Article from April 2018 E-Newsletter

Parkinson Psychosis, Hallucinations, and Delusions
Parkinson’s disease is a neurodegenerative disorder that robs patients of coordination and movement. It has four cardinal motor symptoms; tremor, bradykinesia, rigidity and postural instability. However, all patients have some type of non-motor manifestations. These non-motor symptoms can be as disabling as the motor symptoms. Non-motor symptoms include dysautonomia, sleep disturbance, cognition difficulties, mood disorder or psychosis. Progression of motor and non-motor complications increases morbidity, mortality, and caregiver stress. Early recognition and treatment of these complications will improve quality of life.

Psychosis has been estimated to occur in 20-60% of persons living with Parkinson’s disease (PD). Psychosis associated with PD can be difficult to diagnose and treat. There must be a primary diagnosis of idiopathic PD, recurrent episodes ongoing for longer than one month, and occur after the onset of PD. Other causes of psychosis can be due to dementia, metabolic disorders, and medications. PD psychosis is associated with length of dopaminergic drugs, age of onset of disease, and severity of disease. There is an increased risk of psychosis with Hoehn Yahr score>4, MMSE<24, and age>70 years old. Use of anticholinergics can increase risk. Use of donepezil can decrease risk. (1) It is associated with sleep impairment, depression and dementia (2).

Psychosis is an abnormal condition of the mind in which there is an impaired sense of reality. It usually involves hallucinations or delusions. Hallucinations are the perception of visual, auditory, olfactory or tactile stimulus that is not present or real. Visual hallucinations occur in 39% of patients with psychosis. Visual illusions are present in 72% of patients (3). This is the visual distortion or perception of movement, form, size or color of an object. This is commonly the misinterpretation of bushes or trees as children or animals outside the house. Another common visual illusion is seeing bugs on the floor. Auditory, olfactory, tactile hallucinations are less common.

The treatment of psychosis can be complicated. It must be individualized and follows a slow, methodical process which includes medication analysis and assessment of PD and comorbid diseases. PD psychosis is triggered by dopamine (D2) receptor activation. Decreasing dopaminergic medications may lead to improve psychosis but decrease motor function (4). The first step is to rule out infection, metabolic or structural abnormality causing the onset of psychosis. The next step is tapering medications such as antispasmodic, anticholinergic, benzodiazepine, muscle relaxants and opioids. Then, gradually tapering dopaminergic medications such as amantadine, selegiline, rasageline, dopamine agonists, and levodopa should be considered. The last step is considering use of atypical antipsychotic medications. There has been an increased risk of death in the elderly with use of antipsychotics.

Atypical antipsychotics use in PD psychosis is effective. The goal of treatment is to minimize dopamine D2 receptor blockade while increasing serotonin 5HT2A antagonism. Clozapine may stimulate D2 receptors and block 5HT2A. It may improve REM sleep as well. It does affect adrenergic, histamine, and cholinergic receptors. It has many side effects and requires frequent blood work. Quetiapine also has minimal D2 receptor blockade with 5HT2A blockade but also affects other receptors. Sedation and orthostatic hypotension are the most common side effects. Pimavanserin is more selective to 5HT2A receptor. It is the first medication approved for PD psychosis. It can cause QT prolongation and requires decrease dosing in hepatic and renal impairment.

PD psychosis is a common late symptom of Parkinson’s disease. Early diagnosis and treatment is complicated. Treatment must balance the motor and emotional complications of PD. The goal of treatment is to improve quality of life, lessen caregiver stress, and decrease the need for hospitalization.

1 “Trigger medications and patient related risk factors for Parkinson Disease Psychosis requiring anti-psychotic drugs: a retrospective cohort study”, BMC Neurology, 2013; 12: 145.
2 “Cognitive correlates of psychosis in patients with Parkinson’s disease”, Cognitive Neuropsychiatry, 2014; 19(5): 381-398.
3 “Characteristics, correlates, and assessment of psychosis in Parkinson’s Disease without dementia”, Parkinsonism Related Disorders, 2017; 43: 56-60.
4 “12 year population based study of psychosis in Parkinson’s Disease”, Archives of Neurology, 2010; 67(8): 996-1001.

Article written by Linda Pao, MD, PA | Comprehensive Neurological Care

Article from March 2018 E-Newsletter

Impulse Control Disorders
Parkinson Disease (PD) motor symptoms occur due to a loss of dopamine stimulation of the deep brain nuclei called the striatum. Nerve fibers that originate in the midbrain nucleus, the substantia nigra, which carry the dopamine to the striatum die off. Greater than 60% of these cells have been lost by the time a patient exhibits the first clinical signs of PD such as resting hand tremor or diminished facial expression.
Since the late 1960s the principal strategies for treating PD have been directed at restoring the dopamine deficiency. Levodopa, given as carbidopa/levodopa (Sinemet), is the oldest and most effective therapy for restoring brain dopamine levels and improving movement and decreasing tremor in PD. Dopamine agonist (DA) drugs pharmacologically look like dopamine and stimulate dopamine receptors in the brain and will significantly improve PD symptoms. The DA drugs include oral ropinirole (Requip), pramipexole (Mirapex), and rotigotine (Neupro transdermal patch).

One of the unwanted side effects from using the dopamine stimulating drugs has been the appearance of Impulse Control disorders (ICDs). The most common ICDs include 4 behaviors: excessive gambling, compulsive shopping, compulsive sexual behavior, and compulsive eating. Less frequent ICD behaviors include punding which is repetitive, non-goal directed behavior or nonsensical hobbies, and dopamine dysregulation syndrome in which there is compulsive PD medication use. The ICDs may start slowly and seem quite benign at first, such as an increased interest in going to the casino, or an interest in pornography, or an inappropriate enthusiasm for shopping with purchasing more items than are needed. These ICD behaviors may overtime have devastating consequences as some patients uncontrollably gamble away family savings and others get involved in inappropriate sexual relations and ruin their marriage.

Dopamine plays a significant role in the brain reward circuitry. Increased dopamine stimulation in the amygdala, and in the frontal lobe behavior control networks may lead to decisional impulsivity (making bad decisions quickly). The DA drugs are most often the cause for ICDs. These drugs will stimulate dopamine brain receptors other than the motor control receptors which levodopa effects. The rapid acting formulations of ropinirole and pramipexole are more likely to cause ICD than the extended release forms or than the transdermal form, Neupro.

Carbidopa/Levodopa alone rarely causes ICDs. These behaviors can emerge after a patient has been on the drug for quite some time, so vigilance regarding the development of ICDs is needed. Treatment of ICDs requires first that they be recognized, and secondly that the offending drug (usually a DA) be tapered and discontinued. Patients often will struggle with worsened motor function when the drugs are removed. Antidepressant medications may be needed to help mood disorders which can arise as the behaviors and DA drug withdrawal have their consequences. A low dose of quetiapine, an antipsychotic drug, may be needed to help patients resist impulses. Behavioral strategies such as limiting bank account access and 12 step programs may be needed. Awareness of this problem is the key to successful management and outcomes.

Article written by Thomas C. Hammond MD, FAAN | Marcus Neuroscience Institute and member of the APDA South Florida

Article from February 2018 E-Newsletter

Can Ultrasound Waves Be Used To Treat Parkinson’s Disease?
Patients with Parkinson’s disease for some years may have a fluctuating response to medications, significant dyskinesias, or severe tremor. Surgical treatment is a consideration for such patients. The current FDA approved surgical treatment is deep brain stimulation. There is over 20 years of experience with DBS and it is covered by Medicare and most insurances for appropriate patients.

A new surgical technique is being developed called MRI-focused ultrasound (MRI-FUS). In this method a deep area in the brain called the thalamus is targeted with ultrasound waves using high quality brain MRI imaging. This makes a small stroke-like lesion that suppresses abnormal brain activity that can lead to tremor. Small numbers of patients with essential tremor have been treated with relatively good control of tremor and minor side effects. The ExAblate system manufactured by Insightec earned FDA approval to treat essential tremor in July 2016. Though FDA approved it is not covered by insurance and is available from a few centers in the US on a cash pay basis.

There is an interest in extending the indication to Parkinson’s disease. Advantages of MRI-FUS include the less invasive nature of the procedure and there is no need for hardware to be installed in the body. A few words of caution must be kept in mind. The deep brain target for this MRI-FUS is the thalamus and the technique resembles an old method called thalamotomy used in the pre-DBS era. While this target is good for tremor control it is not the optimal target for control of overall symptoms of Parkinson’s disease. Most centers performing DBS choose the subthalamic nucleus or the globus pallidus as the ideal target, not the thalamus. Secondly, while we have over two decades of experience with DBS, we do not have long-term data with the newer technique. Further clinical trials with long-term follow-up are required before MRI-FUS becomes an accepted part of care for Parkinson’s disease.

Article written by Arif Dalvi, MD, MBA | Palm Beach Neuroscience Institute and Medical Director of the APDA South Florida Chapter.

Article from January 2018 E-Newsletter

Caregiver Burnout
Taking care of yourself is not a symptom of being selfish. It’s important to remember that you cannot serve from an empty vessel. However, all too often, those caring for a loved one forget to take care of themselves, significantly increasing the risk of caregiver burnout. Here are a few signs and symptoms to look for that could indicate you are suffering from caregiver burnout and may need some help:

  • You’re feeling stressed
  • You are using alcohol or drugs more than you did before
  • You are exhausted from losing sleep
  • You often have a short fuse and feel agitated
  • You are self-medicating and potentially overusing prescription medications
  • You’re missing appointments
  • You’re experiencing a lack of interest in social activities and/or seeing your friends
  • You feel angry and/or resent your partner

According to a recent CNN Report, 70 percent of all caregivers over the age of 70 will pre-decease the person they are caring for. It’s critical for family caregivers to seek help and respite care so they can take care of themselves and be the best caregiver they can be to their loved one. Here are just a few steps you can take to help minimize the risk of caregiver burnout:

  • Accept your feelings and understand that it is completely normal to have negative feelings like anger or frustration at times. It doesn’t make you a bad person. Consider talking to a professional who is trained in dealing with physical and emotional issues.
  • Educate yourself on the condition. The more you know, the more effective a caregiver you will be.
  • Remember the importance of taking care of yourself. Maintain a healthy diet, find time to exercise and try to maintain healthy sleep habits.
  • Look for caregiver support services in your area. Support groups where people can talk and share with others who are having a similar experience can be very comforting and helpful. Also, local chapters of national organizations as well as your local Area Agency on Aging can offer additional resources and information.
  • Remember, it takes a village. Do not be afraid to ask for help. Respite care can provide a temporary break for caregivers. It can be anything from a few hours of in-home care to an adult day care center.

Remember, the goal is to seek help before stress affects your health and well-being. If you are caring for a loved one and think you may be experiencing caregiver burnout or any of the signs discussed above, please reach out for help.

Article written by Melissa Morante | ComForcare Senior Services


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