Admission of Parkinsonian patients to a neurological ward in a community hospital

“…From there, patients are usually admitted to the hospital for further evaluation and management, particularly when the psychosis cannot be managed effectively in an outpatient setting. Of all PD patient admissions to a community hospital during a 6-year period, 24% were due to psychosis, and druginduced psychosis was the cause of repeated and prolonged admissions in 29% of patients [ 74 ] . The best setting for acutely psychotic PD patients is a well-controlled, calm environment where people are equipped to manage psychotic patients; this type of environment may be in a psychiatry unit but other settings also may be appropriate.…”

Section: Discussionmentioning

confidence: 99%

Psychosis and Parkinson’s Disease

Vaughan

Goldman

2012

Movement Disorder Emergencies

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The clinical spectrum of Parkinson's disease (PD) psychosis ranges from mild illusions to formed hallucinations or even frank delusions. Hallucinations occur in about one-third of PD patients treated with chronic dopaminergic therapy and are most often visual. Delusions are less common but typically consist of wellsystematized, thematic ideas such as paranoia or in fi delity. PD psychosis may be due to extrinsic (i.e., pharmacological treatment) and/or intrinsic (i.e., diseaserelated) factors. Risk factors for the development of psychosis include older age; advanced disease; akinetic-rigid motor phenotype; concomitant cognitive impairment, depression, or sleep disturbances; and multiple medical problems. When psychosis in PD develops acutely, becomes troublesome or frightening, or poses a safety risk, medical attention is necessary. Medical management of acute psychosis typically includes the following: identifying and addressing speci fi c causes (e.g., infection, medications), reducing or discontinuing medications for PD and other conditions that may aggravate psychosis, and introducing antipsychotic medications. Since antipsychotics with dopamine-blocking properties may worsen parkinsonism, medications with greater serotonergic properties such as clozapine and quetiapine are favored. Effective and well-studied treatments that improve PD psychosis without worsening motor function are still needed. Patient Vignettes Patient 1A 67-year-old man with a 7-year history of Parkinson's disease (PD) presented to the emergency department with agitation. For the past 2 weeks he had accused his wife of having an affair with the neighbor, believed that strangers were living in his house, and insisted that the dog gates were installed to prevent him from leaving the house. He had threatened family members, and fi nally his wife called the paramedics to bring him to the hospital. His medications included the following: carbidopa/levodopa 25/100 mg-2 tablets every 4 h (total eight tablets daily) along with entacapone 200 mg with each dose, carbidopa/levodopa CR 50/200 mg nightly, amitriptyline 25 mg nightly, and aspirin. His medical history revealed frequent urinary tract infections. On examination, he was confused and exhibited motor features of PD including bradykinesia, rigidity, and rest tremor. He was afebrile, and laboratory tests revealed normal blood counts and electrolytes. Urinalysis was suspicious for infection with positive leukocyte esterase and increased white cells. Neuroimaging did not reveal intracranial hemorrhage or evidence of acute stroke. He was admitted to the psychiatric ward for further management of his psychosis. Patient 2A 70-year-old man with a 15-year history of akinetic-rigid PD presented to the emergency department after lighting his bedspread on fi re to kill the insects which he thought were infesting his bed. En route, he called the police claiming that the ambulance driver had kidnapped him against his will. Over the past year, he was reported to spend most of the day in his bedroom...

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“…In this study, infections, cardiovascular diseases, falls, reduced mobility, and psychiatric complications accounted for the majority of admissions. Another example of how use of ERs varies depending on the geographic location is the study of Klein et al 6 . These authors studied the reasons for admission of PD patients to a Neurological Department of an academic institution in Israel over a 6-year period of time.…”

Section: Referencesmentioning

confidence: 99%

An emerging and growing problem

Cardoso¹

2012

Arq. Neuro-Psiquiatr.

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T he vast amount of work produced by David Marsden, Stanley Fahn, and many other investigators in the 1980s and 1990s established the movement disorders as one of the most active and exciting contemporary areas of Neurology. Since its inception in the 19 th century, thanks to the groundbreaking contribution of Jean Martin Charcot, William Gowers, Sir William Osler, among others, this area has been perceived as the realm of chronic and relentlessly progressive disorders, whose care is provided in the setting of outpatient clinics. Recently, there is a growing understand that movement disorders may present with acute problems warranting visits to the emergency rooms. Thus, the comprehensive review of Munhoz et al. on movement disorders emergencies in the current issue of Arquivos de Neuropsiquiatria is timely 1 . The authors tackled etiology, clinical features, and management of a vast gamut of emergencies in patients with movement disorders.In addition to clinical problems related to hyperkinetic and hypokinetic movement disorders in adults reviewed by the authors, there are two issues that should receive the attention of neurologists interested in this field. At least 8% of patients with Parkinson's Disease (PD) and a small, but growing number, of individuals with tremor, dystonia, and other hyperkinetic disorders fail to respond to clinical management. With new advances in functional surgery, many of these subjects are candidates for deep brain stimulation (DBS).As recently reviewed by Morishita et al. 2, more postoperative urgencies and emergencies have emerged. The authors have separated the scenarios into surgery/procedure related (intracranial hemorrhage, dyskinetic storm, postoperative behavioral and cognitive problems, suicide attempt or ideation, others), hardware related (hardware infection, hardware malfunction, lead migration, and lead misplacement), stimulation-induced difficulties (motor or non-motor symptoms), and others. Given their complexity, patients with these movement disorders emergencies should be referred to units where there is a staff comprising neurologists and neurosurgeons experienced with DBS. The second issue is related to pediatric movement disorders. In comparison to adult patients, much less has been published about emergencies in this population. However, a recent review by Kirkham et al. sheds light on this topic 3 . They described 52 patients, and three groups were recognized: psychogenic disorders (n=12), typically >10 years-old, more likely to be female and to have tremor and myoclonus 2 . Inflammatory or autoimmune disorders (n=22), including N-methyl-d-aspartate receptor encephalitis, opsoclonusmyoclonus, Sydenham's chorea, systemic lupus erythematosus, acute necrotizing encephalopathy, and other encephalitis and 3 non-inflammatory disorders (n=18), including drug-induced movement disorder, postpump chorea, metabolic, e.g. glutaric aciduria, and vascular disease, e.g. moyamoya. It noteworthy that, unlike series with adult subjects, there was a significant representation of...

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Admission of Parkinsonian patients to a neurological ward in a community hospital

Cited by 55 publications

References 11 publications

Inpatient Management of Parkinson Disease

Inpatient Management of Parkinson Disease

Psychosis and Parkinson’s Disease

An emerging and growing problem

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