PSYCHIATRIC ASPECTS of PSYCHIATRIC ASPECTS of PARKINSON’S DISEASE PARKINSON’S DISEASE and Related Disorders and Related Disorders Michael J Kelly MD Michael J Kelly MD FRCPC FRCPC Grand River Hospital Grand River Hospital Kitchener-Waterloo Kitchener-Waterloo 7 May 2008 7 May 2008
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PSYCHIATRIC ASPECTS of PARKINSON’S DISEASE and Related Disorders Michael J Kelly MD FRCPC Grand River Hospital Kitchener-Waterloo 7 May 2008.
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PSYCHIATRIC ASPECTS of PSYCHIATRIC ASPECTS of PARKINSON’S DISEASEPARKINSON’S DISEASE
and Related Disordersand Related Disorders
Michael J Kelly MD FRCPCMichael J Kelly MD FRCPC
Grand River Hospital Grand River Hospital Kitchener-WaterlooKitchener-Waterloo
7 May 20087 May 2008
Learning ObjectivesLearning Objectives
Recognize the psychiatric co-morbidities Recognize the psychiatric co-morbidities associated with Parkinson’s Disease and associated with Parkinson’s Disease and related disordersrelated disorders
Better appreciate management of the Better appreciate management of the common neuropsychiatric complications common neuropsychiatric complications
Impact
• The impact of PD on individuals is a wide-ranging as the clinical manifestations of the disease itself
• The disease can make even the most mundane daily activity a challenge
• Most discussion of PD focuses on its motor features, such as tremor, slowness, and imbalance
• Yet the so-called “non-motor” aspects of the illness, depression, anxiety, memory difficulties, sleep disturbances, etc., are often prominent and can cause as much or more difficulty for individuals struggling with the disease
James Parkinson 1817
• “ a more melancholy object I never beheld”
Meds: Friend or Foe?
• Pharmacologic issues regarding appropriate management of the neuropsychiatric aspects are particularly complex
• Some of the medications used to treat PD aggravate neuropsychiatric symptoms
• Agents used to control behavioural disturbances in PD may increase parkinsonism
Treatment Treatment
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Maintain motion
Control emotion
“Motion-Emotion Conundrum”
Behavioural• Behavioural and neuropsychiatric aspects of
PD represent important clinical challenge in optimizing the quality of life of patients and their caregivers.
• Frequently accounts for a substantial portion of the distress associated with the disease, the burden experienced by caregivers, the requirement for institutionalization or nursing home placement.
medications• Step 7: Address disrupted sleep• Step 8: Trial of cholinesterase inhibitors • Step 9: Trial of neuroleptic agents
QuetiapineQuetiapine
Most common first-line agentMost common first-line agent6.25-12.5 mg starting dose6.25-12.5 mg starting doseEscalate as needed/tolerated Escalate as needed/tolerated Adverse effectsAdverse effects
- Sedation - Sedation
- Orthostasis - Orthostasis - Confusion - Confusion - Increased parkinsonism, especially with dementia - Increased parkinsonism, especially with dementia - Increased fluctuations - Increased fluctuations
ClozapineClozapine
Most effective agent for psychosis in PD, but use Most effective agent for psychosis in PD, but use avoided because of need for blood monitoring avoided because of need for blood monitoring Dose range: 6.25 mg od ≥ 200 mg/dayDose range: 6.25 mg od ≥ 200 mg/dayStarting dose 6.25 mg qhs Starting dose 6.25 mg qhs Escalate as needed/tolerated Escalate as needed/tolerated Adverse effects Adverse effects
ICDs: General Treatment StrategoesICDs: General Treatment StrategoesAdjust antiparkinsonian treatment Adjust antiparkinsonian treatment
– Reduce dosage of dopaminergic medications Reduce dosage of dopaminergic medications – Change to a different dopamine agonistChange to a different dopamine agonist– Discontinue dopamine agonist Discontinue dopamine agonist
• Ofen with repeated falls, syncope, transient loss of conciousness
• Neuroleptic sensitivity, delusions, other hallucinations
DLB vs PDD• Arbitrary “ one year rule “
• DLB- dementia syndrome must occur before or within one year of onset of parkinsonism
• PDD-dementia syndrome evident more than one year after onset of parkinsonism ( actually often occurs as a later stage complication, at least 8-10 years after motor symptoms.)
• Cumulative prevalence of dementia 80% in PD pts with 10+ yrs of motor symptoms
DLB vs PDD
2/3 pts with DLB have parkinsonism
In DLB, < resting tremor, <asymmetry and >rigidity, postural and gait impairment
• In autopsy-proven cases, one of myoclonus, absence of rest tremor, no response to levodopa, or no perceived need to treat with levodopa, was10X more likely to represent dx of DLB than PDD