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PD Psychosis – Stepwise Medication Reduction — SCE Neurology MCQ

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ModerateMovement DisordersPD Psychosis – Stepwise Medication ReductionSCE Neurology

A 65-year-old man with PD develops visual hallucinations that are now distressing and persistent. He has lost insight. He is on co-careldopa 25/250 QDS, ropinirole 8 mg TDS, and amantadine 100 mg TDS. What is the stepwise medication reduction approach?

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Correct answer: D — Stepwise reduction in reverse order of therapeutic benefit/risk: stop amantadine first, then reduce/stop ropinirole (dopamine agonist — most hallucinogenic), then cautiously reduce levodopa if necessary — only add an antipsychotic (quetiapine or clozapine) if medication reduction fails

NICE NG71 recommends a stepwise approach to PD psychosis: (1) exclude delirium (infection, constipation, dehydration), (2) reduce/stop non-essential medications in reverse order of hallucinogenic potential and therapeutic benefit: stop amantadine → reduce/stop anticholinergics → reduce/stop DA agonist (most hallucinogenic per mg of anti-parkinsonian effect) → reduce/stop MAO-B/COMT inhibitors → cautiously reduce levodopa (most essential), (3) if medication reduction is insufficient, add quetiapine (low dose) or clozapine (requires blood monitoring). A: The opposite approach is needed. C: Levodopa should be reduced LAST. D: Haloperidol worsens parkinsonism. E: Unchanged will perpetuate psychosis.

Reference: NICE NG71 Parkinson's Disease