Presentation and Management of Psychosis in Parkinson’s Disease and Dementia With Lewy Bodies

Abstract

Treatment in Psychiatry begins with a hypothetical case illustrating a problem in current clinical practice. The authors review current data on prevalence, diagnosis, pathophysiology, and treatment. The article concludes with the authors' treatment recommendations for cases like the one presented.A 73-year-old man with a 10-year history of progressive Parkinson's disease is referred for psychiatric evaluation and treatment by a neurologist for new-onset confusion and visual hallucinations of strangers in his house. Treatment of the early Parkinson's symptoms began with a dopamine agonist, and L-dopa was added later to combat worsening tremor, rigidity, slowed mobility, and difficulty performing basic activities of daily living. A more detailed history elicits new-onset depression and vivid dreaming with insomnia. The patient's wife is concerned about the hallucinations, worsening cognitive impairment, and disturbed sleep, all of which have an impact on her quality of life. Treatment options for addressing these new symptoms include lowering the dosages of antiparkinsonian medications, which can cause or aggravate visual hallucinations and confusion, or adding quetiapine, the atypical antipsychotic drug that is least likely to worsen the parkinsonism. After discussions with the patient and his wife, the decision is made to initiate quetiapine at a dose of 50 mg at bedtime and not to change the antiparkinsonian medication regimen. However, after only a few doses, the patient stops taking the quetiapine because of excessive sedation and increased confusion. An attempt is then made to slowly taper the dopamine agonist, which is more likely than L-dopa to cause psychiatric complications and is less effective as an antiparkinsonian medication. The patient's parkinsonism worsens, however, so the dosage is restored to the previously effective level. The patient's condition continues to deteriorate because of increasing visual hallucinations (now accompanied by persecutory delusions regarding the strangers in the house), confusion, and disturbed sleep. An urgent follow-up evaluation is arranged. How does one differentiate between psychosis in Parkinson's disease (PD) and psychosis in dementia with Lewy bodies (DLB)? How does psychosis present in PD and DLB, and what are risk factors for its occurrence? What is the neuropathophysiology of psychosis in these disorders? What evidence exists for psychopharmacological treatment of psychosis in PD and DLB? How does one optimize the risk-benefit ratio of concomitant use of PD and psychiatric medications?Epidemiology PD is the second most common neurodegenerative disease after Alzheimer's disease, affecting up to 1% of the elderly population. DLB, which may be indistinguishable from PD neuropathologically and has similar clinical features (e.g., dementia, spontaneous parkinsonism, and attentional impairment), is now thought to be the second most common dementing illness after Alzheimer's disease in Western countries. Dementia also occurs commonly in PD, affecting up to 75% of PD ...

Psychopathological features in patients with Parkinson's disease and related caregivers' burden

“…On the other hand, caregivers of the dementia group had more suffering with delusions, hallucinations, aberrant motor behaviour and sleep disturbances; anxiety and depressive symptoms were present as well. This association confirmed previous findings by Weintraub and Hurtig (2007). Besides, it should be considered that in PD patients with dementia hallucinations may predict a more rapid cognitive decline (Burn et al, 2006).…”

“…Recently, Wada-Isoe et al (2008) reported that hallucinations occur in the course of dementia itself. Weintraub and Hurtig (2007) considered the pathophysiology of psychosis in PD as a multifactorial phenomenon, involving dopamine replacement therapy and the neurodegenerative process induced by the disease. Accordingly, these authors emphasize specific neurobiological changes, such as disturbances of cholinergic, serotonergic, noradrenergic and dopaminergic systems, which might explain partially the neuropsychiatric symptoms in PD.…”

“…Persistent neuropsychiatric symptoms such as hallucinations and delusions considerably contribute to the patient's suffering and caregiver's burden (Lyketsos, 2007;Weintraub and Hurtig, 2007;McKinlay et al, 2008). In addition, patients with psychotic symptoms have an increased risk for mortality (Melamed et al, 1999).…”

Activation of Nociceptin/Orphanin FQ Peptide Receptors Disrupts Visual but Not Auditory Sensorimotor Gating in BALB/cByJ Mice: Comparison to Dopamine Receptor Agonists

“…For instance, visual hallucinations are the core criteria for clinical diagnosis of dementia with Lewy body (DLB, dementia along with parkinsonism; Weintraub and Hurtig, 2007). Visual hallucinations are also the most frequent psychotic manifestations in PD and their appearance was linked to the use of dopamine agonists and to the presence of comorbid vulnerabilities, such as cognitive disturbances and dementia (for review, see Weintraub and Hurtig, 2007;Fénelon, 2008;Zahodne and Fernandez, 2008). It is worth noting that excessive secretion of N/OFQ was suggested to be one component of the pathophysiological processes that contribute to development of parkinsonism.…”

Management of non-motor complications in Parkinson’s disease

“…Illusions arise due to mistakenly perceiving actual sensory stimuli due to false recognition of reality and inappropriate assumptions, while hallucinations are the state of perceiving sensations that do not actually exist and delusions arise from believing in imaginary facts [22,25]. Psychosis is a significant risk factor for permanent nursing home placement [14].…”