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CRITICAL EVALUATION 

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CRITICAL EVALUATION

Mrs. SE is an 83-year-old Arabic speaking female who presents a stage 2 progressive Parkinson’s diseases. She also present the ED from a nursing home with a psychotic episode. This essay will present the critical evaluation of antipsychotics use in patients with Parkinson’s disease and the clinical balance of managing psychotic symptoms and extra pyramidal side effects of antipsychotics.

Parkinson’s disease (PD) is a disease that affects the neurons where commonly the neuron in the brain degenerate. The major diagnosis is on the basis of motor impairments. Other symptoms that are not related to impair motor function do occur, and on this part of the paper, the focus shall be on Parkinson’s disease psychosis and especially how antipsychotics can be used to treat Mrs. SE.

It has been estimated that psychotic signs will appear in about 60% of patients who suffer from Parkinson’s disease. Psychotic symptoms affect the quality of Mrs. SE and consequently, the amount of care given increases and in patients with severe psychotic episodes then it becomes a major risk factor for such patients when they are placed in nursing homes, the likelihood of death as a result of the psychotic symptoms increases significantly.

Mrs. SE presents with minor psychotic symptoms, and these have been indicating as yelling and communication with people who did not exist. She was also panicked and upset; these symptoms, even though at a cursory look may seem harmless, they have the potential to hurt the health of Mrs. SE. They can deteriorate to symptoms of depression and a lowered quality of life. It is also of importance to note that Parkinson’s disease psychosis (PDP) is a great contributor to admission, long term hospitalization, and high mortality rate for people with Parkinson’s disease (Aarsland, 2000).

In order to use antipsychotics, it is paramount that the caregiver recognizes the range of the symptoms that are associated with Parkinson’s disease psychosis. In the case of Mrs. SE, the kind of hallucination she exhibits can be said to be a complex visual hallucination. It is a point of contention on whether the use of antipsychotics on patients exhibiting non-threatening and less frequent episodes should be put on treatment; however, it has been shown that 96% of patients having symptoms said to be non-disruptive, their symptoms evolved in severity into disruptive psychotic behavior.

The psychotic symptoms that Mrs.SE exhibits can greatly be attributed to the anti-Parkinson medication that she is taking and the progression of Parkinson’s disease. One of the major cause of this in relation to medication is perhaps the use of dopaminergic drugs that have been shown to increase the risk factor for substantial development of PDP symptoms. Drugs such as amphetamine aid in dopaminergic transmission, thereby promoting psychotic symptoms. Other than medication, it is accepted that there could be other factors that play a part in the development of psychosis in people living with Parkinson’s disease, such include Lewy transmission body disposition, sleep dysfunction etc.

Use of antipsychotics is a complex process that has to take into account the ability of the drugs to induce dyskinesia and other extrapyramidal symptoms when dopaminergic receptors are blocked. These drugs have major differences in how they interact with D2 receptors. First-generation antipsychotics have been seen to cause a higher antagonism with D2 receptors and less extrapyramidal symptoms, while second-generation antipsychotics have been shown to be a better choice for people with Parkinson’s disease but their likelihood of causing extrapyramidal symptoms is higher in comparison.

The first antipsychotic drug that was deemed as safe and showed a positive result in patients with PD was Clozapine, but the study that was conducted to determine the safety and efficacy of the drug in patients with PD showed negative results (Factor, 1994). This was a departure on the efficacy in the treatment of schizophrenia, and in both double-blind controlled studies, the doses were 150mg/d. A more recent study (Freiling, 2007) showed an improvement in efficacy in the use of SGAs class of antipsychotics in the treatment of PD patients. The standard practice uses doses of 6.25 to 12.5mg/d and does not go above 50mg/d when introducing PD patients to clozapine. If this is done, then a drastic reduction in psychotic symptoms will be observed and this without any negative impact on motor symptoms. Low doses help in preventing anticholinergic effects and risk of agranulocytosis associated with clozapine use. One of the things that makes clozapine less attractive in treatment is the strict blood count required every other week for six months and it can be difficult to undertake for home caregivers who many not be well known to manage patients on this drug.

Another drug that has shown results that are not consistent in studies done in relation to the efficacy and safety of Quetiapine. A comparison done by (Merims, 2006) showed that Quetiapine was inferior to clozapine in reducing the number of hallucinations the patients had but was better in reducing delusions and in others study by same conditions were not met as first study i.e. Small sample size and exclusion of patients with delusions. Quentiapine continues to be prescribed in the treatment of patients exhibiting psychosis in PD. The good thing about this drug is unlike clozapine, it doesn’t require regular monitoring of blood count. A study by (Weintraub, 2016) shows increased mortality in patients treated with Quentiapine who suffered from PD. These results do little to give confidence on the safety of antipsychotics and this underscores the need to observe cautiousness when using these drugs in treatment of psychosis in people with Parkinson’s disease.

Risperidone is in the same class of drug (SGA) as clozapine. Many studies have shown that this drug can aggravate motor symptoms and hyperprolactinemia in PD; however, it does seem to respond well to alleviate the symptoms of psychosis in low doses. Clinical trials on efficacy show mixed results. (Ford, 1994) shows deterioration of motor symptoms in all his sample sizes while (Meco 1997) shows the exact opposite, although his study was given lower doses. Recently, there have been reports of increased mortality in Parkinson’s disease, and this shows that extreme attention should be observed when prescribing antipsychotics.

Olanzapine is considered ineffective and deteriorates the motor symptoms of Parkinson’s disease patients. It significantly increases the risk of death in PD patients. Ziprasidone is considered a good option for patients with Parkinson’s disease; it has a higher affinity for serotonergic receptors as compared to dopamine receptors. Studies have shown that the negative side effect of this drug are within an acceptable level and show great efficacy. There is little study to show the efficacy of ziprasidone in treatment of patients with motor symptoms but in bears similar efficacy to clozapine in alleviating psychotic symptoms.

Data on the efficacy of Aripiprazole in reducing psychotic symptoms in Parkinson’s disease was inconclusive but some open label studies showed positive feedback on psychotic symptoms but the deterioration in motor symptoms, and it thus confirms that Aripiprazole is unsuitable for use in patients with Parkinson disease.

There has been new treatment option that have come up, one such treatment is Pimavanserin. Pimavanserin has been seen as a viable option in the treatment of psychosis for patients of Parkinson’s disease. It does not cause sedation and does not negatively affect motor symptoms. In April 2016 the Food and Drug Administration approved it in treating delusions and hallucinations in people with Parkinson’s disease in the United States. This is the only drug that has been registered in the treatment of psychotic disorders in patients exhibiting motor symptoms. Urinary tract infections, falls and peripheral edema was reported but this was no different to the placebo during clinical trials. Since the drug is still in the market safety and efficacy to be established require monitoring to get a true representation. It should also be noted that this drug caused prolonger QTc interval and is, therefore, contraindicated in patients who have QT prolongation or those who use other drugs that prolong QT interval

 

The following discussion presents the shows the clinical balance of managing psychotic symptoms and extrapyramidal side effects of antipsychotics. This follows the necessity and the requirement of managing Mrs. SE Parkinson’s diseases; as we all medics know, there are Parkinson’s diseases affects the central nervous system, which later affects the movement. This is forcing the clinical unit to handle Mrs. SE with much care to avoid further medical conditions, bearing in mind that she also presents psychotic episodes. Based on the symptoms presented by Mrs. SE, hallucination, delusion, and other forms of associated mental disorders. This called for critical clinical management that t was to ensure the there is a balance between the side effects of antipsychotics. Management of psychotic symptoms calls for the medication, which they usually respond to partially. The compliance of the medication is affected by the underlined condition and in this case, Parkinson’s diseases is affecting compliance with the medication. This could result to difficulties and clinical challenges the same to the case of a patient who has been on drug abuse and chemical. Therefore, the administration of antipsychotic drugs and close monitoring when combined can result to improvement and this is advisable to due to the old age of Mrs. SE. reduced immune system and medical condition that has attached the nervous system are thereat to medication and hence more of behavioral and monitoring forms of management preferred. This is with the aim of improving mental stability and capability. The episode and prior diagnosis presented Mrs. SE showed that the condition of the psychotic and its severity was not available. This categorizes this patient to be suffering more for from the side effects of antipsychotics that are yet discussed below. This part of critical evaluation was to analyze and discus the balance between the managing psychotic symptom and the extrapyramidal side effects of antipsychotics in patients with Parkinson’s disease. Some other psychotic symptoms are disorganized speech and thinking incapability. This can also be associated with age and other physical and mental factors.

There are various associated prolonged effects of the psychotic condition, mostly to the person with an underlined medical condition. Impairing brain function and the coordination of information systematically can be seen as some of the problems. And that is why the symptoms that were noticed in Mrs. SE must be categories, the hallucination was classified as the auditory hallucination; hearing of the voice of people when actually there is no one around. An early stage of delusion that was diagnosed to the as a result of the environment and the age that was catching up with her.

As the part of clinical management, psychotherapy that involved the use of distinct behavioral treatment to cater and deal this symptoms as early as possible. The treatment that combines the medicine and therapy was the best that is recommended for a case such as this of Mrs. SE. Counseling alongside the medication can bring the balance between the management, this include the use of supportive psychology that helps  the patient to think and lean new ways of thinking. Cognitive and behavioral therapy (CBT), this focuses on the evaluation and understanding whether the hallucination and delusion are real or not, it also helps in the adherence to the medication (Stahl, 2010). This is alongside the other forms of management.

The use of antipsychotic drugs in the clinical management of the psychotic condition, unfortunately a sad note they may cause variety of the side effect that might impair the mist vital systems of the body.  This can be ranging from extrapyramidal side effects, which are associated with the emergence and the use of antipsychotic drugs. Extrapyramidal side effect majorly presents in the following forms Parkinsonism, akathisia, acute dystonia and tardive dyskinesia. The sides effects associated with the use of antipsychotic drugs in patient who is Parkinson’s diseases may be diverse not only as presented in the categories above. This is due to the fact they already have a compromised immune system and the medical overlap therein (Scigliano, 2013).the sides effects that are most common are as follows, movement disorder, tremor and the rigidity that is bought aby the overdose and prolonged use of  these drugs(Stahl, 2010). The use of these of such drugs also results to more severe and chronic side effects, i.e. constipation, urinary problem and ulceration of the mouth. Orthostatic hypotension and hyperprolactinemia are side effect that are brought by the use of the antipsychotic drug such as risperidone among other drugs of the same nature (Schatzberg, 2003). Especially in the case Mrs. SE, care is to be taken to ensure there is a balance during the management. This can bring a greater confusing in the management of the same and therefore balance is needed to. On the list of the side effects of the use of antipsychotic drug are the effects associated with the cardiac system and the metabolism done by the heart (cardiac metabolism), these include insulin resistance, weight gain and high blood pressure.  To Mrs. SE, these effects can be frequent visitors, the risk of other non-communicable diseases are also elevated in old patients and the people who are suffering from the other chronic infection.  For the balance to perfectly occur in this scenario, the use of risperidone should be avoided and especially to the patients who are suffering from Parkinson’s disease. This is due to the fact that it elevate the symptoms of the Parkinson’s diseases.

However, the utilization of the SGAs subgroup in the patients with Parkinson’s diseases advisable and the moist recommend to avoid the associated side effects. This is due to the fact that they are less chronic and are having a reduced risk of compromising motor and other nervous system function. This bring some sense and the hope in lives of the patient such Mrs. SE. The clinical balance is assured when such organization and the harmony is take care of and the. Antipsychotic drugs such as clozapine, ziprasidone and pimavaserin should be discouraged in the patients who may be having diabetes condition. This recall and brings the sense of the keep and proper diagnosis before the drug is administered to the patient. Heart failure and dyslipidemia are some of the underlining conditions that must be done to ensure balancing clinical management of the side effects of extrapyramidal (Alexopoulos, et al, 2004).

Having that in mind, the use antipsychotics are is also associated with the high rate of mortality in the patients. For the patient with Parkinson’s diseases, the mortality is thought to be brought about by the severe symptoms posed by the same diseased. It’s from the general view that this should be understood even before the management and the data are set for the record. This is supported by the recent research that showed that the use of antipsychotic in the patients of Parkinson’s diseases presented the more hazard and higher risks of death than none users. The risks that was noted and recorded were associated with the use of haloperidol and the olanzapine among other drugs. Therefore, form the above discussion, patient with Parkinson’s disease are exposed to various forms of risks given antipsychotic drugs. Not only are they exposed to extrapyramidal side effects but death as well.

Conclusion

In conclusion, Mrs. SE, as a patient of Parkinson’s disease, should be exposed to drugs that are categorically not risking her life. Treatment Parkinson’s disease should be given a priority first so as to create a good and a conducive medical environment for the function of the drugs. And therefore, the only antipsychotic that can be used in the case of Mrs. SE are Pimavanserin. The other means of managing such condition without side effects demands for the therapy and counseling.  The other medication are safe for other patients but not for Mrs. SE.

 

Aarsland, D., Larsen, J. P., Tandberg, E., & Laake, K. (2000). Predictors of nursing home placement in Parkinson’s disease: a population‐based, prospective study. Journal of the American Geriatrics Society, 48(8), 938-942.

 

Factor, S. A., Brown, D., Molho, E. S., & Podskalny, G. D. (1994). Clozapine: A 2‐year open trial in Parkinson’s disease patients with psychosis. Neurology, 44(3 Part 1), 544-544.

 

Frieling, H., Hillemacher, T., Ziegenbein, M., Neundörfer, B., & Bleich, S. (2007). Treating dopamimetic psychosis in Parkinson’s disease: structured review and meta-analysis. European neuropsychopharmacology, 17(3), 165-171.

 

Merims, D., Balas, M., Peretz, C., Shabtai, H., & Giladi, N. (2006). Rater-blinded, prospective comparison: Quetiapine versus clozapine for Parkinson’s disease psychosis. Clinical neuropharmacology, 29(6), 331-337.

 

Weintraub, D., Chiang, C., Kim, H. M., Wilkinson, J., Marras, C., Stanislawski, B., & Kales, H. C. (2016). Association of antipsychotic use with mortality risk in patients with Parkinson disease. JAMA neurology, 73(5), 535-541.

 

Cummings, J., Isaacson, S., Mills, R., Williams, H., Chi-Burris, K., Corbett, A., & Ballard, C. (2014). Pimavanserin for patients with Parkinson’s disease psychosis: a randomised, placebo-controlled phase 3 trial. The Lancet, 383(9916), 533-540.

 

Cummings, J., Isaacson, S., Mills, R., Williams, H., Chi-Burris, K., Corbett, A.,& Ballard, C. (2014). Pimavanserin for patients with Parkinson’s disease psychosis: a randomised, placebo-controlled phase 3 trial. The Lancet, 383(9916), 533-540.

 

Ford, B., Lynch, T., & Greene, P. (1994). Risperidone in Parkinson’s disease. The Lancet, 344(8923), 681.

 

Scigliano, G., & Ronchetti, G. (2013). Antipsychotic-induced metabolic and cardiovascular side effects in schizophrenia: a novel mechanistic hypothesis. CNS drugs27(4), 249-257.

Alexopoulos, G. S., Streim, J., Carpenter, D., & Docherty, J. P. (2004). Using antipsychotic agents in older patients. The Journal of clinical psychiatry65, 5-99.

Stahl, S. M., & Mignon, L. (2010). Antipsychotics: Treating Psychosis, Mania, and Depression. Cambridge University Press.

Schatzberg, A. F. (2003). New approaches to managing psychotic depression. Journal of Clinical Psychiatry64(1), 19-23.

 

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