How are hallucinations and delusions managed in patients with Parkinson-plus syndromes?

Updated: Sep 24, 2018
  • Author: Stephen M Bloomfield, MD; Chief Editor: Selim R Benbadis, MD  more...
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Pimavanserin (Nuplazid) was approved in April 2016 for treatment of hallucinations and delusions associated with Parkinson disease psychosis. It is the first drug to be approved for this condition. It is a selective serotonin inverse agonist (SSIA). It not only preferentially targets 5-HT2A receptors, but also avoids activity at dopamine and other receptors commonly targeted by antipsychotics. Efficacy was shown in a 6-week clinical trial (n=199) where it was shown to be superior to placebo in decreasing the frequency and/or severity of hallucinations and delusions without worsening the primary motor Parkinson disease symptoms (p=0.001). [48]

Hallucinations can also be alleviated to some extent with older neuroleptics (eg, quetiapine, clozapine), but these can cause marked increase in rigidity and are best avoided. Dementia is the most difficult symptom to treat in this setting. Donepezil and rivastigmine can be tried but do not have any dramatic effect and potentially can worsen motor symptoms. A comprehensive neuropsychological evaluation repeated at intervals of 1 year can help in assessing the progression of cognitive symptoms in a quantitative way and can suggest coping methods.

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