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Prescription of antipsychotic medication inappropriate to patient with Parkinson's disease (03HDC06279)

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(03HDC06279, 29 July 2004)

Psychiatrist ~ Hospital ~ Parkinson's disease ~ Lewy Body dementia ~ Management of aggressive patient ~ Prescription of Acuphase ~ Review of antipsychotic medication ~ Right 4(1)

A 67-year-old man was admitted to hospital for assessment of his deteriorating Parkinson's disease. At the time of his admission, he was functioning independently but experiencing episodes of paranoia and aggression. Whether the cause of these behaviours was Lewy Body dementia (LBD) had not been ascertained.

While in hospital, the man had an aggressive episode and threatened nursing staff. The police were called in to help subdue him. The house surgeon consulted the on-call psychiatrist by telephone about appropriate management. The psychiatrist recommended administering oral quetiapine - an antipsychotic especially useful for controlling aggression in patients with Parkinson's disease. If it could not be administered, they were to inject the man with 200mg of the antipsychotic Acuphase. The patient refused to take the quetiapine and so was injected with Acuphase, while being restrained by the police.

The Acuphase was intended to keep the man sedated for up to three days, but he remained in a deep sleep for four days, and continued to experience variable states of consciousness over the next few weeks. He never recovered his pre-admission level of functioning.

The psychiatrist had advised that the patient would need to be given an anti-Parkinsonian drug over 24 hours to counteract the side effects Acuphase has on patients with Parkinson's disease. He recommended that the man be started on twice-daily quetiapine, three days after the Acuphase, and that the man's current antipsychotic and antidepressant medications be stopped.

The Commissioner's expert psychiatric advisor noted that the man's age and his Parkinson's disease put him at "considerable risk of developing extrapyramidal side effects". A vulnerable person, such as someone with Parkinson's disease, should receive Acuphase only in reduced doses and with caution. Acuphase is recommended only for Parkinson's patients who do not have complications such as LBD; there was insufficient information to conclude that the man had LBD. While it was not inappropriate to prescribe Acuphase in an acute situation such as existed that night, the dose prescribed was excessive. The addition of quetiapine, three days after the Acuphase, prolonged and perpetuated the adverse effects of the Acuphase. Moreover, it was inappropriate to prescribe quetiapine on the night the Acuphase was administered, as there was no reason to anticipate that the man would become aggressive again, especially given the man's declining clinical condition.

The dosage of Acuphase prescribed, and the prescription of quetiapine, amounted to a breach of Right 4(1) by the psychiatrist.

The hospital was also found to have breached Right 4(1).  Although a number of health professionals were involved in assessing the man's condition, investigations were carried out to try to identify the cause of his ongoing sedation, and his ongoing problems were actively managed, no one reviewed the man's overall clinical picture. While it was important to prevent another episode where the man could endanger staff, in the absence of his responsible clinician (who was on leave), it was up to the treating clinicians to determine whether it was appropriate to continue to sedate him, and to find a balance that would enable him to be cared for in the least restrictive manner. That did not occur.
The nursing care given to the man was found to be appropriate to the circumstances.

It was noted that the provision of a secure area, with appropriately trained staff, for patients admitted to the assessment, treatment and rehabilitation ward would better protect staff and patients and enable more appropriate management of similar events.