Long-Term Care Survey Alert

Published on Thu Aug 26, 2004 PDF

Be an assessment detective to help residents regain their hold on reality.

Imagine this scenario: A cognitively intact resident with Parkinson's disease confides that her husband is having an affair, and asks you to please stop sending pet cats and dogs into her room because she's allergic to them.

But you don't have an Eden or pet therapy program and the resident's 90-year-old husband was paralyzed by a stroke years ago.

Time to schedule a psych consult? Not so fast, say experts.

Such symptoms can result from anti-Parkinson's medications, which increase dopamine levels (the opposite of antipsychotic drugs' effect). Approximately 30 percent of people treated for PD experience drug-induced false sensory perceptions - typically recurrent visual hallucinations of people or animals, according to neurologist Joseph Friedman, speaking at a June 2004 National Association of Directors of Nursing Administration in Long-Term Care conference in Orlando, FL. 

Delusions - most typically paranoid ones - can also occur. "Spousal infidelity is a common Parkinson's drug-induced paranoid delusion," according to Ella Hunter, PhD, RN, a nursing professor at Eastern Kentucky University in Richmond, KY, who copresented with Friedman.

Hunter relayed how her own mother, "who had never had a psychotic moment in her life," became suspicious of hospital-based SNF staff within a week after she started taking medication to treat her Parkinson's disease. "She thought caregivers were trying to trick her by taking her money and spying on her," Hunter tells Eli. Luckily, a reduction in medication dosage cleared up her symptoms completely.

Lesson learned: Residents are at highest risk for developing anti-Parkinson's drug-induced psychotic symptoms at the outset of drug therapy when the physician increases the dosage over several days to find a therapeutic level, says Hunter. Residents are also at risk for psychosis if the clinician increases their Parkinson's medication when it no longer works as effectively.

Clinicians treat Parkinson's drug-induced psychotic symptoms by titrating the Parkinson's medication dose to the minimum tolerable effective dose or even stopping it.

If the movement disorder worsens as a result, physicians may try to counteract the resident's psychotic symptoms by prescribing an atypical antipsychotic medication. For example, the atypical antipsychotic drug, quetiapine (Seroquel), has not been shown to cause or exacerbate movement disorders in elderly patients, Friedman tells Eli.

Clinical gem: Monitor all patients on antipsychotic drugs for a decline in mobility or ADL function seen two to four weeks later, Friedman advised. (See the assessment form for patients with Parkinson's, Clip 'N Save: Detect Psychosis And Severity Of Movement Disorder In Patients Taking Anti-Parkinson's Meds.)

Use These Expert Psych and Drug Assessment Tactics

The patient who has developed drug-induced paranoid delusions may be afraid to tell you she is afraid or suspicious, especially if she thinks you're in on a conspiracy to hurt her. So if the resident seems more reticent or guarded than usual - or like she has a secret - share your impressions in a kind, empathetic voice, Hunter suggested.

Tell the person you're there to help keep her safe, Hunter advised NADONA attendees.

For example, Hunter suggested the nurse might say: "Sometimes the drugs you're taking can make people feel a little tense or worried. Are you worried about something?"

 If the person says no, tell him you'll check back on him. "Then leave the door open. Sometimes the person will call you back and blurt out what's on his mind," Hunter said. "Most of the time the person won't have a full-blown paranoia and so will have some insight - and want relief" from his fears, Hunter added.

When assessing sudden psychosis in an elderly patient with PD, you also have to rule out acute reasons for mental status changes, such as infection or electrolyte imbalance, Friedman cautioned.

What if a resident taking anti-Parkinson's medication has Alzheimer's disease, which can also
cause visual hallucinations and delusions of persecution?

"In that population of residents, it can be difficult to tell if such symptoms are due to the medication or progression of the dementia," says Chris Schwerdt, PharmD, director of clinical services for the Nashville, TN office of Omnicare Inc., a provider of pharmacy services to long-term care facilities.

"But if the resident's psychotic symptoms pop up suddenly, the consulting pharmacist may recommend the clinician reduce or stop the anti-Parkinson's medication" to see if the symptoms go away or improve, Schwerdt offers. Or  another med may be the culprit - especially a recently prescribed drug, he adds.