Parkinson's Disease Psychosis: Common, Yet Not Often Reported
by H. Nasrallah, MD;; 6/19/15

Parkinson's disease psychosis is underreported and it is tricky to treat, but a brand new drug in late-stage development is really a promising therapy.

It provides a surprise to clinicians that 50 % of all of us living alongside Parkinson's disease (PD) are troubled by non-motor symptoms throughout their disease. As clinicians, we're often dedicated to characteristic movements like tremor, slowness, rigidity, and walking difficulty, but, increasingly, we understand that patients can also be experiencing memory impairment, psychosis, depression, and vivid dreams.

Parkinson's disease psychosis (PDP) can be a particularly troubling non-motor part of PD, as it is really a risk factor for increased mortality as well as for extended care placement. Once used in a an elderly care facility for PDP, patients will probably remain there permanently.

The hallucinations, delusions, and paranoia which might be the hallmark the signs of PDP4 adversely impact a patient's general emotional state and relationships with family and caregivers, and as well limit their participation in everyday living. Often, patients are a lot easier more troubled by PDP than physicians may initially recognize inside the clinical setting. This could possibly be for the reason that stigma that lots of PD patients and families adhere to these symptoms brings about unwilling to disclose their psychotic symptoms using their psychiatrist or neurologist, or even employ supportive services.

In fact, only 10-20% of patients and/or caregivers ever report symptoms.6 Without education, they can not understand that psychosis can be a common portion of PD progression.

Elicit Symptoms Reporting

With that planned, medical care professional need to take the initiative to be aware of how these kind of symptoms may within PD patients. Of note, patients could be not wanting to admit actually experiencing various hallucinations or delusions, or may attribute visual hallucinations to poor vision. Caregivers will not be conscious that psychosis has emerged until it's got progressed and becomes disruptive.

The most commonly encountered PDP symptom is visual hallucinations, including the patient seeing imaginary people, animals or “creatures.” Patients aren't necessarily alarmed with the hallucinations, but they will often become frustrated when others cannot report seeing them, too. PDP patients could also experience delusional beliefs like paranoia. In fact it is very common for patients to accuse their spouses of infidelity or of stealing money.

Many also become convinced actually being watched. Psychiatrists can also find weather resistant help not merely the PDP patient but in addition their caregiver, because studies have shown a solid correlation involving the clinical emergence of psychosis and increased caregiver stress.

As noted, few patients spontaneously report their psychosis symptoms, rendering it quite a job to have a definative patient history. Specific and direct questioning about psychosis warning signs of hallucinations, paranoia, as well as other delusions is usually needed, to allow diagnosing and management of PDP before symptoms worsen.

Treatment Challenges

Parkinson's patients have reached a heightened risk for PDP as they age, develop memory impairment or depression, or if they make a scene vivid dreams. Psychotic symptoms also can be triggered by infections, for instance utis, or with the medications employed to treat PD or any other co-existing medical disorders for example for pain or bladder infections.

Currently, the treatments for PDP is fixed instead of evidence- based, though reassurance could be useful, and cognitive-behavioral therapy will help. From a pharmacological perspective, reducing potentially offending medications, like those indicated to the therapy for PDP, helps to reduce the concentration of psychosis.

Sometimes, an atypical antipsychotic (AP) is usually prescribed off -label for PDP, even so the usage of those agents can exacerbate the motor symptoms.7 In the case of APs, it's easy to comprehend why, since they can be made to block dopamine D2 receptors inside the brain. In addition, some APs require weekly blood draws to detect potential agranulocytosis.8 Given the undesirable unwanted effects, many patients with PDP will not receive antipsychotic treatment considering that the ultimate goal is always to improve PDP, without worsening the motor the signs of PD.

Potential New Therapy

At on this occasion, there is often a wide recognition on the significant unmet desire for better treatment methods for PDP. A new, selective serotonin inverse agonist (SSIA) medication in development by Acadia Pharmaceuticals for PDP, pimavanserin (Nuplazid), targets 5-HT2A receptors. If approved because of the FDA, pimavenserin will set up a novel and distinctly different (first–in-class) pharmacological strategy to treating psychosis. The company promises to sign up towards the FDA for that drug's approval inside the second 50 % of the year.

In scientific studies, pimavanserin met the main study endpoint by demonstrating an extremely significant decrease in psychosis as compared with placebo and as well met the main element secondary endpoint for motoric tolerability. Also reported from the controlled study were highly significant improvements in most secondary efficacy measures and statistically significant benefits in exploratory efficacy measures of nighttime sleep, daytime wakefulness, and caregiver burden.

Without effective control of PDP, hallucinatory experiences often escalate, delusions be prominent, and symptoms generally be a little more troubling and disabling.2 Caregivers still find it increasingly difficult and stressful to regulate their household's condition.

Therefore, health care providers must be vigilant of their early detection of symptoms so PDP could be promptly addressed to keep up overall standard of living and steer clear of clinical deterioration and unnecessary long -term placement.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


Feb 3, 2008

The Interdisciplinary Team; The Role of the Psychiatrist

by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication