• Parkinson’s disease (PD) psychosis most commonly involves hallucinations and delusions. It usually happens in older people with PD or those who have been on a higher dosage of medication.
• The first step in treating psychosis in PD involves cutting out or decreasing certain medications, often in a specific order.
• Diagnosing Parkinson’s disease psychosis can be difficult, so a properly trained physician should be in charge of the case.

Treating Parkinson’s disease psychosis involves making changes to existing medications and adding medication if psychosis symptoms continue. Hallucinations and delusions are the most common symptoms of Parkinson’s psychosis. Psychosis most commonly happens in older people with PD or those who need higher doses of dopaminergic medications.

Diagnosing Parkinson’s psychosis can be complex. A health care provider trained in managing PD needs to be involved in diagnosis and treatment for you or your loved one.

What Is Parkinson’s Disease Psychosis?

Hallucinations and delusions are the most common symptoms of Parkinson’s psychosis. Hallucinations involve a person seeing, hearing, feeling, smelling, or tasting something that isn’t really present. Most hallucinations in PD psychosis are visual, where someone sees a person or an animal.

Delusions are ongoing thoughts that are not based in the real world. A person with delusions does not intentionally try to have these thoughts. These may include being jealous, feeling persecuted, or fixating on one’s own body or health.

When describing their first hallucination, one MyParkinsonsTeam member said, “In my living room I saw a little boy covered in fur. Lasted a good eight seconds, vivid and defined. I wasn’t startled, just curious and absolutely believed it was real — until it vanished.”

Learn more about recognizing hallucinations and delusions.

Diagnosing Parkinson’s Disease Psychosis

To properly diagnose psychosis in Parkinson’s, 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.

PD psychosis 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 your 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 PD 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.

Treatment Options for Parkinson’s Disease Psychosis

Psychosis in PD 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 will begin treatment.

One MyParkinsonsTeam member mentioned, “Please make sure your doctor knows about your hallucinations. They do have medicines for them.”

Simplifying Parkinson’s Disease Medications

The first step in treating psychosis in Parkinson’s disease is 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 PD. 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 PD. 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 make the effect of levodopa last longer, so it does not wear off as quickly. Entacapone (Comtan), opicapone (Ongentys), and tolcapone (Tasmar) are all COMT inhibitors.

Often, when people with PD stop taking these medications, they experience an increase in the other PD 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 PD, so it can help counteract the increase in symptoms.

Adding Medication If Psychosis Symptoms Continue

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.

If 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:

• Pimavanserin (Nuplazid) 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 PD.
• Clozapine 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 psychosis in PD. Treatment with this drug requires frequent blood testing to monitor for serious side effects that may affect the bone marrow.
• Quetiapine (Seroquel) is an antipsychotic approved by the FDA for schizophrenia, but it can be prescribed off-label to manage psychosis in PD. Doctors usually consider quetiapine when pimavanserin and clozapine are both 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 is not hallucinating as much in the morning.”

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

Talk With Others Who Understand

MyParkinsonsTeam is the social network for people with Parkinson’s disease and their loved ones. On MyParkinsonsTeam, more than 84,000 members come together to ask questions, give advice, and share their stories with others who understand life with Parkinson’s disease.

Has your loved one been diagnosed with Parkinson’s psychosis? Do you have questions about Parkinson’s psychosis? Ask your question or share your experience in the comments below, or start a conversation by posting on your Activities page.