Treat Nonmotor Symptoms in Parkinson's Patients With Advanced Disease

Abstract

Kerri Wachter is a senior writer with Elsevier Global Medical News. TAMPA — Eventually, all patients with Parkinson's disease are candidates for palliative care, but advanced treatment planning, especially for nonmotor symptoms, isn't always discussed with these patients or their families, Dr. Neal E. Slatkin said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. When patients are midway through the progression of Parkinson's disease (PD), “this is time for advanced treatment planning. This is the time to begin to have those difficult discussions with the patients and their families and to make the decisions that need to be made,” said Dr. Slatkin, director of supportive care, pain, and palliative medicine at City of Hope National Medical Center in Arcadia, Calif. In advanced PD, patients may have multiple nonmotor symptoms, such as cognitive impairment, in addition to advanced motor symptoms. Roughly a third of patients report that the nonmotor symptoms affect their quality of life more than the motor symptoms, said Dr. Slatkin, adding that researchers are beginning to recognize that the nonmotor symptoms are just as common and important as are any other PD symptoms. Neuropsychiatric problems are fairly common among patients with advanced PD. Depression occurs in almost 40% of patients, hallucinations (mostly visual) in almost 30%, cognitive impairment in almost 40%, and anxiety in 20%. Risk factors for depression in PD patients include a history of depression, cognitive impairment, and akinetic/rigid type disease. Recognizing and treating depression “truly can be lifesaving for some patients,” said Dr. Slatkin. Doctors who assess and treat PD patients for depression should ask each patient how he or she thinks the drug is working, said Dr. Slatkin. There are many antidepressants available, and for any particular patient, some work better than others. Dr. Slatkin said that sertraline (Zoloft) is probably not a good choice for patients with PD and depression because, in addition to being a selective serotonin reuptake inhibitor, it also is a dopamine reuptake inhibitor that could potentially worsen PD symptoms. Hallucinations, especially visual ones, are common in advanced PD, occurring in roughly 30% of people in this stage. “The important thing to think about with hallucinations in [PD] is that you don't necessarily have to treat them,” said Dr. Slatkin. If the hallucinations are not alarming to the patient, Dr. Slatkin's advice was to hold back on therapy. Hallucinations often are more troubling to caregivers and staff than they are to elderly patients. When psychosis appears, it's important to rule out other factors, such as medications or infection, that could be to blame. For example, anticholinergic medications are associated with psychosis/delirium in PD patients. Other medications that can be associated with psychosis include monoamine oxidase-b inhibitors, dopamine agonists, and catechol O-methyltransferase inhibitors. Given this, it may be desirable to compromise motor function to preserve cognitive function in some people with PD. “That's when we start to eliminate some of the Parkinson's medications,” said Dr. Slatkin. Of the antipsychotics, clozapine should be the first choice because it has been shown to be highly effective in treating psychosis in patients with PD, said Dr. Slatkin. He recommended starting with the lowest dose possible. “We start people at 6.25 mg” used in the morning or twice a day. Quetiapine would be a good second choice because it improves psychosis without exacerbating motor symptoms, he added. In 2005, the Food and Drug Administration ordered manufacturers of atypical antipsychotics, including clozapine and quetiapine, to add a new black-box warning that the drugs are associated with an increased risk of death related to psychosis and behavioral problems in elderly patients with dementia. Some evidence suggests that cholinesterase inhibitors, including donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl), may have potential benefits for PD dementia, though they can induce nausea and weight loss. Dr. Slatkin said that he recommends morning dosing of these drugs. Dr. Slatkin disclosed that he had no potential conflicts of interest.