What is the best course of action for a patient with Parkinson's disease who develops psychosis after urinary catheterization?

From the Guidelines

For a patient with Parkinson's disease who develops psychosis after urinary catheterization, the best course of action is to remove the urinary catheter as soon as possible and perform a urinalysis to rule out a urinary tract infection (UTI) 1. When a Parkinson's patient suddenly develops psychosis in this setting, a UTI should be strongly suspected, as UTIs are common complications of catheterization and can present as acute confusion or psychosis in elderly patients, particularly those with neurological conditions. Some key points to consider in this scenario include:

• The presence of a urinary catheter is associated with a significantly increased risk of delirium, especially in older adults 1.
• Catheter-associated bacteriuria increases and is directly associated with catheter days, making early removal of the catheter crucial 1.
• Removing the urinary catheter as soon as possible can help reduce the risk of UTI and other complications, and encourage mobility and improve patient comfort 1. Rather than immediately reducing dopaminergic medications (which could worsen motor symptoms), the first step should be to rule out infection by performing a urinalysis, which can quickly identify signs of infection such as pyuria, bacteriuria, and nitrites 1. If a UTI is confirmed, treating the infection with appropriate antibiotics will likely resolve the psychosis without needing to adjust Parkinson's medications, thus addressing the most likely reversible cause while maintaining the patient's motor function control.

From the Research

Management of Psychosis in Parkinson's Disease

The management of psychosis in patients with Parkinson's disease (PD) involves several steps:

• Identifying and treating any underlying medical conditions that may be contributing to the psychosis, such as infections or metabolic disorders 2, 3, 4
• Reducing or discontinuing medications that may be inducing or worsening the psychosis, such as anticholinergics, amantadine, and dopamine agonists 2, 3, 5
• Considering the use of atypical antipsychotics, such as clozapine, pimavanserin, or quetiapine, if the above measures are not effective 2, 3, 5, 6
• Using acetylcholinesterase inhibitors in patients with dementia 2, 4, 6

Treatment Approach

The treatment approach for PD psychosis (PDP) should be individualized and based on patient-specific parameters, potential benefits, and side effects:

• The initial approach should focus on addressing concurrent systemic conditions and reducing or discontinuing medications that may be triggering psychotic symptoms 2, 3, 4
• The use of antipsychotic medications should be considered if the above measures are not effective, with atypical antipsychotics being preferred over first-generation antipsychotics 2, 3, 5, 6
• The choice of antipsychotic medication should be based on the patient's specific needs and potential side effects 2, 6

Considerations

When managing psychosis in patients with PD, the following considerations should be taken into account:

• The potential for antipsychotic medications to worsen motor symptoms 3, 4
• The importance of monitoring and adjusting treatment regularly to minimize side effects and optimize benefits 5
• The need for caregiver involvement and support in managing psychotic symptoms and impulse control disorders 5