Department of Neurology, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Marienstrasse 15, 26121, Oldenburg, Germany.
University Clinic of Neurology, Evangelical Hospital, Oldenburg, Germany.
J Neurol. 2024 Dec;271(12):7402-7421. doi: 10.1007/s00415-024-12576-x. Epub 2024 Jul 24.
Impulse control disorders (ICD), psychosis and delirium are part of the spectrum of behavioural changes associated with Parkinson's disease (PD). The diagnostic and therapeutic management of these rather complex neuropsychiatric conditions has been updated in the clinical guideline by the German Society of Neurology (DGN).
Recommendations are based on a systematic literature reviews, other relevant guidelines and expert opinion.
Patients receiving dopamine agonists (DA) therapy should be informed about the symptoms and risks of an ICD and should be routinely screened for ICD symptoms. In the presence of an ICD, DA should be reduced or discontinued and psychotherapeutic treatment may be considered. Non-oral therapies (levodopa/carbidopa intestinal gel infusion or deep brain stimulation) may also be an option for appropriate candidates. Psychosis in PD often has a gradual onset. Cognitive and affective disorders, psychiatric and medical comorbidities as well as polypharmacy are risk factors for a psychosis. Non-pharmacological treatments should be implemented as soon as possible and anti-parkinsonian medications should be adjusted/reduced if feasible. For psychosis associated with PD, quetiapine or clozapine should be used on an as-needed basis and for as short a time as is necessary, with safety monitoring. Delirium in PD may be underdiagnosed due to an overlap with chronic neuropsychiatric features of PD. Although transient by definition, delirium in PD can lead to permanent cognitive decline, motor impairment and increased mortality. Management of delirium includes pharmacological and non-pharmacological interventions.
The updated guideline encompasses the evidence-based diagnostic, non-pharmacological and pharmacological management of ICD, psychosis and delirium in PD.
冲动控制障碍（ICD）、精神病和谵妄是与帕金森病（PD）相关的行为变化谱中的一部分。德国神经病学会（DGN）的临床指南已经更新了这些相当复杂的神经精神疾病的诊断和治疗管理。
建议基于系统文献回顾、其他相关指南和专家意见。
接受多巴胺激动剂（DA）治疗的患者应被告知 ICD 的症状和风险，并应常规筛查 ICD 症状。如果存在 ICD，应减少或停止 DA 治疗，并可考虑进行心理治疗。非口服治疗（左旋多巴/卡比多巴肠凝胶输注或深部脑刺激）也可能是合适患者的选择。PD 中的精神病通常逐渐发生。认知和情感障碍、精神和医学合并症以及多药治疗是精神病的危险因素。应尽快实施非药物治疗，如果可行，应调整/减少抗帕金森病药物。对于与 PD 相关的精神病，应按需使用喹硫平和氯氮平，并在必要时尽可能短的时间内使用，同时进行安全性监测。由于 PD 的慢性神经精神特征重叠，PD 中的谵妄可能被漏诊。尽管定义上是短暂的，但 PD 中的谵妄可导致永久性认知下降、运动障碍和死亡率增加。谵妄的管理包括药物和非药物干预。
更新后的指南涵盖了 ICD、精神病和 PD 中谵妄的基于证据的诊断、非药物和药物管理。
