What is a suitable medication for inpatient agitation in a patient with Parkinson's disease (PD)?

Managing Inpatient Agitation in Parkinson's Disease Patients

Quetiapine is the preferred medication for managing agitation in patients with Parkinson's disease due to its efficacy in controlling psychotic symptoms without significantly worsening motor function.

First-Line Treatment

Atypical Antipsychotics

• Quetiapine (Seroquel)
  • Starting dose: 25 mg daily or twice daily
  • Titrate gradually based on response
  • Maximum dose: 150-300 mg/day in divided doses 1, 2
  • Benefits: Effective for controlling hallucinations and agitation without significant worsening of parkinsonian symptoms
  • Common side effects: Sedation and orthostatic hypotension 3

Alternative Options (If Quetiapine Is Unavailable or Ineffective)

Other Atypical Antipsychotics

• Clozapine
  • Starting dose: Very low (6.25-12.5 mg daily)
  • Drawbacks: Requires blood monitoring due to risk of agranulocytosis
  • Note: While effective, the monitoring requirements make this less practical in many settings 3, 4

Non-Antipsychotic Options

• Lorazepam (Ativan)

  • Dose: 0.5-2 mg every 4-6 hours as needed
  • Useful for short-term management of severe agitation
  • Caution: May cause excessive sedation, respiratory depression, and paradoxical agitation in approximately 10% of elderly patients 5, 6

• Trazodone

  • Starting dose: 25 mg daily
  • Maximum: 200-400 mg/day in divided doses
  • Caution: Use with care in patients with cardiac issues 5

Medications to AVOID in Parkinson's Disease

Typical Antipsychotics

• Haloperidol (Haldol), fluphenazine, thiothixene
  • These cause severe extrapyramidal symptoms and can dramatically worsen Parkinson's motor symptoms 5, 3

Other Medications to Avoid

• Risperidone - Often poorly tolerated due to worsening of motor function 3, 4
• Olanzapine - Frequently worsens motor symptoms in PD patients 3, 4
• Metoclopramide - Has dopamine-blocking properties that worsen parkinsonian symptoms

Treatment Algorithm

1. Rule out underlying causes of agitation

   • Infection, metabolic disturbances, pain
   • Medication effects or interactions
   • Environmental triggers

2. Optimize Parkinson's medication regimen

   • Simplify anti-PD medications if possible
   • Consider if "off" periods are contributing to agitation

3. Initiate quetiapine

   • Start at 25 mg at bedtime
   • Titrate slowly based on response and tolerability
   • Monitor for sedation and orthostatic hypotension

4. If quetiapine is ineffective or not tolerated:

   • Consider clozapine (if blood monitoring is feasible)
   • Consider trazodone for agitation with sleep disturbance
   • For acute severe agitation, consider short-term low-dose lorazepam

5. Reassess frequently

   • Evaluate response after 1-2 weeks
   • If no improvement after 4 weeks of adequate dosing, taper and discontinue 5

Special Considerations

• Monitoring: Assess for orthostatic hypotension, excessive sedation, and worsening of parkinsonian symptoms
• Dosing: Start low and titrate slowly - "start low, go slow"
• Duration: Use the lowest effective dose for the shortest time necessary
• Documentation: Document clear rationale for antipsychotic use in this high-risk population

Pitfalls to Avoid

1. Using typical antipsychotics (haloperidol, etc.) which can severely worsen motor symptoms
2. Starting with doses that are too high, leading to excessive sedation or hypotension
3. Failing to reassess the need for continued antipsychotic treatment
4. Overlooking treatable causes of agitation such as pain, constipation, or urinary retention
5. Ignoring the impact of the hospital environment itself (unfamiliar surroundings, disrupted routines)

By following this approach, you can effectively manage agitation in Parkinson's disease patients while minimizing the risk of worsening their underlying condition.