Use of antipsychotic medications in patients with Parkinson's disease at Auckland City Hospital

Clozapine Use in a Movement Disorder Clinic

BACKGROUND

Clozapine is an effective antipsychotic for Parkinson's disease (PD) that does not worsen motor function and can improve tremor. It is approved for PD psychosis in Europe and Australia.

OBJECTIVE

The aim of this study was to report on the use of clozapine in a movement disorder clinic.

METHODS

We report on patients monitored during the COVID-19 pandemic in clinic over a 7-month period.

RESULTS

Sixty-five patients were seen, of whom 50 had PD. Thirty-one were treated for psychosis, 18 for refractory tremor and 1 for levodopa dyskinesias. The remainder had psychotic symptoms with dementia with Lewy bodies (n = 2) or other movement disorders. Four had clozapine discontinued because of sedation and 1 for agranulocytosis. Three had clozapine temporarily halted because of granulocytopenia but were rechallenged successfully.

CONCLUSIONS

When comparing clozapine use in this clinic as compared with others, we deduce that clozapine is likely significantly underutilized in the United States.

Treatment Patterns With Antipsychotics in Long-Term Care Patients With Parkinson's Disease Psychosis

This study assessed treatment change patterns in Parkinson's disease psychosis (PDP) residents receiving antipsychotic (AP) therapies in U.S. long-term care (LTC) facilities. Residents with PDP in LTC between 01/01/13 and 06/30/16 were identified with ≥1 claim of psychosis, hallucinations, or delusions after PD diagnosis. Treatment patterns were evaluated during the 12 months post index. We identified 864 PDP residents: 408 (47.2%) on AP therapy and 456 (52.8%) on no AP therapy. A total of 335 residents (82.1%) continued, 13 (3.2%) discontinued, 11 (2.7%) switched, and 49 (12.0%) augmented (used ≥2 APs) their index AP therapy. Based on the multivariate regression analysis, younger age, male gender, anemia, anxiolytic use or anxiety, sedatives/hypnotic use, bladder disorders including urinary tract infections, coronary conditions, diabetes, hypertension, and dementia were associated with a higher likelihood of treatment change. Understanding the factors associated with treatment change may inform ways to improve management of PDP in the U.S. LTC setting.

Hallucinations in Older Adults: A Practical Review

Older adults experience hallucinations in a variety of social, physical, and mental health contexts. Not everyone is open about these experiences, as hallucinations are surrounded with stigma. Hence, hallucinatory experiences in older individuals are often under-recognized. They are also commonly misunderstood by service providers, suggesting that there is significant scope for improvement in the training and practice of professionals working with this age group. The aim of the present article is to increase knowledge about hallucinations in older adults and provide a practical resource for the health and aged-care workforce. Specifically, we provide a concise narrative review and critique of (1) workforce competency and training issues, (2) assessment tools, and (3) current treatments and management guidelines. We conclude with a brief summary including suggestions for service and training providers and future research.

Treatment of Older Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease. The prevalence of PD increases with age. The spectrum of clinical features, the rate of progression of the disease, the burden of nonmotor symptoms, and the response to medications are different in older patients with PD from the relatively younger patients. Management of symptoms of PD in older patients is challenging because of possible existence of several age-related systemic illness. While dealing with older patients, it is crucial not to attribute all the physical symptoms to PD. Thorough evaluation for existence of diseases such as normal pressure hydrocephalus and vascular parkinsonism which partially mimic the symptoms of PD carries immense importance. Medical management of parkinsonian symptoms should be preferred with levodopa monotherapy. However, in patients with significant motor fluctuations, dopaminergic agents may be added with caution, as they are notorious for several adverse reactions. Nonmotor symptoms must be provided high importance as they substantially worsen the quality of life. In addition to parkinsonian symptoms, older patients with PD may need to undergo surgery for several conditions. Meticulous perioperative management is crucial as older patients with PD may face several surgery-related complications compared to the younger patients. Compliance to treatment is an important issue in old age. Hence multidisciplinary approach to management of PD in older patients should be emphasized.

[Parkinson's disease and psychoses]

Psychotic symptoms are common in Parkinson's disease (PD) and are associated with increased disability, worsened quality of life, and poor long-term prognosis. In this article, clinical features, hypotheses on pathogenesis, and current treatment strategies for Parkinson's disease psychosis (PDP) are reviewed. According to epidemiological studies, the prevalence of PDP is between 20 to 40 %. Complex visual hallucinations are the most common psychotic symptoms and are present in 17-72 % of the patients. Other sensory disturbances encompass tactile hallucinations and minor hallucinatory phenomena, such as sense of presence and visual illusions. Hallucinations are often accompanied by delusions, whose most frequent themes are persecution and jealousy. The pathophysiology of PDP remains unclear. Different factors have been implicated, including Levo-dopa and dopaminergic medications, neurotransmitter imbalances, neuroanatomic alterations, abnormal visuospatial processes, and genetic predisposition. The first-line strategy in the treatment of persistent and problematic PDP is represented by reduction in anti-PD medications. Second-generation antipsychotics are the treatment of choice, with clozapine being demonstrated as the most effective and tolerable drug for PD patients.

Clozapine use pattern in persons with and without treatment for Parkinson's disease in real-world conditions: a naturalistic study in a community-based sample

OBJECTIVE

To explore the pattern of clozapine use in persons with severe mental illness and in persons with Parkinson's disease and the characteristics associated with early discontinuation in naturalistic conditions.

METHOD

A historical fixed cohort study of persons newly treated with clozapine was performed on a representative community-based sample of persons affiliated to the French health insurance system (n = 611,393). Treatment for Parkinson's disease was used as a proxy for this condition and lack of such treatment as a proxy for severe mental illness (SMI).

RESULTS

The prevalences of antipsychotic and clozapine use were 4.4% and <0.1% respectively. Of the 237 persons with a new outpatient prescription of clozapine, 25% were prescribed an antiparkinsonian treatment. In persons with SMI, the median duration of the index episode of clozapine treatment was 4.9 months (Interquartile range 1.0-20.5). Longer duration was independently associated with coprescription of anxiolytics or antidepressant. Few new additions of antipsychotics were observed during the clozapine episode.

CONCLUSION

Efforts have to be made to optimize clozapine treatment in real-world conditions. Considering the high frequency of persons with Parkinson's disease among clozapine users, further studies have to be performed in this population.

The serotonergic system in Parkinson's disease

Although the cardinal manifestations of Parkinson's disease (PD) are attributed to a decline in dopamine levels in the striatum, a breadth of non-motor features and treatment-related complications in which the serotonergic system plays a pivotal role are increasingly recognised. Serotonin (5-HT)-mediated neurotransmission is altered in PD and the roles of the different 5-HT receptor subtypes in disease manifestations have been investigated. The aims of this article are to summarise and discuss all published preclinical and clinical studies that have investigated the serotonergic system in PD and related animal models, in order to recapitulate the state of the current knowledge and to identify areas that need further research and understanding.