parkinson's disease, Parkinson's Health

Psychosis in PD (PDP): By Dr. De Leon

Image result for images of psychotic people

Since there are so many people that have this problem including myself in the past due to medications, I thought I would address some of the salient points which could help take care of our loved ones better as well as help those of us who live with the disease to manage our symptoms better if present because this is the highest cause of care-giver burden and stress. The presence of PDP also leads to significant disability and poor quality of life. The risk increases with disease duration.

First of all, there are many causes of underlying neuropsychiatric disturbances which can present in the confines’ of Parkinson’s disease. These can be related to treatment(s) or disease itself.

  1. PD process- including visual processing e.g. contrast recognition, visual acuity, and color acuity reduction
  2. Abnormal activation of brainstem and cortical regions
  3. Sleep disturbances
  4. Brain abnormalities e.g. Lewy body
  5. Genetic factors – i.e./ APO E – particularly the E4 allele which increases risk of Alzheimer’s.
  6. Over activation of dopamine neurons by chronic use of dopamine replacement
  7. Decreased serotonin ( due to 6)
  8. Over activity of acetylcholine – same as above

Parkinson’s disease may be associated with a wide range of psychotic symptoms, including delusions, hallucinations in multiple sensory modalities –i.e. auditory, tactile, olfactory, visual, and gustatory). Psychotic symptoms may occur with retained insight, or may involve severe paranoid delusions and confusional states. In the early stage, PD-related hallucinations are primarily visual, with retained insight and a clear sensorium. (Meaning patients are fully aware and awake not confused!) With PD progression (late stages), patients may exhibit worsening hallucinations, with loss of insight. Visual hallucination are most common, (22% to 38% of patients with PD). Visual hallucinations are generally well formed, and may consist of people or animals (less commonly, inanimate objects), tend to persist over time, and typically involve recurring content. Up to 20% of patients experience auditory hallucinations, which usually accompany visual hallucinations and are less likely to occur in isolation. Olfactory and tactile hallucinations are less common, but can occur. These hallucinations tend to occur most often during periods of decreased stimulation (e.g., in the evening or when the lighting is low).

Delusions are also part of the neuropsychiatric disturbances in PD affecting approximately 5% of patients. The delusions tend to be of the paranoid either persecutory or jealous in nature. I myself suffered extreme jealousy directed towards my husband – un -common for me. The subject of mine and the majority of my patients has been an unshakable belief of spousal infidelity). I also have had on occasion independent of any other problems and not related to medication but mere factor of my PD some gustatory and olfactory hallucinations which last only but a few seconds.

Visual hallucinations tend to be non-invasive and non-frightening to the individual since they usually involve children or small animals. the family are the ones usually troubled by this. bit on occasion they can be violent and extremely frightening for patient and scary to watch for family members – these must be treated always.

Of Note, although auditory hallucinations can present themselves in PD, this is an extremely rare occurrence. Auditory hallucinations usually imply a underlying brain structural abnormality ( i.e., stroke), schizophrenia, or  substance abuse.

In PD patients, clinical rating scales like UPDRS, sleep scale, the Hamilton scale, and the PD psychosis questionnaire can help to identify psychotic symptoms and other common comorbid neuropsychiatric disorders, such as depression ( more common in early stage), anxiety( present in about 40% and associated with worsening motor function), impulse control disorders (ICDs) and disorders of sleep. Sleep disorders are an integral part of the disease and occur in as many as 90% of patients. Some of the problems commonly seen are insomnia (my major problem and many of ours – sleep wake cycle appears to be shifted), hypersomnia, sleep fragmentation, sleep terrors, nocturnal movements, restless legs syndrome, sleep apnea, and Rem Behavior disorder. However, to date there are no well validated scales and we depend on clinical diagnosis and exclusion of other things.

In the geriatric PD population common causes of psychosis:

  • Steroids are frequently a cause of psychosis
  • Dehydration
  • Infection (urine especially)
  • Lack of sleep
  • Medications – e.g. amantadine, artane, dopamine agonists

 

How do you treat PDP?

FIRST! Stop offending drugs or correct any of above deficits or infections

Antipsychotics-

  1. Seroquel (quetiapine)- biggest side effect is orthostatic hypotension (low bp) and sedation which is not always a bad thing we often want this to normalize sleep wake cycle. Oher side effects include dry mouth, hyperlipidemia, constipation, dyspepsia, dizziness, weight gain, increased appetite, fatigue, hyperglycemia, dysarthria, and nasal congestion. – I not had problem with these in past much.
  2. Clozaril (clozapine) not used much because of weekly blood draws needed due to possible agranulocytosis.
  3. New medication FDA approved is PRIMAVENSERIN (non-dopaminergic- actually serotonergic antipsychotic) 0nce daily – 2 tablets 17 mg each – the biggest side effect is peripheral edema and confusion. (should be first line of treatment)

Cholinesterase inhibitor:

Exelon (rivastigmine) only FDA medicine approved for PD dementia

So it is possible to have sensory hallucinations early on in the disease as part of illness itself which does not necessarily require intervention if patients are aware and not bothered or interfering with activities of daily living or social aspect. Usually these are olfactory or tactile and occasionally visual. However, as disease progresses visual hallucinations and delusions become more prominent and as PD advances there is a higher likelihood of being related to underlying dementia. Treat symptoms, remove offending causes and treat underlying dementia. But for all PD patients although no current treatment to prevent progression of disease or prevent dementia several things like staying mentally and physically active can help greatly as well as proper nutrition and adequate sleep. Seek immediate attention, if you or loved one experience any of these problems.

parkinson's disease, Parkinson's Health, Parkinson's symptoms, Parkinson's treatment

Preventing and Treating Psychosis Post Anesthesia in PD: By Dr. De Leon

I have heard of many patients being afraid to have procedures of any kind due to occurrence of psychosis and confusion reported by a number of Parkinson’s patients. This problem is not a myth unfortunately. Forty percent of Parkinson’s patients suffer psychosis commonly as disease advances which usually results in more hospitalizations, and increased procedures resulting in a greater need for anesthesia. Thus perpetuating the cycle. However, in my professional experience the majority of these episodes (psychosis post anesthesia) can be avoided by taking a proactive approach.
If surgery is required one must have evaluation of ones Parkinson’s symptoms for severity along with a complete evaluation of your medical regimen and a mini mental status exam prior to surgical procedure. The mini-mental status exam is KEY!!! The latter is particularly important in the face of long standing PD or advanced aged. This combination presents the highest risk for psychosis and delirium which is unfortunately often overlooked by most surgeons. I often would get consulted on other patients after the fact when a patient was psychotic and it never really was a surprised to me only to family and to rest of medical staff! This is true because if they would have bothered doing a full neurologic exam which included a mini mental status – they would have found cognitive deficits already present over 95% of the time prior to surgical procedures. In my patients I always stressed discussing with me prior to any and ALL procedures small or large especially if routine! This way I could have time to discuss with surgeons plan of action ahead of time and be involved in care. This is not always feasible in emergency cases but my patients and their families always knew to have their doctors put in a consult for me to manage their PD during their surgical procedures if hospitalized and receiving general anesthesia. One thing that everyone involved in care of Parkinson’s patients need to be aware of is that –Yes! PD patients represent a management challenge and need extra attention to have the best outcome.

Some of the common reasons people get psychotic with anesthesia:

  • Underlying dementia (often times undiagnosed- in my experience this is the number one reason)
  • Advancing age
  • Interaction of PD meds with anesthesia e.g. Mao inhibitors
  • Pain medication effect in light of PD meds and underlying dementia
  • Poor swallowing leading to pneumonia/ atelectasis
  • Decrease respiration /acid aspiration
  • Urine infections
  • Dehydration

Things to look at before any surgical procedure:

Preoperative continuation of levodopa

Aspiration prophylaxis Interaction of drugs with PD medications patients are taking

Duration of PD and systems disrupted –i.e. how is their cardiac function, their kidney function, their gastrointestinal function, their cognition, etc.

Surgical procedure – is it elective or emergent

Will hospitalization be required?

Type of anesthesia to be used-general vs. local

Will patient need to be bed bound – thus increasing DVT’s (clots) and also worsening PD symptoms like rigidity

First things we have to know about anesthesia:

1) Avoid halothane with levodopa if possible due to an increase in cardiac arrhythmia.

2) Use of Sympathomimetics  with Mao will increase BP- therefore need to suspend things like Azilect, and Eldepryl for up to a week before surgery. At same time recommend increasing other PD meds to compensate for that reduction so that you are the strongest prior to surgery.

3) Mao meds also inhibit metabolism of narcotics therefore narcotic effect can lasts longer in your system after surgery causing greater side effects- so may not want to resume Mao inhibitors right away after surgery if taking pain meds.

4) In advance PD sudden withdrawal of levodopa can be fatal at times causing neuroleptic syndrome. Therefore never recommend stopping this medication always look to take orally dissolvable Sinemet (levodopa/carbidopa) like Parcopa if have to be NPO (nothing by mouth).

5) Keep in mind that often times General anesthesia can relax muscles so much it can delay diagnosis of exacerbation by masking early symptoms.

6) PD patients who undergo general anesthesia have a tendency for increase chest infection due to ineffective cough mechanism and clearing of secretions and poor swallowing.

7) After general anesthesia these is increased nausea and vomiting meds often prescribed for this problem as well as those used with and during anesthesia can worsen PD symptoms.

My recommendations to prevent these common problems with general anesthesia:

Pre -operative care:

I am of the belief that patients should take medications up to the time of surgery by substituting things to bypass the GI system using oral disintegrating tabs such as Parcopa use dopamine agonist patches if necessary and discontinue Mao inhibitors- but increase dose by adding more dopamine after surgery to be able to deal with stress of body.

Don’t forget to evaluate for cognitive status and place on medications to protect many IV/IM/orally disintegrating meds and even patches ( Exelon, Abilify, Geodon, Zyprexa)

Take small sips of liquid if need be to get meds down to avoid exacerbation of symptoms.

If sedation is required Benadryl maybe be best solution because there is an IV form and helps with PD symptoms as well; works great for procedures of the eye.

Also ask for scopolamine patch – this decreases nausea and vomiting due to anesthesia.

Ask for reflux prophylaxis –such as Pepcid IV prior to surgery to avoid reflux and aspiration.

Peri- operative/intra-operative:

If at all possible get local anesthesia or nerve Block to avoid cognitive side effects as well as gi symptoms. Post- operative: Resumption of meds as soon as surgery over is very important. Because timing is so crucial medication schedule must be adhered to pre-intra, and post operatively. After surgery, broad time schedules of medication intake should be avoided completely! Staff MUST be instructed to stick to specific dosing times and not to deviate for more than 15 minutes (max) otherwise this can lead to erratic behavior and severe symptom breakthrough such as increased pain, depression, anxiety, confusion etc.

If unable to swallow post -surgery consider – nasogastric tube to give meds if needed if unable to get oral dissolvable or tolerate patch, etc.

Give water through feeding tube but also make sure getting fluids to prevent dehydration and getting IV antibiotics post -surgery.

Sometimes patients have difficulty voiding post operatively due to spasms of bladder- I recommend baclofen or macrodantin (nitrofurantuon).

If at all possible try to limit narcotics and use instead Tylenol #3, Toradol IV/PO/Vicodin only as needed. Trust me this works best if we follow all these steps are followed and all involved take a proactive role in the care of the PD patient. Of importance is also a temporary increase in PD medication doses during recovery/convalescing period.

Don’t forget to get ancillary consults like OT, PT, ST, and respiratory to provide breathing treatments and an incentive spirometer to prevent pneumonia. A team effort is the way to ensure a much less chance of having psychosis with anesthesia.
Don’t forget to include your neurologists/MDS for a best outcome and decrease post-surgery psychosis.

Sources:

http://www.bcmj.org/article/management-medical-and-surgical-problems-parkinsons-disease

http://practicalneurology.com/2014/10/inpatient-management-of-parkinsons-disease

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141145/