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Introduction

I met my patient, named, Mr Ivan F, during his examination in the emergency department. He is diagnosed with Charles Bonnett Syndrome.

Demographic details

  • Mr Ivan F, is 91 years old, male. He lives at Atawhai, Nelson, New Zealand.
  • He lives with his wife, Ngaire, in an independent Villa at Atawhai, Nelson, New Zealand.

Health History

  • From the past history of the patient, it is evident that neuronal disturbance exists. His body was shaking and after that he fell down.
  • Ivan further, denied fever or sweats. He is conscious. However, he has reported with chest pain. Ivan’s words get muddled at the time. Ivan developed a bit of a slutter over a past weeks.
  • In the subsequent examination, abdominal pain around SPC area and umbilicus, achey pain when started. Ivan is diagnosed with Charles Bonnett Syndrome.
  • He has diagnosed with systolic murmur and hyperlipidaemia

Surgical history

  • 1987: Right hemicolectomy for colon cancer
  • 2012: Surgery for subsequent adhesions with obstruction
  • Diverticulosis
  • 2021: GORD, chronic inflammation of the gastric antrum
  • PVD, macular degeneration and hearing impairment

Medications

Ivan has been prescribed with following medicines:

  • Aspirin 100 mg mane
  • Colecalciferol 1.25 mg on the first of the month
  • Laxsol
  • Donepezil
  • Loratidine 10 mg mane
  • Molaxole 1 mg mane
  • Pantoprazole 40 mg mane
  • Paracetamol 1 gm QDS PRN
  • Quetiapine 25 mg nocte
  • Sertraline 50 mg mane

Ivan is allergy towards Pencillin.

Family History

Ivan do not have any family history of any health disparities

Impression

Recurrent or elemental postural hypotension and Parkinsonian features.

Potential SPC along with associated UTI. Delerium along with symptoms of cognitive impairment along with collateral suprapubic tenderness and mildly raised with inflammatory markers.

Health Appraisal

Ivan do not have any medical history of smoking. He has not carrier of any genetic disorder.

Investigations

Blood test results revealed the following profile:

  • Na 141
  • K 4.2
  • Creatinine 118
  • eGFR 46
  • pH 7.31
  • Partial O98 %

Pathophysiology of current conditions

Gastro-oesophageal Reflux Disease (GORD)

Gastro-oesophageal Reflux Disease (GORD) is the condition in which the stomach contents flow back into the oesophagus, typically after eating. Acute epigastric pain that may radiate to the chest and arms results from it. Numerous factors contribute to this. reduced oesophageal sphincter function, hiatus hernia, elevated abdominal pressure, and/or medicines (Nirwan et al., 2020). The oesophageal sphincter typically keeps the pressure high enough to keep it shut, however because of sporadic relaxation and the inability to completely closure, the stomach's acidic contents will occasionally the oesophagus with reflux. The oesophagus becomes irritated as a result, causing pain. Long-term consequences could occur if GORD recurs and is not addressed such as erosion, ulcers, oesophageal stricture, and even cancer (Chen and Brady, 2019).

Charles Bonnett Syndrome

Complex visual hallucinations in people with visual impairment that are accompanied with partial or total understanding of the unreal character of the visual experience is known as Charles Bonnet syndrome (CBS), which is named after the Genevan natural historian Charles Bonnet (Subhi et al., 2020).

Any cause of visual loss is where the pathophysiology of CBS first begins. These causes, which can impact any region of the visual pathway, frequently include age-related macular degeneration, cataracts, glaucoma, diabetic retinopathy, and cerebral infarction affecting the visual cortex. The prevailing idea for the visual hallucinations observed in CBS is that visual sensory deafferentation causes disinhibitions of cortical areas affecting vision. The end outcome of this disinhibition is spontaneous firing of these vision-related areas, which causes hallucinations. Studies that support this notion have demonstrated through neuroimaging that in individuals who met diagnostic criteria, spontaneous firing occurs during hallucinations in visual cortical regions such as the ventral occipital lobe (Baier et al., 2010).

Parkinson’s Disease

An intricate interplay involving aberrant -synuclein aggregation, mitochondrial dysfunction, lysosome or vesicle trafficking, neuronal transport issues, and neuroinflammation appears to be the cause of Parkinson's disease pathogenesis. The neuropathology affects numerous additional motor and non-motor circuits in addition to speeding up the degeneration of dopaminergic neurons through a combination of disease processes. An imbalance between the direct (facilitatory) and indirect (inhibitory) pathways via the basal ganglia, caused by the death of nigrostriatal dopamine cells, results in bradykinesia (Marino et al., 2020).

PD is caused by the destruction of dopaminergic neurons, which causes a decline in the neurotransmitter's concentration within the synaptic cleft, in the brain region of the substantia nigra, wherein dopamine (DA) is synthesised. Dopamine breakdown by the monoamine oxidase B (MAO-B) enzyme causes glutamate accumulation and oxidative stress, resulting in excitotoxicity. PD symptoms include progressive physical limitations such as stiffness, bradykinesia, tremor, postural instability, and problems with functional functioning. Because there are no laboratory tests, biomarkers, or imaging scans to confirm the condition, the diagnosis of Parkinson's disease (PD) is confirmed by studying the motor symptoms (Jankovic, J., & Tan, 2020).

The basic structural component of LBs is filamentous-synuclein, a protein that is found throughout the brain. It takes on an amyloid-like filamentous form and gets inappropriately phosphorylated and aggregated in Parkinson's disease and other synucleinopathies. A LB's halo is largely composed of -synuclein. Aside from -synuclein, other proteins seen in LBs include ubiquitin, tau, parkin, heat shock proteins (HSPs), oxidized/nitrated proteins, cytoskeletal proteins (such as neurofilaments, MAPs, and tubulin), proteasomal and lysosomal elements, and others.

Neurophysiological recordings defined bradykinesia as an imbalance among two oscillatory rhythms: an excessive (antikinetic) beta activity and insufficient (prokinetic) gamma activity. Beta oscillations in particular are associated with the dopaminergic off state and disappear in response to dopaminergic medications or deep brain stimulation.

Medication and indication

Laxsol

Laxsol belongs to the category of laxative drugs. Laxatives are frequently used in managing symptoms of constipation in the community because they hasten or induce faeces. Adults who live in communities regularly self-diagnose and self-treat constipation, a condition that affects many communities around the world. Chronic constipation, which is typically identified by a combination of clinical symptoms known as the Rome criteria and which was first introduced in 1994 as Rome I criteria, represents a significant cost to the community. Constipation can also be occasional or chronic. Before seeking medical assistance, the majority of adults try to treat their constipation on their own. The use of laxative products, the majority of which can be acquired over-the-counter in pharmacies and other places, is frequently part of self-management (Werth and Christopher, 2021).

Aspirin

It is useful to think of the inflammatory response as a two-part process, having an induction phase and a resolution phase. During the early stages of inflammation, eicosanoids such as prostaglandins and leukotrienes act as local mediators, eliciting potent chemotactic answers from leukocytes, the activation of which is linked to the production of cytokines that are pro-inflammatory at sites of inflammation. Aspirin inhibits IL-1-induced NO and iNOS production. Aspirin significantly reduced iNOS expression in cultured smooth muscle cells, whereas it repressed iNOS production in rat cardiac fibroblasts (Berk et al., 2010).

Colecalciferol

Cholecalciferol (vitamin D3) is a derivative of ergocalciferol (vitamin D2), often known as natural vitamin D. The term "native" in this instance refers to the fact that we can receive vitamin D in the form of cholecalciferol by eating foods high in cholecalciferol (mostly oily or bluefish, egg yolk, fungus, or meat, among others) or vegetable foods high in ergocalciferol. As previously stated, the problem is that there are only trace levels of vitamin D in the few foods that contain it. In fact, the levels of vitamin D received from a normal diet fall well short of the minimal daily intakes advised by the majority of scientific societies and regulatory bodies (Fassio et al., 2021).

Donepezil

Donepezil hydrochloride is a piperidine derivative that is used to treat Alzheimer's disease. It is a centrally acting, fast, and reversible acetylcholinesterase inhibitor. Acetylcholinesterase is an enzyme that degrades acetylcholine after it has been released from the presynapse. Donepezil suppresses acetylcholine hydrolysis by binding permanently to acetylcholinesterase, enhancing acetylcholine availability at synapses and improving cholinergic transmission. Donepezil binds reversibly to acetylcholinesterase, inhibiting acetylcholine hydrolysis and thereby boosting acetylcholine availability at synapses and improving cholinergic transmission. Donepezil is structurally distinct from other anticholinesterase drugs like tacrine and physostigmine (Lieberman et al., 2023).

Paracetamol

Activation of this route cannot fully explain the mechanism of paracetamol's analgesic activity because paracetamol has no affinity for any of the serotonergic receptor types or subtypes, nor for any of the enzymes involved in the manufacture or breakdown of serotonin.

On the WHO analgesic ladder, paracetamol is a first-line medication for pain that can be taken alone or in combination with Non-Steroidal Anti-Inflammatory Drugs (NSAIDS). If pain control is not obtained at this point, a mild opioid such as codeine phosphate or tramadol may be used. According to a recent review, paracetamol only provides a tiny amount of pain relief from OA, with exercise, strengthening, and improving range of motion providing significant benefit nonpharmacologically (Leopoldino et al., 2019).

Pantoprazole

Adults use paracetamol to treat a variety of acute painful disorders, including headaches, musculoskeletal pain, painful periods, osteoarthritic pain, back pain, and tooth pain, as well as postoperative pain. Adults should take two 500 mg tablets orally every 4 hours, up to a maximum of 8 pills in any 24-hour period. In youngsters, the dosage varies from 60 mg (2-3 months) to 480-750 mg (12-16 years old). Paracetamol is available as a single pharmacologically active chemical entity or in combinations with other analgesics such as aspirin, caffeine, or various opioid analgesics (Azimbegova, 2023).

Quetiapine

Quetiapine is an antipsychotic medication classified as nonconventional. It is primarily used to treat schizophrenia, bipolar disorder, and manic and depressive episodes of this condition. Along with its many off-label uses, it is also used to avoid these bouts of aggravation. Atypical antipsychotics cure negative symptoms of psychosis without inducing extrasedation, and they aid in the integration of schizophrenics into society while also removing undesired extrapyramidal symptoms that conventional medicines are known to exert. Unfortunately, many medications, including quetiapine, have additional disadvantages, the most important of which are those connected with the illness spectrum of metabolic syndrome, as well as the numerous interactions quetiapine may have with other pharmaceuticals in cases of polypharmacy (Ferrari et al., 2023).

Sertraline

The SSRI (selective serotonin reuptake inhibitor) drug class includes sertraline as an antidepressant. Presynaptic serotonin reuptake is largely inhibited by the antidepressant sertraline. A build-up of serotonin is the outcome of this restriction of serotonin reuptake. Blocking serotonin reuptake is helpful in diseases like major depression because serotonin in the central nervous system has a function in regulating mood, personality, and alertness. Sertraline also has less of an impact on the uptake of norepinephrine and dopamine, and studies have indicated that it has more dopaminergic activity than other drugs in the same SSRI class. Because of how it works, sertraline is quite effective in treating a variety of mental health issues.

Efficacy

Recently, Ivan underwent a medication review after being admitted to the hospital for her persistent atrial fibrillation. A fresh plan was then started after reviewing the effects of the cardiac medicine. It seemed that the drugs were in control in the pre-admission clinic. As mentioned earlier, omeprazole plays a part. If surgical intervention was not urgent, analgesia for chronic knee joint discomfort would be reviewed.

Interactions

Ivan has been taking Cholecalciferol, Laxsol, Donepezil, Loratidine Molaxole, Pantoprazole, Paracetamol, Quetiapine, Sertraline for a long time. There were no interactions discovered using the New Zealand Formulary interaction tool. Ivan has been shown to allergic to penicillin.

Adverse reactions

Ivan has not shown any adverse drug reactions

Patient factors

Ivan is a 91-years-old woman with few circumstances that would influence the medications she is now taking. Age, allergy and intolerances, metaboliser status, weight, sex, pregnancy, ethnicity, and cultural or personal preferences are all considerations to consider. Penicillin has been linked to a rash. Ivan existing meds will be unaffected by this allergy. The reported reaction occurred some time ago, and other penicillin-based medications have been avoided since then (Best Practise Advocacy Centre, 2015). It is unknown how well Ivan metabolises medications, but research shows that drug metabolism, activity, and bad effects are influenced by age. One of Ivan's drugs, paracetamol, is known for large variations depending on metabolic condition. Ultra metabolizers are at risk of morphine toxicity, whilst poor metabolizers obtain less analgesic benefit but are still at risk of the same side effects (Medsafe, 2018). Ivan only uses paracetamol on rare occasions, and it does help with pain relief.

References

Ayoub, S. S. (2021). Paracetamol (acetaminophen): A familiar drug with an unexplained mechanism of action. Temperature, 8(4), 351-371.

Azimbegova, S. (2023). WHAT IS THE MECHANISM OF ACTION OF A PROTON PUMP INHIBITOR?. Science and innovation, 2(D5), 120-125.

Baier, B., de Haan, B., Mueller, N., Thoemke, F., Birklein, F., Dieterich, M., & Karnath, H. O. (2010). Anatomical correlate of positive spontaneous visual phenomena: a voxelwise lesion study. Neurology, 74(3), 218–222. https://doi.org/10.1212/WNL.0b013e3181cb3e64

Berk, M., Dean, O., Drexhage, H., McNeil, J. J., Moylan, S., O'Neil, A., Davey, C. G., Sanna, L., & Maes, M. (2013). Aspirin: a review of its neurobiological properties and therapeutic potential for mental illness. BMC medicine, 11, 74. https://doi.org/10.1186/1741-7015-11-74

Chen, J., & Brady, P. (2019). Gastroesophageal reflux disease: pathophysiology, diagnosis, and treatment. Gastroenterology Nursing, 42(1), 20-28. DOI: 10.1097/SGA.0000000000000359

Fassio, A., Gatti, D., Rossini, M., Benini, C., Fracassi, E., Bertoldo, E., ... & Adami, G. (2021). Pharmacodynamics of oral cholecalciferol in healthy individuals with Vitamin D deficiency: A randomized open-label study. Nutrients, 13(7), 2293. https://doi.org/10.3390/nu13072293

Ferrari, M., Godio, M., Martini, S., Callegari, C., Cosentino, M., & Marino, F. (2023). Effect of quetiapine on inflammation and immunity: a systematic review. International Journal of Psychiatry in Clinical Practice, 27(2), 196-207. https://doi.org/10.1080/13651501.2022.2101928

Jankovic, J., & Tan, E. K. (2020). Parkinson’s disease: Etiopathogenesis and treatment. Journal of Neurology, Neurosurgery & Psychiatry, 91(8), 795-808. http://dx.doi.org/10.1136/jnnp-2019-322338

Lieberman, O. J., Lee, S., & Zabinski, J. (2023). Donepezil treatment is associated with improved outcomes in critically ill dementia patients via a reduction in delirium. Alzheimer's & dementia : the journal of the Alzheimer's Association, 19(5), 1742–1751. https://doi.org/10.1002/alz.12807

Marino, B. L., de Souza, L. R., Sousa, K., Ferreira, J. V., Padilha, E. C., da Silva, C. H., ... & Hage-Melim, L. I. (2020). Parkinson’s disease: a review from pathophysiology to treatment. Mini reviews in medicinal chemistry, 20(9), 754-767. DOI: https://doi.org/10.2174/1389557519666191104110908

Nirwan, J. S., Hasan, S. S., Babar, Z. U. D., Conway, B. R., & Ghori, M. U. (2020). Global prevalence and risk factors of gastro-oesophageal reflux disease (GORD): systematic review with meta-analysis. Scientific reports, 10(1), 5814. https://doi.org/10.1038/s41598-020-62795-1

Oruch, R., Pryme, I., Fasmer, O., & Lund, A. (2020). Quetiapine: An objective evaluation of pharmacology, clinical uses and intoxication. EC Pharmacol Toxicol, 8, 1-26.

Subhi, Y., Nielsen, M. A., Scott, D. A. R., Holm, L. M., & Singh, A. (2022). Prevalence of Charles Bonnet syndrome in low vision: a systematic review and meta-analysis. Annals of Eye Science, 7, 12.

Werth, B. L., & Christopher, S. A. (2021). Laxative use in the community: A literature review. Journal of clinical medicine, 10(1), 143. http://dx.doi.org/10.1136/gut.2010.227132

Releated Topic: Comprehensive Therapeutic Management: In-Depth Guide

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