4.6 Management of psychological care

At the end stage of Parkinson’s a high incidence of cognitive impairment and dementia is found to occur in up to 60% of people with Parkinson’s after 12 years (Richfield et al, 2013).

Wandering, sundowning, agitation and combativeness are all behavioural symptoms of dementia and can be difficult for families to manage in the community.

Early referral to the psychiatric team is important for management of the symptoms. Education of carers in behavioural management, with support from social services in delivery of care in the home, is also important.

Medications which may be used to treat dementia in Parkinson’s are cholinesterase inhibitors such as rivastigamine and donepezil.

Psychosis can affect people with Parkinson’s whether or not they have cognitive impairment. Visual hallucinations and delusions are the most common psychotic symptoms in Parkinson’s and are quite often related to side effects of medication, so frequent reassessment of medication is important in the end stage. First rule out intercurrent medical conditions, such as constipation, dehydration or infection, which may be hidden causes of psychosis.

Medications such as amantadine typically do not provide symptom management in the late stage of Parkinson’s and can contribute to the development of hallucinations and so can be withdrawn slowly. Other medications which can be withdrawn in descending order are anticholinergics, then MAO-B inhibitors and finally COMT inhibitors. It may also be beneficial to evaluate the use of dopamine agonists in end stage Parkinson’s and to consider moving toward levodopa and carbidopa as monotherapy to reduce psychotic symptoms (Lokk & Fereshtehnejad, 2013).

Agitation and delirium at end of life

At least 80% of dying people experience delirium to some degree, and this may give rise to agitation and restlessness. It is important to involve the specialist palliative care team who have the expertise to manage the delirium and support the family/carers (National End of Life Care Programme et al, 2010).

4.5 Management of social care

4.7 Recognising the actively dying phase