Psychosis in Parkinson's Disease: Current Treatment Options and Impact on Patients and Caregivers

Healthcare resource utilization patterns among patients with Parkinson's disease psychosis and dementia: analysis of US Medicare beneficiaries treated with pimavanserin versus other-atypical antipsychotics or versus quetiapine

BACKGROUND

Pimavanserin (PIM) is the only FDA approved atypical antipsychotic treatment (AAP) for hallucinations and delusions associated with Parkinson's disease psychosis (PDP) among patients with or without coexisting dementia; however, Other-AAPs (i.e. quetiapine (QUE), risperidone, olanzapine, aripiprazole) are commonly prescribed off-label. Healthcare resource utilization (HCRU) patterns among patients with PDP and coexisting dementia (PDP+D) who newly initiate PIM versus (vs.) Other-AAPs (i.e. other AAP-mix) or QUE in real-world settings is limited.

METHODS

A retrospective analysis of Parts A, B, and D claims from the 100% Medicare sample from 04/01/15 to 12/31/21 was conducted. AAP-naïve patients with PDP+D who initiated ≥12-month continuous monotherapy with PIM vs. Other-AAPs or vs. QUE during 04/01/16-12/31/20 were propensity score matched 1:1 on thirty-one variables (age, sex, race, region and 27 Elixhauser comorbidity characteristics). Adjusted log binomial regressions compared all-cause HCRU [(e.g. inpatient hospitalizations and by hospitalization-type [short-term stays (ST-stays), long-term stays (LT-stays), skilled nursing facility stays (SNF-stays)], and emergency room (ER) visits] risk between cohorts.

RESULTS

Of the 5,932 patients with PDP+D, matched cohorts (n = 1,294 in each) on continuous- monotherapy of PIM vs. Other-AAPs or QUE had similar demographics and comorbidities. Adjusted regression results showed those who initiated PIM vs. Other-AAPs had significantly lower relative risk (RR) of ≥1 all-cause inpatient hospitalizations (RR = 0.88, 95% CI: 0.80-0.97), ST-stays (RR = 0.86, 95% CI: 0.77-0.95), SNF-stays (RR = 0.79, 95% CI: 0.68-0.92), and ER visits (RR = 0.89, 95% CI: 0.84-0.94). PIM vs. QUE also experienced significantly lower RR for ≥1 all-cause IP hospitalizations (RR = 0.88, 95% CI: 0.80-0.96), ST-stays (RR = 0.85, 95% CI: 0.77-0.95), SNF-stays (RR = 0.81, 95% CI: 0.70-0.94), and ER visits (RR = 0.88, 95% CI: 0.83-0.94).

CONCLUSIONS

Patients initiating PIM-monotherapy for PDP+D experienced 12% lower all-cause inpatient hospitalizations vs. Other-AAPs or QUE. These results are consistent with prior real-world research in PDP with or without dementia.

CBT for psychosis in Parkinson's disease: A framework for how and why

Psychosis is a serious comorbidity to Parkinson's disease associated with high levels of distress and disability but access to effective treatments remain limited, leading to high rates of emergency hospitalization. Here, we propose a new framework for how cognitive behavioural therapy (CBT) may be used to treat Parkinson's disease psychosis. We note specific adaptions, including aims that focus on reducing distress and disability and extending quality of life; tailored psychoeducation; assessment and formulation that additionally includes disease course, medication effects and side-effects, and Parkinson's specific social factors; addressing anxiety and depression alongside cognitive appraisals for the types of psychotic symptoms more common in Parkinson's disease; appropriate reality testing sensitive to disease progression; and trigger monitoring and management for hallucinations and delusions that carefully distinguishes this from avoidant coping. We review preliminary case study-level evidence for the successful use of CBT for Parkinson's disease psychosis and suggest a road map for its formal evaluation before integration into evidence-based healthcare.

Post-marketing safety of pimavanserin: a real-world pharmacovigilance study based on the FDA adverse event reporting system (FAERS)

BACKGROUND

Pimavanserin is a new non-dopamine neurotransmitter antipsychotic drug. This study aimed to conduct a post-marketing pharmacovigilance study of pimavanserin, through data mining technology using the FDA Adverse Event Reporting System (FAERS) database.

RESEARCH DESIGN AND METHODS

We analyzed adverse event reports for patients using pimavanserin. Data were classified using systematic organ classification (SOC) and preferred term (PT) of the Medical Dictionary for Regular Activities (MedDRA). Four signal algorithms [reporting odds ratio (ROR), proportional reporting ratio (PRR), multi-item gamma poisson shrinker (MGPS), and bayesian confidence propagation neural network (BCPNN)] were used to detect positive signals, and the median time-to-onset was determined.

RESULTS

Adverse drug events (ADEs) related to pimavanserin (n = 31,852) were analyzed, exhibiting an annual linear upward trend (p = 0.027). The ADEs involved 27 SOCs, but only 'Psychiatric disorders' simultaneously satisfied four algorithms. Overall, 153 PTs simultaneously satisfied four algorithms. Subgroup analysis of differences in the top 30 signal intensity PTs according to sex yielded significant results for seven PTs (p < 0.05). The median time-to-onset was 97 days, the highest proportion occurred within the first 30 days (31.79%).

CONCLUSIONS

Some new PT signals not listed in the label were identified, and some PT signals showed differences according to sex.

[Schizophrenic spectrum disorders and Parkinson's disease]

The case demonstrated the difficulties of differential diagnosis and selection of therapy in patients with Parkinson's disease and schizophrenic spectrum disorders. A clinical case of a 45-year-old male with a 10-year history of paranoid schizophrenia, with hallucinatory paranoid attacks and a steady increase in negative symptoms in the form of apato-abulic defect, is presented. The use of antipsychotics was associated with neuroleptic parkinsonism, well responding to therapy, and reduced when the patient discontinued antipsychotic therapy. However, after 10 years of schizophrenia, Parkinson's syndrome manifested without neuroleptics; the antipsychotic therapy led to a sharp deterioration in motor status. A neurologist specializing in extrapyramidal disorders made the following diagnosis: Parkinson's disease, mixed form, Hoehn and Yahr stage 2. According to the neurologist's recommendation, typical neuroleptics were replaced with quetiapine, and levodopa was added to therapy. During treatment, the parkinsonism symptoms significantly decreased without an increase in psychotic symptoms. The clinical case illustrates the challenges in diagnosing Parkinson's disease in a patient with schizophrenia and the complexity of treating such comorbidities. When managing such patients, close collaboration between psychiatrists and neurologists is necessary to make an accurate diagnosis and select the optimal therapy. The introduction of the multidisciplinarity principle will make it possible to achieve the fastest diagnosis and selection of balanced therapy in this category of patients.

Risk of agranulocytosis and neutropenia in patients with Parkinson's disease psychosis receiving clozapine treatment: A systematic review and meta-analysis

OBJECTIVE

To assess the cumulative incidence of severe neutropenia and agranulocytosis (SNA) and mild and moderate neutropenia (MMN) in patients with Parkinson's disease psychosis (PDP) who receive clozapine treatment.

METHODS

We searched multiple databases to identify clozapine studies in PDP patients. Incidence rates were assessed during short-term (within 1 month), medium-term (within 6 months), and long-term (> 6 months) monitoring periods. A proportional meta-analysis was performed using random-effects and generalized linear mixed models (GLMMs).

RESULTS

We included 691 PDP patients from 19 studies. During the short-term monitoring period, none of the 573 participants in 16 studies developed SNA. The pooled incidence of SNA was 0.001 (95 % confidence interval [CI]: 0.000-0.253, 525 participants, 15 studies) during the medium-term period and 0.002 (95 % CI: 0.000-0.015, 475 participants, 12 studies) during the long-term period. The pooled incidence of MMN was 0.004 (95 % CI: 0.000-0.281, 164 participants, 7 studies) for short- and medium-term periods and 0.013 (95 % CI: 0.002-0.094, 193 participants, 7 studies) in the long-term period. Funnel plot asymmetry indicated potential bias in the medium-term dataset of SNA (p = 0.035).

CONCLUSION

Clozapine treatment in PDP patients may carry a very low risk of SNA and a low risk of MMN.

Structural MRI study of Pareidolia and Visual Hallucinations in Drug-Naïve Parkinson's disease

Visual hallucinations (VH) and pareidolia, a type of minor hallucination, share common underlying mechanisms. However, the similarities and differences in their brain regions remain poorly understood in Parkinson's disease (PD). A total of 104 drug-naïve PD patients underwent structural MRI and were assessed for pareidolia using the Noise Pareidolia Test (NPT) were enrolled. Subcortical gray matter volume and cortical surface volume were analyzed using the FreeSurfer software. Structural analyses revealed associations between NPT scores and atrophy in the right thalamus, right hippocampus, right temporal cortex, and right orbitofrontal cortex in all PD participants. These results were almost the same after adjusting for right-handed 97 patients with PD. It is considered that hallucinations in patients with PD are related to altered integration of sensory input (bottom-up) and prior knowledge (top-down) within the visual system. Our findings indicate that pareidolia in PD involves both bottom-up (thalamus and temporal cortex) and top-down (orbitofrontal cortex) processing disturbances; in contrast, VH predominantly involves bottom-up but not top-down regions. Understanding these distinctions could aid in the development of targeted interventions for hallucinations in patients with PD.

The effects of chemogenetic targeting of serotonin-projecting pathways on L-DOPA-induced dyskinesia and psychosis in a bilateral rat model of Parkinson's disease

Introduction

Parkinson's disease (PD) is commonly characterized by severe dopamine (DA) depletion within the substantia nigra (SN) leading to a myriad of motor and non-motor symptoms. One underappreciated and prevalent non-motor symptom, Parkinson's disease-associated psychosis (PDAP), significantly erodes patient and caregiver quality of life yet remains vastly understudied. While the gold standard pharmacotherapy for motor symptoms Levodopa (LD) is initially highly effective, it can lead to motor fluctuations like LD-induced dyskinesia (LID) and non-motor fluctuations such as intermittent PDAP. One source of these fluctuations could be the serotonergic raphe nuclei and their projections. Serotonin (5-HT) neurons possess the machinery necessary to convert and release DA from exogenous LD. In DA-depleted brain regions these 5-HT projections can act as surrogates to the DA system initially compensating but chronically leading to aberrant neuroplasticity which has been linked to LID and may also contribute to non-motor fluctuations. In support, recent work from our lab established a positive relationship between LID and PDAP in parkinsonian rats. Therefore, it was hypothesized that normalizing 5-HT forebrain input would reduce the co-expression of LID and PDAP.

Methods

To do so, we expressed 5-HT projection specific inhibitory designer receptor exclusively activated by designer drugs (DREADDs) using Cre-dependent AAV9-hM4di in tryptophan hydroxylase 2 (TPH2)-Cre bilaterally 6-OHDA-lesioned rats. Thereafter we used the designer drug Compound 21 to selectively inhibit 5-HT raphe projections during LD treatment to modulate the expression of PDAP, assayed by prepulse inhibition (PPI) and LID, quantified by the abnormal involuntary movements (AIMs) test.

Results

Our results suggest that chemogenetic inhibition of 5-HT raphe-projecting cells significantly reduces LID without affecting stepping ability or established sensorimotor gating deficits.

Discussion

Overall, this study provides further evidence for the complex influence of 5-HT raphe-projecting neurons on LD's neurobehavioral effects.

Comprehensive analysis of adverse events associated with pimavanserin using the FAERS database

OBJECTIVE

Pimavanserin, a novel 5-HT2A receptor antagonist, has been approved for the treatment of Parkinson's disease psychosis (PDP). This study aims to conduct a comprehensive analysis of the adverse events (AEs) of pimavanserin by analyzing the FDA's Adverse Event Reporting System (FAERS) database.

METHODS

AE reports related to pimavanserin in the FAERS database from the second quarter of 2016 to the fourth quarter of 2023 were mined. Signal detection methods, including the Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Empirical Bayesian Geometric Mean (EBGM), were employed to identify and classify AEs.

RESULTS

The study collected 12,839,687 AE reports, with 30,997 reports primarily suspecting pimavanserin, identifying 166 Preferred Terms (PTs) across 27 System Organ Classes (SOCs). The data showed that males reported more frequently than females, with the highest reporting in patients aged 75 and above. Reports increased over time, with a significant rise in 2023 compared to 2016. Major categories of AEs included hallucination, death, product dose omission issue, and confusional state, with death being notably the second most reported issue. Strong and new potential AEs were identified, including sleep-related issues like somnolence, insomnia, and sleep talking; cognitive and behavioral issues such as alexithymia, belligerence, and aggression; dose-related issues like prescribed underdose and underdose; and other AEs like nonspecific reactions.

CONCLUSION

This study reveals potential AEs of pimavanserin, including sleep disorders and cognitive changes, underscoring the importance of careful monitoring and personalized treatment in managing PDP.

On the Optimal Diagnosis and the Evolving Role of Pimavanserin in Parkinson's Disease Psychosis

Parkinson's disease (PD) is associated with the development of psychosis (PDP), including hallucinations and delusions, in more than half of the patient population. Optimal PD management must therefore involve considerations about both motor and non-motor symptoms. Often, clinicians fail to diagnosis psychosis in patients with PD and, when it is recognized, treat it suboptimally, despite the availability of multiple interventions. In this paper, we provide a summary of the current guidelines and clinical evidence for treating PDP with antipsychotics. We also provide recommendations for diagnosis and follow-up. Finally, an updated treatment algorithm for PDP that incorporates the use of pimavanserin, the only US FDA-approved drug for the treatment of PDP, was developed by extrapolating from a limited evidence base to bridge to clinical practice using expert opinion and experience. Because pimavanserin is only approved for the treatment of PDP in the US, in other parts of the world other recommendations and algorithms must be considered.

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.

Incremental health care resource utilization and costs associated among patients with Parkinson's disease psychosis and incident dementia: An analysis of medicare beneficiaries

BACKGROUND

Real-world evidence examining the incremental health care resource use (HCRU) and cost burden of incident dementia among patients with Parkinson's disease psychosis (PDP) are needed within the United States (US).

OBJECTIVES

To compare HCRU and cost burden between PDP patients with incident dementia (PDP + D) versus without incident dementia (PDP).

METHODS

A retrospective analysis of inpatient (Part A), outpatient (Part B), and prescription drug (Part D) claims from the 100% Medicare sample was conducted to compare PDP + D patients versus PDP patients between 01/01/14-12/31/18. Patients with a diagnosis of dementia, psychosis, secondary parkinsonism, or other psychotic disorders, during 12-month pre-index were excluded. Patients in both groups were matched using 1:1 propensity score matching (PSM) methodology using 31 variables (age, sex, race, region and 27 Elixhauser comorbidity characteristics). Differences in 12-month post-index HCRU rates and mean per patient per year (PPPY) costs for all-cause inpatient (IP) hospitalizations, and by type of IP stay (i.e., short-term [ST-stay], skilled nursing facility [SNF-stay] and long-term [LT-stay]) were analyzed via logistic and gamma log-link regression models.

RESULTS

Of the 12,484 patients who met our study criteria, 1855 PSM-matched cohorts were identified. Mean age, gender, and comorbidities were similar in PSM groups. Approximately, 50.3% with PDP + D reported ≥1 all-cause IP hospitalizations versus 36.0% with PDP (p < 0.05) during 12-month follow-up. Specifically, all-cause ST-stay, SNF-stay, and LT-stay among PDP + D versus PDP patients were: 45.2% versus 35.7%, 28.3% versus 15.7%, and 8.5% versus 6.0% (p < 0.05), respectively. Psychiatric-related ST-stay, SNF-stay, and LT-stay among PDP + D versus PDP patients were: 12.3% versus 9.0%, 7.5% versus 3.4%, and 2.4% versus 1.2% (p < 0.05), respectively. Mean PPPY all-cause IP hospitalization costs for PDP + D patients versus PDP patients was $17,891 (±29,882) versus $11,599 (±$25,247) (p < 0.05).

CONCLUSIONS

Patients with PDP + D experience significantly higher all-cause and psychiatric-related IP hospitalizations, including ST-stays, LT stays, and SNF stays. They also had 54% greater mean PPPY IP hospitalization costs versus PDP patients.

Parkinson's disease updates: Addressing the pathophysiology, risk factors, genetics, diagnosis, along with the medical and surgical treatment

After only Alzheimer's disease (AD), Parkinson's disease (PD) is the second most prevalent neurodegenerative disease. The incidence of this disease increases with age, especially for those above 70 years old. There are many risk factors that are well-established in the contribution to the development of PD, such as age, gender, ethnicity, rapid eye movement sleep disorder, high consumption of dairy products, traumatic brain injury, genetics, and pesticides/herbicides. Interestingly, smoking, consumption of caffeine, and physical activities are the protective factors of PD. A deficiency of dopamine in the substantia nigra of the brainstem is the main pathology. This, subsequently, alters the neurotransmitter, causing an imbalance between excitatory and inhibitory signals. In addition, genetics is also involved in the pathogenesis of the disease. As a result, patients exhibit characteristic motor symptoms such as tremors, stiffness, bradykinesia, and postural instability, along with non-motor symptoms, including dementia, urinary incontinence, sleeping disturbances, and orthostatic hypotension. PD may resemble other diseases; therefore, it is important to pay attention to the diagnosis criteria. Parkinson's disease dementia can share common features with AD; this can include behavioral as well as psychiatric symptoms, in addition to the pathology being protein aggregate accumulation in the brain. For PD management, the administration of pharmacological treatment depends on the motor symptoms experienced by the patients. Non-pharmacological treatment plays a role as adjuvant therapy, while surgical management is indicated in chronic cases. This paper aims to review the etiology, risk factors, protective factors, pathophysiology, signs and symptoms, associated conditions, and management of PD.

Neurological update: non-motor symptoms in atypical parkinsonian syndromes

Among people with Parkinson's disease (PD), non-motor symptoms (NMS) are a well-recognised cause of significant morbidity and poor quality of life. Yet, it is only more recently that NMS have been recognised to affect the lives of patients with atypical parkinsonian syndromes in a similar fashion. The aim of this article is to highlight and compare the relative prevalence of NMS among patients with atypical parkinsonian syndromes in the published literature, which largely remain underreported and unaddressed in routine clinical practice. All NMS that are recognised to occur in PD are also found to commonly occur in atypical parkinsonian syndromes. In particular, excessive daytime sleepiness is more prevalent among atypical parkinsonian syndromes (94.3%) compared to PD (33.9%) or normal controls (10.5%) (p < 0.001). Urinary dysfunction (not limited to urinary incontinence) is not only found to occur in MSA (79.7%) and PD (79.9%), but has also been reported in nearly half of the patients with PSP (49.3%), DLB (42%) and CBD (53.8%) (p < 0.001). Apathy is significantly more common among the atypical parkinsonian syndromes [PSP (56%), MSA (48%), DLB (44%), CBD (43%)] compared to PD (35%) (p = 0.029). Early recognition and addressing of NMS among atypical parkinsonian syndromes may help improve the holistic patient care provided and may encompass a range of conservative and pharmacotherapeutic treatments to address these symptoms.

Development of sensitive magnetic nanoparticle assisted rapid sandwich assay(s-MARSA) to monitor Parkinson's disease and Schizophrenia pharmacotherapy

Parkinson's disease and Schizophrenia fall under low dopamine neurodegenerative and high dopamine psychiatric disorders respectively. Pharmacological interventions to correct mid-brain dopamine concentrations sometimes overshoots the physiological dopamine levels leading to psychosis in Parkinson's disease patients and, extra-pyramidal symptoms in schizophrenia patients. Currently no validated method is available to monitor side effects in such patients, Apolipoprotein E is one of the CSF biomarkers identified in the recent past that shows an inverse relation to mid-brain dopamine concentration. In this study, we have developed s-MARSA for the detection of Apolipoprotein E from ultra-small volume (2 μL) of CSF. s-MARSA exhibits a broad detection range (5 fg mL^-1 to 4 μg mL^-1) with a better detection limit and could be performed within an hour utilizing only a small volume of CSF sample. The values measured by s-MARSA strongly correlates with the values measured by ELISA. Our method has advantages over ELISA in having a lower detection limit, a broader linear detection range, shorter analysis time, and requiring a low volume of CSF samples. The developed s-MARSA method holds promise for the detection of Apolipoprotein E with clinical utility for monitoring pharmacotherapy of Parkinson's and Schizophrenia patients.

Tinetti balance performance is associated with mortality in older adults with late-onset Parkinson's disease: a longitudinal study

BACKGROUND

Parkinson's disease (PD) is associated with a 3-fold mortality risk, which is closely related to advancing age. Evidence is lacking regarding the factors associated with the risks of mortality or nursing-home (NH) admission, in elderly patients with PD. We aimed at identifying the clinical characteristics associated with these outcomes, in older community-dwelling patients with late-onset PD.

METHODS

Retrospective, observational analysis of data from geriatric day hospital patients. Motor assessment included Unified Parkinson Disease Rating Scale (UPDRS) part III score, Tinetti Performance Oriented Mobility Assessment (POMA) balance and gait tests, and gait speed. Levodopa equivalent dose, comorbidity, cognitive performance, Activities of Daily Living performance were examined. Cox proportional hazards models were performed to identify the factors associated with mortality and NH admission rate (maximum follow-up time = 5 years).

RESULTS

We included 98 patients, mean age 79.4 (SD = 5.3) of whom 18 (18.3%) died and 19 (19.4%) were admitted into NH, over a median follow-up of 4 years. In multivariate Cox models, poor balance on the Tinetti POMA scale (HR = 0.82 95%CI (0.66-0.96), p = .023) and older age (HR = 1.12 95%CI (1.01-1.25), p = .044) were the only variables significantly associated with increased mortality risk. A Tinetti balance score below 11/16 was associated with a 6.7 hazard for mortality (p = .006). No specific factor was associated with NH admissions.

CONCLUSIONS

Age and the Tinetti POMA score were the only factors independently associated with mortality. The Tinetti POMA scale should be considered for balance assessment and as a screening tool for the most at-risk individuals, in this population.

Should patients with Parkinson’s disease only visit a neurologist’s office? - a narrative review of neuropsychiatric disorders among people with Parkinson’s disease

Introduction: Parkinson’s disease is a neurodegenerative disease that is often accompanied by disorders such as depression, psychotic disorders, cognitive disorders, anxiety disorders, sleep disorders, impulse control disorders. The aim of the study was to review the literature and present the characteristics of neuropsychiatric disorders occurring in people suffering from Parkinson’s disease, with the specification of the above-mentioned disorders.

Material and method: The literature available on the PubMed platform from 1986 to 2022 was reviewed using the following keywords: Parkinson’s disease, depression, anxiety disorders, psychotic disorders, sleep disorders, cognitive disorders, impulse control disorders. Original studies, reviews, meta-analyzes and internet sources were analyzed.

Results: The above-mentioned neuropsychiatric disorders appear with different frequency among people suffering from Parkinson’s disease and occur at different times of its duration or even precede its onset for many years. The non-motor symptoms in the form of depressed mood, energy loss or changes in the rhythm of the day may result in a delay of appropriate therapy and thus in complications. Neuropathological changes in the course of Parkinson’s disease as well as dopaminergic drugs used in its therapy influence the development of neuropsychiatric disorders.

Conclusions: In order to avoid misdiagnosis, practitioners should use, e.g. scales intended for patients with Parkinson’s disease. To prevent the consequences of the aforementioned disease entities, methods of early diagnosis, determination of risk factors and standardization of the treatment process must be determined. Consistent care for patients with Parkinson’s disease is significant, not only in the neurological field, but also in the psychiatric one.

Management of psychiatric and cognitive complications in Parkinson's disease

Neuropsychiatric symptoms (NPSs) such as affective disorders, psychosis, behavioral changes, and cognitive impairment are common in Parkinson's disease (PD). However, NPSs remain under-recognized and under-treated, often leading to adverse outcomes. Their epidemiology, presentation, risk factors, neural substrate, and management strategies are incompletely understood. While psychological and psychosocial factors may contribute, hallmark PD neuropathophysiological changes, plus the associations between exposure to dopaminergic medications and occurrence of some symptoms, suggest a neurobiological basis for many NPSs. A range of psychotropic medications, psychotherapeutic techniques, stimulation therapies, and other non-pharmacological treatments have been studied, are used clinically, and are beneficial for managing NPSs in PD. Appropriate management of NPSs is critical for comprehensive PD care, from recognizing their presentations and timing throughout the disease course, to the incorporation of different therapeutic strategies (ie, pharmacological and non-pharmacological) that utilize a multidisciplinary approach.

Pimavanserin and Parkinson's Disease Psychosis: A Narrative Review

Pimavanserin (PMV) is the first approved drug for treating hallucinations and delusions in Parkinson's disease (PD) psychosis. Psychosis is one of the leading causes of nursing home placement in people with PD. Furthermore, hallucinations are a more frequent cause of institutionalization than motor disability or dementia related to PD. The management of PD psychosis involves antipsychotic medications. Most of the drugs in this class directly block dopamine D2 receptors, leading to significantly worsening motor symptoms in patients with PD. The most commonly used medications for managing PD psychosis are quetiapine, clozapine, and PMV. This literature review aims to study pimavanserin's history, mechanism, clinical trials, and post-marketing experience. PMV is a potent 5-HT2A receptor antagonist/inverse agonist. Moreover, this drug can interact with 5-HT2C receptors. We calculated some physicochemical descriptors and pharmacokinetic properties of PMV. Eight clinical trials of PMV and PD psychosis are registered on ClinicalTrials.gov. Only four of them have complete results already published. Meta-analytic results showed that PMV efficacy is inferior to clozapine. However, PMV has a significantly lower number of side-effects for managing psychosis in PD. Medicare database assessment revealed 35% lower mortality with PMV compared to other atypical antipsychotics. Moreover, sensitive statistical analysis demonstrated that PMV is a protective factor for the risk of falls in individuals with PD.

Management of Parkinson's Disease Psychosis

Objectives To discuss therapeutic management of Parkinson's disease psychosis (PDP) and the burdens associated with it. Parkinson's disease (PD) is an incurable, progressive, and devastating neurodegenerative disease. The prolonged use of dopamine agonists to improve the motor symptoms of PD may result in nonmotor complications such as psychosis. These complications are as devastating as the motor symptoms that accompany PD. PDP is associated with financial burden for patients and health care organizations. Data Sources PubMed search using the phrases Parkinson's disease, Parkinson's disease psychosis, clozapine, quetiapine, and "pimavanserin." Conclusion Pimavanserin is the only US Food and Drug Administration approved drug for the management of hallucinations and delusions associated with PD psychosis. The off-label use of clozapine and quetiapine has demonstrated clinical utility; however, there is still a need for the development of novel therapeutic molecules to avoid side effects associated with current therapeutic options and reduce the burdens of patients, caregivers, and health care institutions.

Hallucinations and delusions associated with Parkinson's disease psychosis: safety of current treatments and future directions

INTRODUCTION

: Over half of Parkinson's disease (PD) patients develop psychotic symptoms, and PD psychosis (PDP) is associated with significant distress to patients, caregiver burden, and impairs quality of life. Pharmacological therapy is limited to atypical antipsychotics.

AREAS COVERED

: This review will summarize efficacy but will focus on the safety of antipsychotics for treating PDP, and in particular the off-target safety issues including cognitive impairment, sleep disturbance, cardiovascular effects, and motor function.

EXPERT OPINION

: Pimavanserin is the only medication approved in the US for treating PDP, however clozapine is also considered efficacious. Despite lack of substantial evidence for efficacy, quetiapine is commonly used to treat PDP. Despite the effectiveness of pimavanserin and clozapine for treating PDP, a need exists for additional pharmacological agents that are effective for PDP while providing an acceptable safety and tolerability profile. Medications to treat PDP should avoid worsening motor function, and also minimize sleep disturbances, cognitive impairment, cardiovascular effects, and other non-motor safety concerns. A neutral effect or reduction in mortality risk associated with PD and PDP would be ideal, and low rate of discontinuation due to AEs is desirable. Lastly, medications that can be used safely in combination with other pharmacological agents is essential.

Management of Psychiatric Disorders in Patients with Parkinson's Diseases

Parkinson's disease (PD) is a heterogeneous progressive neurodegenerative disorder, with a triad of motor symptoms with akinesia/bradykinesia, resting tremor (4-6 Hz), and rigidity. It is the second most common neurodegenerative disease after Alzheimer's disease. The overall management of PD depends on the status of symptoms, functioning of the patients, impairment, disability, and its impact on quality of life. Depression, anxiety disorders, apathy, anhedonia, psychosis, cognitive impairments, dementia, and impulse control disorders (ICDs) are the common psychiatric symptoms/disorders comorbid with PD. Depression remains the most common psychiatric disorder reported to be comorbid with PD. Several pharmacological and nonpharmacological management strategies are used for the treatment of comorbid psychiatric disorders in PD. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are used to treat depression in patients with PD. The best evidence of efficacy in PD psychosis is for clozapine and pimavanserin. The treatment for cognitive impairments in PD remains poorly researched. Rivastigmine is the only approved treatment for PD as per the Food and Drug Administration. Pramipexole, a dopamine agonist (DA), is reported to cause improvement in the symptoms of decreased willingness in apathy. The treatment approaches for different sleep disorders in PD are different. Identifying the cause, reviewing the patient's ongoing medications, and evaluating the impact of comorbid medical conditions and sleep hygiene are common to all conditions related to sleep disorders. The first approach for treating ICD symptoms is the reduction or discontinuation of DAs. The psychiatric symptoms in patients with PD are highly prevalent, and their management should be included in the basic treatment algorithm for PD. This paper summarizes common psychiatric symptoms/disorders in PD and their management approaches.

Emerging Perspectives in the Diagnosis and Management of Depression and Psychosis in Parkinson's Disease

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