What is the management of delirium or agitation in patients with Progressive Supranuclear Palsy (PSP)?

From the Guidelines

Management of delirium or agitation in patients with Progressive Supranuclear Palsy (PSP) should prioritize non-pharmacological interventions and, when necessary, the use of atypical antipsychotics like quetiapine at low doses, as evidenced by recent guidelines 1.

Key Considerations

• Identifying and treating underlying causes such as infections, metabolic disturbances, or pain is crucial in managing delirium or agitation in PSP patients.
• Environmental modifications, including maintaining a consistent routine, ensuring adequate lighting, minimizing noise, and having familiar objects nearby, can significantly reduce confusion.
• When medications are necessary, atypical antipsychotics at low doses are preferred due to their lower risk of extrapyramidal side effects compared to typical antipsychotics.

Medication Recommendations

• Quetiapine, starting at 12.5-25mg at bedtime, is considered a safer option due to its lower propensity for extrapyramidal side effects, as suggested by clinical practice guidelines 1.
• Clozapine may be considered in refractory cases but requires regular blood monitoring due to the risk of agranulocytosis.
• Benzodiazepines, such as lorazepam, should be used cautiously and at low doses (0.25-0.5mg) for short periods in cases of severe agitation, given their potential to worsen confusion and increase the risk of falls.

Important Considerations for PSP Patients

• PSP patients are particularly sensitive to medications affecting the central nervous system due to their widespread neurodegeneration.
• All medications should be started at low doses with slow titration while monitoring closely for adverse effects to minimize risks and optimize symptom control.
• The use of pharmacological interventions should be limited to patients with distressing delirium symptoms or safety concerns, and medications should be used in the lowest effective dose for a short period, as recommended by guidelines 1.

From the Research

Management of Delirium or Agitation in Patients with PSP

• The management of delirium or agitation in patients with Progressive Supranuclear Palsy (PSP) is a complex issue, and there is no specific treatment for these symptoms 2, 3.
• However, a patient-centered approach encompassing compassion, communication, and empathy is recommended for the care of patients with PSP, including those experiencing delirium or agitation 4.
• The treatment of PSP is generally supportive and symptomatic, and may involve a multidisciplinary team approach to manage the various symptoms of the disease, including delirium and agitation 2, 3, 5.
• Non-pharmacological treatment strategies, such as education and support for patients and families, may also be beneficial in managing delirium and agitation in patients with PSP 3, 4.
• Pharmacological treatments, such as coenzyme Q-10 and levodopa, may provide some symptomatic relief for patients with PSP, but their effectiveness in managing delirium and agitation is not well established 6, 5.

Challenges in Managing Delirium or Agitation in Patients with PSP

• Patients with PSP are at risk of undesirable outcomes, including poor communication and inconsistent care, during care transitions, which can exacerbate delirium and agitation 4.
• The lack of specific treatments for delirium and agitation in patients with PSP, and the limited understanding of the underlying pathophysiology of these symptoms, pose significant challenges for clinicians 2, 3, 6.
• The complexity of PSP, with its multiple symptoms and deficits, requires a comprehensive and individualized approach to management, including the management of delirium and agitation 3, 5.