Thursday, 11 October 2007

Parkinson's Disease

I've looked at a young chap (well, 66, so young to my mind) who unfortunately has Parkinson's Disease (PD). He's under the care of a physician who's been grappling with his PD but found the psychotic features tricky to manage, so asked for my views.

In PD there're regions of the brain where there is not enough dopamine. Result : my chap's rigid, literally unable to initiate movement and struggling to initiate speech and action. Medication is given to boost dopamine, helping improve the symptoms of his PD so he can play pool, read his paper, walk to the shops with his wife. Much better.

An unhappy side effect of the treatment is that the neuropsychiatric sequelae of PD become more prominent. That's to say, he has hallucinations and delusions. He awoke to see animals on his bed at 3.00am and had to get up, causing difficulties on the ward. This was compounded by his conviction that his wife had died and he had to get to her (so attempted to climb out of a window to leave the ward). Charging round a geriatric ward at 3.00am and making escapes unsettles staff, hence a referral to me.

I can start using an effective antipsychotic to help with his hallucinations and delusions. These types of medicine effectively reduce dopamine levels in the brain, improving his mental health. Result : his psychotic experiences (the hallucinations and delusions) improve but the dopamine antagonism works against his PD medication and his PD gets worse.

One antipsychotic, quetiapine, can work well . . . I've tried this but it's sedating him excessively so isn't an option.

Clozapine can also help, but is also very sedating (and can stop your body making blood cells to fight off infection, which kills you, and rarely you can get serious heart damage, which kills you). You need frequent (initially weekly) blood tests while you take clozapine and then ongoing blood tests at regular intervals since it's so hairy. Given his sensitivity to sedation I don't see him tolerating clozapine but it can be tried.

He's too unwell to be able to communicate preferences or discuss treatment options meaningfully and proffer valid consent. His wife obviously can't consent for him but I sought her opinion and she's keen for me to do "what ever is best" for him.

So what to do?

Either he's physically locked in (as his PD is bad) and mentally better (as his psychotic symptoms are managed). Or he's physically well and active (as his PD is well managed) and mentally unwell (with intense intrusive psychotic symptoms).

Any thoughts?


Elaine said...

My father had Parkinson's , first noticed when he was in his early 60s, and his family lived with the struggle to balance the treatment of the disease with treating the paranoia and hallucinnations. It was a difficult task, but in my view, it was better to have the side effects under "better" control, while giving some freedom of movement.

Both he and we(and hospital staff too)had difficulty coping with some of the more bizarre side effects of the anti Parkinsons meds.

Zarathustra said...

I've been recently nursing a patient who has both schizophrenia and Parkinsons - with the same dilemma. Treat the schizophrenia, and we risk worsening the Parkinsons, and vice versa.

Our consultant psychiatrist is in the process of writing to the patient's neurologist asking whether this chap might be a candidate for treatment of his PD with Deep Brain Stimulation rather than dopamine agonists. Other than that I'm not aware of any additional avenues we're exploring.

Aphra Behn said...

What does the patient think?

Milk & Two Sugars said...

I'm with Aphra - what is the patient's opinion when he is well? I expect the average adult would be more troubled by a nasty psychosis than even quite severe bradykinesia ('less it's going to give him aspiration pneumonia, in which case he'd be playing roulette).

Otherwise I wonder whether you think his Parkinson's might respond to ECT? I realise it's by no means a common approach (and he's a little younger than your average PD patient), but if he's a good candidate he might gain several months of improved morbidity on both counts.

The Shrink said...

Zarathustra, I have no idea what Deep Brain Stimulation is!

Aphra, M&2S, he's not able to guide us on care effectively.

As I posted :
He's too unwell to be able to communicate preferences or discuss treatment options meaningfully . . .

I've tried at different times on different days but been unable to have that conversation with him.

M&2S I'm thinking similarly, so on discussing things with his wife and medical team this afternoon we've reduced his sinemet and continue a better dose of quetiapine and see how it pans out over the weekend 'til I review him on Monday.

Aphra Behn said...

I missed that bit on my first read-through. Soz.


BenefitScroungingScum said...

Difficult. When he was physically well on medication was he really well enough to be able to play pool, hold and read the newspaper and walk to the shops with his wife? If so, from my perspective (which of course is different from that of a fully able bodied medical professional) that sounds pretty reasonable.
From what you say, it sounds like the hallucinations were all during the night time?
If I were in your patient's shoes and unable to communicate, I would want the trade off of night time hallucinations (which I have experienced brought on by medication, actually I also tried to climb out of a window in the middle of the night!) in return for the amount of physical activity described. Seems like an ok trade off under the circumstances. However, if the hallucinations are 24/7 that puts a different spin on things.
Bendy Girl

Zarathustra said...


When the consultant psychiatrist brought up the suggestion of asking about Deep Brain Stimulation, I asked her what it is and how it works. She replied, "I'm not sure myself. Why don't you look it up on Google?"

I do wonder if she might be clutching at straws.

But apparently this is deep brain stimulation:

Though I do notice from that page that one of the potential side-effects is hallucinations. Still, I guess there's nothing wrong with her asking the neurologist about it.

Calavers said...

We had a massive chunk of our syllabus last year dedicated to Parkinsons, and the questions section at the end had all these scenarios about what meds to start various patients on.

I never thought beyond the two-dimensional scenarios, though, taking into account things like his mental health and the fact that the patient may not be able to communicate well enough...

Neuro and psych for me come next year... I hope I manage to stay strong throughout, cos these sorts of scenarios seem pretty hard on the heart.


Dr. DJ said...

It's not my preferred medication (based on my experiences in Gen Adult) but where I work, we've had success using very low dose Aripiprazole when Quetiapine has been intolerable. As long as the patient is monitored for akithesia it seems to be a reasonable alternative.

The Shrink said...

Dr DJ, I'd considered amisulpiride simply 'cause I am very familiar with it, with aripiprazole I've always gone for 30mg since it's not got a linear dose response curve and instead you're after maximal receptor occupancy . . . on that basis although it's well tolerated in older adults at 30mg (less akithisia than many other Rx) I've no idea what that does in terms of exacerbating PD. It's a very good thought which I'd not considered though, thank you!

Dr. DJ said...

From clinical experience alone, I also find amisulpride to be a relatively effective and tolerable drug. Looking over my previous post I can see it can be misread. I was referring to the use of Aripiprazole specifically for the neuropsychiatric effects of Parkinson's as an alternative to quetiapine. I think difficult situations like you describe led to the consultants here trying it (the lower incident of EPSEs being the rationale for choice) and response has anectodally been good.