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Drug discarding: A problematic therapeutic event in Parkinson's disease

Motor fluctuation is one of the most important clinical problems in the treatment of Parkinson’s disease (PD). We describe a patient with PD in whom our attempts to improve wearing-off continually failed. We discovered that the PD patient discarded the antiparkinsonian drugs because of a delusional belief that they were laced with toxins. Although this type of delusion is rare in PD, it should be kept in mind that drug-discarding may be induced as a psychiatric symptom and result in poor motor control. A 65-year-old woman had been diagnosed with PD 7 years earlier. Her past and family histories were unremarkable. She was initially treated by levodopa (with carbidopa) 500 mg/day and amantadine 150 mg/day. Her motor symptoms responded well but several years later, the patient experienced motor fluctuations, particularly wearing-off. We added cabergoline to the drug regimen. Even after increasing the dose of cabergoline to 5 mg/day, her parkinsonism progressively worsened to the point that she deteriorated from stage II to Hoehn and Yahr scale over a period of months. Because of an inability to move, she often came to the emergency room, claiming that she had no medications, although we confirmed that she had sufficient quantities. To investigate and improve the worsening of parkinsonian symptoms, we admitted her to our hospital. She was alert and well oriented without signs of clinical dementia. Scores of the Mini-Mental State Examination were 26/30. She had typical bilateral parkinsonian symptoms, more marked on the left with tremor at rest, cogwheel rigidity, and difficulty in rhythmic tapping of the fingers. Retropulsion occurred to a postural challenge. Brain MRI showed normal findings. After admission, a nurse noticed the patient’s drugs in a trash container. The patient said that she did not discard them; however, the next day her drugs were again in the trash. She implied that she might have discarded them by accident. On these days, she had a decline in motor functions, although she adamantly denied not taking her medication. With consent from the patient, we agreed that her drugs were to be managed by the nursing staff. After this arrangement, her parkinsonian symptoms improved. Although she continued to have motor fluctuations (stage II on, stage III off), she was soon able to leave hospital. A few months after discharge, her Parkinsonism symptoms again deteriorated, even though her husband managed her drugs. At this time, she refused to take her drugs or if she took them, she quickly spat them out. She claimed that someone had laced her drugs with unidentified complex toxins that included life-threatening chemicals such as sarin. We concluded that her drug-discarding behavior was based on a delusional belief. We had noticed that she had other delusional symptoms, but it was only at this point that we realized that she feared being poisoned by antiparkinsonian drugs. We started to decrease the dose of dopamine agonist and added quetiapine hydrochloride 100 mg/day, but no beneficial effect was obtained. She was admitted again and we stopped all antiparkinsonian drugs except levodopa; but in spite of these reductions, her delusional beliefs failed to diminish. We changed quetiapine to resperidone 3 mg/kg, and her delusional state diminished gradually, although a simultaneous deterioration of the parkinsonian symptoms occurred. Finally, her psychiatric symptoms improved substantially but on only 500 mg/day of levodopa she could not stand or walk by herself. In PD patients, abnormal drug-taking behaviors include welldocumented cases of levodopa addiction1,2 and hedonistic homeostatic dysregulation.3–5 These behaviors involve selftreatment well beyond the dose required objectively to treat their motor signs. On the other hand, in the present patient, the patient was fearful of taking antiparkinsonian drugs and purposefully took less than prescribed. This type of discarding behavior is not widely reported, although medication compliance concerns have recently been voiced as frequent problems in patients with Parkinson’s disease.6 Purposeful drugdiscarding behavior, as part of psychosis or not, may be rare in Parkinson’s disease, but it should be kept in mind as a potential cause of motor fluctuations or declining drug efficacies in PD patients.