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Sudden onset of Hallucinations


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#1 redcarnation

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Posted 25 September 2011 - 08:45 PM

My husband has had PD for 25 years, he has now just turned 72 years of age. His current PD meds are Artane 5mg, 3 per day; Sinemet 250/25, 2 per day and Sinemet CR, 2 per day. Others are cholesterol lowering meds, and Atenolol + Plavix added when he had a minor heart attack in Feb 2010. All of these medications he has been taking for many years except for the last two. He had DBS inserted in April 2000 with good results for his tremors. However both batteries went flat for the 2nd time - 1 in Aug 2010 and the other Jan 2011. After initial increased tremors, they settled down and he resumed the same dosage of PD meds (slight increase for 2 weeks until tremors subsided). He decided not to have the batteries replaced for now as he is doing better without them, he says - walking better, more alert, less sleepy. He has managed well, being completely self caring and doing everything for himself. Then 2 weeks ago he started seeing bugs and worms that weren't there - in his food, clothes, on the floor. He saw a neurologist last Wednesday and he put him on Quetiapine 1/2 tab to be increased to 1 tab after a week. Day 5 today with the new drug and no change in him, bugs are still everywhere and he is convinced they are real. My question is - I thought the hallucinations could be from his medications? He has some short term memory loss over the last 2 years but did quite well on the memory test his neurologist gave him last Wednesday - 28 correct answers out of 30. It is hard for me to see him like this, so consumed with seeing bugs that are not there. What else can I do to help him?

#2 Dr. Okun

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Posted 29 September 2011 - 09:14 AM

I recently put this on the blog at http://mdc.mbi.ufl.edu the blog has a few more tips

For you watch out for UTI's and also the anticholinergic.

How common do Parkinson’s disease patients develop psychosis?

Psychosis in Parkinson’s disease generally comes in two forms: hallucinations (when patients see or hear or feel things that aren’t really there) or delusions (which are fixed false beliefs). When hallucinations occur, they are mostly visual (usually these are non-threatening, and patients mostly see small people or animals, or loved ones who have already died, not interacting with them but doing their own thing) (Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000). Sometimes, they can be threatening, but this is less common. Auditory hallucinations (more commonly seen in schizophrenia) are rare in Parkinson’s disease and if they do occur, they are usually accompanied by visual hallucinations.

Delusions are usually of a common theme, typically of spousal infidelity. Other themes are often paranoid in nature (such as thinking that people are out to steal from one’s belongings, or to harm or place poison on their food, or substitute their Parkinson medications, etc.) Because they are paranoid in nature, they can be more threatening and more immediate action is often necessary, compared to visual hallucinations (Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000). It is not uncommon that patients actually call 9-1-1 or the police to report a burglary or a plot to hurt them.

Unfortunately, psychosis occurs in up to 40% of Parkinson’s disease patients (Fenelon et al 2000). In the early stage of Parkinson’s disease psychosis, the patient often still has a clear understanding and retains their insight, but this tends to worsen over time and insight may eventually be lost. At later stages, patients may be confused and have impaired reality testing; that is, they are unable to distinguish personal, subjective experiences from the reality of the external world. Psychosis in Parkinson’s disease patients frequently occurs initially in the evening, then later on spills into the rest of the day.

What triggers psychosis in Parkinson’s disease?

Psychosis in Parkinson’s disease is believed to be due to long term use of parkinsonian medications especially dopaminergic and anticholinergic drugs (Fenelon 2008; Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000). However, significant medication exposure is no longer a pre-requisite in Parkinson’s disease psychosis (Ravina, Marder, Fernandez, et al 2007). The “continuum hypothesis” states that medication-induced psychiatric symptoms in Parkinson’s disease starts with sleep disturbances accompanied by vivid dreams, and then develops into hallucinations and delusions, and ends in delirium. However this theory is now being challenged (Goetz 1998).

How is psychosis managed?

The urgency of treatment will depend on the type and characteristics of psychosis. Sometimes, when the hallucinations are mild and benign, and insight is retained, it is best that the Parkinson regimen be kept as is. However, when a patient is experiencing more threatening paranoid delusions, then more aggressive treatment is warranted (Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000).

The management of psychosis includes:

(1) ruling out the possible reversible causes (such as infections, metabolic and electrolyte imbalances, sleep disorders);
(2) decreasing or discontinuing adjunctive antiparkinsonian drugs (with cautious monitoring of motor function). Typically, when a patient is on several anti-parkinsonian medications, we “peel off” one drug at a time, until the psychosis resolves or further ‘peeling’ is no longer practical because of worsening of Parkinson motor symptoms. We usually eliminate drugs in the following order: anticholinergic drugs , amantadine, selegiline or rasagiline, dopamine agonists, catechol O-methyltransferase (COMT) inhibitors, and finally levodopa;
(3) simplifying the Parkinson’s disease medication regimen;
(4) adding a new or second generation antipsychotic (be careful: some antipsychotics can be harmful to Parkinson’s disease patients! To be discussed in more detail in Module 5)
(5) If psychosis occurs in a Parkinson’s disease patient with cognitive impairment or dementia, a cholinesterase inhibitor (such donepezil, rivastigmine) may be considered;
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#3 MassonP

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Posted 29 February 2012 - 01:28 PM

I recently put this on the blog at http://mdc.mbi.ufl.edu the blog has a few more tips

For you watch out for UTI's and also the anticholinergic.

How common do Parkinson’s disease patients develop psychosis?

Psychosis in Parkinson’s disease generally comes in two forms: hallucinations (when patients see or hear or feel things that aren’t really there) or delusions (which are fixed false beliefs). When hallucinations occur, they are mostly visual (usually these are non-threatening, and patients mostly see small people or animals, or loved ones who have already died, not interacting with them but doing their own thing) (Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000). Sometimes, they can be threatening, but this is less common. Auditory hallucinations (more commonly seen in schizophrenia) are rare in Parkinson’s disease and if they do occur, they are usually accompanied by visual hallucinations.

Delusions are usually of a common theme, typically of spousal infidelity. Other themes are often paranoid in nature (such as thinking that people are out to steal from one’s belongings, or to harm or place poison on their food, or substitute their Parkinson medications, etc.) Because they are paranoid in nature, they can be more threatening and more immediate action is often necessary, compared to visual hallucinations (Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000). It is not uncommon that patients actually call 9-1-1 or the police to report a burglary or a plot to hurt them.

Unfortunately, psychosis occurs in up to 40% of Parkinson’s disease patients (Fenelon et al 2000). In the early stage of Parkinson’s disease psychosis, the patient often still has a clear understanding and retains their insight, but this tends to worsen over time and insight may eventually be lost. At later stages, patients may be confused and have impaired reality testing; that is, they are unable to distinguish personal, subjective experiences from the reality of the external world. Psychosis in Parkinson’s disease patients frequently occurs initially in the evening, then later on spills into the rest of the day.

What triggers psychosis in Parkinson’s disease?

Psychosis in Parkinson’s disease is believed to be due to long term use of parkinsonian medications especially dopaminergic and anticholinergic drugs (Fenelon 2008; Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000). However, significant medication exposure is no longer a pre-requisite in Parkinson’s disease psychosis (Ravina, Marder, Fernandez, et al 2007). The “continuum hypothesis” states that medication-induced psychiatric symptoms in Parkinson’s disease starts with sleep disturbances accompanied by vivid dreams, and then develops into hallucinations and delusions, and ends in delirium. However this theory is now being challenged (Goetz 1998).

How is psychosis managed?

The urgency of treatment will depend on the type and characteristics of psychosis. Sometimes, when the hallucinations are mild and benign, and insight is retained, it is best that the Parkinson regimen be kept as is. However, when a patient is experiencing more threatening paranoid delusions, then more aggressive treatment is warranted (Zahodne and Fernandez 2008a; Zahodne and Fernandez 2008b; Fernandez 2008; Fernandez et al 2008; Friedman and Fernandez 2000).

The management of psychosis includes:

(1) ruling out the possible reversible causes (such as infections, metabolic and electrolyte imbalances, sleep disorders);
(2) decreasing or discontinuing adjunctive antiparkinsonian drugs (with cautious monitoring of motor function). Typically, when a patient is on several anti-parkinsonian medications, we “peel off” one drug at a time, until the psychosis resolves or further ‘peeling’ is no longer practical because of worsening of Parkinson motor symptoms. We usually eliminate drugs in the following order: anticholinergic drugs , amantadine, selegiline or rasagiline, dopamine agonists, catechol O-methyltransferase (COMT) inhibitors, and finally levodopa;
(3) simplifying the Parkinson’s disease medication regimen;
(4) adding a new or second generation antipsychotic (be careful: some antipsychotics can be harmful to Parkinson’s disease patients! To be discussed in more detail in Module 5)
(5) If psychosis occurs in a Parkinson’s disease patient with cognitive impairment or dementia, a cholinesterase inhibitor (such donepezil, rivastigmine) may be considered;



#4 MassonP

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Posted 29 February 2012 - 01:49 PM

Hello Dr., My father in law had been diagnosed with PD for approx. 11 yrs. One of his main complaints is feeling very anxious and hullucinations. He has been seeing a new Neurologist for about 1 1/2 months now. She has tried to change his medication over this period in an attempt to stop the hullucinations. When he first visited the doctor he was only taking Stalevo 100. She had us stop the meds. for 2 days before starting him back on the Stalevo and 1/2 of Carbidopa/Levo at breakfast and gradually increasing his dosage of Carbidoa/Levo. He did wonderful when he was off the meds for the 2 days and the first 3 days of taking the 1/2 of Carbidopa/Levo. Currently he is back on the Stalevo 3x day and Arizect 1mg 1x/day, but is hullucinting quite a bit night and day. It seems that the less he sleeps the more he hullucintates which causes him to lose sleep, a vicious cycle. Would it be ok to stop all his meds for 1 or 2 days in an attempt to get him to stop hullucinating which may help him sleep?

I also want to say that I appreciate the time you take to answer my questions. Thank you so very much!

#5 Dr. Okun

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Posted 03 March 2012 - 05:11 PM

Drug holidays can be very dangerous and we never recommend abruptly stopping PD meds (can precipitate a condition called neuroleptic malignant syndrome).

For hallucinations a better approach you can discuss with your doctor is to switch to regular sinemet instead of Stalevo (Comtan can push up drug levels and result in hallucinations). We also usually get away from MAO, amantadine, and dopamine agonists...but this is not always true.

We like to titrate by 1/2 and sometimes quarter tablets until we find the right dose and interval to keep patients on without hallucinations. (could be for example sinemet 25/100 1 1/2 every 2 hours). If you can't get the right dose or interval with this strategy, then we also add either seroquel or clozaril to control hallucinations.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips




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