Use of ziprasidone in parkinsonian patients with psychosis

Second-generation antipsychotics for Parkinson's disease psychosis: A systematic review and network meta-analysis

OBJECTIVE

This network meta-analysis assessed the efficacy, tolerability, and acceptability of second-generation antipsychotics (SGAs) for Parkinson's disease psychosis (PDP).

METHODS

We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov for randomized controlled trials investigating SGAs for PDP up to October 26, 2023.

RESULTS

We included 16 trials (N = 1252) investigating clozapine, melperone, olanzapine, pimavanserin, quetiapine, ulotaront, and placebo. In comparisons between SGAs and placebo, the findings were: i) Standardized mean differences, 95% confidence intervals (SMDs, 95%CIs), for psychotic-symptom reduction revealed the first rank of clozapine (-1.31, -1.73 to -0.89), the second rank of pimavanserin, with significant inferiority of quetiapine (SMD = 0.47, 0.02 to 0.92); ii) Mean differences (MDs, 95%CIs) for abnormal movement, as assessed by the Unified Parkinson's Disease Rating Scale - Part III, indicated that clozapine had the least motor side effects (-0.92, -2.75 to 0.91); iii) Risk ratios (RRs, 95% CIs) for adverse-effect dropout rates were lowest for melperone (1.02, 0.20 to 5.24); and iv) RRs (95% CIs) for all-cause dropout rates were lowest for clozapine (0.73, 0.42 to 1.25).

CONCLUSIONS

For patients with PDP, clozapine may substantially reduce psychotic symptoms with minimal abnormal movement, high acceptability, and moderate overall tolerability. Pimavanserin, not quetiapine, could be an alternative.

Drug repositioning based on weighted local information augmented graph neural network

Drug repositioning, the strategy of redirecting existing drugs to new therapeutic purposes, is pivotal in accelerating drug discovery. While many studies have engaged in modeling complex drug-disease associations, they often overlook the relevance between different node embeddings. Consequently, we propose a novel weighted local information augmented graph neural network model, termed DRAGNN, for drug repositioning. Specifically, DRAGNN firstly incorporates a graph attention mechanism to dynamically allocate attention coefficients to drug and disease heterogeneous nodes, enhancing the effectiveness of target node information collection. To prevent excessive embedding of information in a limited vector space, we omit self-node information aggregation, thereby emphasizing valuable heterogeneous and homogeneous information. Additionally, average pooling in neighbor information aggregation is introduced to enhance local information while maintaining simplicity. A multi-layer perceptron is then employed to generate the final association predictions. The model's effectiveness for drug repositioning is supported by a 10-times 10-fold cross-validation on three benchmark datasets. Further validation is provided through analysis of the predicted associations using multiple authoritative data sources, molecular docking experiments and drug-disease network analysis, laying a solid foundation for future drug discovery.

Systematic Review on Parkinson's Disease Medications, Emphasizing on Three Recently Approved Drugs to Control Parkinson's Symptoms

Parkinson's Disease (PD) is a disease that involves neurodegeneration and is characterised by the motor symptoms which include muscle rigidity, tremor, and bradykinesia. Other non-motor symptoms include pain, depression, anxiety, and psychosis. This disease affects up to ten million people worldwide. The pathophysiology behind PD is due to the neurodegeneration of the nigrostriatal pathway. There are many conventional drugs used in the treatment of PD. However, there are limitations associated with conventional drugs. For instance, levodopa is associated with the on-off phenomenon, and it may induce wearing off as time progresses. Therefore, this review aimed to analyze the newly approved drugs by the United States-Food and Drug Administration (US-FDA) from 2016-2019 as the adjuvant therapy for the treatment of PD symptoms in terms of efficacy and safety. The new drugs include safinamide, istradefylline and pimavanserin. From this review, safinamide is considered to be more efficacious and safer as the adjunct therapy to levodopa as compared to istradefylline in controlling the motor symptoms. In Study 016, both safinamide 50 mg (p = 0.0138) and 100 mg (p = 0.0006) have improved the Unified Parkinson's Disease Rating Scale (UPDRS) part III score as compared to placebo. Improvement in Clinical Global Impression-Change (CGI-C), Clinical Global Impression-Severity of Illness (CGI-S) and off time were also seen in both groups of patients following the morning levodopa dose. Pimavanserin also showed favorable effects in ameliorating the symptoms of Parkinson's Disease Psychosis (PDP). A combination of conventional therapy and non-pharmacological treatment is warranted to enhance the well-being of PD patients.

Effect of biological treatments on psychotic symptoms in lewy body disease: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Parkinson disease and dementia with Lewy bodies (collectively termed Lewy body disease) are common neurodegenerative conditions of later life and are frequently associated with distressing psychotic symptoms. The best approach to manage these symptoms is yet to be established and current treatments carry the risk of serious adverse effects.

METHODS

We performed a systematic review and meta-analysis of 19 randomized controlled trials investigating the efficacy of biological treatments for psychotic symptoms in Lewy body disease.

RESULTS

The summary effect estimate did not show a statistically significant benefit of biological treatments for psychotic symptoms in Lewy body disease (SMD -0.48, 95%CI -1.01 to 0.04). This was irrespective of the choice of intervention (SMD -0.53, 95%CI -1.20 to 0.14 for antipsychotic trials) or disease status (SMD -0.59, 95%CI -1.24 to 0.05 for trials of Parkinson disease). There was a significant effect for biological treatments compared with placebo in trials that lasted at least 6 weeks (SMD -0.25, 95%CI -0.43 to -0.08) and those with sample sizes greater than 100 participants (SMD of -0.28 95%CI -0.45 to -0.11).

CONCLUSIONS

In this systematic review and meta-analysis, treatment of psychotic symptoms by biological means did not improve symptoms compared with placebo. Small sample sizes, modest treatment durations, and other methodological differences across the trials do make it difficult to draw firm conclusions. Longer, adequately powered trials utilizing established and novel treatments are needed to provide more definitive evidence to guide clinicians in the best choice of agent to treat these distressing and often persistent symptoms.

A Systematic Review and Case Series of Ziprasidone for Psychosis in Parkinson's Disease

The atypical antipsychotic ziprasidone has been considered inappropriate for use in patients with Parkinson’s disease (PD), as most atypical antipsychotics worsen parkinsonism. However, the current evidence for safety and efficacy of ziprasidone in PDP has not been evaluated in a systematic fashion. We review published experience with ziprasidone for treating psychosis in PD via systematic search of MEDLINE, Embase, Cochrane CENTRAL, and Clinicaltrials.gov with terms related to “ziprasidone” and “Parkinson’s disease”, inclusive of case reports and prospective studies. We also add seven cases of ziprasidone exposure in patients in our center with idiopathic PD or Lewy body dementia (DLB), selected by retrospective query of all clinical data since 1996. In our review, two prospective trials and 11 case reports or series were found, with ziprasidone found to be generally effective for treatment of psychosis and with few adverse events reported. Our case series did not support efficacy of ziprasidone; it was generally safe in PD, but two patients with DLB had adverse motor events. We conclude that, although ziprasidone occasionally can produce substantial worsening of motor signs, it usually is well tolerated, and may provide in some cases a useful alternative to quetiapine, clozapine and pimavanserin, particularly in the acute care setting. Further randomized controlled studies are needed.

Treatment of psychiatric disturbances in hypokinetic movement disorders

Introduction: We reviewed studies that assessed the treatment of psychiatric disturbances in Parkinson's disease and atypical parkinsonisms. Neuropsychiatric disturbances in these conditions are frequent and have a profound impact on quality of life of patients and of their caregivers. It is therefore important to be familiar with the appropriate pharmacological and non-pharmacological interventions for treating these disorders. Areas covered: The authors searched for papers in English in Pubmed using the following keywords: Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia, depression, apathy, anxiety, fatigue, sleep disorders, obsessive compulsive disorders, psychosis, hallucinations, delusions, impulse control disorders. Expert opinion: In Parkinson's disease, depression may benefit from the optimization of dopaminergic therapy, from the use of antidepressants acting on both the serotoninergic and noradrenergic pathways and from cognitive behavioral therapy. Psychosis in Parkinson's disease may improve with the use of clozapine; the serotonin inverse agonist pimavanserin has been shown to be effective. Treatment of impulse control disorders is primarily based on the removal of dopamine agonists. No controlled studies have investigated the treatment of neuropsychiatric disorders in multiple system atrophy, progressive supranuclear palsy or corticobasal degeneration. Acethylcholinesterase inhibitors may be used to treat hallucinations in Lewy body dementia.

Neuropsychiatric Issues in Parkinson's Disease

Cognitive and neuropsychiatric symptoms are common in Parkinson's Disease and may surpass motor symptoms as the major factors impacting patient quality of life. The symptoms may be broadly separated into those associated with the disease process and those that represent adverse effects of treatment. Symptoms attributed to the disease arise from pathologic changes within multiple brain regions and are not restricted to dysfunction in the dopaminergic system. Mood symptoms such as depression, anxiety, and apathy are common and may precede the development of motor symptoms by years, while other neuropsychiatric symptoms such as cognitive impairment, dementia, and psychosis are more common in later stages of the disease. Neuropsychiatric symptoms attributed to treatment include impulse control disorders, pathologic use of dopaminergic medications, and psychosis. This manuscript will review the current understanding of neuropsychiatric symptoms in Parkinson's Disease.

The Efficacy and Safety of Antipsychotic Medications in the Treatment of Psychosis in Patients with Parkinson's Disease

Psychotic symptoms are present in up to 50% of patients with Parkinson's disease. These symptoms have detrimental effects on patients' and caregivers' quality of life and may predict mortality. The pathogenesis of psychotic symptoms in Parkinson's disease is complex, but the use of dopaminergic medications is one of the risk factors. The treatment of psychotic symptoms in Parkinson's disease is complicated due to the ability of antipsychotic medications to worsen motor symptoms. The efficacy of clozapine in the treatment of psychosis in patients with Parkinson's disease has been confirmed in several clinical trials; however, the adverse effects and the necessity of blood count monitoring are the reasons why the use of this drug is challenging. The studies on safety and efficacy of other antipsychotics conflicting results. The use of antipsychotics in these patients is also associated with increased mortality. Psychotic symptoms in Parkinson's disease per se are also proven predictors of mortality. Thus it is necessary to treat psychotic symptoms but the choice of an antipsychotic should be based on careful risk/benefit assessment. Pimavanserin as a novel therapeutic option with more favorable adverse effects profile is now available for this indication, but careful postmarketing monitoring is necessary to establish the true picture of this drug's long-term safety and efficacy.

Adverse reactions to antipsychotics in Parkinson disease: an analysis of the Spanish pharmacovigilance database

PURPOSE

Although antipsychotics are well known for causing a plethora of adverse drug reactions (ADRs), the main concern when used to treat psychosis in Parkinson disease (PD) has traditionally been motor function worsening. The limited number of patients included in clinical trials contributes to underreport less common ADR. The aims of this study were to describe ADR to antipsychotics occurring in patients with PD notified to the Spanish Pharmacovigilance System and to contrast them with published reports.

METHODS

All notifications from the Spanish Pharmacovigilance System for the last 30 years (1984-2014) where an antipsychotic was considered suspicious of the ADR in patients who were also on dopaminergic therapy were reviewed. In addition, a systematic search of MEDLINE (1966-2014) was conducted with the following Medical Subject Headings (MeSH) terms: "Parkinson disease" and "antipsychotic agents" or "psychotic disorders" and "drug-related side effects" or "adverse reactions."

RESULTS

Forty-four notifications were selected for evaluation. Quetiapine was the most frequently implicated drug since 2002, and previously clozapine was the drug implied in higher number of notifications. The most severe ADR was neuroleptic malignant syndrome, which was described in 5 patients (3 cases related to quetiapine, one to haloperidol, and another to olanzapine).

CONCLUSIONS

Some previously unreported ADRs caused by antipsychotic drugs in patients with PD have been described for the first time in this study, although there are in general well-known antipsychotic adverse effects. It is remarkable that some notifications involve the use of drugs not recommended in these patients.

[Parkinson's disease and psychoses]

Psychotic symptoms are common in Parkinson's disease (PD) and are associated with increased disability, worsened quality of life, and poor long-term prognosis. In this article, clinical features, hypotheses on pathogenesis, and current treatment strategies for Parkinson's disease psychosis (PDP) are reviewed. According to epidemiological studies, the prevalence of PDP is between 20 to 40 %. Complex visual hallucinations are the most common psychotic symptoms and are present in 17-72 % of the patients. Other sensory disturbances encompass tactile hallucinations and minor hallucinatory phenomena, such as sense of presence and visual illusions. Hallucinations are often accompanied by delusions, whose most frequent themes are persecution and jealousy. The pathophysiology of PDP remains unclear. Different factors have been implicated, including Levo-dopa and dopaminergic medications, neurotransmitter imbalances, neuroanatomic alterations, abnormal visuospatial processes, and genetic predisposition. The first-line strategy in the treatment of persistent and problematic PDP is represented by reduction in anti-PD medications. Second-generation antipsychotics are the treatment of choice, with clozapine being demonstrated as the most effective and tolerable drug for PD patients.

Behavioral effects of levodopa

In recent years, levodopa-induced behavioral changes have received increased attention in the medical literature and in clinical practice. The spectrum of these symptoms includes non-motor fluctuations with neuropsychiatric symptoms, compulsive behaviors such as punding, dopamine dysregulation syndrome, and impulse control disorders, psychosis and hallucinations, as well as hypomania and mania. Despite knowledge of the clinical features associated with these behaviors, many of them are probably underdiagnosed. Although the mechanisms underlying behavioral symptoms are still incompletely understood, recent data from imaging and pathological studies have increased our understanding and guided new treatment strategies. Appropriate management remains challenging, because reduction of levodopa (l-dopa) and dopaminergic treatment is often recommended; however, doses required for control of motor symptoms may still induce behavioral changes. Newer modes of delivery of dopaminergic treatment, deep brain stimulation, and nondopaminergic agents may either provide alternatives for treatment of these behavioral problems or permit treatment of parkinsonism with less risk of these behavioral disorders.

Almost all antipsychotics result in weight gain: a meta-analysis

Introduction

Antipsychotics (AP) induce weight gain. However, reviews and meta-analyses generally are restricted to second generation antipsychotics (SGA) and do not stratify for duration of AP use. It is hypothesised that patients gain more weight if duration of AP use is longer.

Method

A meta-analysis was conducted of clinical trials of AP that reported weight change. Outcome measures were body weight change, change in BMI and clinically relevant weight change (7% weight gain or loss). Duration of AP-use was stratified as follows: ≤6 weeks, 6–16 weeks, 16–38 weeks and >38 weeks. Forest plots stratified by AP as well as by duration of use were generated and results were summarised in figures.

Results

307 articles met inclusion criteria. The majority were AP switch studies. Almost all AP showed a degree of weight gain after prolonged use, except for amisulpride, aripiprazole and ziprasidone, for which prolonged exposure resulted in negligible weight change. The level of weight gain per AP varied from discrete to severe. Contrary to expectations, switch of AP did not result in weight loss for amisulpride, aripiprazole or ziprasidone. In AP-naive patients, weight gain was much more pronounced for all AP.

Conclusion

Given prolonged exposure, virtually all AP are associated with weight gain. The rational of switching AP to achieve weight reduction may be overrated. In AP-naive patients, weight gain is more pronounced.

A fixed-dose randomized controlled trial of olanzapine for psychosis in Parkinson disease

Background: Psychosis is a common and debilitating side effect of long-term dopaminergic treatment of Parkinson disease (PD). While clozapine is an effective treatment, the need for blood monitoring has limited its first-line use. 

Objective: Since olanzapine shows similar receptor affinity to clozapine, we hypothesized that it might be an effective alternative to clozapine for treatment of drug-induced psychosis (DIP) in PD, and that lower doses than usual might make it tolerable.

Methods: In 1998-2003 we conducted a four-week, double-blind, placebo-controlled, parallel group, fixed-dose trial of olanzapine (0, 2.5mg, or 5mg) in 23 PD patients with DIP while allowing for clinically realistic dose adjustments of dopaminomimetic mid-study. The primary outcome measures were Brief Psychiatric Rating Scale (BPRS) ratings scored from videotaped interviews after study termination by an observer blinded to dose assignment and to interview timing, and CGI (Clinical Global Impression). The Unified Parkinson’s Disease Rating Scale motor subscale (UPDRS) was the primary measure of tolerability.

Results: Intention-to-treat analysis found no significant differences among treatment groups in study completion or serious adverse events. However, a disproportionate number of olanzapine vs. placebo subjects reported mild side effects (p<0.04), many citing motor worsening. Fourteen patients completed the study (seven on placebo, two on 2.5mg olanzapine, five on 5mg olanzapine). In study completers, analysis by repeated measures ANOVA revealed no significant difference between olanzapine and placebo groups in BPRS psychosis reduction (p=0.536), parkinsonism (p=0.608), or any other measured parameters (CGI, MMSE, Beck Depression Inventory, Hamilton Depression score, PDQ‑39, Schwab-England ADL assessment, and sleep scores).

Conclusion: This study adds to other evidence that olanzapine is ineffective in treating medication-induced psychosis in Parkinson disease.

Psychiatric care in Parkinson's disease

OBJECTIVE

Parkinson's disease (PD) is a degenerative and disabling disease in which medical providers focus mainly on ameliorating problems in day-to-day functioning. This review summarizes current knowledge about the efficacy and tolerability of psychopharmacological agents in the treatment of depression, anxiety, psychosis, and insomnia in patients with PD. Recommended or promising nonpharmacological interventions are also reviewed.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULT

Findings in the research literature provide growing evidence concerning the antidepressant treatment of patients with PD. Psychoeducational interventions for managing depression and anxiety symptoms also appear promising. Music therapy has proven to be particularly effective for patients with PD. Psychosis is common in patients with PD. When psychosis is induced by antiparkinson drugs, a dose reduction can be considered, but it is seldom successful. Patients with PD do not generally tolerate conventional antipsychotic medications, justifying evaluation of newer atypical agents in this population. Cholinesterase inhibitors have also become increasingly important in the treatment of PD in recent years. Finally, insomnia is a very frequent complaint in patients with PD and may also contribute to the development of depression. Patients should be encouraged to improve sleep hygiene and use behavioral interventions. Definitive trials of treatments for sleep disorders in this population are also warranted.

CONCLUSION

Therapeutic approaches to the treatment of PD and its associated psychiatric symptoms must be individualized and may involve a combination of antiparkinson drugs, psychopharmacological treatment, and/or psychotherapeutic interventions.

Ziprasidone versus clozapine in the treatment of psychotic symptoms in Parkinson disease: a randomized open clinical trial

OBJECTIVE

To compare the efficacy and safety of ziprasidone versus clozapine in patients with psychotic symptoms in Parkinson disease.

METHODS

A 4-week, randomized, single-blind, open-label, parallel comparison of ziprasidone and clozapine was completed. Sixteen patients with Parkinson disease were included. Psychosis was assessed using the Brief Psychiatric Rating Scale (BPRS), and the Scale for the Assessment of Positive Symptoms (SAPS). The Unified Parkinson's Disease Rating Scale and the Abnormal Involuntary Movement Scale were used to assess motor conditions during the study period. Measures of drugs' adverse effects, white blood cell count, and the Clinical Global Impression Scale-Severity Subscale were performed. Cognitive changes were assessed with the Mini-Mental State Examination.

RESULTS

Fourteen patients completed the study, 8 patients on clozapine and 6 patients on ziprasidone. The final mean dosage for clozapine was 32.14 mg/d and that for ziprasidone was 35 mg/d. Throughout the study, neither the Unified Parkinson's Disease Rating Scale, the Abnormal Involuntary Movement Scale, or the Mini-Mental State Examination showed statistical differences in both groups. Psychotic symptoms, assessed with SAPS and BPRS, were reduced in both groups but with more intensity in the ziprasidone group (effect size in SAPS, 1.3, and effect size in BPRS, 1.7) than in the clozapine group (effect size in SAPS, 0.36, and effect size in BPRS, 0.53).

CONCLUSIONS

Ziprasidone seems to be at least as effective as clozapine in the treatment to ameliorate psychotic symptoms in PD.

Atypical Antipsychotic Drugs in the Treatment of Parkinson’s Disease

Parkinson’s disease (PD) patients often develop psychotic symptoms that severely affect quality of life and limit the use of medications to ameliorate motor symptoms. Psychotic symptoms are a major cause for nursing home placement. While these symptoms do not always require treatment, they often do but antipsychotic drugs all share the common pharmacological mechanism of blocking dopamine D2 receptors which may worsen motor problems in this very vulnerable population. Double blind, placebo controlled trials (DBPCT) have shown that clozapine is effective at controlling the psychotic symptoms at doses far below those used in schizophrenia, without worsening motor function, even improving tremor. DBPCT have demonstrated that olanzapine worsens motor function without improving psychosis. Quetiapine has been shown in DBPCT to be free of motor side effects in PD patients but not effective, whereas many open label studies have indicated that quetiapine is effective. The other atypical have been the subjects of conflicting open label reports. The effects of the atypicals in PD psychosis is reviewed.

An update expert opinion on management and research strategies in Parkinson's disease psychosis

INTRODUCTION

Psychosis, a frequent complication in Parkinson's disease (PD), contributes significantly to morbidity, mortality, nursing-home placement and quality of life. Medication side effects, issues of trial design and negative outcomes have limited clinical advances of new treatments for PD psychosis. Evidence-based medicine maintains clozapine as the most effective antipsychotic in PD without motor worsening, despite risk of agranulocytosis. Safe, effective treatments that improve psychosis without exacerbating parkinsonism are urgently needed.

AREAS COVERED

This article reviews the: i) phenomenology of PD psychosis, ii) pharmacological rationale for antipsychotics in PD; iii) clinical trials of antipsychotics in PD; iv) novel research strategies such as neuroimaging, genetics and animal models; and v) associated challenges in studying and treating PD psychosis. Preparation of this review included an extensive literature search using PubMed.

EXPERT OPINION

Management of PD psychosis is complex. Challenges pertaining to study design, rating scales, subject recruitment and completion have limited PD psychosis treatment trials. Novel research strategies focus on nondopaminergic systems and incorporate neuroimaging, genetic associations and animal models. These strategies also have challenges but have the potential to enhance our understanding of PD psychosis and advance the development of agents that can ultimately be tested in well-designed, randomized, controlled trials.

The serotonergic system in Parkinson's disease

Although the cardinal manifestations of Parkinson's disease (PD) are attributed to a decline in dopamine levels in the striatum, a breadth of non-motor features and treatment-related complications in which the serotonergic system plays a pivotal role are increasingly recognised. Serotonin (5-HT)-mediated neurotransmission is altered in PD and the roles of the different 5-HT receptor subtypes in disease manifestations have been investigated. The aims of this article are to summarise and discuss all published preclinical and clinical studies that have investigated the serotonergic system in PD and related animal models, in order to recapitulate the state of the current knowledge and to identify areas that need further research and understanding.

Managing psychosis in Parkinson’s disease

SUMMARY Psychotic symptoms are common in drug-treated Parkinson’s disease patients. These consist primarily of visual hallucinations, but also include other symptoms, in particular auditory symptoms. Delusions are considerably less common but are more problematic because they are most commonly paranoid in nature. Psychotic symptoms carry a poor prognosis in terms of an increased risk of imminent dementia, nursing home placement and death. Only clozapine has level I evidence to support its use, but quetiapine is usually used first as it is sometimes helpful and is the only other antipsychotic drug proven not to worsen motor function in Parkinson’s disease. There is less support for the use of cholinesterase inhibitors. Electroconvulsive therapy may be used in extremis, when all else fails.

Incidence, prescription patterns, and determinants of antipsychotic use in patients with Parkinson's disease

Empirical data regarding the choice of antipsychotics for the management of psychosis in patients with Parkinson's disease are limited. This study aimed to evaluate the incidence and prescribing patterns of antipsychotics and to determine the predictors associated with the prescribing of typical antipsychotics in patients with Parkinson's disease. This was a retrospective cohort study analyzing data from the National Health Insurance Research Database in Taiwan between January 1, 2000, and December 31, 2006, in which patients with Parkinson's disease (ICD-9-CM codes 332) initially receiving any antiparkinsonian drug (n = 2095) were followed up to evaluate the subsequent use of antipsychotics. Kaplan-Meier statistics and multiple logistic regression were employed to evaluate the cumulative probability of antipsychotic use and determinants of prescribing of typical antipsychotics, respectively. The cumulative probability of initiation of an antipsychotic within 6 years was found to be 51%, and the proportion of patients who began taking an atypical antipsychotic increased from 11.1% in 2001 to 36.1% in 2005. Physician specialty was found to be the most influential predictor of the prescribing of typical antipsychotics: physicians with an internal medicine specialty were 10.62 times more likely (95% confidence interval, 4.64-24.32) to prescribe typical antipsychotics than were neurologists. The use of antipsychotics in Parkinson's disease is common, and the use of typical antipsychotics dominates antipsychotic treatment. Particular attention needs to be paid to improving practice, including efforts that encourage primary care providers to have the appropriate choice of antipsychotics in patients with Parkinson's disease.

Nonmotor symptoms in Parkinson’s disease: the dark side of the moon

Nonmotor symptoms may appear during the course of Parkinson’s disease, complicating the advanced phase in particular, but are also common in the premotor phase of Parkinson’s disease. The appearance of nonmotor manifestations represents a milestone, determining a worse prognosis and lower quality of life; however, they are often misdiagnosed and untreated. The spectrum of nonmotor symptoms encompasses mood disorders, psychosis, dementia, sleep disorders, impulse-control disorders and autonomic dysfunctions. This article describes these nonmotor symptoms and their management.

Parkinson's disease psychosis 2010: a review article

Psychotic symptoms are common in Parkinson's disease (PD), generally associated with the medications used to treat the motor symptoms. On rare occasion they occur in patients not taking medication for PD. Psychotic symptoms are usually hallucinations, typically visual, less commonly auditory, and rarely in other domains. Hallucinations are generally stereotyped and without emotional content. Initially patients usually have insight so that the hallucinations are benign in terms of their immediate impact but have poor prognostic implications, with increased risk of dementia, worsened psychotic symptoms and mortality. Delusions occur in about 5-10% of drug treated patients and are considerably more disruptive, being paranoid in nature, often of spousal infidelity or abandonment by family. Treatment of Parkinson's disease psychosis (PDP) focuses on reducing the psychiatric symptom load while balancing the competing problem of mobility. Contributors to the psychotic symptoms should be searched for, such as systemic illness and other psycho-active medications. If none are identified or can be eliminated then the PD medications should be reduced to the lowest levels that allow tolerable motor function. Once this level has been reached there are two schools of thought on treatment, using either acetylcholinesterase inhibitors or atypical anti-psychotics. Only clozapine has level I evidence to support its use. Quetiapine is the only other anti-psychotic free of motor side effects, but it has failed double blind placebo controlled trials to demonstrate efficacy.

Current approaches to the treatment of Parkinson's disease

Enormous progress has been made in the treatment of Parkinson's disease (PD). As a result of advances in experimental therapeutics, many promising therapies for PD are emerging. Levodopa remains the most potent drug for controlling PD symptoms, yet is associated with significant complications such as the "wearing off" effect, levodopa-induced dyskinesias and other motor complications. Catechol-o-methyl-transferase inhibitors, dopamine agonists and nondopaminergic therapy are alternative modalities in the management of PD and may be used concomitantly with levodopa or one another. The neurosurgical treatment, focusing on deep brain stimulation, is reviewed briefly. Although this review has attempted to highlight the most recent advances in the treatment of PD, it is important to note that new treatments are not necessarily better than the established conventional therapy and that the treatment options must be individualized and tailored to the needs of each individual patient.

Course, prognosis, and management of psychosis in Parkinson's disease: are current treatments really effective?

It is essential to recognize and treat psychosis in Parkinson's disease for several reasons. Studies have shown that psychosis in Parkinson's disease patients is a strong risk factor for nursing home placement. Psychosis may be the greatest source of stress for caretakers of Parkinson's patients; it is often persistent, and its presence markedly increases mortality. Treatment of psychotic symptoms should occur only after potential medical and environmental causes of delirium have been eliminated or addressed. Initial pharmacologic changes should include limiting the patient's antiparkinsonian medications to those that are necessary to preserve motor function. Should that fail, an atypical antipsychotic is presently the treatment of choice. An emerging treatment option is acetylcholinesterase inhibitors. This article reviews what is currently known about the course, prognosis, and treatment strategies in Parkinson's disease psychosis.

Pathophysiology and treatment of psychosis in Parkinson's disease: a review

Psychotic symptoms in Parkinson's disease (PD) are relatively common and, in addition to creating a disturbance in patients' daily lives, have consistently been shown to be associated with poor outcome. Our understanding of the pathophysiology of psychosis in PD has expanded dramatically over the past 15 years, from an initial interpretation of symptoms as dopaminergic drug adverse effects to the current view of a complex interplay of extrinsic and disease-related factors.PD psychosis has unique clinical features, namely that it arises within a context of a clear sensorium and retained insight, there is relative prominence of visual hallucinations and progression occurs over time. PD psychosis tends to emerge later in the disease course, and disease duration represents one risk factor for its development. The use of anti-PD medications (particularly dopamine receptor agonists) has been the most widely identified risk factor for PD psychosis. Other risk factors discussed in the literature include older age, disease severity, sleep disturbance, cognitive impairment, dementia and/or depression.Recent efforts have aimed to explore the complex pathophysiology of PD psychosis, which is now known to involve an interaction between extrinsic, drug-related and intrinsic, disease-related components. The most important extrinsic factor is use of dopaminergic medication, which plays a prominent role in PD psychosis. Intrinsic factors include visual processing deficits (e.g. lower visual acuity, colour and contrast recognition deficits, ocular pathology and functional brain abnormalities identified amongst hallucinating PD patients); sleep dysregulation (e.g. sleep fragmentation and altered dream phenomena); neurochemical (dopamine, serotonin, acetylcholine, etc.) and structural abnormalities involving site-specific Lewy body deposition; and genetics (e.g. apolipoprotein E epsilon4 allele and tau H1H1 genotype). Preliminary reports have also shown a potential relationship between deep brain stimulation surgery and PD psychosis.When reduction in anti-PD medications to the lowest tolerated dose does not improve psychosis, further intervention may be warranted. Several atypical antipsychotic agents (i.e. clozapine, olanzapine) have been shown to be efficacious in reducing psychotic symptoms in PD; however, use of clozapine requires cumbersome monitoring and olanzapine leads to motor worsening. Studies of ziprasidone and aripiprazole are limited to open-label trials and case reports and are highly variable; however, it appears that while each may be effective in some patients, both are associated with adverse effects. While quetiapine has not been determined efficacious in two randomized controlled trials, it is a common first-line treatment for PD psychosis because of its tolerability, ease of use and demonstrated utility in numerous open-label reports. Cholinesterase inhibitors currently represent the most promising pharmacological alternative to antipsychotics. Tacrine is rarely tried because of hepatic toxicity, and controlled trials with donepezil have not shown significant reductions in psychotic symptoms, due perhaps to methodological limitations. However, results from an open-label study and a double-blind, placebo-controlled trial involving 188 hallucinating PD patients support the efficacy of rivastigmine. With regard to non-pharmacological interventions, case reports suggest that electroconvulsive therapy has the potential to reduce psychotic symptoms and may be considered in cases involving concurrent depression and/or medication-refractory psychosis. Limited case reports also suggest that specific antidepressants (i.e. clomipramine and citalopram) may improve psychosis in depressed patients. Finally, studies in the schizophrenia literature indicate that psychological approaches are effective in psychosis management but, to date, this strategy has been supported only qualitatively in PD, and further studies are warranted.

Presentation and management of psychosis in Parkinson's disease and dementia with Lewy bodies

A 73-year-old man with a 10-year history of progressive Parkinson’s disease is referred for psychiatric evaluation and treatment by a neurologist for new-onset confusion and visual hallucinations of strangers in his house. Treatment of the early Parkinson’s symptoms began with a dopamine agonist, and /-dopa was added later to combat worsening tremor, rigidity, slowed mobility, and difficulty performing basic activities of daily living. A more detailed history elicits new-onset depression and vivid dreaming with insomnia. The patient’s wife is concerned about the hallucinations, worsening cognitive impairment, and disturbed sleep, all of which have an impact on her quality of life. Treatment options for addressing these new symptoms include lowering the dosages of antiparkinsonian medications, which can cause or aggravate visual hallucinations and confusion, or adding quetiapine, the atypical antipsychotic drug that is least likely to worsen the parkinsonism. After discussions with the patient and his wife, the decision is made to initiate quetiapine at a dose of 50 mg at bedtime and not to change the antiparkinsonian medication regimen. However, after only a few doses, the patient stops taking the quetiapine because of excessive sedation and increased confusion. An attempt is then made to slowly taper the dopamine agonist, which is more likely than /-dopa to cause psychiatric complications and is less effective as an antiparkinsonian medication. The patient’s parkinsonism worsens, however, so the dosage is restored to the previously effective level. The patient’s condition continues to deteriorate because of increasing visual hallucinations (now accompanied by persecutory delusions regarding the strangers in the house), confusion, and disturbed sleep. An urgent follow-up evaluation is arranged.

Management of the behavioral aspects of Parkinson's disease

Parkinson's disease is a progressive and debilitating movement disorder that is diagnosed by its motor signs. The behavioral manifestations of Parkinson's disease are prevalent and frequently complicate the course of the disease. These may be due to the illness itself or its treatment and are often more disabling than the motor symptoms. This review focuses on the management of the most common behavioral symptoms of Parkinson's disease, including depression, anxiety, psychosis, dementia, delirium, sleep disorders, fatigue, apathy, emotionalism and compulsive behaviors.

The management of psychosis in movement disorder patients

Psychosis may be seen with several movement disorders. As pharmacological treatments can sometimes worsen movement disorders, psychosis in these situations can be complex for clinicians to manage. This review covers the management of psychosis in three different movement disorders: Parkinson's disease, dementia with Lewy bodies and Huntington's disease.

Open-label flexible-dose pilot study to evaluate the safety and tolerability of aripiprazole in patients with psychosis associated with Parkinson's disease

Psychosis affects at least 5% to 8% of medication-treated patients with idiopathic Parkinson's disease (PD). Treatment options include reducing medications used for the treatment of PD-related motor symptoms or introducing an atypical antipsychotic drug. Only clozapine has been demonstrated to be efficacious and tolerated in double-blind controlled trials. This study evaluated the effect of aripiprazole, an atypical antipsychotic, on psychosis in PD in an open-label pilot study. Fourteen patients meeting entry criteria were started on aripiprazole 1 mg/day and titrated up to a maximum dose of 5 mg as needed. Subjects were evaluated on the Unified Parkinson's Disease Rating Scale (UPDRS) part III for motor function, the Neuropsychiatric Inventory (NPI), and the Brief Psychiatric Rating Scale (BPRS) for psychiatric response. Statistically significant improvement in mean BPRS and positive BPRS subscales occurred with open-label aripiprazole, but eight subjects discontinued the study due to worsened Parkinsonism (three), worsened psychosis (two), worsening of both (two), and lack of efficacy (one). While some patients had a favorable response, aripiprazole was associated with an exacerbation of motor symptoms. In this small study on psychosis in PD, aripiprazole did not appear promising.

Use of atypical antipsychotics in neurodegenerative diseases

Behavioral and psychotic disturbances are common symptoms in neurodegenerative disorders, and can lead to caregiver stress, nursing home placement and mortality. There is an expanding literature evaluating the effects of atypical antipsychotic (AA) drugs for treating these problems. The results in both primary dementias and Parkinson’s disease suggest that not all AA drugs are equal in terms of efficacy or safety. Furthermore, Parkinsonian and other side effects of the AAs are important to consider when evaluating outcomes. The recent US FDA warning of increased mortality has increased uncertainty in using these drugs. This article reviews the AAs and their use in Parkinson’s disease, dementia with Lewy bodies, Alzheimer’s disease and other associated dementias.

Treatment of drug-induced psychosis in Parkinson's disease with ziprasidone can induce severe dose-dependent off-periods and pathological laughing

"Atypical anti-psychotics" are substances of choice in treating drug-induced psychosis (DP) in Parkinson's disease (PD). We report on four patients with DP who received treatment with ziprasidone after previously applied clozapine and quetiapine had failed. Three patients showed a significant improvement of DP, without deterioration of motor function. In one case, ziprasidone considerably increased decline in off-periods. Two patients developed pathological laughing as a possible side-effect of ziprasidone. Ziprasidone may serve as an additional "atypical anti-psychotic" for the treatment of DP in PD but can also induce deterioration of motor function.

Non-motor aspects of Parkinson's disease

Parkinson's disease is primarily considered to be a movement disorder and is defined by its motor signs. Yet, the behavioral manifestations of the disease are often more debilitating than its motor complications. This review will focus on the non-motor aspects of Parkinson's disease, including mood, psychosis, cognitive, sleep, fatigue, apathy, delirium, and repetitive disorders, that may occur. The phenomenology, pathology, and treatment of the behavioral symptoms of Parkinson's disease will be discussed.

Combating psychosis in Parkinson's disease patients: the use of antipsychotic drugs

Parkinson's disease (PD) patients commonly experience psychotic symptoms, with the most frequent manifestation being visual hallucinations. In PD, psychosis is predominantly drug induced and an important issue for clinicians to address as it increases the risk of nursing home placement as well as mortality. This review summarises the current knowledge regarding the clinical manifestations, pathophysiology and risk factors for drug-induced psychosis in patients with PD and focuses on treatment, especially with regard to the atypical antipsychotics.

Management of Parkinson???s Disease Dementia

Parkinson's disease dementia (PDD) ultimately develops in about 80% of patients with Parkinson's disease (PD), and cross-sectional studies have found that some 30% of these patients will experience neuropsychiatric symptoms, such as visual hallucinations and psychosis. The most consistently reported risk factors for dementia in PD are age, severe parkinsonism and mild cognitive impairment. In PDD, both subcortical cognitive and cortical cognitive profiles are described. Specific disorders of sleep, such as rapid eye movement sleep behaviour disorder, excessive daytime sleepiness and sleep attacks, occur frequently. Alzheimer and Lewy body pathology coexist, but the Lewy body pathology in limbic and cortical areas seems to be the main cause of dementia. Neurochemical changes in the biogenic amines and acetylcholine are common, and magnetic resonance imaging studies have shown cortical atrophy in wide cortical areas, including the hippocampus. All PD patients should be screened for mild cognitive impairment and dementia. A large randomised clinical trial showed that the cholinesterase inhibitor rivastigmine has desirable effects on cognition and neuropsychiatric symptoms in PDD patients. Atypical antipsychotic agents may improve psychosis in PDD, but the evidence for this is poor and adverse effects from such therapy are common and may be severe. Non-pharmacological interventions can also be effective but require further study.