Parkinsons disease Psychiatric issues
Psychiatric and behavioral disorders in Parkinson's disease may include visual hallucinations, delusions, and depression. Managing psychosis involves identifying underlying causes, adjusting antiparkinson medications, and considering antipsychotic agents like quetiapine, clozapine, or pimavanserin. These drugs have specific dosing considerations and potential side effects.
2024-01-07 01:13:37 - Editor
Overview of Psychiatric Disorders:
A variety of psychiatric and behavioural disorders may occur in Parkinson disease. They most commonly include visual hallucinations, such as, sense of movement and an illusionary experience. Other manifestations include delusions, often paranoid persecution, and depression. Auditory and olfactory hallucinations can also occur but are less common in the disease. (1, 2, 3)
Management of Psychosis:
Firstly, identifying the underlying causes such as infection (UTI, pneumonia need to be ruled out). Anticholinergic agents, MAOB inhibitors, sedatives, anxiolytics, and antidepressants agents could worsen these symptoms. (3)
Also, antiparkinson medication adjustments have shown additional benefits for improvement in psychiatric symptoms. (4)
For patients with refractory psychotic symptoms, pharmacological treatment by antipsychotic agents including quetiapine at 12.5- 25 mg daily at
bedtime, clozapine at an initial dose of 6.25 mg/day, in 1 or 2 divided doses, and pimavanserin (34 mg orally once daily) at is necessary. Quetiapine is widely prescribed
and clozapine is the most effective agent. Pimavanserin is a newer alternative, but its long term efficacy and safety are not yet identified. (5, 6, 7)
Quetiapine has to be started at a low dose and may be titrated up if needed. Also, a daytime dose could be added if needed to control daytime psychotic symptoms. Antipsychotic drugs including quetiapine are associated with QT prolongation and suppression of the bone marrow.(8)
References
1- Vendette M, Gagnon JF, Décary A, et al. REM sleep behavior disorder predicts cognitive impairment in Parkinson disease without dementia. Neurology 2007; 69:1843.
2-Jozwiak N, Postuma RB, Montplaisir J, et al. REM Sleep Behavior Disorder and Cognitive Impairment in Parkinson's Disease. Sleep 2017; 40.
3-Gagnon JF, Vendette M, Postuma RB, et al. Mild cognitive impairment in rapid eye movement sleep behavior disorder and Parkinson's disease. Ann Neurol 2009; 66:39.
4- Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson's disease. Mov Disord 2005; 20:1255.
5- Apaydin H, Ahlskog JE, Parisi JE, et al. Parkinson disease neuropathology: later-developing dementia and loss of the levodopa response. Arch Neurol 2002; 59:102.
6-Kövari E, Gold G, Herrmann FR, et al. Lewy body densities in the entorhinal and anterior cingulate cortex predict cognitive deficits in Parkinson's disease. Acta Neuropathol 2003; 106:83.
7- Friedman JH. A Retrospective Study of Pimavanserin Use in a Movement Disorders Clinic. Clin Neuro pharmacol 2017; 40:157.
8-Morgante L, Epifanio A, Spina E, et al. Quetiapine versus clozapine: a preliminary report of comparative effects on dopaminergic psychosis in patients with Parkinson's disease. Neurol Sci 2002; 23 Suppl 2:S89.