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What’s New in the Patient Safety World

April 2020

More on Inappropriate Medications in Parkinson’s



Most of our prior columns on medication errors in patients with Parkinson’s Disease (PD) have focused on the difficulties hospitals have meeting the necessary timing of medication doses for inpatients. But we’ve also noted that many patients with PD get prescribed medications that may worsen symptoms of PD or be otherwise contraindicated. Most often those are medications having significant anti-dopaminergic activity, such as butyrophenones and phenothiazines.


But patients with PD also have a high incidence of psychosis. Symptoms may include visual hallucinations, delusions, and systemized hallucinations that are often severe enough to merit treatment. Patients with PD also have a high incidence of dementia and depression, which may put them further at risk for psychosis.


In our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing” we noted a study (Mantri 2018) which looked at patterns of dementia treatment and frank prescribing errors in older adults with Parkinson Disease. 27.2% were given a prescription for at least 1 antidementia medication. Of those receiving an acetylcholinesterase inhibitor (ACHEI), 44.5% experienced at least 1 high-potency anticholinergic–ACHEI event. They did find variation in such prescribing by race/ethnicity, sex, and geography.


In our March 19, 2019 Patient Safety Tip of the Week “Updated Beers Criteria” we noted the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults (AGS 2019) specifically commented on Parkinson’s Disease. After reviewing and discussing the evidence on antipsychotics to treat psychosis in patients with Parkinson disease, the panel decided to remove aripiprazole as preferred and add pimavanserin. Thus, the 2019 Beers Criteria recognize quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson disease. Note that the Beers Criteria also recommend avoiding the anticholinergic drugs benztropine and trihexyphenidyl for prevention or treatment of Parkinson’s, since more effective agents are available.


A new study of patients with PD and comorbid depression living in nursing homes (Chekani 2020) examined incidence of inappropriate atypical antipsychotics, namely asenapine, brexpiprazole, iloperidone, lurasidone, olanzapine, paliperidone, risperidone, or ziprasidone as specified in the 2015 AGS Beers criteria. Appropriate atypical antipsychotic included aripiprazole, clozapine, or quetiapine. (Note that they used the 2015 AGS Beers criteria rather than the updated 2019 criteria, which would have considered aripiprazole to be inappropriate. It also did not note the use of pimavanserin.) The incidence of atypical antipsychotic use was 17.50% among PD patients over a 2-year follow-up. The percentage of inappropriate use among atypical antipsychotic users was 36.32%. The likelihood of inappropriate antipsychotic use was higher for patients who had dementia or COPD. However, patients who were taking levodopa, dopamine agonists, Catechol-O-methyltransferase (COMT) inhibitors, Monoamine Oxidase (MAO) inhibitors type B, or amantadine were less likely to receive inappropriate antipsychotics.

There is a point we are trying to emphasize with all of this. Parkinson’s Disease, probably more so than any other condition, is frequently associated with features that call for medications that are often contraindicated because of other features. We find it hard to believe that anyone could conceivably remember all the ramifications without assistance. This is a situation desperately calling for a sophisticated clinical decision support system to help guide appropriate medication management whether the patient is an outpatient, inpatient, or LTC patient.



Our prior columns on problems related to Parkinson’s Disease patients as inpatients:







Mantri S, Fullard M, Gray SL, et al. Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease. JAMA Neurol 2018; Published online October 1, 2018



2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriatr Soc 2019; First published: 29 January 2019



Chekani F, Holmes HM, Johnson ML, Chen H, Sherer JT, Aparasu RR. Use of Atypical Antipsychotics in Long-Term Care Residents with Parkinson’s Disease and Comorbid Depression. Drug Healthc Patient Saf 2020; 12: 23-30






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