Parkinsons Management

Question 1

What drug can cause psychotic symptoms in parkinsons

Answer 1

Dopamine agonist Levodopa

Question 2

Does a parkinsons patients have insight into hallucinations

Answer 2

Yes, most patients know that they are hallucinating (benign hallucination)

• 5% lackk insight

Question 3

What is a potential biomarker for diagnosing parkinsons stage, disease progression and distribution?

Answer 3

PD psychosis predicts cogntive decline

Question 4

What does the widespread of cortical lewy body lead to?

Answer 4

• Loss of insight
• multiple modality hallucinations and delusions

Question 5

Management of PD psychosis

Answer 5

• Exclude causes of delirium
• Withdraw antiparkinsonian medication regime- anticholinergics, selegiline, dopamine agonists, COMT inhibitors
  -L-dopa therapy, only in lowest dose possible to maintain motor function (motion/emotion dilemma)
• Explore other options (supportive therapies)
• Pimavanserin 5HT2A inverse agonist (reduces serotonin receptor activity by binding to it without psychotic side effects)

Question 6

Problems with the use of antipsychotic meds in parkinsons

Answer 6

• Risperidone and Olanzapine - cause significant motor deterioration
• Quetiapine vs placebo trials indicate negative results at low dosage (up to 200mg).
• Antipsychotics associated with increased mortality in clinical trials

Question 7

Effective Pharmaceuticals for PD Psychosis

Answer 7

• Clozapine & Quetiapine (low dose)

Question 8

What can be worsen by PD anxiety?

Answer 8

Tremor

Question 9

What psychiatric disorder usually precedes movement disorder (PD)

Answer 9

Depression

Question 10

Non-pharmacological treatment options for PD

Answer 10

• CBT helpful for anxiety and depression
• Metacognitive therapy: psychological distress due to perseverative cognitive processes /attentional strategies
• DBS

Question 11

What can be the limits or problems with CBT use in PD patients?

Answer 11

• reality testing of beliefs = PD is indeed an uncurable disease

Question 12

Pharmacological treatment of PD anxiety or depression

Answer 12

• fluoxetine & sertraline (acts activitating)
• Paroxetine (mildly sedating, lessens anxiety)

-Citalopram/Escitalopram (helpful for anxiety, less potential for drug interaction)

Question 13

Side effects of anxiety meds

Answer 13

Fluoxetine& Sertraline: nausea, insomnia, anxiety, and sexual dysfunction

Paroxetine: nausea, dry mouth, and sexual dysfunction

Citalopram/Escitalopram: causes less sexual dysfunction

Question 14

Atypical Antidepressants used in PD

Answer 14

Mirtazapine:
-for depression with anxiety and insomnia
-SEs sedation (greater at lower doses), weight gain, dry mouth, less sexual dysfunction

Venlafaxine:
-anti-anxiety properties
- SEs nausea, dizziness, constipation and sweating (Blood pressure monitoring recommended)

Bupropion:
apathy, fatigue and poor concentration due to stimulant properties

Trazodone – Repurposed drug targeting eIF2α-P-mediated translational repression prevent neurodegeneration in mice.

Question 15

Tricyclic antidepressants:

Answer 15

• Second or third line due to side effect profile:
• Anticholinergic effects can cause confusion/affect cognition
  -Hypotension can lead to falls.
  -Sedation, weight gain, and sexual dysfunction are common