Is my mom's Parkinson's medications causing her to yell out loud?
My mom has Parkinson's and over the last three months, she has fallen on two separate occasions and broke both hips. She did quite well with her recovery the first time but since her second fall, she has really gone down hill. Physically she has healed from her surgery but is also recovering from a broken wrist after falling out of her wheelchair at the nursing facility. what we are experiencing over the last 2-3 weeks is a continuous yelling out, so much that her throat is hoarse. She is on Sinemet, Klonopin and Namenda amongst other medications for other things. The Nurse Practitioner that is responsible for her care thinks that the Klonopin is the cause of this behavior in addition to the Namenda that can cause some of this on rare occasions. It is heartbreaking to see her like this. She knows what is happening around her because she will occasionally try to join in on a conversation by saying a name or word repeatedly but goes back into her yelling. Can you give me any indication if we are on the right track? Is the trauma from her falls causing this or is it med related?
This sounds like a very difficult situation for you and your mom. When patient's such as your mom have had PD for a number of years, it can affect areas of the brain associated with cognition and can result in confusion, impulsive actions, hallucinations and "acting out." Often any trauma will worsen things acutely, but in these circumstances, we often try to get rid of medications that adversely affect the memory like Klonopin, anti-cholinergic medications, dopamine agonists, narcotics etc. In addition, we often try to "minimize polypharmacy" to use as few medications as possible. Finally, if there is no success, we may suggest very low doses of medications like quetiapine (Seroquel) which can be quite helpful, particularly if taken at bedtime.
Today's edition of the Wall Street Journal, in the Health and Wellness section, has an article "Drug Concerns in Parkinson's." It states that antipsychotic drugs such as Seroquel are routinely prescribed for dementia in advanced Parkinson's despite FDA warnings of an increased risk of death in older patients. The article mentions that clozapine, available as a generic drug, has been shown to be effective for Parkinson's psychosis symptoms. I would be curous as to why the Doctor did not mention clozapine.
I am writing in reply to the comment posted by GLMMOLIVER regarding the use of quetiapine and clozapine in PD. This brings up an important issue regarding "evidence based medicine" and how it can effectively be applied to actually taking care of patients. Interestingly, this article does not mention the fact that clozapine also carries a "black box warning" ....in fact carries 5 black box warnings regarding the risk of agranulocytois (bone marrow failure), cardiac toxicity, the risk of seizures, and in fact carries the same black box warning as the other atypical antipsychotics regarding the risk of increased mortality in elderly patients with dementia related psychosis. Further, the FDA requires that we draw blood WEEKLY on patients for the first six months that we use this drug and then every 2 weeks for six months and then monthly.
I only respond so forcefully to your comment, because gathering limited information (as the authors of this story in the WSJ did) presents an inaccurate picture of data as we know it. Parkinson's doctors know that there is little data to support the use of low dose quetiapine, but many find that it can be effective and use as low of a dose as possible to balance benefits of the medication and side effects. As I indicated above, this is an option after we have exhausted the strategies of reducing meds that may worsen hallucinations. Sometime we end up making these tough decisions because hallucinations can be dangerous as well. We have seen too many patients fall because they are confused, think they saw an animal in th room etc.
I hope this helps explain why physicians who do take care of a lot of PD patients act in the way that they do. Its important not to oversimply the decision making process as each patients' situation is unique and although large studies do guide our decisions, they don't always apply to every patient in every case
Thank you, Dr. Glass, for responding re clozapine. My wife has advanced Parkinson's and is doing well with 25 mg Seroquel at night and 12.5 during the morning for anxiety/depression, etc., as prescribed by Johns Hopkins physicians.
My mom is taking 25 mg of Suerquel for sleep every night. I need to let the doctor know this! My mom also just started yelling out at night. And she has been coughing to the point she keeps me awake.
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