PSYCHOSIS (HALLUCINATIONS AND DELUSIONS) IN PARKINSON'S DISEASE

HALLUCINATIONS IN PARKINSON’S DISEASE

Main symptoms of Parkinson’s disease

Parkinson’s disease (PD) is a slowly progressive degenerative disease of brain. The major symptoms are tremors (shivering), slowness of movements, stiffness and postural imbalance.  These symptoms lead to motor disability and interfere with walking, as well as with other activities of daily living.

Memory impairment in Parkinson’s disease

The mental functions are usually normal in patients with PD, however, 10% of patients can develop dementia (memory impairment along with other cognitive dysfunction), especially in later stages of illness.

What are hallucinations?

Other significant problem in people with PD in later stages is hallucination. Hallucination is often visual. In this condition, patient sees something, which is not there. For example, they may see snakes or lizards in their room (which are not there), and get disturbed with them. They may also see strangers in their house, which are supposedly there to spy on them or harm them. These hallucinations are very upsetting for the patient, making them anxious and depressed. Some patients also have sleep disturbance due to hallucinations.

What are the causes of hallucinations in patients with PD?

1.     Adverse effects of anti-parkinsonian medicines.

2.     Infections such as urinary tract infection or pneumonia,

3.     Side effects of other medications such as pain killers and sleeping pills,

4.     Parkinson’s disease mimic such as Diffuse Lewy body disease (DLBD). In DLBD, patients may have slowness and rigidity (just like PD). However, they have prominent hallucinations and dementia (unlike PD). Moreover, DLBD patients do not respond to levodopa treatment.

Other symptoms of psychosis in patients with PD

1.     Illusions,

2.     Delusions especially paranoid

3.     Confusion,

4.     Sleep disturbance

Delusion refers to a condition where a patient believes in something, even when there is an evidence of the contrary.

How common is psychosis in PD?

About one third of patients with PD suffer from psychosis. So, it is quite common.

How do we manage psychosis in patients with PD?

Management of psychosis can be done in a stepwise fashion as outlined below:

1.     Underlying alternate causes should be looked for and managed. This would include looking for infection and offending drugs.

2.     Comorbid psychiatric conditions, such as anxiety and depression, if present, should be treated.

3.     Minor symptoms such as vivid dreams or minor hallucinations (which are non-disturbing in nature) do not require any treatment.

4.     Anti-parkinsonian drugs should be reduced or stopped. First to eliminate are trihexiphenydyl, amantadine and selegeline/rasagiline. If psychotic symptoms persist, then, the next drugs to be reduced are dopamine agonists (ropinirole and pramipexole), entacapone and levodopa.

5.     In people with cognitive impairment, cholinesterase inhibitors such as rivastigmine or donepezil can be used.

6.     Anti-psychotic medication- quetiapine is the most commonly used.

7.     The first and only FDA approved drug for treating PD psychosis (hallucinations and delusions) is PIMAVANSERIN (Nuplazid). The dose is 34 mg capsules once daily.

DR SUDHIR KUMAR MD DM

Consultant Neurologist

Apollo Hospitals, Hyderabad

04023607777

drsudhirkumar@yahoo.com

https://www.facebook.com/bestneurologist/

IMPORTANT INFORMATION ABOUT LEVODOPA USE IN PARKINSON’S DISEASE

IMPORTANT INFORMATION ABOUT LEVODOPA USE IN PARKINSON’S DISEASE

Levodopa is one of the most important medicines used for treating Parkinson’s disease (PD). It is sold in combination of levodopa and carbidopa. The commonly used brand names for this medicine are syndopa, sinemet, tidomet and duodopa. Levodopa is very useful in ameliorating the symptoms of PD, especially the tremors and rigidity. However, there are several important points of note regarding its use. The current article highlights a few of them.

1. Try to avoid levodopa use in early PD: Though levodopa is very effective in controlling symptoms of PD even in early stage, it is better to avoid using it in early PD. This is because the risk of dyskinesia (abnormal movements as a side effect of levodopa) and rapid wearing off (reduced efficacy of levodopa) are more common, if levodopa is started early in the course of disease. Also, levodopa loses the efficacy after longer use, so, it makes sense to start it later.

2. Use the lowest effective dose of levodopa: It may be tempting to use levodopa at a higher dose or more frequently, as the symptom control would be better with that. However, for the same reason mentioned above, it is better to use levodopa at the lowest possible dose, and as less frequently as possible.

3. Take levodopa on empty stomach: Presence of food in stomach may interfere with the absorption of levodopa; so, it is better to take levodopa on empty stomach. In the initial days of starting levodopa, there may be nausea or vomiting, so, it may be taken after food or snacks.

4. Reduce or evenly space the amount of protein intake: High protein diet prevents proper absorption of levodopa. So, the protein intake should be evenly spaced out in the day; or better, it can be shifted to dinner time (as most doses of levodopa are taken before dinner time).

5. Avoid pyridoxine (vitamin B6) intake: Pyridoxine can reduce the effects of levodopa, if taken alone. However, pyridoxine does not interfere with the effects, if levodopa is taken along with carbidopa (as in most cases).

6. Hallucinations and psychosis can be a side effect of levodopa: Use of levodopa does increase the risk of visual and auditory hallucinations, and other psychotic reactions (agitation, anger, irritability, etc). However, it is not a simple relationship. The severity & duration of PD, presence of cognitive impairment and daytime somnolence, all increase the risk of psychotic reactions with levodopa use.

7. Avoid using levodopa in late evenings: The risk of hallucinations and other psychotic reactions are higher if levodopa is used in late evenings or nights. So, avoid it at those times, as much as possible.

8. Avoid breaking, crushing or chewing the controlled release (CR) tablets: Those taking medicines such as syndopa CR, tidomet CR, etc should swallow the entire tablet, without breaking or crushing (which would reduce its efficacy).

9. There is a risk of dependence and abuse with levodopa: Levodopa increases the dopamine levels in brain and may cause effects such as euphoria (feeling of extreme happiness) and other positive mental effects. Therefore, a small group of patients with PD may increase the dose of levodopa by self and take upto 1500-2000 mg per day. These patients accept the side effects of high dose levodopa (such as hallucinations, nausea, loss of appetite), in order to experience the positive mental effects. This behavior (of dependence and abuse of levodopa) should be recognised and treated.

10. Other side effects of levodopa to watch for:

a.     Dizziness or fainting sensation on standing up (may occur due to fall in BP on standing),

b.     Feeling of nausea, vomiting, loss of appetite

c.      Sudden sleep episodes: Patients taking levodopa may fall asleep without any drowsiness or warning. It can occur while driving or doing other activities needing full concentration, which can be potentially harmful.

d.     Sleep disturbance or insomnia at nights. 

DR SUDHIR KUMAR MD (Medicine) DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad, India

Phone: 0091-40-23607777/60601066

Email: drsudhirkumar@yahoo.com

Online consultation: https://www.doctorspring.com/doctors/sudhir-kumar