From the Guidelines
Management of Parkinson's drug withdrawal delirium requires immediate reinstatement of dopaminergic medications, preferably via nasogastric tube if oral intake is compromised, to prevent severe dopamine deficiency and life-threatening complications. The first step is to restart the patient's usual antiparkinsonian medications as soon as possible. If the original medication cannot be administered, equivalent doses of alternative dopaminergic agents should be used: levodopa/carbidopa (25/100 mg three to four times daily), ropinirole (1-4 mg three times daily), or pramipexole (0.125-1 mg three times daily) 1. For severe cases with inability to take oral medications, rotigotine transdermal patch (4-8 mg/24 hours) can be applied. It is crucial to avoid typical antipsychotics like haloperidol as they block dopamine receptors and worsen symptoms, especially in patients with Parkinson's disease or dementia with Lewy bodies due to the risk of extrapyramidal side effects (EPSEs) 1.
Key Considerations
- Ensure adequate hydration and electrolyte balance
- Treat any underlying infections
- Close monitoring of vital signs and neurological status is essential
- If agitation requires treatment, quetiapine (25-50 mg) or clozapine (12.5-25 mg) are preferred as they have minimal impact on motor symptoms, although caution is advised due to potential side effects such as sedation, orthostatic hypotension, and metabolic effects with long-term use 1.
Medication Management
- Restart dopaminergic medications as soon as possible to prevent further dopamine deficiency
- Use alternative dopaminergic agents if necessary, with careful consideration of dosing and potential side effects
- Avoid typical antipsychotics and instead opt for atypical antipsychotics with minimal impact on motor symptoms if agitation treatment is required.
From the Research
Parkinson Drug Withdrawal Delirium Management
- Delirium in Parkinson's disease (PD) is an acute and fluctuating disturbance of attention and awareness, with pre-existing cognitive disturbances or dementia being significant risk factors 2.
- Patients with PD are at an increased risk for delirium, which may be underdiagnosed due to overlap between delirium and chronic neuropsychiatric features of PD or side effects of dopaminergic medication 2, 3.
- Management of delirium comprises pharmacological and non-pharmacological measures, with adjustments of anti-parkinsonian medication recommended to prevent or treat delirium, although no hard evidence is available from controlled studies 2.
- Withdrawal of dopaminergic medication, such as dopamine agonists, can lead to severe life-threatening withdrawal symptoms, including dopamine agonist withdrawal syndrome (DAWS) 4, 5.
- Tapering off levodopa, COMT inhibitors, and MAO-B inhibitors may worsen motor and non-motor symptoms, and should be done cautiously 4.
- Non-pharmacological interventions, such as withdrawing precipitating or distressing factors and providing sensory, emotional, and environmental support, can help prevent or palliate delirium 2.
- In cases of acute delirium, transfer to the intensive care unit and administration of dexmedetomidine may be effective in managing symptoms 6.