• Parkinson’s disease psychosis (PDP) most commonly involves hallucinations and delusions. It usually happens in older people with Parkinson’s or those who have been on a higher dosage of medication.
• An important step in treating psychosis in Parkinson’s may include cutting out or decreasing certain medications. If symptoms don’t improve, antipsychotic medications may be added.
• Unfortunately, the development of Parkinson’s psychosis is associated with a higher risk of death.

Most people living with Parkinson’s disease eventually develop some symptoms of Parkinson’s disease psychosis, including hallucinations and delusions. If you or your loved one are living with Parkinson’s, educating yourself about treatment options for psychotic symptoms and what psychosis may mean for life expectancy can help you feel better prepared.

Treating PDP involves making changes to existing medications and adding antipsychotic medication if psychosis symptoms continue. The first step requires getting a confirmed diagnosis of Parkinson’s psychosis from a neurologist experienced in treating movement disorders.

Diagnosing Parkinson’s Disease Psychosis

Hallucinations and delusions are the most common symptoms of PDP. People with Parkinson’s are at a higher risk for developing psychotic symptoms if they’re older and/or require higher doses of dopaminergic medications.

Diagnosing Parkinson’s psychosis can be complex. A health care provider trained in managing Parkinson’s needs to be involved in diagnosis and treatment for you or your loved one. To properly diagnose PDP, a health care provider will rule out other diseases and disorders that can also cause psychosis, such as dementia with Lewy bodies, schizophrenia, delirium, or major depression with psychosis.

PDP can be a side effect of Parkinson’s medicine. Psychosis can also emerge as part of the brain changes involved in Parkinson’s as the disease progresses.

Once a health care provider has confirmed that the psychosis hasn’t come from another disease or disorder, they’ll also make sure of the following:

• The person with Parkinson’s has, in fact, been experiencing hallucinations or delusions.
• Parkinson’s symptoms began before any of the psychosis symptoms.
• The psychosis symptoms have been happening either continually or every now and then for at least one month.

Learn more about what causes Parkinson’s psychosis.

Treatment Options for Parkinson’s Disease Psychosis

Psychosis in Parkinson’s is a serious medical concern. A properly trained physician, such as a neurologist or psychiatrist, should be in charge of treating it. Once the physician has confirmed Parkinson’s psychosis, they’ll recommend treatment options.

The First Step: Modifying Parkinson’s Medications

The first step in treating PDP is usually to cut out or decrease the dosage of certain medications. “When I first started taking a new drug four times daily, the night hallucinations were dreadful,” one MyParkinsonsTeam member shared. “When I told my neurologist about these, she dropped the medication to three per day, and I have to take my last one no later than 5 p.m., otherwise I will hallucinate.”

Health care providers usually remove PD drugs in the following order:

• Anticholinergics block the effect of the neurotransmitter acetylcholine in the brain, helping to offset lowered dopamine levels in the brain. Trihexyphenidyl and benztropine mesylate (Cogentin) are examples of this class of drug.
• Amantadine — sold as Gocovri and Symmetrel — is used to increase the level of dopamine in the brain, which can help control movement difficulty in people with Parkinson’s. One MyParkinsonsTeam member reported, “I had hallucinations years ago with amantadine, but my doctor reduced the dosage and they stopped.”
• Dopamine agonists imitate the effect of dopamine in the brain and can help manage the movement symptoms of Parkinson’s. Pramipexole dihydrochloride (Mirapex), rotigotine transdermal system (Neupro), bromocriptine mesylate (Parlodel), and ropinirole (Requip) are all examples of dopamine agonists.

Some clinicians may also cut out the following types of medications:

• Monoamine oxidase inhibitors (MAOIs) are used to increase dopamine levels in the brain by slowing the breakdown of dopamine. Rasagiline (Azilect), selegiline (Eldepryl or Zelapar), and safinamide (Xadago) are examples of MAOIs.
• Catechol-O-methyl transferase (COMT) inhibitors are used mainly to extend the effect of levodopa so it doesn’t wear off as quickly. Entacapone (Comtan), opicapone (Ongentys), and tolcapone (Tasmar) are all COMT inhibitors.

Often, when people with Parkinson’s stop taking these medications, they experience an increase in the other symptoms the drugs had been keeping at bay. In these cases, a doctor may increase the dosage of levodopa. Levodopa helps to manage the movement problems of Parkinson’s, so it can help counteract the increase in symptoms.

The Next Step: Adding Antipsychotic Medication

Many people with Parkinson’s psychosis will still have psychosis symptoms after making changes to their existing medication. These psychosis symptoms may be mild at this point, and the doctor may just want to monitor them for a while.

For people whose hallucinations and delusions become serious, a health care provider may prescribe medications to manage these symptoms. Below are the primary drugs used to treat psychosis in people with Parkinson’s:

• Nuplazid, a formulation of pimavanserin, is approved by the U.S. Food and Drug Administration (FDA) for the treatment of hallucination and delusions in Parkinson’s psychosis. It is the first drug specifically approved to treat Parkinson’s psychosis. Clinical trial results showed it was superior to a placebo (“sugar pill”) for lessening hallucinations and delusions without increasing the motor symptoms of Parkinson’s.

• Clozapine (Clozaril, FazaClod ODT, Versacloz) is an antipsychotic that usually does not significantly worsen the motor signs of PD. Two studies separately showed that clozapine works better than a placebo for PDP. Treatment with this drug requires frequent blood testing to monitor for serious side effects that may affect the bone marrow.

• Seroquel, a formulation of quetiapine, is an FDA-approved antipsychotic that some doctors prescribe off-label to manage PDP. Doctors usually consider quetiapine when both pimavanserin and clozapine are ineffective in treating psychosis symptoms.

A MyParkinsonsTeam member reported, “Nuplazid is helpful for hallucinations and delusions. It’s expensive, but most insurance covers it with prior approval from the neurologist. My dad started it almost one month ago, and he isn’t hallucinating as much in the morning.”

Another member shared, “I’m taking Seroquel for my hallucinations. No problems anymore.”

Learn more about ways to manage hallucinations and delusions.

Life Expectancy With Parkinson’s Psychosis

Symptoms of Parkinson’s psychosis seem to negatively influence life expectancy. People with Parkinson’s who develop psychosis have a much higher risk of death compared with those who haven’t developed psychotic symptoms. The use of antipsychotic drugs to treat these symptoms is also associated with increased mortality.

Symptoms of PDP can also significantly affect caregivers and loved ones. Read tips for caregivers dealing with hallucinations and delusions.

Talk With Others Who Understand

On MyParkinsonsTeam — the social network for people with Parkinson’s disease and their loved ones — more than 98,000 members come together to ask questions, give advice, and share their stories with others who understand life with Parkinson’s disease.

Are you or your loved one living with symptoms of Parkinson’s psychosis? Have you found any treatment options that help? Ask a question or share your experience in the comments below, or start a conversation by posting on your Activities page.