Presentation title: Delirium Revealed As A Case Of Progressive Supranuclear Palsy-A Workshop On Parkinson Plus Syndromes

Progressive supranuclear palsy (PSP) is a type of neurodegenerative extrapyramidal syndrome. The prevalence of PSP in studies is found to be 5.8-6.5 per 100,000 individuals with a slightly male preponderence. Onset is usually between 55 and 70 years of age and median survival is around 6 years after the onset of symptomatology.It is characterized by motor symptoms, such as postural instability, rigidity, akinesia, supranuclear gaze palsy, pseudobulbar palsy; levodopa-unresponsive parkinsonism, and behavioral and cognitive symptoms. Early PSP is also difficult to differentiate from PD; as it shares many features like abnormalities in gait, speech, and eye movements. Neuropsychiatric symptoms commonly observed in patients with PSP are dementia, apathy, depression, anxiety, disorders of sleep and disinhibition. A 60 year old man presented with impaired memory, disturbed sleep and restless behaviour for 2months in geriatric mental health outpatient department. He had a history of tremors on both the hands and stiffness of body which was gradually progressive for last 4 years. They consulted a neurologist 1.5 years back as his symptoms were severe enough to hamper in day to day functioning. He was diagnosed as a case of idiopathic Parkinson's Disease and was prescribed Tab Levodopa 100mg and Carbidopa 25mg combination preparation thrice daily. On medication within 2months, family members reported decrease in his symptoms. For last 6months new symptoms like frequent falls during walking without any precipitant developed. Falls usually occurred within a few steps of walking mostly towards the left side and following which he sustained an injury over his left eye leading to lower lid ectropion. The activity of the patient became restricted and he started to remain confined to his bed for the fear of falls since last 3months. They consulted a physician again and he was prescribed Tab Trihexyphenydyl 2mg three times a day and dose of Tab Levodopa 100mg and Carbidopa 25mg combination increased to four times a day and Tab Levodopa 100mg and Carbidopa 25mg combination contolled relase preparation was added at bedtime. After taking those medications the frequency of falls increased, forgetfulness appeared, sleep got disturbed, at night he becomes restless and some confusion in behavior like pointing things, picking bed linen were noticed during evening hours. On examination the patient had prominent vertical wrinkling of forehead, wide opened eyes with reduced blinking,