PSYCHOSIS (HALLUCINATIONS AND DELUSIONS) IN PARKINSON'S DISEASE

HALLUCINATIONS IN PARKINSON’S DISEASE

Main symptoms of Parkinson’s disease

Parkinson’s disease (PD) is a slowly progressive degenerative disease of brain. The major symptoms are tremors (shivering), slowness of movements, stiffness and postural imbalance.  These symptoms lead to motor disability and interfere with walking, as well as with other activities of daily living.

Memory impairment in Parkinson’s disease

The mental functions are usually normal in patients with PD, however, 10% of patients can develop dementia (memory impairment along with other cognitive dysfunction), especially in later stages of illness.

What are hallucinations?

Other significant problem in people with PD in later stages is hallucination. Hallucination is often visual. In this condition, patient sees something, which is not there. For example, they may see snakes or lizards in their room (which are not there), and get disturbed with them. They may also see strangers in their house, which are supposedly there to spy on them or harm them. These hallucinations are very upsetting for the patient, making them anxious and depressed. Some patients also have sleep disturbance due to hallucinations.

What are the causes of hallucinations in patients with PD?

1.     Adverse effects of anti-parkinsonian medicines.

2.     Infections such as urinary tract infection or pneumonia,

3.     Side effects of other medications such as pain killers and sleeping pills,

4.     Parkinson’s disease mimic such as Diffuse Lewy body disease (DLBD). In DLBD, patients may have slowness and rigidity (just like PD). However, they have prominent hallucinations and dementia (unlike PD). Moreover, DLBD patients do not respond to levodopa treatment.

Other symptoms of psychosis in patients with PD

1.     Illusions,

2.     Delusions especially paranoid

3.     Confusion,

4.     Sleep disturbance

Delusion refers to a condition where a patient believes in something, even when there is an evidence of the contrary.

How common is psychosis in PD?

About one third of patients with PD suffer from psychosis. So, it is quite common.

How do we manage psychosis in patients with PD?

Management of psychosis can be done in a stepwise fashion as outlined below:

1.     Underlying alternate causes should be looked for and managed. This would include looking for infection and offending drugs.

2.     Comorbid psychiatric conditions, such as anxiety and depression, if present, should be treated.

3.     Minor symptoms such as vivid dreams or minor hallucinations (which are non-disturbing in nature) do not require any treatment.

4.     Anti-parkinsonian drugs should be reduced or stopped. First to eliminate are trihexiphenydyl, amantadine and selegeline/rasagiline. If psychotic symptoms persist, then, the next drugs to be reduced are dopamine agonists (ropinirole and pramipexole), entacapone and levodopa.

5.     In people with cognitive impairment, cholinesterase inhibitors such as rivastigmine or donepezil can be used.

6.     Anti-psychotic medication- quetiapine is the most commonly used.

7.     The first and only FDA approved drug for treating PD psychosis (hallucinations and delusions) is PIMAVANSERIN (Nuplazid). The dose is 34 mg capsules once daily.

DR SUDHIR KUMAR MD DM

Consultant Neurologist

Apollo Hospitals, Hyderabad

04023607777

drsudhirkumar@yahoo.com

https://www.facebook.com/bestneurologist/

DO THE MARKS IN AN EXAMINATION REALLY MATTER A LOT?

HOW IMPORTANT ARE THE MARKS IN AN EXAMINATION?

Anuja’s suicide

When I was 10 year old, I remember once, there was a crowd gathered around Anuja’s (name changed) house, who lived about 100 meters away from our house. I too wanted to go there to find out what was happening, but was not allowed by my parents. Later on in the evening, I came to know that she committed suicide by hanging, as she scored only 81% marks in her tenth board examinations, which was well below her parents’ and her expectations. We hear several similar stories from different parts of our country. Depression, stress and anxiety are common before & during examinations. If one does not score high marks, they feel worthless, unfortunately leading to suicide in some cases.

Mental problems among students

I have been increasingly seeing young students with various psychological problems, such as sleep disturbance, anxiety, headaches, poor memory, body pains, decreased energy and depression. Fear of exam or fear of scoring low marks in an exam are the main reasons for these symptoms.

But is scoring high marks so important?

Marks have limited importance:
1. One needs to score “pass” marks in order to get promoted to the next class, which ranges from 35-50% in various classes/schools/colleges. 
2. One needs to score “qualifying” marks in order to become eligible to write competitive exams for UPSC, engineering, medical, etc (which ranges from 50-75% in various exams).

3. Class XII marks are taken into account for admissions into graduate courses of a few good colleges (which can be as high as 99% in some cases).

Drawbacks and demerits of marks:
1. There is no perfect correlation between marks and knowledge. A student with good knowledge may score lesser marks and someone with lesser knowledge may get very high marks. 
2. Examinations, unfortunately, do not assess the practical knowledge, intelligence, judgment and application of a student; they mainly assess the retention, recall and memory abilities. Communication skills, ability to deal with difficult situations, and interpersonal skills, which are so important in real life, are also not assessed by the “marks” system.
3. Marks obtained in 10th and 12th board exams do not have any meaning in the job/occupation one chooses later. For example, no patient of mine has ever asked me my marks from school or college days (however, I would be proud to tell those figures, as I scored high in most of the exams).

So, what should students do?
1. One should study to gain and acquire knowledge. Understanding the concepts is more important than just memorizing them. 
2. Marks do not matter much and obtaining high marks in an exam should not be the sole goal. 
3. Studies would be a pleasure, if it is taken as a means of gaining knowledge, rather than a means to score high marks in an exam. 
4. One should study “round-the-year” and not just before the exams. This would reduce the pressure prior to the exams. 
5. There is no need to feel bad, if one gets” low” marks in an examination. Most of the great men & women in the world were not class toppers in their school or college days.

I would be pleased to have your comments on this article.

DR SUDHIR KUMAR MD DM
Consultant Neurologist
Apollo Hospitals, Hyderabad
drsudhirkumar@yahoo.com

https://www.facebook.com/bestneurologist/

TAKING CARE OF A PATIENT AFTER BRAIN STROKE (PART 2)

TAKING CARE OF A STROKE SURVIVOR (PART 2)

NON-DRUG ASPECTS OF PATIENT CARE

In my previous article posted on 11th August 2011, I had discussed about the various medications that are required to be taken by a stroke patient. However, there are several other aspects of post-stroke care that are equally important to make the life of a stroke survivor better & more comfortable.

1. Assessment of swallowing

Eating food is probably the most important function and a normal swallowing ensures that the patient can take liquids and solid food. Swallowing can be impaired in a stroke of medulla oblongata (brain stem or posterior circulation) and also in bilateral hemispheric strokes. Sometimes, the patient may be too drowsy to swallow. In a person who is awake and conscious, the adequacy of swallowing can be assessed by a swallow test. The patient is made to sit up and asked to swallow a glass of clear water. If he can drink it within half a minute without coughing or choking, then the swallowing seems to be adequate and the patient may be started on oral feeding.

2. Feeding

Feeding and good nutrition is an important aspect of ensuring a good post-stroke recovery. For patients who can swallow, normal food can be given by mouth as early as possible. For people who can not swallow, there are two options. In the first option, a tube (Ryles tube or naso-gastric tube) is inserted from nose upto the stomach and is kept secured by an adhesive near the nose. Then, liquid diet (milk, juice, etc) can be given at 2-hourly intervals through the tube. Ensure that the patient is not lying down while feeding, and the patient head end should be elevated by 30-45 degrees and left so for at least half an hour after feeding. The other option is PEG (percutaneous endoscopic gastrostomy), where a tube is inserted directly into the stomach by a minor surgical procedure by the gastroenterologist. The advantage of PEG (over the naso-gastric tube) are two-fold: i) It can be kept for much longer periods. Ryle's tube needs to be changed every 2-4 weeks. ii) Different types of food can be given via PEG.

3. Physiotherapy

Physiotherapy is the only method by which the strength and balance of the person can be improved upon. Many patients have significant residual weakness and imbalance after brain attack (stroke). They may be unable to stand or walk without support. They may also be unable to use their hands for any meaningful work. This is where physiotherapy is very important. Physiotherapy should be done under guidance of qualified physiotherapists. It should be done on a regular basis. Many patients ask for medicines or operations to improve the muscle weakness; unfortunately there are none, but good & regular physiotherapy can definitely make the muscle power & strength better.

4. Speech therapy

Many stroke survivors have language dysfunction. This can range from difficulty in understanding spoken words, inability to read or write, speaking or repeating the spoken words. In right-handed individuals, language area is located in the left side of brain. Therefore, language problems are more common after strokes on the left side of brain (which causes right sided weakness also). Additionally, patients with stroke in cerebellum (posterior circulation) may have slurred speech, but they are able to understand and speak. Patients with speech problems benefit from speech therapy. This can be taken under the guidance of trained speech therapists/rehab experts.

5. Nursing care

Good nursing care is very important in the post-stroke recovery. This includes feeding, bladder & bowel care, frequent position changing, and bathing. A stroke survivor may be dependent on others for activities of daily living and this is where nursing care is important. If a person lies on the same position for long, bed sores may develop, so, the position of the patient should be changed every two hours. Patient may have urinary and fecal incontinence (lack of control leading to voiding of uring and stool in clothes). This can be overcome with the help of adult diapers or changing clothes/bedsheets as per the needs.

6. Prevention of deep vein thrombosis

Blood clots may develop in the leg veins of people who are immobile. Therefore, in stroke survivors with paralysis of legs, there is a higher chance of clots forming in the leg veins (deep vein thrombosis or DVT). This can be minimised by frequent passive movements of the paralsed leg by the care-giver. There are compression stockings available in the market, which can be worn by the stroke patient to prevent DVT.

7. Cognitive stimulation and counseling:

Patients with stroke are prone to develop dementia (memory loss and other cognitive dysfunction) and depression. The risk can be minimised by various measures. Firstly, the patient should be kept in a well-lit room where abundant natural light comes in. Some stroke survivors may have reversal of sleep rhythm (they may sleep during the day and keep awake at nights). This rhythm may delay the recovery from stroke. Therefore, the patient should be kept busy/engaged during the day and not allowed to sleep. If the patient finds it difficult to sleep during nights, a small dose of sleeping pill may be used. Patients may be encouraged to listen to songs/music (through head phones, etc); allowed to meet with various friends or relatives; talk as often as possible (if patients can not talk, even listening is important for brain stimulation, so the visitors should be encouraged to talk even if the patient does not respond).

Depression after stroke is also common. So, proper counseling and psychotherapy is important. Sometimes, antidepressant medications may also be required.

8. Sexual functions

There is no restriction as such, and sexual functions can be resumed as per the patients' ability. Sexual drive may diminish after stroke, and sometimes, there may be linmitations due to physical handicap. These can be overcome to a great extent with the halp of an understanding partner.

9. Diet

• A good diet is essential for proper recovery.
• A diabetic should follow the diabetic diet.
• Generally, the diet should be low in fat and cholesterol content.
• As constipation is common in post-stroke patient, the diet should be rich in fibre content.

10. Physical activity

Physical activity is encouraged in stroke survivors. They should be encouraged to stand and walk inside home or be taken for an evening or morning walk with an attendant. If these is a risk of fall, use of a walking stick or walker is encouraged. Prolonged sick leave or bed rest is not advised, and the patient should return to normal life activites as early as possible.

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/040-60601066