Rapid Progression of Parkinsonian Symptoms in Lewy-Body Dementia after Administration of Antipsychotics: Case Report- Juniper publisher
JUNIPER PUBLISHERS- Open Access Journal of Toxicology (OAJT)
Author: Ali M K
Abstract
This case is of a 60 year old female patient who
lives in an apartment and has no prior psychiatric history. Recently the
patient had been getting more and more agitated, paranoid, increasingly
withdrawn and did not maintain her ADLs. Patient mentioned being tired,
not being able to sleep as people living upstairs play loud music. Upon
investigation, there was no loud music being played by the patient's
neighbors at night or at any time. Patient also complained of the people
living upstairs did not like her and disturbs her which in fact was not
true. Patient lives alone in the apartment and used to be active and
all household chores were performed by the patient herself but recently
patient has been really lazy and keeps lying on the couch and does not
perform her chores. Patient has also started threatening people
including her daughter. Patient worked in the city before and has been
married twice but both resulting in separations and divorce. As per
daughter, patient is easily forgetful, repeats things again and again.
Patient denies using any drugs or illicit substances and has no
significant medical problem. However according to the daughter patient
has a past history of IV heroin abuse (20 years ago) and alcohol abuse.
Introduction
The research is being conducted to find out that if
treating lewy body dementia with anti-psychotics rapidly increases
Parkinsonian symptoms. According previous researches, anti psychotics
have shown to cause drug induced Parkinsonism. This research is based
upon whether or not there is any relationship in between the two.
Case Presentation
This is a case of a 60y/o Female, domiciled in an
apartment, unemployed, no prior psychiatric history, brought in by EMS
activated by daughter because patient was increasingly withdrawn,
getting more and more agitated , paranoid and not maintains her ADL. On
questioning, patient mentions that she feels tired, did not sleep for
many days and does not want to give enough information but reported
that, "lady upstairs in my apartment is against me, does not like me,
playing loud music in the middle of the night and disturbed me, and I
can't sleep."
As per daughter, patient was living alone in an
apartment, doing everything on her own, but since the past few months
patient is gradually becoming more and more isolated and withdrawn, not
taking care of herself. As per daughter, her mother was always active,
cooked on her own; always cleaned the apartment, good hygiene, always
did her nail , but since the past few months patient is not cooking, the
apartment is a mess, not clean at all, they found no food in the
refrigerator, and losing weight. As per other family members, the
patient is also increasingly paranoid, irritable and thinks that lady
upstairs is against her and disturbs her by playing loud music.
Patient's daughter spoke with the lady upstairs on her mom’s
persistence, who told the patient's daughter that she is not playing any
loud music and in fact goes to work and sleeps early Patient
additionally has been threatening people including her daughter lately.
As per daughter; patient has become more forgetful, with perseveration.
According to her daughter, patient had past history of IV heroin abuse
(20 years ago) and alcohol abuse,patient denied recent substance abuse
and on testing urine toxicology was negative. No recent history of
trauma.
The patient was admitted to treat the symptoms of
paranoid delusions. Primary pathology at the time of admission most
likely was Major depressive disorder with psychotic features with
possible dementia as patient reported anhedonia, poor concentration,
reduced sleep, and poor attention along with her paranoid delusions. She
also has recent stressors including recent divorce, unemployment, and
poor family support.
On testing performed CT scan showed frontal lobe
atrophy, ventricular dilatation, and micro-vascular ischemia. Labs: TSH,
B12, CMP, LFTS were all normal and within limits. Patient's strengths
were her, previous employment history, no family psychiatry history, no
past psychiatric history and higher education. Risks included her poor
insight into her disease, unemployment, heroin/alcohol abuse history,
delusions, and paranoid behavior.
Patient worked in the city for many years. Patient
has married twice, last marriage seven years ago and they were separated
in April, 2012 and after few months eventually divorced. Since then
patient has been single. No significant medical problem.
Patient was started on low dose typical
antipsychotic, Haldol 0.5mg per-oral q12h, with gradually increasing the
dose to reduce psychosis. As the patient was started on the medication,
her delusions significantly improved, on the contrary, patient
developed severe parkinsonian symptoms such as akinesia, bradykinesia
and impaired swallowing as the dose of Haldol was increased up till 2mg
BID. This episode significantly increased the suspicion of Lewy Body
Dementia. This suspicion with CT scan changes made the suspicion more
concrete. On CT scan there was severe dilatation of the ventricles and
sulci, particularly in frontal lobes, consistent with atrophy.
Additionally there were mild peri-ventricular white matter
hypo-densities with preservation of the distinction between grey and
white matter. After witnessing the changes seen on CT scan, neurology
was consulted, who performed the MOCA, on which the patient scored
16/30. They recommended discontinuation of Haldol and initiation of
Seroquel 25mg QHS. After initiation of Seroquel, the patient improved
considerably, as his parkinsonian symptoms resolved, and his swallowing
greatly improved. Over the course of stay in the hospital, patient's
Seroquel was increased up till 125mg QHS. Patient was discharged from
the hospital on this dose, clinically stable.
Discussion
Lewy body dementia is a type of progressive brain
disorder in which lewy bodies (protein alpha synuclein) build up in
areas of the brain that regulate behavior, cognition and movement. This
condition impairs functions such as memory retention, thinking,
executive functions and the ability to understand visual information [1].
Patients may have fluctuations in attention or alertness, problems with
movement including tremors, stiffness, difficulty walking,
hallucinations and alterations in sleep and behavior. It is also said to
be probably the second most common cause of degenerative dementia in
older people, only Alzheimer’s disease is more common [2].
Parkinsonism is a general term used to describe
neurological or brain disorders that cause symptoms similar to those
seen in Parkinson's disease [3].
These symptoms include an ongoing loss of motor control system which
causes resting tremors, stiffness, postural instability and slow
movement [4,5].
It also causes a wide range of non motor symptoms which include
depression, loss of olfactory function, and cognitive changes. The
symptoms mentioned are also similar to those observed in patients
suffering from lewy body dementia therefore it is difficult to
distinguish lewy body dementia from Parkinson’s disease [6].
Anti psychotics are drugs used to treat symptoms of
psychosis such as delusions, hallucinations, paranoia or confused
thoughts. It is used in diseases such as schizophrenia, severe
depression and severe anxiety [7].
These drugs are also useful at stabilizing episodes of mania in
patients suffering from bipolar disorder. The main action of
antipsychotic drugs is that they act on dopamine receptors reducing the
levels of excessive dopamine. They may also affect levels of other
neurotransmitters namely acetylcholine, nor-adrenaline and serotonin [8].
Older antipsychotics are called typical or first generation
antipsychotics. First generation antipsychotics are now rarely used and
are only used when second generation antipsychotics are not effective.
Atypical antipsychotics are less likely to produce drug induced
disorders such as Parkinsonian symptoms, restlessness, rigidity, tardive
dyskinesia, tremors and other unwanted movements [5].
These are more effective at treating the negative symptoms of
schizophrenia such as lack of motivation and social withdrawal and are
also more effective in treatment resistant patients. Clozapine was the
first atypical antipsychotic to be approved by the US food and drug
administration [3].
All antipsychotics are related to adverse effects which include
increased risk of sedation, sexual dysfunction, postural hypotension,
cardiac arrhythmias and sudden cardiac death.
According to researches, Parkinsonian symptoms are
worsened or aggravated when treated with antipsychotics. The extra
pyramidal symptoms caused by antipsychotics include Parkinsonism (pseudo
Parkinsonism), akathisia, acute dystonia and tardive dyskinesia [9].
The Parkinsonian symptoms caused by antipsychotics are reversible which
can be treated by reducing the dosage or adding oral anti cholinergic
agents but keeping in mind that these drugs can cause their own side
effects. The Parkinsonian symptoms caused by antipsychotics include
quivering of the hands and arms as well as rigidity in the shoulders and
arms. It also causes bradykinesia, akinesia,hyper salivation and small
shuffling gait. The cause of drug induced Parkinsonian symptoms is
related to drug induced changes in the basal ganglia which occur after
the inhibition of the dopaminergic receptors by the antipsychotic drugs [10].
Conclusion
After research it can be stated that there is some
relation between Parkinsonian symptoms in lewy body dementia and
antipsychotics. Patients taking antipsychotic drugs for Parkinsonian
symptoms in lewy body dementia were found to have even worse symptoms
than patients who were not using antipsychotics. Therefore it can be
stated that the symptoms are aggravated and there is also rapid
progression of Parkinsonian symptoms in lewy body dementia after the
administration of antipsychotics.
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