Overview Of Therapeutic Drugs
Several studies have reported the therapeutic effects of antidementia and antipsychotic drugs on VH. There are two types of globally used antidementia drugs, cholinesterase inhibitors and NMDA receptor antagonists. We reviewed key previous studies on these drugs.
Cholinesterase inhibitors reduce VH and mostly do not worsen parkinsonism . They can be used as first-line drugs. Although there is no study showing that memantine ameliorates VH sufficiently, it may improve cognitive function . It can be used as an additional drug. Antipsychotic drugs should be used in a minimal dose due to high risks of mortality and adverse events . However, some of them reduce VH without causing intolerable adverse events . They should be used for cases that are difficult to control.
Hereafter, we will explain the studies on and detailed characteristics of these drugs and propose a treatment strategy.
How Common Is Parkinsons Disease Psychosis
Between 20-40% of people with Parkinsons report the experience of hallucinations or delusions. When followed as the disease progresses over the years, this number increases. The increase does not mean that the hallucinations are persistent across the majority of patients. However, it is important to note that these statistics sometimes include delirium, in which the symptoms are temporary due to medication that needs to be adjusted or infection that needs to be treated, and isolated minor symptoms or minor hallucinations, including illusions, where instead of seeing things that are not there , people misinterpret things that are really there. These are the most common types of psychosis in people with PD, with different studies placing the occurrence between 25-70% of people with Parkinsons. Typically, if the person with PD only has these minor hallucinations, their doctor will not prescribe an antipsychotic medication, though more significant psychosis that requires medication may develop over time. In one study, 10% of those with minor hallucinations had their symptoms resolved within a few years, while 52% saw their symptoms remain the same and 38% saw their psychosis symptoms get worse.
We recommend that people with Parkinsons not use a single percentage to represent the prevalence of hallucinations and PDP. Parkinsons is a complex disease and as it progresses the percentages and risk of symptoms will change.
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The Importance Of Sleep
For people with , good quality sleep is hard to come by. More than 75% of people with Parkinsons struggle with disrupted sleep, according to the Parkinsons Foundation, whether due to the symptoms themselves or medication side effects. Moreover, people with Parkinsons disease who also struggle with sleep dysfunction are five times more likely to experience psychosis, according to a study in Clinical Neuropharmacology.
In fact, having a sleep disorder like vivid dreaming or general insomnia is considered a risk factor for psychosis onset in Parkinsons, according to the Parkinsons Foundation. It can go either way, where hallucinations may keep patients up at night or poor sleep is making hallucinations worse, says Dr. Pan. Its not surprising that if you are sleep-deprived, you might be more prone to having hallucinations.
Hallucinations can occur at any time of day, but they often are worse at night, adds Dr. Hui. One possible reason: Patients can be more disoriented in the darkness, with fewer visual cues around to reorient themselves to reality, says Dr. Pan.
Getting better sleep sounds great on paper, but tougher in reality. These tips from the Parkinsons Foundation can help:
Make sure to bring up any sleep issues with your healthcare team as wellthey can provide strategies and incorporate sleep improvement into your Parkinsons management plan.
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Selfcare For The Person With Parkinsons
- Join a Parkinsons support group if you dont already belong to one. Talk about your experiences, ask for help if you need it and share whats worked and not worked for you.
- Offer to have coffee with someone you know has been newly diagnosed and offer them support and encouragement.
- Make time to exercise and get out in nature every day.
- Communicate frequently with your doctors and discuss the possibility of tweaking your medications if your symptoms become worse.
- Rest when you need it.
- Plan a day trip or a vacation and get away from your normal surroundings.
- Take control where you can and keep authoring your own story.
- Practice meditation or yoga or tai chi to relax and calm your mind.
- Start a new project that youre excited to work on every day.
- Communicate with your care partners and let them know how they can best help you.
Why Isnt There A Greater Awareness Of Parkinsons Disease Psychosis
Its not uncommon for people with Parkinsons disease psychosis to remain silent about their experiences.2,4,9 In fact, only 10% to 20% actually report their symptoms to their physicians.4-9 Work continues to be done to raise awareness of this condition. You can find more information on the non-motor symptoms associated with Parkinsons disease here.
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Features Of Parkinsons Disease Psychosis
PDP typically arises later in the course of the disease, approximately 10 years after initial diagnosis of PD. Symptoms typically arise in the context of retained insight and clear sensorium . Over time, symptoms such as visual hallucinations or delusions tend to recur and progress and insight is lost. Prominent hallucinations early in the course of the disease may suggest Lewy body dementia, Alzheimers disease, or a preexisting psychiatric disorder .
Whats The Treatment For Parkinsons Disease Psychosis
The single most important thing to do when it comes to Parkinsons disease psychosis is to tell your care providers and partners the minute you notice changes in your vision, hearing, thinking and behavior. The earlier they know whats going on, the sooner they can begin interventions to help you feel better.
Once you bring your concerns up to your doctor, they will typically do a clinical evaluation, review your medications and dosage, assess your lifestyle and determine the severity of your symptoms. Depending upon what they find, they may refer you to counseling or therapy, adjust your medication, change your medication, eliminate medication or do all of the above. If none of those strategies work, they may try antipsychotic drug therapy to see if they can adjust chemical levels in the brain. This can bring with it an entirely different set of problems so its important to be invested every step along the way and be sure youre well-informed before you move in that direction.
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Practical Tips For Caregivers Of People With Parkinson’s Psychosis
This 2-page tip sheet has bullet point suggestions for what to do if the person you care for experiences hallucination, delusions or confusion, or becomes agitated or aggressive. In addition, there are tips for how to best be prepared for a doctors appointment when you bring this behavior to the attention of your medical team.
Risk Factors For Parkinsons Psychosis
Understanding the risk factors for hallucinations and delusions can help you recognize symptoms of Parkinsons psychosis. The following factors may increase the likelihood of experiencing hallucinations and delusions:
- Advancing cognitive impairment, including worsening memory loss
- History of depression
- Sleep disorders and sleep disturbances
- Changes to medications
- Worsening medical conditions outside of Parkinsons
We have noticed that when my father had delusions, its been when his general health is not good, or when he has been in the hospital for PD-related issues, a MyParkinsonsTeam member commented.
Questionnaires used in a clinical setting can help assess the risk of developing hallucinations or delusions, or establish that they are occuring. These include:
- PD nonmotor symptom scale
- Parkinson Psychosis Questionnaire
- Scale for Evaluation of Neuropsychiatric Disorders in Parkinsons Disease
Individuals with Parkinsons or their caregivers can speak with a neurologist to understand if any of these tools would be helpful in their particular situation.
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Parkinson’s Disease Psychosis: The What When Why And How
Psychosis is a psychiatric term used in neurology to refer to a spectrum of abnormalities. Parkinsons disease psychosis is where people experience hallucinations or delusions. Hallucinations is seeing, hearing, or smelling things that dont exist. With tactile hallucinations, one can feel a presence that isnt there. Delusions are believing something that is not true, like that a spouse is being unfaithful or caregivers are stealing. In this one-hour talk, movement disorder specialist Christopher Goetz, MD, focuses on hallucinations and spends a little time on delusions.
Support Your Loved One And Yourself
PDP is also associated with increased caregiver stress and burden, nursing home placement and increased morbidity and mortality. But, your loved one is certainly not alone in living with PDP, and an effective management plan can improve the complications. Seek out the support that he or she needs, but also make sure that you are getting the emotional care you personally need in order to be an effective advocate for your loved one.
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Predictive Factors And Pathophysiology
Patients with isolated minor hallucinations/illusions differed from patients without hallucinations only by the presence of more depressive symptoms on the CES-D rating scale, suggesting that depressive symptoms are a facilitating factor. Indeed, depression may sometimes trigger or aggravate hallucinations associated with deafness or ocular pathology . However, when we analysed depression according to CES-D cut-off scores, the difference between the Parkinsons disease patients with minor hallucinations/illusions and those with no hallucinations was not significant. Interestingly, hallucinations involving the deceased spouse have been reported in up to half of widowed persons, with a higher frequency in the elderly . In the present study, the `presence was that of a deceased relative in only three cases bereavement cannot therefore explain the bulk of the cases.
Dopaminergic agents and other treatments
In the present study, non-hallucinators were more likely to be on anticholinergics or selegiline than patients with hallucinations. A similar paradoxical, negative association between anticholinergics and hallucinations was found by Sanchez-Ramos and colleagues . This reflects the recommendation whereby the use of these drugs in patients with cognitive impairment is avoided because of the well-known risk of cognitive worsening and/or hallucinations in this population.
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Keep Your Home Well Lit
A dark environment may be associated with increased hallucinations, says Dr. Barrett. For some people, increased lighting may help, he says. However, this could also have a negative effect on sleep, so it should be approached with that in mind. After all, adequate sleep can help you feel better, he says. Talk with your doctor about adjustments that might work for you.
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What Triggers Psychosis In Parkinsons Disease
Psychosis in Parkinsons disease is believed to be due to long term use of parkinsonian medications especially dopaminergic and anticholinergic drugs . However, significant medication exposure is no longer a pre-requisite in Parkinsons disease psychosis . The continuum hypothesis states that medication-induced psychiatric symptoms in Parkinsons disease starts with sleep disturbances accompanied by vivid dreams, and then develops into hallucinations and delusions, and ends in delirium. However this theory is now being challenged .
Overview Of Pdp Management
Physical Versus Emotional Control:The intertwining pathophysiology of psychosis and PD through dopaminergic pathways presents healthcare professionals and patients with the unfortunate choice between physical and emotional stability. Dopaminergic agents that treat the symptoms of PD and maintain physical control are predominately associated with the triggering of psychosis symptoms through D2-receptor activation.9,11 This swing to emotional instability could be broadly treated in one of two ways. One option is to stop the anti-PD agent however, this is not feasible for most patients because physical instability and motor symptoms would return. Alternatively, an antipsychotic could be added, but nearly all typical and atypical antipsychotics work via D2-receptor antagonism, potentially tipping the scale toward physical instability. Accordingly, methods used in practice involve dose reduction of offending agents, as tolerated, or the use of an atypical antipsychotic with low D2-receptor affinity.9,11
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How To Talk To Someone With Hallucinations Or Delusions
- It is usually not helpful to argue. Avoid trying to reason. Keep calm and be reassuring.
- You can say you do not see what your loved one is seeing, but some people find it more calming to acknowledge what the person is seeing to reduce stress. For example, if the person sees a cat in the room, it may be best to say, “I will take the cat out” rather than argue that there is no cat.
Page reviewed by Dr. Kathryn P Moore, Movement Disorders neurologist at Duke Health, a Parkinson’s Foundation Center of Excellence.
Risk Factors And Conceptual Models For Visual Hallucinations In Pd
Several disease-related and other factors have been linked to visual hallucinations in PD. The presence of visual hallucinations is associated with the duration of PD , older age, disease severity, and the presence of motor fluctuations . Other established risk factors include female sex , visual impairment , cognitive impairment , REM sleep behavior disorder , autonomic dysfunction , depression , apathy , and anxiety . A bidirectional association between visual hallucinations and cognitive impairment has been observed in PD, with the presence of minor visual hallucinations often preceding any significant cognitive decline and visual hallucinations representing a risk factor for later development of PD dementia .
Studies of the etiological basis of visual hallucinations in PD psychosis have focused on both the role of individual risk factors and the interrelationships between multiple factors. Explanatory models have emphasized dysfunction of components of attentional and perceptual processing or dream imagery intrusion with dopaminergic and other medications as likely playing a modulating role .
Dysfunctional attentional network interactions have also been demonstrated in DLB , which may be associated with the generation of visual hallucinations . In addition, thalamo-cortical dysfunction, with decoupling between thalamic nuclei and the DMN, has been proposed to underly psychosis in DLB and PD .
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Network Changes And Thalamic Drivers
Visual hallucinations have fascinated neurologists and neuroscientists for many years, with their tantalisingly rich and often narrative detail. Due to their transient nature, they have been challenging to investigate, with no clear mechanism found, but many theories have been proposed. Previous models for visual hallucinations considered them as cortical release phenomena, where spontaneous activity occurs in the absence of visual stimuli. Alternative models suggested that hallucinations arise due to incorrect binding of objects into visual scenes.
Advances in computational modelling and network neuroscience have opened up approaches to understanding the brain in new ways. Recent models suggest that Parkinsons hallucinations could arise due to a shift in dominance of difference networks. Specifically, there is thought to be a breakdown in those networks directed to attention and perception, and overactivity of the default mode network ,, a large-scale network that becomes activated during rest, and in day dreaming and mind-wandering. Indeed abnormal levels of default mode network activation are seen in patients with Parkinsons hallucinations.
Adapted from Zarkali A, Adams RA, Psarras S, Leyland LA, Rees G, Weil RS. Increased weighting on prior knowledge in Lewy body-associated visual hallucinations. Brain Commun. 2019 1:fcz007. doi:10.1093/braincomms/fcz007
Hallucinations And Delusions In Parkinsons Disease
This blog post is based on the latest research and a Parkinsons Foundation Expert Briefing about hallucinations and delusions in Parkinsons. After an explanation of what hallucinations and delusions are, there are tips for what to do, how to minimize these behaviors through lifestyle changes, and medication treatment options.
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How To Care For Someone Who Experiences Delusions
If the person youre caring for experiences confusion or delusions, heres what you can do in the moment:
- Stay as calm and patient as you can and remember that this belief has nothing to do with you and only with what is going on in their mind
- Remove any objects in the room that could pose a danger to them or to anyone else
- Clear space so there are no tripping hazards and its easy for the person to move around
- Do not try to reason with the person or convince them why their belief is false
- Reassure them that everything is going to be okay
- If the person becomes aggressive, minimize your movements and remain calm
- Ask the person to talk to you about what they are feeling and really listen to them so they dont feel threatened
- If you feel like you or they are in danger, call 911
Here are a few actions you can take once the delusion has passed:
- Inform their doctor immediately
- Educate others who may care for the person how to handle the situation if it happens
- If the person is open to it, discuss it with them and ask them to explain what the experience is like for them and if theres anything different you could do next time
- Seek expert advice if you feel like you need support in managing these episodes
How To Care For Someone Who Experiences Hallucinations
If the person you care for experiences a hallucination, there are a few things youll want to do in the moment and others youll want to do when the moment passes.
The most important thing to remember is to never try and talk the person with Parkinsons out of their hallucination. They are actively experiencing it and by trying to talk them out of it, they may either feel like they arent being heard or that their experience is being diminished.
What matters in the moment is their safety and your reassurance that theyre going to be okay. You might calmly say, I understand that youre seeing X. Im not having that experience, and I just want you to know that everything is going to be okay, theres nothing dangerous happening here and youre safe.
Other strategies Dr. Joanne Hamilton, PhD, ABPP-CN of Advanced Neurobehavioral Health of Southern California, shared with us are to:
Here are a few actions you can take once the hallucination has passed:
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