Sunday, August 7, 2022

Parkinson’s And Visual Hallucinations

What Is A Delusion

Joseph H. Friedman, M.D.: Hallucinations and Parkinson’s

A delusion is a thought or belief that is not based on reality, as opposed to a hallucination which involves seeing, hearing, tasting or feeling things that do not exist.

People who experience delusions may be convinced that they are true, even though they are irrational – for example paranoia – that someone is trying to cause them harm or that there is a conspiracy against them. Delusions can be difficult to overcome, particularly if they involve a carer or other close contact, as they may provoke suspicion, mistrust or jealousy and so strain relationships. Severe delusions can cause anxiety or irritability, especially if the person finds it difficult to tell whether things are real or not.

Some people with Parkinson’s experience a mixture of delusions, hallucinations and illusions which may make them feel confused and impact on daily life.

How Is Psychosis Managed

The urgency of treatment will depend on the type and characteristics of psychosis. Sometimes, when the hallucinations are mild and benign, and insight is retained, it is best that the Parkinson regimen be kept as is. However, when a patient is experiencing more threatening paranoid delusions, then more aggressive treatment is warranted .

The management of psychosis includes:

  • Ruling out the possible reversible causes
  • Simplifying the Parkinsons disease medication regimen
  • Adding a new or second generation antipsychotic
  • If psychosis occurs in a Parkinsons disease patient with cognitive impairment or dementia, a cholinesterase inhibitor may be considered
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    Hallucinations According To The Duration Of The Disease

    We found that the prevalence of hallucinations of all types and of visual hallucinations in the 3 months preceding inclusion in the study increased with the duration of the disease. Moreover, the duration of Parkinson’s disease was an independent predictor of visual hallucinations in the multivariate analysis. Other studies gave conflicting results on the relationship between hallucinations and disease duration. In a retrospective study of 100 patients, logistic regression analysis also showed an association between `psychosis’ and an increased duration of the disease . An association between the duration of the disease and the occurrence of hallucinations was also found by some investigators but not by others .

    Table 1

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    Hallucinations And Delusions In Parkinsons Disease

    It might be surprising to learn that 20 to 30 percent of people with Parkinsons disease will experience visual hallucinations. While typically not a symptom of PD itself, they can develop as a result to a change in PD medication or as a symptom of an unrelated infection or illness. It is important to know the signs of hallucinations and how to manage them.

    Hallucinations and other more severe perceptual changes can be distressing to family often more so than to the person experiencing them. For the well-being of people with PD and caregivers, it is important to identify hallucinations as early as possible and take steps to reduce them.

    The following article is based on the latest research and a Parkinsons Foundation Expert Briefings about hallucinations and delusions in Parkinsons hosted by Christopher G. Goetz, MD, Professor of Neurological Sciences, Professor of Pharmacology at Rush University Medical Center, a Parkinsons Foundation Center of Excellence.

    Examples Of Delusions In Pd

    Shedding a light on visual hallucinations in Parkinson
    • Jealousy
    • Belief: Your partner is being unfaithful.
    • Behavior: Paranoia, agitation, suspiciousness, aggression.
  • Persecutory
  • Belief: You are being attacked, harassed, cheated or conspired against.
  • Behavior: Paranoia, suspiciousness, agitation, aggression, defiance, social withdrawal.
  • Somatic
  • Belief: Your body functions in an abnormal manner. You develop an unusual obsession with your body or health.
  • Behavior: Anxiety, agitation, reports of abnormal or unusual symptoms, extreme concern regarding symptoms, frequent visits with the clinician.
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    Models Of Visual Hallucinations

    In recent years, a number of models have been proposed which link disturbances in brain function with VH. Current models of normal visual perception see the subjective experience of vision as resulting from an internal, sparse, functional, predictive, dynamic representation of the visual input that the brain would receive if that representation were correct. Given this conceptualization, it is perhaps not surprising that disturbance in any part of this system can produce misperceptions. With potentially different causes in different patients, or even within the same one, there may thus not be a single final pathway for hallucinations in PD.

    Arnulf et al. proposed the first PD-specific model in 2000 suggesting that hallucinations reflected the intrusion of dreams into the waking state. In spite of the associations of VH with disturbed sleep and dreaming, more recent evidence suggests that these may reflect co-incidental disturbances in closely related but separate systems rather than causal links. Phenomenological differences between dreams and hallucinations further suggest that other models may fit the data better .

    In 2005, Collerton et al. and Diederich et al. separately published similar interactive models which locate the generation of VH in the faulty interaction between top down internal representations and bottom up sensory input.

    Talk About Your Hallucinations And Delusions

    Your hallucinations or delusions can be distressing for those around you. They may be unsure how to react so let them know what you are going through and how best they can help you. They will be more able to support you if you share your experiences with them, particularly if you know what the most common triggers are and what can be done to make the hallucinations or delusions go away.

    Counselling can sometimes be helpful, particularly if the hallucinations or delusions strain relationships. Your doctor will be able to advise on the available types of counselling.

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    What Is A Hallucination

    A hallucination is a perception of something that does not actually exist. This may be visualised, heard, felt, smelled or tasted. Hallucinations are sometimes confused with illusions, which are distortions of a reality rather than something that is purely imagined – as with hallucinations.

    Visual hallucinations: In Parkinson’s, hallucinations are most commonly visual and may be in black and white, in colour, still or moving. Often the images involve small animals and children. They may disappear quickly or may last for some time.

    Auditory hallucinations: auditory hallucinations are less common. These generally involve hearing voices or other familiar sounds. Auditory hallucinations can also be part of a depressive symptomatology.

    Tactile hallucinations: hallucinations may be tactile, that is, you may feel a sensation, like something touching you.

    Smell and taste hallucinations: less commonly you may feel that you can taste something you havent eaten, or you may smell something that is not present, such as food cooking or smoke.

    Usually hallucinations are not threatening or distressing. If you hallucinate you may be unaware that your perceptions are not real, and sometimes imagined images or sensations can be comforting. But hallucinations can also be distressing and you may feel threatened or frightened and may need reassurance and comfort from those around you.

    How Can I Help My Loved One

    Can we prevent hallucinations in Parkinson’s?

    Your loved ones hallucination episodes are certainly disturbing, but they are usually harmless. Unlike hallucinations caused by other neurodegenerative diseases, hallucinations associated with Parkinsons disease are most often benign.

    Not all hallucinations need to be treated. If they do not disrupt your loved ones daily life, there are ways to manage them well. It is still important to inform your neurologist for proper follow-up.

    Talk to your loved one about their hallucinations. Together, determine what you can do when they are having a hallucination. This will help both of you be prepared and reassured when it happens.

    If the hallucinations are severe, do not tell your loved one that the hallucinations are not real. This will only increase the disparity between reality and the hallucination. It may also create unnecessary conflict with your loved one who is convinced that they are hallucinating.

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    What Are Parkinsons Hallucinations

    Symptoms of psychosis occur in up to 50% of people with Parkinsons disease.

    Parkinsons disease psychosis is considered a neuropsychiatric condition. This means it involves neurology and psychiatry . While the psychosis involves mental health symptoms, they are caused by Parkinsons disease, which is a disease of the nervous system.

    Psychosis in Parkinsons disease comes in two forms:

    • Hallucinations: Sensory experiences that are not really happening
    • Delusions: False beliefs not based on reality

    These symptoms can be debilitating and scary for the people experiencing them. They can interfere with a persons ability to care for themselves and to relate to other people.

    Psychotic symptoms in Parkinsons disease are associated with increased caregiver distress, risk of hospitalization and nursing home placement, and healthcare costs.

    A study suggests the presence of hallucinations and delusions in people with Parkinsons disease is a predictor of mortality .

    How To Talk To Someone With Hallucinations Or Delusions

    • It is usually not helpful to argue with someone who is experiencing a hallucination or delusion. 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. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinsons Foundation Center of Excellence.

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    Clinical Disorders Of Vision In Parkinson’s Disease

    In patient surveys, large proportions of PD and virtually all PDD/DLB patients report some disturbance of vision. Symptoms include complaints about dry eyes, photophobia, diplopia, difficulties with reading, difficulties estimating spatial relations, or freezing when passing narrow spaces. Although, as a group, PDD/DLB patients perform worse on just about every measure of visual function – visual acuity, contrast sensitivity, motion and colour perception are all impaired in PD – there is substantial individual variation .

    The causes of such symptoms and signs can rarely be established with confidence. Potential explanations include reduced blink rate, oculomotor abnormalities or reduced retinal contrast sensitivity. Alternatively, they may be an expression of cortical dysfunction manifesting as visuoperceptual, visuospatial and attentional impairment, or general perceptual slowing. As these factors usually co-exist, it can be difficult to disentangle the purely perceptual from lower level disturbances of visual and motor function.

    Cortical visual processing depends upon two overlapping, but distinct, networks – the dorsal and ventral streams. There is now considerable evidence that the disease process in PD and DLB impacts on both of these streams, influencing the nature of the visual symptoms reported by patients.

    What Should I Do When My Loved One Is Experiencing A Hallucination

    Shedding a light on visual hallucinations in Parkinson

    Most importantly, dont try to convince your loved one that what theyre experiencing isnt real. Theyll feel like youre putting down an experience that seems authentic to them.

    Once a person has lost insight, itll be very difficult to convince them that what theyre experiencing isnt happening. Trying to argue with them may agitate and even enrage the person. Making them anxious could cause their hallucinations to get worse.

    Instead, talk to the person gently and reassuringly. You might say something like, I understand that you see a dog in the corner of the room. Everything is going to be OK. Youre safe. You might even say that the dog must have left already.

    Remember that the person cant control what theyre experiencing. Try to be as sympathetic as you can when you talk to them.

    One approach that can help is to turn on all the lights in the room. Hallucinations are more likely to happen in dimly lit areas, and this can be caused by disease-related changes that affect the eyes.

    Then, have the person really focus on what theyre seeing. That may reset their brain and help them see whats actually in front of them.

    If the person doesnt have insight, try a distraction. Move them to a different room. Turn on the TV or play a game they like.

    Try to keep your loved one as calm as possible. If they become very agitated or violent, call their doctor or 911.

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    Recognizing Symptoms Of Delusions

    People with Parkinsons delusions frequently believe they are being mistreated. As a result, people experience paranoia, mistrust, anger, and anxiety. Jealousy delusions usually a belief that a spouse is being unfaithful are very common. Persecutory delusions the false belief that someone is cheating or conspiring against you are also common. Persecutory delusions are often directed at someone the person with Parkinsons interacts with regularly, like a spouse, family member, or caregiver.

    Caregivers on MyParkinsonsTeam share their experiences with jealousy and persecutory delusions:

    • Husband still thinks I’m slipping out at night, which I understand is the number one delusion for a spouse!
    • He is saying I am lying to him and he is showing signs of being paranoid.
    • They provoke severe anxiety in my husband and sometimes he believes men are after him. He can become distrustful of me and his health care aide, whom he likes very much. These bad episodes can last one hour or six hours.
    • My mom tells me I don’t feed her or I make her eat things that she doesn’t like.

    Some delusions are more general confusions of reality. As one caregiver described, He mixes reality and old memories and TV programs and fantasy to create a different kind of reality. Another caregiver shared, He is POSITIVE we are not where we are, that he has two cats, etc.

    Categorising Visual Hallucinations In Early Parkinsons Disease

    Article type: Research Article

    Authors: Clegg, Benjamin J.a * | Duncan, Gordon W.b c | Khoo, Tien K.d e | Barker, Roger A.f | Burn, David J.g | Yarnall, Alison J.b h | Lawson, Rachael A.b h

    Affiliations: Institute of Cellular Medicine, Newcastle University, UK | Institute of Neuroscience, Newcastle University, UK | Centre for Clinical Brain Sciences, University of Edinburgh, UK | School of Medicine and Menzies Health Institute Queensland, Griffith University, Australia | School of Medicine, University of Wollongong, New South Wales, Australia | John Van Geest Centre for Brain Repair, University of Cambridge, UK | Faculty of Medical Science, Newcastle University, UK | Newcastle University Institute for Ageing, Newcastle University, UK

    Correspondence: Correspondence to: Benjamin Clegg, Newcastle Magnetic Resonance Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK. Tel.: +44 0191 208 6000 E-mail: .

    Keywords: Cognition, Parkinsons disease, quality of life, visual hallucinations

    DOI: 10.3233/JPD-181338

    Journal: Journal of Parkinson’s Disease, vol. 8, no. 3, pp. 447-453, 2018

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    Medications To Help Treat Parkinsons Disease Psychosis

    Your doctor might consider prescribing an antipsychotic drug if reducing your PD medication doesnt help manage this side effect.

    Antipsychotic drugs should be used with extreme caution in people with PD. They may cause serious side effects and can even make hallucinations and delusions worse.

    Common antipsychotic drugs like olanzapine might improve hallucinations, but they often result in worsening PD motor symptoms.

    Clozapine and quetiapine are two other antipsychotic drugs that doctors often prescribe at low doses to treat PD psychosis. However, there are concerns about their safety and effectiveness.

    In 2016, the approved the first medication specifically for use in PD psychosis: pimavanserin .

    In clinical studies , pimavanserin was shown to decrease the frequency and severity of hallucinations and delusions without worsening the primary motor symptoms of PD.

    The medication shouldnt be used in people with dementia-related psychosis due to an increased risk of death.

    Psychosis symptoms caused by delirium may improve once the underlying condition is treated.

    There are several reasons someone with PD might experience delusions or hallucinations.

    How Can I Tell If I Am Experiencing Hallucinations

    Psychosis, Hallucinations & Delusions Bombshell for Parkinson’s Caregivers

    Hallucinations are conscious processes that last a certain amount of time. You can talk about them with someone close to you when they occur.

    To know if you are hallucinating, you need to be able to confront reality with your perception. You can do this verification yourself or with the help of someone close to you.

    In any case, you have to be prepared to accept that your perception may have been tainted. Fortunately, these hallucinations are not related to Parkinsons disease progressing into a form of dementia. They usually disappear when you change your medications.

    Speak to your neurologist. They will be able to do tests to evaluate the causes of your hallucinations and possibly review your medication dosages.

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    Inborn Errors Of Metabolism

    A handful of inborn errors of metabolism may cause visual hallucinations. While these are quite rare, they are nonetheless important to consider because patients with inborn errors of metabolism may present with hallucinations at a time when their disease is treatable and when serious neurologic damage has not yet occurred. Specific inborn errors of metabolism that may present with visual hallucinations include homocysteine remethylation defects, urea cycle defects, GM2 gangliosidosis, Neimann-Pick disease type C, and -mannosidosis.

    Study Design And Patients

    This study involved data obtained in 40 PD patients and in 22 age- and sex-matched healthy controls, most of whom were included in a previously published study, which was performed in the OLVG West between July 1, 2017 and November 21, 2017. In summary, all included patients were diagnosed with PD by a neurologist specialized in movement disorders, fulfilled the UK Parkinsons Disease Society Brain Bank Criteria, had a modified Hoehn and Yahr stage between 2 and 5, had a disease duration of at least three years and were older than 50 years. Exclusion criteria for all participants were a neurodegenerative disorder other than PD, and a visual acuity of the best eye below 0.1. The study was performed in accordance with the Declaration of Helsinki Principles and the study protocol was approved by the Medical Ethics Committee of Amsterdam UMC, location VU University Medical Centre in Amsterdam, the Netherlands. All participants provided written informed consent.

    For the present study, we included three patients that were excluded from our earlier study: two patients with strabismus and one patient with amblyopia. In these three cases, only the healthy eyes were included in the analysis. Furthermore, we excluded the eyes of participants with glaucoma or an intra-ocular pressure of 21 or higher and the eyes where the segmentation was unreliable due to insufficient OCT scan quality . Patients were examined while they were in the on state.

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