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Dr. Pahwa:
Hello, I am Rajesh Pahwa, Professor of Neurology at the University of Kansas Medical Center. Today, I'm going to talk about Develop the Plan, Work the Plan: Integrating Ongoing Patient Assessments.
So you have heard a little bit about PD psychosis. We all know PD psychosis is common as the disease progresses. And it is very important to ask all our patients about PD psychosis at every visit. It is not only important when we first start evaluating the patient, but even if we start treating the patient for PD psychosis, we need to continue to ask them, because after treatment, their psychosis may not completely resolve, or the psychosis may get worse at every visit.
I screen for PDP at every visit. I usually give patients and caregiver a questionnaire to fill before I see them. And I ask both the patient and the caregiver to, together, fill this questionnaire. There are two main questions on my questionnaire. One is: Does the patient see, hear, or otherwise sense things that others do not? For example, seeing people or animals that are not there, hearing music, or misidentifying objects, for example, a bunch of clothes look like a little child to them. I also ask them: Does a patient believe things others do not believe to be true? For example, the spouse is cheating, others or causing harm or deceiving them? So these are issues that the patient fills before I validate them.
If the patient says yes, then I sit down and talk to the patient and the caregiver to assess how often this is occurring, how bothersome it is for the patient or the caregiver, to evaluate whether I need to further manage the psychosis by either adding another medication, or assessing if they have an infection or something that needs to be treated. And this can happen before they are any antipsychotic medications, or even if they are on medication for their psychosis, and are again beginning to have worsening of psychosis.
One important thing to remember is psychosis is usually associated with cognitive decline and depression. So what I do is when I assess my patients for PD psychosis, I also evaluate if they have underlying anxiety, depression, or cognitive impairment, because if they do have one of these associated issues, then treating the depression, anxiety, or cognitive impairment will be more helpful for them.
In fact, one of the most common antipsychotics that we use is pimavanserin. And in patients who are on pimavanserin, in the clinical trial that was done, patients who are also on cognitive enhancing medications such as cholinesterase inhibitors, like rivastigmine, it was seen that using the two drugs in combination provides greater benefit for their antipsychotic benefits. So if a patient has issues with cognitive impairment, I usually add a cholinesterase inhibitor such as rivastigmine, or donepezil because using that along with pimavanserin seems to help more with their PD psychosis.
We have to keep in mind that there are long-term issues that happen with PD psychosis, often just like any Parkinson's patient who is progressing. We need to assess for falls, urinary tract infections. They may actually worsen the psychosis. So if a patient is doing well, and is having worsening of their psychosis, check for any infection. Like I mentioned earlier, the psychosis will progress even if we are treating them with medication, so we have to reevaluate. And the psychosis gets worse again, we have to consider whether we need to add additional antipsychotic medications. And the other thing is just a disease progression itself and what issues that we need to evaluate.
One thing to remember, which is extremely important, is the caregiver. Because once the patient starts having PD psychosis, the caregiver is really struggling with the patient, especially if the patient loses insight. So not only do we need to treat the patient, but we also need to discuss with the caregiver what kind of issues they are struggling with, because patients’ hallucination patients’ confusion, patients’ depressions are all stressors that the caregiver has, hence early intervention of the psychosis, often evaluating the caregiver if they need psychological assessment and even seeing a psychologist, having them go to support groups, and in general educating the patient that - I'm sorry, the caregiver, that in case the patient is saying something that is not true, it's not that really that they might be having an affair, but the patient does not realize that and they need to basically evaluate that and accept some of the issues that may be going on. So education also becomes very important, but it is very important to keep the caregiver in mind.
The other issues that happen with PD psychosis long term is that patients often go to the ER more frequently, whether it is because they get an agitation, whether it's confusion, often then they require increased inpatient care because they go to the ER, they end up being in the hospital. This also leads to often more frequent outpatient visits. And because of the stressors associated with the caregiver, and the increased care they're receiving, these patients often end up in the nursing home. So we always recommend a multidisciplinary approach in our patients. Not only is the neurologist or the movement disorder neurologist important, but the nurse is equally important. The internist is important. The pharmacist to manage the medication. The psychologist, or speech, occupational, dietitian, all of those are equally important. And finally, the social care worker because she might help them place in a situation which might be really the best for them.
And I always say don't forget palliative care. Palliative care can be offered to a patient at any stage of the disease. Hospice is more when we look at the end stage disease. So depending on the stage of the patient, both hospice and palliative care might be options.
With that, I would like to end that patients with PD psychosis should be screened at every visit irrespective of there being treatment. Patients with PD psychosis should be evaluated also for depression, anxiety, and cognitive issues. Worsening of psychosis may require additional antipsychotic medications. Caregiver stressors should be evaluated and managed. And palliative care and hospice should be included in long-term plans.
Thank you very much for listening.
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