From the Guidelines
For an end-stage Parkinson's patient with increased anxiety and combativeness, quetiapine (option 3) is generally the best choice among the options provided. This recommendation is based on the most recent and highest quality study available, which suggests that quetiapine may offer benefit in the symptomatic management of delirium and has a lower risk of worsening Parkinson's motor symptoms compared to other antipsychotics like haloperidol or risperidone 1. Typically, a low starting dose of 12.5-25mg at bedtime is recommended, which can be gradually increased as needed while monitoring for side effects.
Some key points to consider when using quetiapine in this context include:
- Monitoring for orthostatic hypotension, sedation, and metabolic effects
- Using the lowest effective dose for a short period of time only
- Considering non-pharmacological strategies such as maintaining routine, creating a calm environment, and addressing underlying causes of anxiety or agitation
- Avoiding the use of benzodiazepines like lorazepam for long-term management due to risks of sedation, falls, and dependence, although they may be used in acute situations with careful assessment of patient distress and safety risks 1.
In contrast to quetiapine, haloperidol and risperidone should generally be avoided in Parkinson's patients as they strongly block dopamine receptors and can significantly worsen motor symptoms 1. Lorazepam may help with acute anxiety but is not ideal for long-term management due to its potential for sedation, falls, and dependence 1.
From the Research
Medication Options for End-Stage Parkinson's Patients
- Haldol (haloperidol) is a neuroleptic medication that can produce medicinal effects against hyperactivity, agitation, and mania, as well as schizophrenia, but long-term usage raises the risk of acquiring a neurological condition like Parkinson's disease 2.
- Lorazepam is not mentioned in the provided studies as a treatment option for end-stage Parkinson's patients with increased anxiety and combativeness.
- Quetiapine is an atypical antipsychotic medication that has been studied for the treatment of psychosis in patients with Parkinson's disease, but its efficacy is no better than that of placebo or clozapine 3, 4.
- Risperidone is not mentioned in the provided studies as a treatment option for end-stage Parkinson's patients with increased anxiety and combativeness.
Considerations for Treatment
- The management of delirium in Parkinson's disease patients involves pharmacological and non-pharmacological measures, and the administration of neuroleptics and other psychoactive drugs is controversially discussed and should be reserved for patients with severe agitation or distressing psychosis 5.
- Quetiapine has been shown to be well-tolerated in patients with Parkinson's disease and psychosis, but its introduction did not exacerbate parkinsonian symptoms 3.
- Pimavanserin may be more clinically useful for promptly managing psychosis in patients with Parkinson's disease and dementia with Lewy bodies, while quetiapine may confer additional secondary benefits long-term 6.