Psychosis in Parkinson’s

Disease: Management Strategies

Greg Pontone, M.D.,

M.H.S.
Director of Parkinson’s Disease Neuropsychiatry Clinic
Johns Hopkins University School of Medicine
 New-Onset Review
A complete medical
Psychosis in antiparkinsonian
workup
Parkinson’s agents

• Blood work • Chest x-ray • Increased?

• Physical • Brain imaging • Changed?
examination Review medications
• Specific medical
diagnostics

• Opiates
• Anticholinergic bladder medications
• Sleep aids
• Centrally acting medications

Goldman, J. G., & Holden, S. (2014). Treatment of psychosis and dementia in Parkinson’s disease. Current treatment options in neurology, 16(3), 281.
 • Use an antipsychotic.
• Use cholinesterase inhibitors (some
evidence).

If a medical cause is
Treatment
excluded,

Nonpharmacological strategies
• Look away from visual hallucination; then look
back.
• Improve room lighting.
• Avoid isolation.

Goldman, J. G., & Holden, S. (2014). Treatment of psychosis and dementia in Parkinson’s disease. Current treatment options in neurology, 16(3), 281.
Antipsychotic Therapy in Parkinson’s
Disease Psychosis

Antipsychotic D2 receptors Postsynaptic membrane

Clozapine
Quetiapine
Pimavanserin
 The Efficacy and Safety of Clozapine and
Quetiapine for Parkinson’s Psychosis
Treatmen Descript Safety Specialized
t ion Monitoring
Clozapine Efficacious Acceptable risk Absolute neutrophil count

Quetiapine Insufficient Acceptable risk None required

evidence
Minimizes psychotic
agitation and
distress

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's disease. Movement Disorders, 26(S3), S42-S80.
 The Mechanism and Efficacy of Pimavanserin
for Parkinson’s Psychosis

Treatmen Mechanis Efficacy Comment

t m of
Action
Pimavanserin 5-HT2A inverse Efficacious Tested in nondemented
agonism Parkinson’s disease psychosis
FDA approved in 2016

- https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm498442.htm
- 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 randomised, placebo-controlled phase 3 trial. The Lancet, 383(9916), 533-540.
 The Risk of Using Antipsychotics
in Parkinson’s Disease

Possible worsening of Parkinson’s disease

Increased risk of all-cause mortality in the elderly

http://www.fda.gov/Drugs/DrugSafety/ucm124830.htm
Key Points

• The evaluation of new-onset psychosis in Parkinson’s must always start with a workup
for medical illness.

• Screen for any medications that might worsen psychosis (e.g., increases in dopamine
replacement therapy, addition of anticholinergics or opiate pain medications).

• Antipsychotics recommended for Parkinson’s disease psychosis are clozapine,

pimavanserin, and quetiapine.
Key Points

• If reduction of dopamine replacement therapy is necessary, medications with the least

(relative) motor benefit should be removed first (e.g., amantadine, MAOIs, COMT
inhibitors, dopamine agonists, and finally, levodopa).
Next Presentation

Impulse Control Disorders in

Parkinson’s Disease