Caregiver Burnout Research Articles

Health Care Utilization by Children with Disabilities and Evaluation of Factors Affecting Caregiver Satisfaction

Aim: Health care is lacking for some level of mental disability for various reasons. The aim of this study was to examine health care utilization by individuals with severe disabilities applied to the health committee of a university hospital and to examine the factors that determine caregiver satisfaction by assessing their burden of care, quality of life, and level of burnout. Methods: Of the 840 disabled individuals who applied to Recep Tayyip Erdoğan University Faculty of Medicine Training and Research Hospital, Rize, Turkey between January 2016 and 2019, 48 with severe disability caregivers were included in the study. Their sociodemographic information, level of health care, and caregiver satisfaction were analyzed using sociodemographic data forms. The Zarit Caregiver Burden Scale, Maslach Burnout Inventory, and Family Quality of Life Scale were used to assess the caregiver data. Results: More than half of the 48 children with severe disabilities were male (52.1%).Disabled females and female caregivers appeared to increase the level of emotional burnout of caregivers according to Maslach Burnout Inventory and Family Quality of Life Scale (p:0.01, p:0.05, p:0.02, p:0.03). Groups receiving home care was found with satisfaction. Disabled children and caregivers who were living within an urban area have significant differences with Maslach Burnout Inventory Personal Success (p:0.03). Conclusion: Disability is more of a risk for males. The sex of the disabled individual and caregiver were factors that affected caregiver burnout. Home care services increases caregiver satisfaction. Living within an urban area decreased the level of burnout on caregiver. Keywords: Caregiver burden, caregiver satisfaction, children disabilities, health care, family quality DOI: 10.7176/JHMN/83-01

Caregiver perceptions of end-of-life care in patients with high-grade glioma

Patients dying from high-grade gliomas (HGG) suffer from high symptom burden in the end-of-life (EoL) phase. Family caregivers are most informed about the patient's symptoms and disease course. The aim of this study is to assess caregiver perception on quality of EoL care of HGG patients. Caregivers prospectively participated in the Toolkit After-Death Bereaved Family Member Interview, part of the Toolkit of Instruments to Measure End-of-Life Care (TIME survey). This validated survey assesses EoL care in areas such as physical comfort and emotional support, advance care planning, focus on the individual, attention to family, and coordination of care. The quality of EoL care was measured by domain scores (0 = care was always optimal, 1 = care was always suboptimal) or with a 0-10 scale. Of the 55 enrolled family caregivers, 44 completed the interview and rated the overall care high (8.90 ± 1.36/10), perceived that patients' wishes were respected (9.46 ± 0.95) and that they died in dignity (9.65 ± 0.98). Caregivers perceived high satisfaction with information and decision-making (0.18), advance care planning (0.19), focus on the individual (0.16), and care coordination (0.11). Attention to family (0.25) needed improvement. Only 41% of caregivers were confident that they knew what to do at the time of death and 46% felt that the healthcare team did not provide them with someone to turn to in distress. Caregivers reported high overall satisfaction with EoL HGG care, though attention to family and communication needed improvement. Focus should therefore be on improved caregiver communication to improve EoL care, caregiver burnout, and bereavement in HGG populations.

English

BACKGROUND Autism is one of the most demanding types of disorders in terms of caregiver’s intervention. A significant amount of distress is always associated with a long term, pervasive intervention and attention given by the care giver. The above scenario leads to depression, adjustment disorder along with suicidal tendencies among the care givers leading to poor prognosis of the disease progress in children and emergence of stress related mental illness in the care givers. Pro-active assessment, diagnosis and management of the above among the care givers might be beneficial for both the child and the care giver along with other family members. METHODS This study was conducted in the special schools of Kancheepuram from December 2019 to February 2020. The cross-sectional study aimed to assess caregiver burden and the variations of burden with varying social and language development in parents of children with ASD (Autism Spectrum Disorder). A total of 60 parents whose children were diagnosed to have Autism Spectrum Disorders were assessed to scale the caregiver burden using Burden Assessment Schedule, and semi structured socio-demographic questionnaire. RESULTS Majority of the caregivers showed an impact on multiple areas of life. 59 % of the caregivers showed significant impact on wellbeing with 84 % feeling depressed and anxious. Lack of appreciation for care was seen in 85 % of the caregivers. Relationship with others was very much impacted in about 14 % of the caregivers. Perceived severity of illness was impacted in 53 % population. CONCLUSIONS Bringing up a child with an autism spectrum disorder is a significant chronic stressor sufficient to disrupt various areas of an adult life and also to cause mental illnesses. Early recognition and management of burden is of immense value in the wellbeing of the caregiver, more importantly in the prognosis of the child’s disorder. KEYWORDS Autism Spectrum Disorder, Caregiver Burden Assessment, Caregiver Burnout

407 - The Baycrest Quick-Response Caregiver Tool: The Role for a New Tool for Caregivers of Persons with Dementia

Background:Responsive behaviours in dementia are associated with poor outcomes for the person with dementia (PWD) and caregiver burnout. Family caregivers need a variety of tools to manage responsive behaviours. The Baycrest Quick-Response Caregiver Tool was developed to provide caregivers with a tool that can be used in real time. In this study, the feasibility, impact, and effectiveness of this new tool were studied in family caregivers and health care providers (HCP) using quantitative and qualitative measures.Methods:Family caregivers were recruited and were asked to complete a pre-survey before being sent the link to the educational tool. One month after the telephone survey, caregivers were sent an online post-survey to gather their feedback on the tool and the impact of the tool on caregiver well -being. Healthcare providers were also recruited and reviewed the tool through an online feedback survey. The feasibility, impact, and effectiveness of the tool were assessed using quantitative and qualitative measures.Results:Caregivers had a moderate degree of and reported a high level of competence - these scores were maintained throughout the study. Caregivers reported that tool positively impacted their compassion towards the person with dementia (PWD), and that their interactions with improved. 100% of HCP who completed the feedback survey would recommend the tool to other HCP and to caregivers of PWD. The caregivers and HCP provided specific suggestions for improvement.Conclusions:The Baycrest Quick-Response Caregiver Tool was found to be feasible and helpful. It provides caregivers and HCP with an additional approach for responsive behaviours.

413 - Telehealth in Multiethnic Caregiver Support Group: Transition from Telephone to Video in the Age of COVID-19

Background:Caregivers of persons with Alzheimer’s Disease and Other Dementias are a population in need of support as they are vulnerable to emotional, physical, and mental exhaustion associated with caregiver burnout. While CDC guidelines state that social distancing is the greatest protective factor, it can already exacerbate feelings of isolation and stress. Technology offers the opportunity to maximize socialization and access to healthcare; however, research shows that digital platforms are most underutilized by older and lower socioeconomic patients.Objective:This report describes the transition of a weekly caregiver support group from telephone to video conferencing to improve connectedness during a period of social isolation.Method:In 2020, the caregiver support group met weekly over the phone. At each session, there were increased discussions of moving the telephone support group to a video platform. A focused discussion about technology platforms was held to gain an understanding of caregiver attitudes and thoughts regarding technology in which caregivers worried that a video platform would be intrusive and invasive. In June 2020, unreliable phone service resulted in the group transitioning to video.Results:The caregiver group consisted of 5 active members, 2 African American, 2 Asian, and 1 Caucasian. Initial problems included connectivity issues, needing to switch to multiple devices, and assistance with troubleshooting and utilizing the platform. However, caregivers reported feeling that the transition to video was the most natural next step and assisted with reducing feelings of isolation, anxiety, and fear they reported as a result of social distancing due to COVID-19. Caregivers reported feeling connected and because they knew each other so intimately, no longer felt video was intrusive.Conclusions:For older populations who are not familiar with technology, it is important to take steps before beginning a new platform service. This allows for a natural progression to unfamiliar technology. The video platform provided an opportunity for caregivers to be together while apart, which is important for mental health and decreasing caregiver burden.

Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers.

Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking. To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs. We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis. Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation. Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.

Is It Time for Precision Dialysis?

In 2015, President Obama announced funding for precision medicine to augment personalized medicine, which has been described as “the right treatment for the right patient in the right place at the right time.” Patients with ESKD experience high symptom burden and mortality, necessitating more

The philosophical clinical approach to burnout in caregivers in the light of Covid-19

The crisis caused by the Covid-19 pandemic has highlighted the risks of burnout in caregivers and more specifically the question of ethical suffering. A philosophical clinical approach to burnout enables it to be analysed as a form of existential suffering linked to our shared vulnerability, as well as to more socio-organisational failings.

Needs, Aggravation, and Degree of Burnout in Informal Caregivers of Patients with Chronic Cardiovascular Disease.

This study aimed to answer three main questions with respect to home caregivers for people with cardiovascular disease: (1) Are the needs of home caregivers being met (and at what level)?; (2) what is the level of emotional exhaustion, depersonalization, and personal accomplishment of home caregivers?; (3) what sociodemographic variables of home caregivers are related to unmet needs and level of emotional exhaustion, depersonalization, and personal accomplishment? The study used the Camberwell Modified Needs Assessment questionnaire and the Maslach Burnout Inventory questionnaire. This study reports on 161 informal home caregivers of patients with cardiovascular disease. We found that younger caregivers were less likely to report unmet needs (p = 0.011), and showed lower rates of burnout on depersonalization and emotional exhaustion. In addition, caregivers who worked more often reported higher levels of met needs (p = 0.022), and showed lower rates of burnout on depersonalization (p = 0.005) and emotional exhaustion (p = 0.018). Subjects residing in urban areas were more likely to report unmet needs (p = 0.007), and showed higher rates of burnout on emotional exhaustion (p = 0.006). Older caregivers who are unemployed and reside in cities should be offered programs to determine their unmet needs and to receive support.

Design and validation of an electrophysiological based tool to assess chronic stress. Case study: burnout syndrome in caregivers

Caregiver burnout syndrome is an increasingly seen condition, although the subjective nature of self-administered psychometric tests and the lack of a consensual diagnostic tool might hinder a proper diagnosis. The availability of objective psychosomatic measures of stress might facilitate the early diagnosis and clinical management of these patients. For this reason, the aim of this work was to develop a quantitative tool to evaluate the stress level of caregivers in a noninvasive and repeatable manner. An observational, controlled, matched study was designed including a group of 38 principal caregivers of chronic patients and a control group of 38 non-caregivers. Psychometric, biochemical, and electrophysiological data were analyzed along with sociodemographic data. A quantitative chronic stress reference scale (CSRs) was constructed based on the weighted contribution of several psychometric and biochemical variables and afterwards, a predictive psychosomatic model (ESBSm) correlated with CSRs was elaborated from extracted variables of several electrophysiological signals monitored for 10 min. The resulting CSR scale shows a high power to discriminate caregivers from the control group while the ESBSm shows a 79% correlation with the CSR scale validated through a 5-fold process. Therefore, the results demonstrate that the ESBS model is an objective and validated tool to diagnose the degree of stress linked to burnout in caregivers of chronic patients from a 10-min session of noninvasive monitoring with a reliability equivalent to the questionnaires currently used to quantify stress in caregivers.

Do informal caregivers experience more burnout? A meta-analytic study

ABSTRACT Informal caregivers often report exhaustion when providing care, which can be related to forms of burnout. Yet, there is no systematic inventory of studies comparing caregivers and non-caregivers in terms of burnout. For the present meta-analysis, studies comparing burnout in informal caregivers and non-caregivers were screened and included. Two categories of studies were found: those on family care burnout (spousal or parental burnout) and those on professional burnout (mostly in healthcare). For family care burnout studies, informal caregivers reported more emotional exhaustion, and, to a lesser extent, depersonalization and reduced personal accomplishment than non-caregivers. For studies on professional burnout, workers providing informal care also reported more emotional exhaustion than workers not providing such a care. Overall, the results indicate that providing informal care represents a risk for role burnout. In family care burnout studies, these results confirm the assumption that providing informal care adds extra weight on the individuals’ shoulders. In professional burnout, these results support the role accumulation theory, pointing that an additional weight in one’s role, i.e., providing informal care, has an impact on another role, work. This work emphasizes the consideration of the multifaceted impact that the caregiving role can have on the individual.

Defining and understanding the burn out of gerontological caregivers

The malaise in the gerontology sector can be accounted for and new explanations for caregiver burnout can be proposed. Through a review of the literature, an overview of the issue can be drawn up and a theoretical and clinical reflection can be initiated. After having contextualized the extent of the phenomenon, we will present the plural conceptions of burn out and its origin. A new look will be taken at this syndrome by raising a set of factors potentially involved in the exhaustion of caregivers.

Demonstrating Occupational Therapy’s Distinct Value: Addressing the Quadruple Aim of Health Care Through Doctoral Capstone Projects

The quadruple aim of health care focuses on enhancing health care systems through improving quality patient care, improving the health of populations, providing care in cost-efficient ways, and improving the experience of providing health care by decreasing provider and caregiver stress and burnout. The purpose of this retrospective review is to share how the curricular design and doctoral capstone process from one postprofessional occupational therapy doctorate program have been designed to support students in recognizing occupational therapy’s distinct value in creating sustainable practice changes to move their respective health care systems forward. The postprofessional occupational therapy doctorate curriculum over 12 years has supported over 250 students in creating sustainable practice change projects in various work settings across the US. Doctoral capstone projects can be an effective platform for illustrating occupational therapy’s distinct value by showing how occupational therapy services are unique and valuable in health care institutions. A strong curricular design with supports related to focusing on all aspects of the quadruple aim is an effective mechanism for enhancing care.

Stressful Life Events, Coping, Social Support, Subjective Well-Being and Burnout in Primary Key Caregivers of Patients with Schizophrenia and Bipolar Affective Disorder in Relapse

Stressful Life Events, Coping, Social Support, Subjective Well-Being and Burnout in Primary Key Caregivers of Patients with Schizophrenia and Bipolar Affective Disorder in Relapse

Efficacy of \u201cFamily Connections\u201d, a program for relatives of people with borderline personality disorder, in the Spanish population: study protocol for a randomized controlled trial

BackgroundPatients with borderline personality disorder (BPD) experience significant affect regulation difficulties that cause serious consequences in their work, emotional, and social environments. This dysfunctional pattern also produces great suffering and a heavy burden on their relatives. Fortunately, some studies show that treatment of relatives of people with BPD begins to be important in the patients’ recovery and in improving family dynamics. One of the treatments that has obtained the most empirical support is Family connections (FC). This 12-session program is an adaptation of different Dialectical Behavior Therapy strategies. To test the efficacy of FC, five uncontrolled clinical trials were conducted, with pre-post treatment and follow-up assessments. The results of these studies and subsequent replications showed an improvement in family attitudes and caregiver burnout. Our research team adapted FC for delivery in the Spanish population. We intend to test the efficacy of this program versus a treatment as usual condition. Moreover, we aim to test the efficacy of this program and study its effectiveness (in terms of participants’ acceptance). This paper presents the study protocol.MethodsThe study is a randomized controlled trial. The participants will be recruited in a Personality Disorders Unit and randomly assigned to one of two treatment conditions: Family Connections group (FC) or Treatment As Usual (TAU). Primary outcome measures will be the BAS and FAD-GFS. Secondary outcomes will include DASS-21, FES, GS, and QLI. Participants’ treatment acceptance and degree of satisfaction will also be measured. Participants will be assessed at pre-, post-treatment, and 6-month follow-up. Intention to treat and per protocol analyses will be performed.DiscussionThis is the first study on FC for relatives of people with borderline personality disorder (BPD) compared to an active condition (TAU), and this is the first time relatives’ and patients’ data will be analyzed. In addition, it is the first study to test the efficacy of the program in Spain. This intervention could contribute to improving the efficiency and effectiveness of current treatment programs for relatives of people with BPD, help to decrease burden, and improve the family connection.Trial registrationClinicalTrials.gov ID: NCT04160871. Registered November 15th 2019.

Mindfulness-Based Stress Reduction (MBSR) Group Intervention to Reduce Burnout among Caregivers in Nursing Home

Professional caregivers are prone to experience burnout. Burnout is a condition of physical, emotional, and mental fatigue caused by prolonged stress due to work negatively impacts work performance and well-being of professional caregivers. The present study aims to explore the effectiveness of group intervention using Mindfulness-Based Stress Reduction in reducing burnout and enhancing the psychological well-being of professional caregivers in a nursing home. Five caregivers (four males and one female) participated in four intervention sessions and a follow-up session. Maslach Burnout Inventory and Ryff’s Psychological Well-Being Scale was used to measure burnout and psychological well-being, respectively. Qualitative data were also obtained through interviews at the end of the intervention. Statistical analysis using the Wilcoxon Signed-Rank Test indicated that MBSR was not significantly effective in reducing burnout and enhancing psychological well-being. However, a trend of positive improvement was observed, indicating the potential benefits of MBSR for reducing burnout in professional caregivers. Limitations of this study are explained in the discussion section.

A Component Analysis of the Mindfulness-Based Positive Behavior Support (MBPBS) Program for Mindful Parenting by Mothers of Children with Autism Spectrum Disorder.

ObjectivesMindfulness-Based Positive Behavior Support (MBPBS) has been shown to be effective in reducing stress and burnout in parents and professional caregivers of children and adolescents with intellectual and developmental disabilities (IDD) and autism spectrum disorder (ASD). The aim of this study was to assess the comparative effects of the mindfulness (MB) and positive behavior support (PBS) components against the MBPBS program for mindful parenting.MethodsThe study utilized a three-arm randomized controlled trial design, with a 10-week pre-treatment control condition, 30 weeks of intervention, and 3 years of post-intervention follow-up. Mothers of children with ASD were randomly assigned to the MB, PBS, and MBPBS conditions and provided 3 days of training specific to each condition. The effects of these programs were assessed on the mothers (i.e., training attendance, meditation time, perceived psychological stress) and spillover effects were assessed on their children with ASD (i.e., aggression, disruptive behavior, compliance with mothers’ requests).ResultsMothers in the MBPBS condition reported greater reductions in perceived psychological stress, followed by those in the MB condition, and with no significant changes reported by those in the PBS condition. Reduction in the children’s aggression and disruptive behavior followed a similar pattern, with most to least significant reductions being in MBPBS, MB, and PBS condition, respectively. Significant increases in compliance (i.e., responsiveness to mothers’ requests) were largest in the MBPBS condition, followed by MB, and then PBS. Changes across all variables for both mothers and their children were maintained for 3 years post-intervention. After time and training type were controlled for, meditation time was a significant predictor in reducing aggressive and disruptive behaviors, and in enhancing compliance of the children with mothers’ requests.ConclusionsPositive outcomes for mothers and their children with ASD were significantly greater in the MBPBS condition, followed by the MB condition, and least in the PBS condition. MBPBS appears to be an effective mindful parenting program on the assessed variables.

COVID-19 and telemedicine: Immediate action required for maintaining healthcare providers well-being

The well-being of the health care workforce is the cornerstone of every well-functioning health system. As a result of the pandemic, medical healthcare providers are under an enormous amount of workload pressure along with increased total health expenditures. The overwhelming burden of COVID-19 illness could lead to caregiver burnout. Direct-to-consumer telemedicine can enable patients to connect with their healthcare provider at a distance. This virtual platform could be used by smartphones or webcam-enabled computers and allows physicians to effectively screen patients with early signs of COVID-19 before they reach to hospital.

GABAPENTIN FOR BEHAVIORAL AND PSYCHIATRIC SYMPTOMS OF DEMENTIA: RENEWING THE CALL FOR AN INTERVENTION STUDY

Introduction Behavioral and Psychiatric Symptoms of Dementia (BPSD) increase patient mortality, healthcare costs and caregiver burnout. While behavioral interventions are the most effective treatment for BPSD, many patients are not able to regulate their agitation using only behavioral interventions, and therefore require pharmacotherapy. Various agents such as risperidone, quetiapine and trazodone have shown positive data for treating both BPSD and decreasing related caregiver burnout, but many of these agents are associated with significant increases in morbidity and mortality, as well as intolerable side effects. Several case reports describe using gabapentin, an anti-epileptic and FDA-approved treatment for neuropathic pain, as an off-label treatment for BPSD. BPSD in some patients may be driven by unreported neuropathic pain, which gabapentin can treat effectively. Additionally, gabapentin has known anxiolytic properties that can theoretically improve BPSD. A 2018 systematic review by Supasitthumrong et al highlights data supporting the use of gabapentin as a treatment for BPSD, but noted there has yet to be a definitive trial establishing gabapentin as an effective intervention for BPSD. We delineate two cases of patients with BPSD who were treated with gabapentin to highlight the need for a randomized controlled trial so that guidelines can be established for the treatment of BPSD with gabapentin. Methods Approximately 3000 CL psychiatry consultations placed between March 2017-May 2019 for patients admitted to the inpatient medicine service at the West Roxbury VA Medical Center in West Roxbury, MA, were reviewed. In the first round of screening, records were filtered based on patient problem lists for the presence of a neurocognitive disorder, any chronic pain condition and prescription of gabapentin. Seventy-one patients met criteria based on the initial screening. In the second round of review, records were further filtered for the utilization of gabapentin for the treatment of BPSD. Two patients met these criteria and the cases were further reviewed for psychiatry recommendations, as-needed behavioral medication utilization, behavioral scales and behavioral reports. Results The first case is an 82-year-old male with Alzheimer's dementia, who had unsatisfactory treatment of agitation with trazodone and quetiapine 25mg twice daily. Subsequently, for over a month, he was treated with gabapentin on a gradual dose increase from 100mg twice daily to three times daily. A favorable sustained response was achieved as no additional as needed medications for agitation were required and the patient scored well on both Cohen-Mansfield Agitation Inventory (6/14) and Rating Anxiety in Dementia Scale (6). Following this intervention, subsequent episodes of agitation were limited to delirium, especially during UTIs. The second case is a 97-year-old male with mixed Alzheimer's and vascular dementia who continued to have breakthrough agitation despite being treated with trazodone 25mg nightly. He was started on gabapentin 200mg daily for three weeks, in the setting of a fall that resulted in a wrist injury. After this intervention, he continued to require quetiapine at doses up to 25mg daily, as well as haloperidol at doses up to 7mg daily to manage breakthrough agitation. This behavioral pattern and intervention lasted for three weeks until the patient's BPSD was stabilized and he was discharged to an acute rehabilitation facility. Conclusions In the two cases presented, treating BPSD with gabapentin resulted in mixed findings. While the first case shows gabapentin as a potentially efficacious and well-tolerated treatment for BPSD, it is difficult to elucidate the role gabapentin played in the second patient's improved behavioral regulation. There are many potential factors that may contribute to these discrepant findings. The first patient with Alzheimer's Dementia was followed for months while the second patient with mixed dementia patient was only followed for three weeks. Next, it is unclear whether gabapentin is equally efficacious in Alzheimer's dementia versus concomitant Alzheimer's and vascular dementia. Additionally, the age difference of 17?years may have also contributed to the 97-year old's limited response to gabapentin. Also, the first patient received a total gabapentin dose of 300mg while the second patient received 200mg. Lastly, the second patient presented in the context of pain due to a fall while the first patient did not. This case series magnifies the challenges of using gabapentin for BPSD without specific indications or established dosing recommendations. While gabapentin may be an effective treatment for BPSD, we present these cases to highlight the need for an interventional randomized controlled trial investigating gabapentin as a treatment for BPSD. This research was funded by: None

“MANAGING THE MENAGERIE IN MY HOME”, SUCCESSFUL CLOZAPINE TITRATION FOR “PIMAVANSERIN-RESISTANT” PARKINSON'S DISEASE PSYCHOSIS

Introduction The umbrella term “synucleinopathies” includes Parkinson's disease (PD), Dementia with Lewy bodies (DLB), Parkinson's disease-dementia (PDD), and Multiple System Atrophy (MSA), all of which share a similar pathogenesis, clinical presentation, and treatment plan. The shared clinical features include neurocognitive decline, autonomic dysfunction, parkinsonian motor features, and neuropsychiatric symptoms including depression, anxiety, and psychosis. Parkinson's Disease Psychosis (PDPsy) is best characterized by visual hallucinations. These psychotic symptoms can lead to impairments in activities of daily living, earlier nursing home placement, and caregiver burnout. The initial treatment plan for PDPsy usually involves a dose reduction of dopaminergic agents. If an acceptable reduction of psychotic symptoms is not achieved with this strategy, the use of an antipsychotic medication is often considered – usually clozapine, quetiapine, and now pimavanserin (a novel 5-HT2A inverse agonist). All of these agents share a minimal propensity to worsen parkinsonian motor symptoms. At present, there are no trials directly comparing clozapine and pimavanserin (the two agents with the best evidence base for PDPsy), making the choice of antipsychotic somewhat arbitrary. Methods Presented here is a case of PDPsy, wherein the patient's psychosis improved after a cross-titration from a dual-antipsychotic regimen of pimavanserin and quetiapine to a monotherapy regimen of clozapine. A review of the literature was gathered through October 2019 MEDLINE, EMBASE, and PsycINFO. Further studies found through this process were reviewed to identify additional reports. Results Mrs. KJ is a 62-year-old, married female with a medical history limited to idiopathic PD diagnosed in 2011. When first diagnosed, she developed an acute adjustment disorder and was treated with escitalopram. In January 2019, she was referred to our clinic for management of PDPsy that had begun in 2016. She described her psychosis as a “circus-menagerie” of animals living in her house as well as significant delusions of marital infidelity. Prior to our involvement, carbidopa-levodopa and ropinirole had been decreased, quetiapine had been initiated, and pimavanserin had been added, all with minimal resolution of psychosis. After discontinuing escitalopram and increasing the dose of quetiapine without benefit, a decision had to be made whether to abandon pimavanserin and try clozapine. The barriers to starting clozapine, including side effects, were weighed against its unknown comparative efficacy to pimavanserin. An eventual decision was made to initiate clozapine followed by the discontinuation of quetiapine and then pimavanserin. The “circus of animals” greatly decreased, and she gained insight into her delusions. The accompanying review resulted in 16 articles from MEDLINE, 29 from EMBASE and 4 from PsycINFO. While the literature supports clozapine's efficacy, there are frequent references to barriers to its initiation, including the need for frequent blood draws and the high potential side effect burden (though one of these potentially problematic side effects – its anticholinergic properties, may result in a reduced need for dopaminergic agents). There are no trials (open-label or otherwise) or case reports directly comparing clozapine to pimavanserin for PDPsy. Conclusions This is the first report of a successful titration from pimavanserin to clozapine for PDPsy. As access to pimavanserin increases, its use will expectedly increase, and it may become a first-line treatment for PSDsy. This case describes a potentially useful treatment strategy for the “pimavanserin-resistant” patient by demonstrating that a trial of clozapine after sub-optimal response to pimavanserin can lead to further symptom improvement. The decision to use antipsychotics for PDPsy should take a shared, patient-centered approach. For clozapine, this includes a discussion of its potential life-threatening side effects, the need for enrollment in a national REMS program, and its blood monitoring requirements. To date, there have been no head-to-head comparisons of clozapine with pimavanserin making the step-wise plan of when to initiate and/or abandon quetiapine, clozapine, or pimavanserin for PDPsy an unknown. This case adds to the shared decision-making process by providing evidence of the potential benefits of switching to clozapine when psychosis persists. Additional, large scale studies are needed to compare pimavanserin with other atypical antipsychotics, particularly clozapine. This research was funded by: Not applicable