Acute Psychosis in Parkinson’s Disease

1. Ade Wijaya, MD – September 2021

2.  Psychotic symptoms occur in up to 30% of
patients with Parkinson’s disease who take
long-term dopaminergic treatment
throughout the disease course;
 Their occurrence suggests a poor prognosis
and high mortality
Friedman JH. Parkinson disease psychosis: update. Behav Neurol 2013;27:469–77.

3.  Integral part of Parkinson’s Disease
 Frequently triggered or aggravated by
antiparkinsonian medications
 Predictor of imminent cognitive decline
ffytche DH, Creese B, Politis M, et al. The psychosis spectrum in Parkinson disease. Nat Rev Neurol 2017;13:81–95.

4. Visual
Hallucination
Paranoid
Delusion
ffytche DH, Creese B, Politis M, et al. The psychosis spectrum in Parkinson disease. Nat Rev Neurol 2017;13:81–95.

5. Doparminergic
Treatment
Advance Age
Visual
Problems
Dementia
ffytche DH, Creese B, Politis M, et al. The psychosis spectrum in Parkinson disease. Nat Rev Neurol 2017;13:81–95.

6.  Psychotic symptoms may appear in relation to
underlying systemic conditions such as
infection, toxic-metabolic derangements,
surgery and other neurological disorders (ie,
subdural haematoma related to falls).
Simonet C, et al. Pract Neurol 2020;20:15–25. doi:10.1136/practneurol-2018-002075

7. Doparminergic
Agents
Pain Killers
Antidepressants
Simonet C, et al. Pract Neurol 2020;20:15–25. doi:10.1136/practneurol-2018-002075

8.  Acute psychosis is an emergency
 The management includes:
Intensive antipsychotic treatment, such as
bucodispersable risperidone or intramuscular
aripiprazole, although worsening of
parkinsonism must be expected.
Benzodiazepines can help if anxiety dominates
the clinical picture.
Containment measures are a last resort
Byrne P. Managing the acute psychotic episode. BMJ 2007;334:686–92.

9.  Review medication changes
 Exclude external precipitants factors such as
urinary tract infection or pneumonia, require
urine analysis and chest X-ray
 Drug reduction: A common strategy is first to
reduce anticholinergic drugs, then MAO
inhibitors, amantadine, dopamine agonist, COMT
inhibitors and eventually levodopa
 if possible reducing mainly tricyclic
antidepressants, opioids and dopaminergic drugs
Goldman JG, Vaughan CL, Goetz CG. An update expert opinion on management and research
strategies in Parkinson's disease psychosis. Expert Opin Pharmacother 2011;12:2009–24

10.  Quetiapine
 Clozapine
 Pimavanserin
Simonet C, et al. Pract Neurol 2020;20:15–25. doi:10.1136/practneurol-2018-002075

11.  Common
 Poor prognosis
 Integral part of Parkinson’s Disease
 Triggered or aggravated by antiparkinsonian
medications
 Visual hallucionations and paranoid delusions
 Acute psychosis is an emergency
 Exclude external precipitants, drug reduction,
quetiapine