Before any antipsychotic, the MN665 Unit 2 analysis screens for delirium and reviews amantadine; only then does it weigh pimavanserin against low-dose clozapine for a composite Parkinson's patient. Searches like "mn 665 unit 2 assignment example", "mn665 unit 2 sample" and "mn665 unit 2 example" land here.
Hallucinations in Parkinson's Disease: A Staged Case Analysis for a 74-Year-Old Retired Tool-and-Die Maker
[Student Name]
Purdue University Global
MN665: PMHNP Diagnosis and Management Across the Lifespan II
Unit 2 Assignment
[Instructor Name]
[Date]
Composite patient written as a model document. Doses are bracketed; nothing here is a prescribing instruction.
Part 1: Case Summary
A composite 74-year-old retired tool-and-die maker has had Parkinson's disease for nine years. For four months he has seen small children playing in the back garden, usually at dusk; at first he knew they were not real, but that insight is fading, and last week he went outside to tell them to leave. For six weeks he has also been convinced that his wife is seeing another man, and he has begun checking her phone. He has no fever, cough or urinary symptoms, and his wife reports no sudden change in his alertness from one hour to the next. His Montreal Cognitive Assessment score is 23, below the usual cutoff of 26 for normal cognition (Nasreddine et al., 2005), with points lost on recall and on drawing the clock.
His medicines are [carbidopa-levodopa] four times a day, [amantadine] twice a day, added three years ago for dyskinesia, and [trihexyphenidyl] twice a day, started by a previous clinician for tremor. His gait is slow but steady with a cane, and he fell once last year. He and his wife have been married 48 years; she is exhausted and frightened by the accusations, and she says the man she married "would never have said these things."
Part 2: Delirium First
Delirium must be excluded before psychosis is attributed to Parkinson's disease, because delirium has a cause that can be found and treated and because an antipsychotic given for delirium can hide the cause. The Confusion Assessment Method asks whether there is an acute onset or fluctuating course, inattention, and either disorganized thinking or an altered level of consciousness (Inouye et al., 1990). He counts backward from 20 without error, his thinking follows a clear line, and his alertness is steady across the visit; his wife confirms that his symptoms have built slowly over months. The screen is negative.
A basic workup supports the finding: complete blood count, electrolytes, glucose, kidney and liver function, calcium, thyroid function, vitamin B12 and a urinalysis, all within normal limits, with no new medicines in the past three months and no alcohol. Had the screen been positive, the analysis would have stopped here and turned to finding the cause of the delirium, because nothing that follows would be safe to start.
Part 3: Medicines That May Be the Cause
Several drugs used in Parkinson's disease can provoke hallucinations and delusions, and the usual approach is to reduce them in order, starting with the ones that contribute least to motor control. Two of his three medicines fall in that group.
Trihexyphenidyl comes first. Anticholinergic drugs are a common cause of confusion and hallucinations in older adults, and they add to the cholinergic deficit that accompanies cognitive decline in Parkinson's disease. His tremor is mild, and a MoCA of 23 is a reason to avoid anticholinergic load in any case. The proposal is to taper it over [two weeks] and watch his tremor and his hallucinations.
Amantadine comes second. It can cause hallucinations, particularly in older adults, and its benefit for his dyskinesia must be weighed against that. If hallucinations continue four weeks after trihexyphenidyl is withdrawn, the proposal is a gradual reduction of amantadine, since stopping it suddenly can cause withdrawal symptoms and a return of dyskinesia.
Levodopa is left alone at this stage. It is the drug that keeps him walking, and reducing it would trade quieter hallucinations for a worse gait and a higher risk of falls.
These are framed as proposals for his neurologist, who manages his motor symptoms. The psychiatric nurse practitioner writes the proposal and the reasoning, and the neurologist decides whether and how to carry it out. If the hallucinations fade after these reductions, the case ends there, without any new drug.
Part 4: If Symptoms Persist, Three Options on Four Criteria
Suppose his hallucinations and the delusion about his wife continue after both reductions. Most antipsychotics would worsen his parkinsonism, because they block the dopamine receptors his disease has already depleted. Three options are commonly considered, and each is scored on four fixed criteria: evidence in this disorder, motor effects, monitoring burden and cost.
Pimavanserin. Evidence: approved by the FDA in April 2016 specifically for hallucinations and delusions of Parkinson's disease psychosis, on the strength of a six-week phase 3 trial in which it reduced psychotic symptoms more than placebo (Cummings et al., 2014), and rated efficacious in a Movement Disorder Society evidence review (Seppi et al., 2019). Motor effects: it acts on serotonin receptors rather than dopamine receptors, and the trial found no worsening of motor function. Monitoring: it can prolong the QT interval, so an electrocardiogram is taken before starting and his other medicines are checked for QT effects. Cost: high, often requiring prior authorization.
Clozapine. Evidence: two trials published in 1999 found that low doses reduced drug-induced psychosis in Parkinson's disease without worsening motor function (French Clozapine Parkinson Study Group, 1999; Parkinson Study Group, 1999), and the same review rated it efficacious. Motor effects: minimal at low doses. Monitoring: heavy, because clozapine can cause a dangerous fall in white blood cells, which requires regular blood counts, and it can also cause sedation, orthostatic hypotension and drooling. Cost: low for the drug, high in visits and blood draws.
Quetiapine. Evidence: widely used, but placebo-controlled trials in Parkinson's disease psychosis have not shown clear benefit, and the evidence review judged it insufficient (Seppi et al., 2019). Motor effects: modest at low doses. Monitoring: sedation and orthostatic hypotension. Cost: low.
The Choice
Pimavanserin is chosen if symptoms persist. It has the strongest evidence specific to this disorder, it does not worsen motor function, and its monitoring burden is manageable for a couple who would struggle to reach a laboratory every week. Its limits are stated plainly. Like every antipsychotic, it carries a boxed warning of higher mortality when these drugs are given to older people whose psychosis stems from dementia, and his MoCA of 23 means that warning applies to the conversation with him and his wife. Its effect develops over several weeks, not days, so the plan cannot expect quick relief. Clozapine is kept as the named fallback if pimavanserin does not help after an adequate trial, and the blood count monitoring that makes it harder for this household is discussed with them before it is ever needed.
Part 5: Monitoring
His wife keeps a simple log of hallucinations and accusations, noting the time of day and what was happening. The MoCA is repeated in six months. His gait and falls are reviewed at each visit, with his neurologist informed after each medication change. If pimavanserin is started, an electrocardiogram is repeated after it reaches a steady dose. Delirium is reconsidered at any sudden change, such as new confusion, drowsiness or a fever.
Talking With Them
His wife was told that the accusations are a symptom of his illness, not a sign that he has stopped loving her, and she was given the name of a Parkinson's caregiver support group. He was told, gently, that his brain is seeing things that are not there and that the plan is to change his medicines one at a time to see whether it stops. He agreed, on the condition that his walking not suffer.
References
Cummings, J., Isaacson, S., Mills, R., Williams, H., Chi-Burris, K., Corbett, A., Dhall, R., & Ballard, C. (2014). Pimavanserin for patients with Parkinson's disease psychosis: A randomised, placebo-controlled phase 3 trial. The Lancet, 383(9916), 533-540. https://doi.org/10.1016/S0140-6736(13)62106-6
French Clozapine Parkinson Study Group. (1999). Clozapine in drug-induced psychosis in Parkinson's disease. The Lancet, 353(9169), 2041-2042. https://doi.org/10.1016/S0140-6736(99)00860-0
Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948. https://doi.org/10.7326/0003-4819-113-12-941
Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695-699. https://doi.org/10.1111/j.1532-5415.2005.53221.x
Parkinson Study Group. (1999). Low-dose clozapine for the treatment of drug-induced psychosis in Parkinson's disease. New England Journal of Medicine, 340(10), 757-763. https://doi.org/10.1056/NEJM199903113401003
Seppi, K., Ray Chaudhuri, K., Coelho, M., Fox, S. H., Katzenschlager, R., Perez Lloret, S., Weintraub, D., Sampaio, C., & the Collaborators of the Parkinson's Disease Update on Non-Motor Symptoms Study Group on Behalf of the Movement Disorders Society Evidence-Based Medicine Committee. (2019). Update on treatments for nonmotor symptoms of Parkinson's disease: An evidence-based medicine review. Movement Disorders, 34(2), 180-198. https://doi.org/10.1002/mds.27602
How this MN665 Unit 2 example is structured
The analysis is sequenced as a clinician would have to act, so the antipsychotic decision sits fourth. Every stage closes on a stated result that would stop the sequence: a positive delirium screen redirects to its cause, and hallucinations that fade after the anticholinergic is withdrawn end the case without any new drug. Medication reductions are framed as proposals for his neurologist, since motor control belongs to that clinician and a psychiatric plan cannot buy quieter hallucinations with a worse gait. The option comparison scores all three agents on four fixed criteria: evidence in this disorder, motor effects, monitoring burden and cost. Pimavanserin is chosen, with its QT warning and its onset over weeks spelled out. Clozapine is kept as the named fallback, and the blood count monitoring that makes it harder for this household is stated plainly.
Get an MN665 Unit 2 example written to your instructions
Along with the rubric, send the Unit 2 case as your MN665 instructor wrote it, medication list and any cognitive scores included. Staged the way a clinician would have to act, with a stop point at each stage and the option comparison last, your first custom analysis arrives free in 24-48h. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
MN665 Unit 2 questions, answered
Why does a complex case analysis delay the medication decision?
Because in cases like this one the first steps may make a new drug unnecessary. Excluding delirium and reducing medicines that provoke symptoms are cheaper and safer than adding an agent, and graders expect them to come first. Write each stage with the result that would end the sequence, so the order reads as reasoning rather than as a checklist.
Is it acceptable to recommend clozapine for an older adult?
In some cases, yes, when the evidence favors it and the monitoring is feasible. Low-dose clozapine has trial support in Parkinson's disease psychosis. State the blood count monitoring the label describes, the burden it places on the patient and family, and why it is or is not the right first choice here. Leaving the monitoring out is the error graders notice.
How should the analysis handle input from the patient's spouse?
Record it as collateral history and note that the patient agreed to its use where the case says so. A spouse frequently notices hallucinations or new beliefs first, and here the belief concerns her directly, which calls for care. Include her safety and support needs in the plan without treating her account as a substitute for his.