A 65-year-old man is brought to the office by his daughter due to decreased activity and impaired sleep over the past month. He was diagnosed with Parkinson disease 2 years ago. According to his daughter, he displays very few emotions and does not want to do anything. She says, "He has been slowing down these past few years and I suppose that was to be expected, but I am worried that he's getting worse so quickly. He just sits in his chair and watches TV with a blank expression. He has been waking up early in the morning, which is very unusual for him. When I suggest that he should go out, he says he is too tired or makes excuses. It's like he doesn't care much about anything." The patient is quiet during most of the discussion. He does not disagree with his daughter's comments, but says, "I'm alright. I manage. I don't have much to add." The patient is adherent with his current levodopa/carbidopa treatment. His other medication is pravastatin for hypercholesterolemia. He does not use tobacco, alcohol, or illicit drugs. Physical examination shows masklike facies and slowed movements. Mild hand tremor and postural instability have improved since his last visit. Which of the following is the most appropriate next step in pharmacological management of this patient?

Question

A 65-year-old man is brought to the office by his daughter due to decreased activity and impaired sleep over the past month.  He was diagnosed with Parkinson disease 2 years ago.  According to his daughter, he displays very few emotions and does not want to do anything.  She says, "He has been slowing down these past few years and I suppose that was to be expected, but I am worried that he's getting worse so quickly.  He just sits in his chair and watches TV with a blank expression.  He has been waking up early in the morning, which is very unusual for him.  When I suggest that he should go out, he says he is too tired or makes excuses.  It's like he doesn't care much about anything."  The patient is quiet during most of the discussion.  He does not disagree with his daughter's comments, but says, "I'm alright.  I manage.  I don't have much to add."  The patient is adherent with his current levodopa/carbidopa treatment.  His other medication is pravastatin for hypercholesterolemia.  He does not use tobacco, alcohol, or illicit drugs.  Physical examination shows masklike facies and slowed movements.  Mild hand tremor and postural instability have improved since his last visit.  Which of the following is the most appropriate next step in pharmacological management of this patient?

Quizplus · Accepted Answer

Explanation: Depression affects up to 50% of patients with Parkinson disease (PD) and can negatively impact quality of life. It can be easily overlooked because some depressive symptoms may be mistakenly attributed to the progression of PD. For example, depressed, blunted affect looks similar to masked facies; psychomotor slowing is similar to bradykinesia. This patient's one-month history of decreased interest, low energy, and early- morning awakening is concerning for depression. Because his other Parkinson symptoms, such as tremor and postural instability, appear to have improved since his last visit, an antidepressant trial would be the most appropriate next step in pharmacological management. Selective serotonin reuptake inhibitors (eg, sertraline) are typically used first due their favorable side effect profile. Nonpharmacological approaches, such as cognitive-behavioral therapy, can also be considered to treat depression. (Choices A, D, and E) These interventions could be considered if the patient's motor symptoms were inadequately controlled. (Choice B) The second-generation antipsychotic quetiapine has been used to treat psychosis, a frequent complication of PD, which is characterized by visual hallucinations and delusions. Educational objective: Identifying underlying depression in patients with Parkinson disease is often difficult as psychomotor slowing and blunted affect can resemble bradykinesia and masked facies, respectively. Pharmacological treatment consists of antidepressant medications, specifically selective serotonin reuptake inhibitors. References: A comprehensive overview of the neuropsychiatry of Parkinson's disease: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28271905) Antidepressive treatments for Parkinson's disease: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26037457)

A 65-Year-Old Man Is Brought to the Office by His