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Geropsychiatric

Clinical Pearl: Parkinson’s Disease Considerations and Treatment

By Sharon Bronner

Parkinson’s disease (PD) has been reported by the Centers for Disease Control and Prevention as the 14th leading cause of death.

Prevalence increases with age, and trends of aging in the global population ensure healthcare professionals will encounter PD increasingly over the coming decades. Psychosis associated with PD most often occurs in patients who are older, who have more advanced disease, and who manifest greater cognitive impairment. Parkinson’s disease psychosis symptoms may consist of hallucinations and delusions.

The clinical definition of the main features of psychosis includes hallucinations, illusions, and delusions. The current ICD-10 guidelines define hallucinations as a disorder characterized by a false sensory perception in the absence of an external stimulus, whereas an illusion is regarded as a misperception of an externally present stimulus.

PD can be debilitating with physical and mental symptoms. The older adult may present with mobility concerns, and experience fatigue, weight loss, sleep disturbances, mood disorders, and psychosis. The prevalence of psychosis occurs with disease duration, in addition to new visual symptoms of the psychosis continuum, and identification of frontal executive, visual perceptual, and memory dysfunction at different disease stages.

Treatment

Nonpharmacological treatments for PD psychosis such as reassurance and discussion with the patient are being explored but have not yet been firmly established. One of the most important considerations is to ensure the older adult does not have access to weapons. In addition, it is important to keep in mind that other acute or subacute illnesses may cause these symptoms to emerge.

An increase in symptoms may be due to a simple problem such as urinary tract infection or something more complex such as subdural hematoma. Since hallucinations tend to occur in the evening and nighttime with lower light, well-lighted rooms and a nightlight may provide some benefit. It is important to be aware of sundowning syndrome.

Pharmacological treatments for PD psychosis consist of atypical antipsychotic medications. Medications typically used to manage symptoms have included quetiapine (Seroque®) and, less commonly, clozapine. Clozapine (Clozaril®) is infrequently prescribed because of the burdensome requirement for monitoring blood counts for the small but potentially fatal risk of neutropenia. Pimavanserin (Nuplazid®) was developed specifically to treat PD psychosis by its action at serotonin receptors, a quality shared by quetiapine and clozapine. The golden rule for starting medications in older adults is start low and go slow for increasing medications.

Sharon Bronner, DNP, MSN, APRN, GNP-BC, ACHPN, Hct
sbronner@optum.com


References

  • Chang, A., & Fox, S.H. (2016). Psychosis in Parkinson’s disease: Epidemiology, pathophysiology, and management. Drugs, 76(11), 1093-1118.
  • Cummings, J., Isaacson, S., Mills, R., Williams, H., Chi-Burris, K., Corbett, A., … Ballard, C. (2014). Pimavanserin for patients with Parkinson’s disease psychosis: A randomized, placebo-controlled phase 3 trial. Lancet, 383(9916), 533-540.
  • Ffytche, D., Creese, B., Politis, M., Chaudhuri, K.R., Weintraub, D., Ballard, C., & Aarsland, D. (2017). The psychosis spectrum in Parkinson disease. Nature Reviews Neurology, 13(2), 81-95. https://doi.org/10.1038/nrneurol.2016.200
  • Hacksell, U., Burstein, E.S., McFarland, K., Mills, R.G., & Williams, H. (2014). On the discovery and development of pimavanserin: A novel drug candidate for Parkinson’s psychosis. Neurochemical Research, 39(10), 2008-2017.
  • Hermanowicz, N. (2018). Parkinson disease psychosis: Evaluation and treatment. Neurology Times. https://www.neurologytimes.com/parkinson-disease/parkinson-disease-psych...
  • Seppi, K., Weintraub, D., Coelho, M., Perez-Lloret, S., Fox, S.H., Katzenschlager, R., ... Sampaio, C. (2011). The Movement Disorder Society evidence-based medicine review update: Treatments for the non-motor symptoms of Parkinson disease. Movement Disorders, 26(Suppl. 3), S42-80.