About Parkinson’s Disease (PD) Psychosis
The hallucination and delusion the patient is able to report is just the tip of the iceberg.— Craig Chepke, MD
A major challenge for patients, caregivers, and clinicians
Symptoms of PD psychosis can get worse over time1,2
- Hallucinations with insight can progress to hallucinations without insight and delusions
- Because patients commonly do not disclose their nonmotor symptoms, screening early for hallucinations and delusions may help identify psychosis earlier
Hallucinations are abnormal perceptions without a physical stimulus that can involve any sensory modality. Delusions are false, fixed, idiosyncratic beliefs that are maintained despite evidence to the contrary.3
Hallucinations and delusions can impact daily life4-7
- PD psychosis is significantly associated with difficulty performing activities of daily living
- Patients with PD psychosis have a higher incidence of falls and fractures than PD patients without psychosis*
- PD psychosis can add to the burden of caring for a patient with PD
- Hallucinations (along with older age, functional impairment, and dementia) are independent predictors of nursing home admission
Patients with PD psychosis often have comorbid dementia8
- In a retrospective analysis, more than 50% of patients with PD psychosis had comorbid dementia†
*IRR for composite falls and fractures=1.44; 95% CI, 1.39-1.49. Falls and fractures were identified by using inpatient and outpatient ICD-9-CM and ICD-10-CM diagnosis codes in any diagnostic position. PD patients without psychosis were identified in the Medicare claims databases (2008-2018) and followed from the first PD diagnosis date during the study period (n=24,164). Patients with a subsequent diagnosis of psychosis were included in the PD psychosis group (n=12,082). Patients in both groups were propensity score–matched based on characteristics within blocks of time since cohort entry.
†A 10-year retrospective analysis of healthcare claims from a large US managed care population identified patients with PD (N=4490; mean age 69.3 years) who were enrolled in the health plan as of September 2007. The estimated point prevalence of PD psychosis within this population ranged from 4 to 45 per 1000 PD patients.8
Are you seeing patients like these in your practice?
PD psychosis can impact daily life and increase caregiver burden.4,6 Explore these patient profiles to learn more about hallucinations and delusions associated with PD psychosis, and learn about a treatment option.
Mai,
age 68
Mai is experiencing hallucinations and sometimes sees ants in her food and often asks her husband to cook something different.
Patient history
- History of Parkinson’s disease (PD)
- Diagnosed with hallucinations and delusions associated with PD psychosis
Current medications
- carbidopa/levodopa
- MAO-B inhibitor
Recent visit assessment
- Bradykinesia, mild rigidity, one near-fall
- Experiencing hallucinations and delusions
Changes on examination
- Sees ants in her food and requests something different
- Refuses to eat some meals and often feels fatigued
MAO-B=monoamine oxidase-B.
Oliver,
age 78
Oliver no longer trusts certain aides because of his delusions and occasionally rejects help.
Resident history
- History of Parkinson’s disease (PD)
- Diagnosed with hallucinations and delusions associated with PD psychosis
- Admitted to a long-term care community 1 year ago
Current medications
- carbidopa/levodopa
- COMT inhibitor
Recent visit assessment
- Hallucinations and delusions increasing in frequency over the last 6 months
- Not responding to nonpharmacological interventions
Changes on examination
- Sees a man in his room and believes he and staff
are stealing - No longer trusts certain aides and occasionally
rejects help
COMT=catechol-O-methyltransferase.
Charlie,
age 72
Charlie regularly sees a stranger in the yard and thinks he is real. He rushes after the stranger and has nearly fallen several times. He has a history of PD dementia.
Patient history
- History of Parkinson’s disease (PD) with comorbid dementia
- Recently diagnosed with hallucinations and delusions associated with PD psychosis
Current medications
- carbidopa/levodopa
- acetylcholinesterase inhibitor
- MAO-B inhibitor
Recent visit assessment
- Psychosis has not been managed by adjustments in PD medications
- Balance problems have worsened
Changes on examination
- Chases after strangers he sees and believes are
breaking in - Reluctant to leave his home, affecting his
family’s routine
MAO-B=monoamine oxidase-B.
Dana,
age 80
Dana thinks some of the nursing staff are trying to poison her, due to delusions associated with PD psychosis. She has a history of PD dementia.
Resident history
- History of Parkinson’s disease (PD) with comorbid dementia and comorbid diabetes
- Recently diagnosed with hallucinations and delusions associated with PD psychosis
Current medications
- carbidopa/levodopa
- memantine
- MAO-B inhibitor
- metformin
Recent visit assessment
- Moderate motor function impairment
- Hallucinations and delusions increasing in frequency
Changes on examination
- Sometimes sees people who don’t exist; believes nursing staff is trying to poison her
- Gets up in the middle of the night and started refusing to come to group activities
MAO-B=monoamine oxidase-B.
Learn about the proven efficacy of NUPLAZID® (pimavanserin).
Need a resource about PD psychosis to share with your patients?
IMPORTANT SAFETY INFORMATION and INDICATION
WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS
- Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.
- NUPLAZID is not approved for the treatment of patients with dementia who experience psychosis unless their hallucinations and delusions are related to Parkinson’s disease.
- Contraindication: NUPLAZID is contraindicated in patients with a history of a hypersensitivity reaction to pimavanserin or any of its components. Rash, urticaria, and reactions consistent with angioedema (e.g., tongue swelling, circumoral edema, throat tightness, and dyspnea) have been reported.
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Warnings and Precautions: QT Interval Prolongation
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NUPLAZID prolongs the QT interval. The use of NUPLAZID should be avoided in patients with known QT prolongation or in combination with other drugs known to prolong QT interval (e.g., Class 1A antiarrhythmics, Class 3 antiarrhythmics, certain antipsychotics or antibiotics).
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NUPLAZID should also be avoided in patients with a history of cardiac arrhythmias, as well as other circumstances that may increase the risk of the occurrence of torsade de pointes and/or sudden death, including symptomatic bradycardia, hypokalemia or hypomagnesemia, and presence of congenital prolongation of the QT interval.
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- Adverse Reactions: The adverse reactions (≥2% for NUPLAZID and greater than placebo) were peripheral edema (7% vs 2%), nausea (7% vs 4%), confusional state (6% vs 3%), hallucination (5% vs 3%), constipation (4% vs 3%), and gait disturbance (2% vs <1%).
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Drug Interactions:
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Coadministration with strong CYP3A4 inhibitors increases NUPLAZID exposure. Reduce NUPLAZID dose to 10 mg taken orally as one tablet once daily.
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Coadministration with strong or moderate CYP3A4 inducers reduces NUPLAZID exposure. Avoid concomitant use of strong or moderate CYP3A4 inducers with NUPLAZID.
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Indication NUPLAZID is indicated for the treatment of hallucinations and delusions associated with Parkinson’s disease psychosis.
Dosage and Administration Recommended dose: 34 mg capsule taken orally once daily, without titration, with or without food.
NUPLAZID is available as 34 mg capsules and 10 mg tablets.
Please read the full Prescribing Information, including Boxed WARNING.
References:
- Goetz CG, Fan W, Leurgans S, Bernard B, Stebbins GT. The malignant course of “benign hallucinations” in Parkinson disease. Arch Neurol. 2006;63(5):713-716.
- Chaudhuri KR, Prieto-Jurcynska C, Naidu Y, et al. The nondeclaration of nonmotor symptoms of Parkinson’s disease to health care professionals: an international study using the nonmotor symptoms questionnaire. Mov Disord. 2010;25(6):704-709.
- Ravina B, Marder K, Fernandez HH, et al. Diagnostic criteria for psychosis in Parkinson’s disease: report of an NINDS, NIMH work group. Mov Disord. 2007;22(8):1061-1068.
- Aarsland D, Larsen JP, Cummings JL, Laake K. Prevalence and clinical correlates of psychotic symptoms in Parkinson’s disease: a community-based study. Arch Neurol. 1999;56(5):595-601.
- Forns J, Layton JB, Bartsch J, et al. Increased risk of falls and fractures in patients with psychosis and Parkinson disease. PLoS One. 2021;16(1):e0246121. doi:10.1371/journal.pone.0246121.
- Martinez-Martin P, Rodriguez-Blazquez C, Forjaz MJ, et al. Neuropsychiatric symptoms and caregiver’s burden in Parkinson’s disease. Parkinsonism Relat Disord. 2015;21(6):629-634.
- Aarsland D, Larsen JP, Tandberg E, Laake K. Predictors of nursing home placement in Parkinson’s disease: a population-based, prospective study. J Am Geriatr Soc. 2000;48(8):938-942.
- Holt RJ, Sklar AR, Darkow T, Goldberg GA, Johnson JC, Harley CR. Prevalence of Parkinson’s disease-induced psychosis in a large U.S. managed care population. J Neuropsychiatry Clin Neurosci. 2010;22(1):105-110.