From the Guidelines
Quetiapine is the preferred antipsychotic for treating delirium in patients with Parkinson's disease, due to its minimal impact on dopaminergic pathways and lower risk of worsening parkinsonian symptoms. According to the guidelines, quetiapine may offer benefit in the symptomatic management of delirium 1. The suggested starting dose of quetiapine is 25 mg (immediate release) orally, stat, with a reduction in dose recommended for older patients and those with hepatic impairment 1.
Key Considerations
- Quetiapine is available in oral formulations only for acute management 1
- Sedation is a well-recognised side effect of quetiapine, which may be advantageous in patients with hyperactive delirium 1
- Other atypical antipsychotics like risperidone, olanzapine, and haloperidol should be avoided as they can significantly worsen parkinsonian symptoms by blocking dopamine receptors
- Non-pharmacological approaches should be implemented first, including maintaining a consistent environment, ensuring adequate sleep, treating underlying causes, and minimizing anticholinergic medications
Pharmacological Interventions
- The use of pharmacological interventions in the management of delirium in adults should be limited to patients who have distressing delirium symptoms or if there are safety concerns where the patient is a potential risk to themselves or others 1
- Medications should be used in the lowest effective dose and for a short period of time only 1
- Benzodiazepines are effective at providing sedation and potentially anxiolysis in the acute management of severe symptomatic distress associated with delirium, but should be used with caution due to the risk of falls and deliriogenic effects 1
From the FDA Drug Label
NUPLAZID is an atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. INDICATIONS AND USAGE NUPLAZID is an atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis.
The recommended antipsychotic for treating delirium in patients with Parkinson's disease is pimavanserin (NUPLAZID), with a recommended dose of 34 mg taken orally once daily 2 2.
- Key points:
- Indication: Treatment of hallucinations and delusions associated with Parkinson's disease psychosis.
- Dosage: 34 mg taken orally once daily, without titration.
- Administration: Can be taken with or without food.
- Important consideration: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death, and NUPLAZID is not approved for the treatment of patients with dementia who experience psychosis unless their hallucinations and delusions are related to Parkinson's disease 2.
From the Research
Antipsychotic Recommendations for Delirium in Parkinson's Disease
- The treatment of delirium in patients with Parkinson's disease (PD) involves a comprehensive approach, including the management of psychotic symptoms 3, 4, 5, 6, 7.
- Atypical antipsychotics, such as pimavanserin, clozapine, and quetiapine, are commonly used to treat psychosis in PD patients 3, 4, 5, 6, 7.
- Pimavanserin is a highly selective serotonergic receptor antagonist that has been shown to be effective in treating PD psychosis without worsening motor function 3, 5.
- Clozapine is also effective in alleviating psychotic symptoms in PD patients, but its use is limited due to the risk of agranulocytosis and the need for frequent white blood cell count monitoring 4, 5, 6.
- Quetiapine may be effective in some cases, but its use is often limited due to the risk of sedation and orthostatic hypotension 4, 5, 6, 7.
Key Considerations
- The choice of antipsychotic medication should be based on patient-specific parameters, potential benefits, and side effects 4, 5, 7.
- A thorough review of current medications is recommended to identify potential triggers of psychotic symptoms 7.
- Antiparkinsonian medications should be reduced to the minimum therapeutic dose or discontinued in a sequential manner to minimize the risk of worsening motor symptoms 7.
- Cholinesterase inhibitors may be beneficial in patients with comorbid dementia 7.
Treatment Approach
- The initial approach to managing delirium in PD patients involves addressing concurrent systemic conditions, such as infections, medical conditions, and substance misuse or withdrawal 7.
- A stepwise approach to reducing antiparkinsonian medications and introducing antipsychotic therapy is recommended to achieve a balance between improving psychotic symptoms and minimizing the risk of worsening motor symptoms 7.