Dr. Grossberg (00:05):

Hello, I'm Dr. George Grossberg. I'm professor and director of the Division of Geriatric Psychiatry in the Department of Psychiatry and Behavioral Neuroscience at Saint Louis University School of Medicine. Welcome to episode four of this podcast series. The title of this episode is Parkinson's Disease Psychosis in the Long-Term Care Setting. Joining me today is Dr. Amita Patel, an esteemed colleague, a true expert in long-term care, who's director at the Joint Township District Memorial Hospital in St. Marys, Ohio, which I believe is near Akron. Is that right, Amita? Dr. Patel (00:49):

It's near Dayton, Ohio. Dr. Grossberg (00:52):

Dayton. Oh, I'm wrong about that. But near Dayton, Ohio. Thank you for correcting that. I want to welcome you Amita, and we look forward to having a great podcast together. Dr. Patel (01:00):

Thank you for having me. Dr. Grossberg (01:02):

We're going to be discussing a number of different topics within our podcast. We're going to be talking about the relationship between Parkinson's disease psychosis and institutionalization. We'll talk about how to screen for Parkinson's disease psychosis in the long-term care environment. We'll discuss the importance of recognizing Parkinson's disease psychosis in the long-term care setting. We'll focus on appropriate therapeutic approaches to manage Parkinson's disease psychosis, particularly in the long-term care setting. And then toward the end, I'm going to ask you Amita to discuss with us when you would refer to a specialist or try to seek specialty consultation. (01:53):

Before we get to the various aspects of our podcast today, let's kind of talk about how we define Parkinson's disease psychosis and really how common it is, whether in the long-term care environment or in general. So initially, before we talk about psychosis in Parkinson's disease, of course, we need a primary diagnosis of Parkinson's disease, which is generally based on the UK, the United Kingdom Parkinson's Disease Brain Bank Criteria. (02:28):

Once we've firmly established a clinical diagnosis of Parkinson's disease and we're going to be considering psychosis in that context, here's what's required. At least one of the following symptoms, hallucinations, which we kind of broadly define as abnormal perceptions without a physical stimulus. And most commonly with Parkinson's disease psychosis, it's a visual hallucinations. Or delusions which are confirmed false beliefs despite evidence to the contrary. Most commonly, the delusions are paranoid or accusatory. Or illusions which are misperceptions of real stimuli in the environment. And then lastly, false sense of presence. This is a unique symptom in Parkinson's disease psychosis where the individual senses that there's someone else around, but there is in fact no one else looking over their shoulder. Also, very important is the notion that these symptoms occur after a firm Parkinson's disease diagnosis. And we also want to keep in mind that they need to be recurrent or continuous for at least one month. (03:54):

Now, what about the kind of the epidemiology and kind of burden of Parkinson's disease psychosis? We know that about 50% or half of Parkinson's patients will experience psychotic symptoms sometime during the course of their disease. We also know that Parkinson's disease psychosis is associated with a number of features. One would be, for example, kind of an adverse impact on activities of daily living. There's an increased risk of depression. We see a lower quality of life. We see increased burden on the care partner. And very, very importantly to our topic today, there's an increased risk of nursing home placement as well as of morbidity and even mortality in patients who show symptoms of Parkinson's disease psychosis. (04:53):

Now, fairly recently, there was a study done looking at the relationship between Parkinson's disease psychosis and institutionalization. It was a large retrospective cohort study done between 2007-2015. And it was very interesting what they found. They found that after one year individuals who were diagnosed with Parkinson's disease psychosis, about 12% of them were in long-term care, some type of custodial care versus only 3.5, close to 4% of patients without psychotic symptoms. So nearly three times as many. Now, what happened at five years? So at five years, patients with Parkinson's disease psychosis, nearly 26% were in long-term custodial care compared with only 10% of Parkinson's disease patients without psychotic symptoms. So showing us that the relative risk for institutionalization in patients with Parkinson's disease psychosis was about 3.4. So these individuals are more than three times as likely to end up in the long-term care setting. (06:11):

Now let's kind of turn to you, Amita, if you don't mind. And I'm really curious about your recommendations and your procedures on how do you screen for Parkinson's disease psychosis. And how often do you recommend that we all should be screening? Dr. Patel (06:28):

So when patients are in long-term care setting, whenever patient is admitted to the facility, if they have a diagnosis of Parkinson's disease, we do initial screening for psychotic symptoms because patients are not going to be coming forward and really talking about their psychotic symptoms because they do not associate psychosis with Parkinson's disease. So we have to do the initial assessment and include psychosis assessment with the initial assessment when they are admitted. We have to do regular assessment for psychotic symptoms in all residents who have Parkinson's disease diagnosis. And then whenever we do a quarterly assessment of our patients, we have to do again, repeated assessment for psychotic symptoms on a quarterly basis. (07:25):

Now, in long-term care, our assessment is what we call multidisciplinary. So it's not only that the physician is doing the assessment. So the psychotic symptoms are noticed by the physician, the nurses, the unit managers. It could be the physical therapist, occupational therapist, the speech therapist who's involved. It could be the ancillary staff. It could be even the housekeeper. It could be the nurse's aid who's taking care of the patient, who's giving the ADL care. So it's very multidisciplinary care personnel who actually do the full assessment in noticing if the patient is having psychotic symptoms. We also involve the family members in asking them if they've noticed any changes as far as their behavior or they've noticed any other psychotic symptoms during their visits or interaction with the patient. So it's a very multidisciplinary assessment that we do on a regular basis. (08:28):

But we never associate psychotic symptoms automatically with Parkinson's disease. We always like to exclude other medical conditions like any metabolic changes, any infections that patients may develop, any changes in their medications. It could be that their Parkinson's disease medications were titrated, patients are on pain medications, other medications that could be contributing to their psychotic symptoms. It could be anticholinergic medications or other primary psychiatric conditions that can also cause psychosis. So it's very important to rule out those conditions before you attribute that psychosis related to Parkinson's disease. Dr. Grossberg (09:18):

Yeah, I think those are very important points. I had a couple of thoughts about what you just kind of reviewed. The first was about the importance of the housekeeping staff and the nursing home. I saw a study fairly recently that looked at who are the people that spend the most time with patients one-on-one in the long-term care environment. And it's often not the nurses because they're taking care of so many different patients. It may not be even the nurse's attendant or aid, but it's often that housekeeper who comes in and maybe changes the bed and sweeps the floor, cleans the bathroom, and so on, who's with the patient in the room for a long period of time. And if they're aware of what to look for and what to report back to the nursing staff, that can be obviously very, very useful. (10:12):

The second point that you brought out, I think in your last point was the notion that delirium, and any and all causes of delirium. As you pointed out, whether it's infections or bad drugs and so on, would be the first thing I'd be thinking about before we kind of automatically say that the psychosis in this Parkinson's patient is coming from the underlying disease. We want to make sure it's not coming from other sources before we ascribe it to the Parkinson's disease. So thank you for all of that. Those were excellent points. (10:48):

Now, one other, I think an important issue, which I wanted you to kind of talk about, it's really not in my bailiwick, but I know this is part of your areas of expertise, is the notion of coding or appropriate coding for Parkinson's disease psychosis in the long-term care environment. So I wonder if you could share information about coding with us. Dr. Patel (11:13):

So by the time the patients arrive, like you discussed before, in a long-term care setting, they're pretty advanced in their Parkinson's disease. So it's not uncommon that along with their Parkinson's disease, they also have Parkinson's disease dementia. It's not uncommon. So more likely to have Parkinson's disease dementia also by the time they arrive in a long-term care setting. So when you code, it's very important to know whether they have only Parkinson's disease with their psychosis or they have also Parkinson's disease with dementia, with psychosis. So when you code, you have to code for Parkinson's disease and then code for either hallucinations and delusions, whichever they have, or code for Parkinson's disease, and then code for dementia with psychotic disturbance. And that can be dementia unspecified, mild, moderate, or severe. Now we have specific code related to Parkinson's disease related dementia with psychosis. Dr. Grossberg (12:23):

So that's I think a real advance, and it's something that we didn't have before. Related to the point that you made about how by the time patients move into the long-term care arena with Parkinson's disease,

that they often also have accompanying dementia. We actually published a study a few years ago looking at Parkinson's patients in our teaching nursing homes, and we found that the overall prevalence of Parkinson's disease was between 8% and 10%. So that's not small, it's a lot of Parkinson's patients. And then we went further to look at what percentage of those individuals met criteria for Parkinson's disease dementia. We found about 50%. And that was probably kind of a generous... Not a generous figure, it could be even higher. So I think the coding can be very useful for us. (13:20):

So I wanted to move on to kind of therapeutic approaches. Thank you, Amita, for all of that because once we've kind of established that a patient has Parkinson's disease psychosis, we need to start thinking about what are our treatment or therapeutic options. Generally speaking, it's always a good idea to think non-pharmacologically first. So before we think about pharmacotherapy, we want to make sure that there aren't things that we can do non-pharmacologically that may be helpful. So for example, if the individual is having illusions, misperceptions of things in the environment, which could be under the rubric of Parkinson's disease psychosis, we want to make sure that they're not having any visual problems. They've had a recent eye exam. Patient I had recently was found to have severe cataracts that were distorting everything. And once the cataract surgery occurred, they did much, much better. Adjusting lighting in the environment or minimizing noise or distractions and so on. Particularly if the symptoms occur when you have a low light in the evening or low light time or environment, there are things we can do in the environment to improve or to modify the psychotic symptoms. (14:44):

We can also talk about behavioral or psychosocial strategies or interventions, whether it's music therapy or other sensory therapies, activities programming. Sometimes in the soft psychotic symptoms, we can use diversionary activities and that may be enough. It may in fact keep the patient functional without the need to think about pharmacotherapy. But, of course, that's not going to work for everyone. And many individuals, in fact, are going to require pharmacological approaches. And, Amita, I wonder if maybe you might talk about the different pharmacotherapeutic approaches and what are the options that we have. Dr. Patel (15:31):

When the psychotic symptoms really persist, so after the behavioral interventions that you really discussed that we have tried, and if they fail, and if the psychotic symptoms really start to impact the quality of the life for the patient and we see that the symptoms continue to persist, then we really need to think about using pharmacotherapy options for these patients. The International Parkinson's Movement Disorder Society recommendations really look at different pharmacotherapy options. They have looked at clozapine, which has shown some efficacy, but it really doesn't have great as far as practical implications because you have to have weekly CBC. So it really requires specialized monitoring, which is so difficult to do in these patients. (16:31):

Olanzapine has not shown any efficacy. It doesn't have acceptable risk, and it's not been found to be very useful. Same with quetiapine, it has acceptable risk without specialized monitoring. It's possibly useful. But one medication that pimavanserin, which is FDA-approved specifically for this indication, found to be very efficacious with acceptable risk without specialized monitoring and clinically very, very useful. So that's the medication of choice when it comes to using as a first-line treatment for Parkinson's disease psychosis. Dr. Grossberg (17:15):

Thank you for that. So I know that you work in the long-term care environment, and obviously, you're a specialist yourself, but let's assume that we put ourselves into the shoes of the primary care physician who's taking care of patients in the long-term care setting. When should they be considering kind of calling in a specialist for the patient with Parkinson's disease psychosis? Dr. Patel (17:42):

So if there is a primary care physician really managing the patient, then they really should be calling in psychiatrist or a neurologist to really manage these patients. Normally, it is really difficult sometimes to get the psychiatrist. Most of the facilities now have psychiatric nurse practitioners that manage these patients with supervision by the psychiatrist. So really either there is a psychiatrist who's coming into the facility managing the patients or psychiatric nurse practitioner with the psychiatrist supervising the psychiatric nurse practitioner. Or sometimes there is a neurologist who is available or the patients could be sent out for a neurologist to be seen and managed by the neurologist, or a telemedicine consult with a psychiatrist or a psychiatric nurse practitioner is also available. So really, when a primary care physician notices that a patient with Parkinson's disease has psychotic symptoms that are persistent, I would highly recommend a consultation with a psychiatric nurse practitioner, a psychiatrist, or a neurologist. Dr. Grossberg (19:12):

Yeah, I think you're making some excellent points. You're also pointing out how difficult it is often to find specialists, particularly those that may be able to come in person to the facility, hence the greater use of telehealth or telepsychiatry. I'm reminded that we are providing telepsychiatry consultations to a long-term care facility in Northwest Missouri, a rural area. They don't have a psychiatrist or neurologist, but they don't have a specialist for a hundred miles from where they're at. So they're turning to us and we're over 200 miles away to provide telepsychiatry consultation for the kinds of patients that you and I have been talking about today. (19:57):

So thank you, Amita. That was a wonderful discussion. I'm very happy to have had you on the program today. And, of course, we want to thank our listening audience for being part of this activity. We want to let them know that they should continue to answer the questions that follow and complete the evaluation that also follows at the end of our program. So thank you again, Amita. Dr. Patel (20:23):

Thank you for inviting me to be part of this discussion. Appreciate it