hi all

this was posted is august and september
but i'm re-posting it now for anyone
who may have missed it

janet

orginally posted 970822
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BX: PS: Abstracts: Drug-Induced Psychosis in PD
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Neuropsychiatric adverse effects of antiparkinsonian drugs.
Characteristics, evaluation and treatment.   1997
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Parkinson's disease (PD) is a progressive neurological condition that
causes considerable disability in the elderly.

Drugs used to treat PD, such as levodopa, offer symptomatic relief but
often have neuropsychiatric adverse effects, most prominently psychosis and
delirium.

Aged patients and those with dementia are particularly vulnerable to these
adverse effects.

Evaluating PD patients with drug-induced neuropsychiatric adverse effects
is made difficult by their complex clinical presentations.

The treatment of drug-induced psychosis and delirium begins with
manipulating the antiparkinsonian drug regimen, but this frequently worsens
motor function.

Atypical antipsychotics such as clozapine have been successfully employed
to treat the psychosis without worsening the motor disability.

Patient intolerance of clozapine therapy has prompted open-label studies
with newer agents such as risperidone, remoxipride, zotepine, mianserin and
ondansetron.

Drugs Aging 1997 May;10(5):367-383
Young BK, Camicioli R, Ganzini L
Mental Health Division, Portland Veterans Affairs Medical Center, Oregon, USA
PMID: 9143857, MUID: 97288925

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Hallucinosis in idiopathic Parkinson's disease   1997
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BACKGROUND: Hallucinosis is a complication of the treatment of idiopathic
Parkinson's disease commonly thought to afflict older, chronically
medicated, cognitively impaired patients.

However, patients with idiopathic Parkinson's disease of short duration
experiencing hallucinosis on relatively low doses of dopaminergic
medication have been found.

The aim, therefore, was to investigate the homogeneity of a population of
patients with idiopathic Parkinson's disease and hallucinosis.

METHODS: The clinical, demographic, and cognitive correlates of
hallucinosis were investigated in a sample of 129 patients with idiopathic
Parkinson's disease.

RESULTS: There were two subgroups of patients with idiopathic Parkinson's
disease experiencing hallucinosis.

In patients with a disease duration of five years or less, hallucinosis was
associated with rapid progression of the motor component of the disease but
not cognitive impairment.

In patients with idiopathic Parkinson's disease of longer than five years
duration, hallucinosis was associated with postural instability, global
cognitive impairment, and lack of depressive affect.

In all patients with idiopathic Parkinson's disease, hallucinosis was more
prevalent when they were treated with a direct acting dopamine receptor
agonist.

Hallucinosis was not associated with age at onset of idiopathic Parkinson's
disease or dosage of dopaminergic medication.

CONCLUSION: Hallucinosis in idiopathic Parkinson's disease is
heterogeneous, falling into two groups.

The difference in the pathophysiological basis of hallucinosis in these two
groups of patients is discussed.

J Neurol Neurosurg Psychiatry 1997 Oct;63(4):434-440
Graham JM, Grunewald RA, Sagar HJ
University of Sheffield, Department of Clinical Neurology, Royal Hallamshire
Hospital, UK.
PMID: 9343119, MUID: 98001284

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ABSTRACT: Drug-induced psychiatric states frequent in PD   1995
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In the prelevodopa era, depression and other psychiatric disorders were
described in PD, but in untreated patients psychosis was rare.

Since the development of levodopa and other pharmacological treatments for
PD, however, psychotic symptoms have become much more common (10-50%).

In some individuals these problems can be more disabling than the motor
features of PD and, as a result, pose a serious threat to the patient's
ability to maintain independence.

The drug-induced psychoses consist of several distinct psychiatric
syndromes that can be divided broadly into those occurring on a background
of a clear sensorium and those which are accompanied by confusion and
clouding of consciousness.

Benign organic hallucinosis is the most common of these syndromes (30%).

It usually occurs on a background of a clear sensorium and may not be a
particularly troublesome problem if the patient is able to retain insight
into the nature of these symptoms.

More disabling syndromes usually include delusional thinking that is
frequently paranoid, confusion and even frank delirium.

Although all these psychotic syndromes can occur in isolation, there is a
tendency for mild symptoms to progress to more disabling ones if adequate
and timely treatment is not instituted.

Abnormal dreaming and sleep disruption often precede these difficulties by
weeks to months and may provide an important early clue to their onset.

The mechanisms responsible for drug-induced psychotic symptoms in PD are
unknown, but dopaminergic (especially mesolimbic) and serotoninergic
systems are likely to be involved.

The treatment of the drug-induced psychoses in PD should be undertaken in a
stepwise manner.

A detailed discussion of this approach, including the use of anti-PD
medication adjustment, clozapine, and other medications (neuroleptic and
nonneuroleptic) and ECT is provided.

Although drug-induced psychoses are the most important of the drug-induced
psychiatric states, mania, anxiety, and hypersexuality may also occur.

Depression is also common in PD, but it is unlikely to occur as a side
effect of antiparkinsonian medications.


Adv Neurol 1995;65:115-138
Factor SA, Molho ES, Podskalny GD, Brown D
Albany Medical College, Department of Neurology, New York, 12208, USA
PMID: 7872135, MUID: 95176970

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ABSTRACT: To determine factors that are predictive for the
development of hallucinations associated with PD   1996
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BACKGROUND: Hallucinations are a common difficulty for patients with
established PD, and hallucinations and psychosis may be the most common
causes for nursing home placement.

The characteristics of the hallucinations associated with PD differ from
the hallucinations associated with schizophrenia or cocaine abuse.

Multiple factors have been suggested as causal.

DESIGN AND METHODS: A total of 214 consecutive patients were interviewed
during routine visits to the Parkinson's Disease Clinics in Columbus, Ohio,
and Miami, Fla, using a hallucination questionnaire, Folstein Mini-Mental
State Examination, and an attempt to correlate age, duration of disease,
medication, and psychological or sleep disorders with the hallucinations.

RESULTS: Hallucinations were almost exclusively visual and were present in
55 of the 214 patients.

Dementia, age, duration of disease, history of depression, or history of
sleep disorder were strongly associated with the hallucinations.

CONCLUSIONS: While reduction in levodopa and anticholinergic medication
doses is appropriate in the management of hallucinations, the factors that
predispose patients to hallucinations include dementia and advancing age.

The phenomena of visual hallucinations associated with PD, while not fully
explained, are unique enough to be of interest to all neurologists and
neuroscientists.

Arch Neurol 1996 Dec;53(12):1265-1268
Sanchez-Ramos JR, Ortoll R, Paulson GW
Department of Neurology, University of Miami School of Medicine, Fla, USA.
PMID: 8970453, MUID: 97125374

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ABSTRACT: Drug treatment of PD in the 1990s  1997
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Advances in the medical treatment of Parkinson's disease have improved the
disability related to complications of long term levodopa therapy,
including motor fluctuations, dyskinesias and neuropsychiatric toxicity.

A range of new dopamine agonists are in various stages of preclinical and
clinical development.

Cabergoline appears to be effective in improving moderate motor
fluctuations, and a number of dopamine partial agonists that can act as
either agonists or antagonists depending on the degree of denervation and
receptor sensitivity are being investigated.

Apomorphine represents a significant advance in the treatment of well
developed motor fluctuations in selected patients who are able to master
the technique of subcutaneous administration.

The catecholamine-O-methyl transferase inhibitors are proving useful in
phase III studies in the management of patients with moderate motor
fluctuations.

A role for glutamate antagonists is supported by animal and early clinical
data, although the poor therapeutic index associated with the currently
available nonselective, noncompetitive glutamate antagonists has prompted a
search for more selective antagonists with less toxicity.

The management of levodopa-induced dyskinesias remains a major therapeutic
challenge.

Some reports of dopamine partial agonists, selective D2 receptor
antagonists and atypical antipsychotics being useful await confirmation.

Neuropsychiatric toxicity probably remains the major dose-limiting adverse
effect of levodopa and is a major reason for parkinsonian patients being
admitted to nursing homes.

The development of new atypical antipsychotics with improved therapeutic
indices, along with the possible use of serotonergic antagonists, may
improve management of this difficult problem.

The challenge will be to fit these new forms of treatment into our present
range of available drugs and to assess their relative role within the
emerging framework of functional neurosurgery for parkinsonian disability.


Drugs 1997 Feb;53(2):195-205
Hughes AJ
Austin and Repatriation Medical Centre, Heidelberg, Victoria, Australia.
PMID: 9028741, MUID: 97180565

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ABSTRACT: Drug-Induced Psychosis + Delirium in PD   1997
------------------------------------------------------------------------

Parkinson's disease (PD) is a progressive neurological condition that
causes considerable disability in the elderly.

Drugs used to treat PD, such as levodopa, offer symptomatic relief but
often have neuropsychiatric adverse effects, most prominently psychosis and
delirium.

Aged patients and those with dementia are particularly vulnerable to these
adverse effects.

Evaluating PD patients with drug-induced neuropsychiatric adverse effects
is made difficult by their complex clinical presentations.

The treatment of drug-induced psychosis and delirium begins with
manipulating the antiparkinsonian drug regimen, but this frequently worsens
motor function.

Atypical antipsychotics such as clozapine have been successfully employed
to treat the psychosis without worsening the motor disability.

Patient intolerance of clozapine therapy has prompted open-label studies
with newer agents such as risperidone, remoxipride, zotepine, mianserin and
ondansetron.


Drugs Aging 1997 May;10(5):367-383
Young BK, Camicioli R, Ganzini L
Portland Veterans Affairs Medical Center, Oregon, USA.
PMID: 9143857, MUID: 97288925

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ABSTRACT: Inappropriate Medication Prescribing   1997
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OBJECTIVE: To estimate the prevalence of inappropriate medications
prescribed by office-based physicians for patients 65 years or older.

DESIGN: A nationwide cross-sectional survey of office visits by the elderly.

SETTING: The National Ambulatory Medical Care Survey (NAMCS) 1992, a
national probability sample survey of office visits by ambulatory patients
within the continental US.

SUBJECTS: A national probability sample of patients 65 years or older
visiting office-based physicians. National estimates are based on the
National Center for Health Statistics weighting procedure for the NAMCS
sample.

MAIN OUTCOME MEASURES: Prevalence of 20 inappropriate medications that
should be entirely avoided in the elderly, using criteria developed by a
panel of national experts in geriatric medicine and geriatric pharmacology.

RESULTS: In the US during 1992, an estimated 8.47 million (95% CI 7.66=
million to 9.28 million) office visits by the elderly indicated prescribing
of at least 1 of the 20 inappropriate medications.

Approximately 7.75 million (95% CI= 6.98 million to 8.52 million) visits by
the elderly involved 1 inappropriate medication and 0.72 million (95% CI
0.51 million to 0.93 million) visits included 2 inappropriate medications.

According to the NAMCS, office-based physicians prescribed at least 1
inappropriate medication to 7.58% of the elderly who received prescriptions.

The most frequently prescribed inappropriate medications were propoxyphene,
amitriptyline, dipyridamole, diazepam, and chlorpropamide.

Elderly patients rarely received prescriptions from office-based physicians
for drugs such as secobarbital, isoxsuprine, trimethobenzamide, and
carisoprodol.

Furthermore, office-based physicians did not prescribe cyclandelate,
pentobarbital, or phenylbutazone for the elderly.

CONCLUSIONS: The prescribing of inappropriate medications by office-based
physicians raises concerns regarding the quality of care for the elderly in
ambulatory settings.

The crux of improving patient care in ambulatory settings rests with
collaborative efforts between physicians and pharmacists.

Ann Pharmacother 1997 Jul;31(7-8):823-829
Aparasu RR, Fliginger SE
College of Pharmacy, South Dakota State University, Brookings 57007 USA.
[log in to unmask]
PMID: 9220038, MUID: 97363746

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ABSTRACT: Psychotic Disorders in the Elderly   1997
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OBJECTIVE: To review the epidemiology, phenomenology, and treatment of
psychotic disorders in late life.

METHOD: The literature relating to psychotic symptoms in the elderly is
reviewed, with a focus on the following categories: primary psychotic
disorders, mood disorders, delirium, Parkinson's disease (PD), and somatic
hallucinoses (including Charles Bonnet syndrome [CBS] and musical
hallucinosis).

Practical clinical treatment implications are discussed.

RESULTS: The prevalence of psychotic symptoms increases with age, largely
because of underlying medical illnesses such as dementia, delirium, and
other neurological disorders that are exacerbated by sensory deficits
coupled with social isolation.

Treatment with the traditional high-potency neuroleptics is complicated by
extrapyramidal symptoms, and sedation, postural hypotension, and
anticholinergic effects complicate the use of low-potency traditional agents.

Although clozapine may have a narrow use in the treatment-resistant
schizophrenia and PD, it is poorly tolerated in the elderly.

Risperidone has a wider use in this population and has a favourable
clinical profile (at low doses). Other new neuroleptics await more formal
evaluation in the elderly.

CONCLUSION: Psychotic disorders in old age have more organic associations,
which cause greater difficulty in their treatment.

Further Evaluation of the use of atypical agents in this elderly group is
indicated.

Can J Psychiatry 1997 Jun;42 Suppl 1:19S-27S
Thorpe L
Department of Psychiatry, University of Saskatchewan, Saskatoon.
PMID: 9220126, MUID: 97363834

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ABSTRACT: Clozapine + Drug-Induced Psychosis in PD   1997
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Clozapine, the only commercially available atypical neuroleptic, is
approved for the treatment of schizophrenic patients who are unresponsive
to or intolerant of typical neuroleptics.

It has an unusual pharmacologic profile compared with standard
neuroleptics, and it follows that clinical response to this drug is also
different.

It has shattered the notion that a drug must be capable of inducing or
worsening parkinsonism to be a potent antipsychotic.

Based on these findings, it is being used increasingly by neurologists for
psychiatric and nonpsychiatric problems in patients with movement disorders.

The most common use for clozapine among neurologists is in the management
of drug-induced psychosis in Parkinson's disease (PD).

This problem has been a source of increased morbidity and mortality in PD
because of a lack of adequate therapeutic intervention.

At this time, because of success in numerous open trials, with improvement
of > 80% of patients, clozapine therapy for psychosis in PD is becoming the
standard of care.

It also appears to be of value in the management of some motor features of
PD, including tremors and dyskinesia and possibly even sensory symptoms
such as akathisia and pain.

The literature also suggests that clozapine may be of potential benefit in
hyperkinetic movement disorders including essential tremor, Huntington's
disease, and tardive dyskinesia.

We review the current data concerning the use of clozapine in patients with
these movement disorders and others.

Mov Disord 1997 Jul;12(4):483-496
Factor SA, Friedman JH
Albany Medical College, Department of Neurology, New York, USA.
PMID: 9251065, MUID: 97394752

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ABSTRACT: Drug-induced psychosis is a serious late complication
of PD that requires aggressive treatment.    1995
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Recent studies have found clozapine a highly effective and ECT a possibly
useful intervention.

Two cases are presented that illustrate a possible treatment role for ECT.

The cases demonstrate that ECT has significant but short-lived
antipsychotic effects when used alone.

However, patients who do not respond to clozapine monotherapy can be given
adjunctive treatment with ECT.

The combination therapy resulted in abrupt alleviation of psychotic
symptoms in one of the cases, and maintenance with low-dose clozapine
allowed for long-term efficacy.

On the basis of these findings, a therapeutic approach to patients with
drug-induced psychosis in PD is suggested.

J Neuropsychiatry Clin Neurosci 1995;7(3):304-307
Factor SA, Molho ES, Brown DL
Albany Medical College, Department of Neurology, New York 12208, USA.
PMID: 7580188, MUID: 96076000

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