also try to to assess if he has engaged in any abnormal risk taking behaviors such as gambling, or hypersexuality, as the literature demonstrates that these are common psychiatric complications of sinemet as well.

As far as I know, the data backing that dopaminergic meds increase gambling is sparse & more research is needed to verify it. I personally though find it believable. Enhance dopamine--it may enhance the effect in the nucleus accumbens. I do though agree with Anasazi that at this point, worrying about gambling in this situation is low on the list of priorities.

It has though affected my practice. I would not consider Welbutrin as a treatment option in a patient with Pathological Gambling. Besides, the limited amount of data suggests the use of an SSRI in that disorder.