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My mother has been getting progressively paranoid lately, fearing that people are going to harm her and thinking that her neighbors will do harm to her property and belongings. She has, however, been in the same house with basically the same neighbors for more than 20 years. She was recently diagnosed with Parkinson's disease (PD) and has been taking levodopa/carbidopa at a moderate dosage. Would you advise further evaluation of her paranoia? What is the best approach to managing this condition?
Clarence Lowery, MD
Psychiatric symptoms in this patient clearly preceded the diagnosis of PD, making unlikely the possibility that the conditions are connected. Nevertheless, the diagnosis of PD has to be taken into account when deciding which is the best drug for the treatment of her paranoia syndrome. In addition, it is likely that antiparkinsonian drugs may aggravate psychosis, even when such a condition existed before the onset of PD. A practical first step would be to order a brain MRI to rule out a structural cause of psychosis. Laboratory tests are also necessary, as infection or disturbances in electrolytes can cause psychiatric disturbances in older people or can aggravate them if they are already present. If structural brain lesions and metabolic abnormalities are not present, the next step is the therapeutic treatment of the paranoia syndrome.
Atypical neuroleptics used in PD patients for the treatment of a psychosis that is or is not related to PD are quetiapine and clozapine. Other atypical neuroleptics, like risperidone or olanzapine, may be associated with worsening of parkinsonian symptoms. My first choice would be quetiapine; the initial dosage could be 12.5 mg once or twice a day, but the dose could be increased according to the clinical response up to 25 mg 2 or 3 times a day. Sometimes doses up to 200 or 300 mg/day may be necessary; these are usually well tolerated, but sedation is a side effect in some patients.
If paranoia is not well controlled with quetiapine, a second choice would be clozapine. This drug is an atypical antipsychotic compound that is sometimes associated with serious and abrupt loss of white blood cells. In order to check for this potential complication, monitoring with weekly complete blood counts is required. Finally, another item that needs to be controlled in this case is the antiparkinsonian treatment. Dopamine agonists and anticholinergics are not recommended in this patient, and levodopa should be at the lowest useful dose for the adequate control of parkinsonian symptoms.
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