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/

PARKINSON'S DISEASE

PARKINSON’S DISEASE (PD)

What is Parkinson’s disease (PD)?

Parkinson’s disease is a disease of the brain, which is caused by selective degeneration of nerves in the basal ganglia, leading to deficiency of dopamine in brain.

What are the symptoms of Parkinson’s disease?

The most typical symptoms of this disease include:

1. Tremors- shaking of hands and feet,
2. Slowness of all activities,
3. Stiffness of arms and legs,
4. Loss of balance while standing or walking.

A patient may have only one or some or all of these at onset. However, as the disease progresses, all of them would eventually develop all these symptoms.

What are some of the other symptoms of Parkinson’s disease?

Other symptoms that may occur in a patient with Parkinson’s disease are:

1. Mask-like facies or expressionless face, (even in situations of happiness, they may fail to express it on the face),
2. Stooped posture, with head & trunk bent forwards,
3. Slurred and low volume speech (it is often difficult to comprehend what they are saying),
4. Slow speed of walking,
5. Reduced swinging of arms while walking,
6. Very small letters while writing, referred to as Micrographia,
7. Reduced blink rate (which makes them give a staring look),
8. Short, shuffling steps while walking,
9. Loss of balance while turning, leading to falling forwards.

Why this disease is called Parkinson’s disease?

This is because the very first description of this disease was given by a doctor named Dr James Parkinson, a neurologist from UK. In his honour, the disease was given his name.

Which age group is commonly affected with Parkinson’s disease?

This disease typically affects people above 40 years of age, and the incidence increases with advancing age.

Occasionally, this can occur in people younger than 40, when it is called young onset Parkinson’s disease (YOPD).

How is Parkinson’s disease diagnosed?

Like many other neurological problem, Parkinson’s disease too is diagnosed on the basis of typical symptoms (as described above).

It may be difficult to diagnose PD in very early stages, as the affected person may have only minor symptoms such as mild tremors of hands, and perfectly well otherwise. However, careful examination by a Neurologist would help confirm its diagnosis in this stage too.

Is there a very specific test for diagnosing Parkinson’s disease, especially in early stage?

In doubtful cases, or in very early stages, PET scan (positron emission tomography) can help in accurate diagnosis of PD. This facility is available in our hospital, and I do use it in some cases.

Can Parkinson's disease be transmitted genetically to the children of patients suffering from this disease?

In about 10% of cases, PD can be genetic in origin. But about 90% of cases of PD are sporadic (they have no family history of Parkinson's disease).

What are the treatment options available for Parkinson’s disease?

The mainstay of treatment of PD is medications. Various medications are available. These include levodopa/carbidopa combination (which provide direct dopamine to the brain); ropinirole & pramipexole (which increase the action of dopamine); trihexiphenidyl, amantadine, entacapone, etc.

The choice of drug depends on the patient’s symptoms as well as the severity & duration of PD.

Your neurologist is the best person to decide the most appropriate medications and their doses.

What are the common side effects with medications used for treating PD?

Though these medications are generally safe, some side effects may occur:

1. Giddiness while sitting up or standing- this is because of drop in BP while standing, which is a side effect of levodopa/carbidopa (syndopa/sinemet),
2. Behavioural disturbances- agitation, hallucinations (seeing something that is not there or hearing something when no one is speaking, etc), sleep disturbances can occur with syndopa, especially if the last dose is taken late (such as after 8 pm). 
3. Nausea, vomiting, loss of appetite may occur with syndopa.
4. Abnormal movements of hands or feet, akin to dancing or rhythmic movements, referred to as dyskinesias.

What are the common precautions while taking medications for PD?

1. Medications for PD should be taken on empty stomach, as presence of food may interfere with their absorption,

2. They should be taken on exact time, as advised by the doctor,

3. Any change in the dosage or timing of the medications should be done only after consulting the neurologist.

How long are the medications required in Parkinson’s disease?

Medications are usually required for lifelong. However, the dose would change as per the severity of disease.

Are botulinum toxin injections (Botox) helpful in treating PD?

In selected cases, where there is increased rigidity or dystonia, botox may be useful. The decision can be made by the neurologist after clinical examination.

Are there any surgeries available for treating Parkinson’s disease?

Deep brain stimulation (DBS) surgery is the standard surgery performed in some cases of PD. This surgery can be compared to pacemaker (of heart); wherein an electrode is placed in the brain.

It should be noted that not all cases of PD require surgery, nor would all cases of PD benefit from DBS surgery.

Patients with predominant tremors of hands may be the best candidates for DBS surgery.

Another group of patients who may benefit are those with inadequate response to levodopa, or those with levodopa-induced dyskinesias (see above under side effects).

The decision regarding the need or usefulness of surgery can be made by the neurologist after detailed clinical evaluation.

Is DBS surgery available in India?

Yes, many centers in India (Mumbai, Bangalore, New Delhi, Hyderabad, Trivandrum, etc) have the facilities for doing DBS surgery in India.

We perform DBS surgery in our institute too.

What kind of outcome can be expected in patients with PD after treatment?

1. There is no cure available for PD,
2. Disease continues to progress despite medical treatment, and the severity of disease would worsen over time,
3. The disease leads to severe motor disability, hampering the activities of daily living and occupation,
4. There is generally no increase in the chances of death, if the patients are looked after well.
5. However, it should be noted that a reasonably good quality of life can be maintained with proper medical treatment and physiotherapy for more than 20 years after the onset of PD symptoms.

Is there a specific diet to be followed by patients suffering from Parkinson’s disease?

Protein content should be reduced by 50%, and protein-rich foods (such as pulses, meat, etc) should be shifted to dinner time (after the last dose of syndopa has been taken). This is to ensure proper absorption of syndopa, as presence of high protein food may interfere with the absorption of levodopa.

Is there any limitation on physical activities?

No, there is none. In fact, it is better for a patient with PD to indulge in regular physical activities, including outdoor games, to maintain good physical fitness & mobility.

If you have any additional queries on Parkinson's disease, please send me an email: drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Health City, Hyderabad, India

Phone: 0091-40-23607777

Email: drsudhirkumar@yahoo.com