Psychiatric comorbidities in patients with Parkinson disease and psychosis

Clinical characteristics and treatment of psychosis in Parkinson's disease: A narrative review

Parkinson's disease (PD) is a chronic, progressive, neurodegenerative disorder whose clinical presentation consists of motor and non-motor signs and symptoms. Among the non-motor symptoms, psychosis can occur in the later stages of the disease. Psychosis in PD (PDP) is a common, complex, and significantly disabling disorder associated with poorer quality of life, accelerated cognitive decline, need for hospitalization or institutionalization, and mortality. Hallucinations are a significant symptom of PDP, sporadic at first but more frequent in the later course of the disease, and significantly disrupt daily activities. Appropriate and timely screening of psychotic manifestations is necessary for adequate therapeutic procedures. After the exclusion of comorbid conditions as a possible cause of psychosis, correction of antiparkinsonian therapy may be required, and if necessary, the introduction of antipsychotics. The latest therapeutic recommendations include the use of pimavanserin, if available, otherwise second-generation or atypical antipsychotics. Although PDP has long been recognized as a possible complication in the course of the disease, further clinical studies are needed to fully understand its etiopathogenesis and pathophysiological mechanisms.

Retrospective analyses evaluating the mortality risk associated with pimavanserin or other atypical antipsychotics in patients with Parkinson disease psychosis

Introduction

Parkinson's disease (PD) is associated with increased mortality risk (MR), reflecting progression of motor and nonmotor symptoms. PD psychosis (PDP), a common nonmotor symptom, increases with prolonged disease and elevates the MR of PD even further. Pimavanserin is the only FDA-approved treatment for PDP. This review summarizes real-world evidence around the MR of patients with PDP treated with pimavanserin versus off-label atypical antipsychotics.

Methods

A PubMed search was conducted using the following search terms: pimavanserin AND antipsychotic AND mortality AND Parkinson's disease AND psychosis. Inclusion criteria specified the entry of retrospective, observational, and open-label studies comparing pimavanserin to atypical antipsychotics or untreated controls.

Results

A total of 10 of the 32 articles met inclusion criteria. Among five comparisons of pimavanserin with atypical antipsychotics, two were large (n = 21,719; n = 21,975), representative, Medicare-database studies, which demonstrated comparable or lower all-cause pimavanserin MR. Among three pimavanserin versus control studies, two reported lower or comparable pimavanserin MR and one, long-term care study reported higher MR for pimavanserin versus non-pimavanserin treated patients with unknown PDP status. Two open-label extensions reported pimavanserin mortality rates of 6.45 and 18.8 deaths per 100 patient-years, which are comparable to, or lower than, mortality rates for PD, PDP, and other atypical antipsychotics. Most studies (70 %; 7 of 10) demonstrated pimavanserin's MR was lower than or similar to other atypical antipsychotics or untreated controls.

Conclusions

Pimavanserin did not increase the MR in PDP. Pimavanserin's MR appears to be comparable to or lower than other atypical antipsychotics prescribed for PDP, including quetiapine.

Phantosmia in Parkinson's Disease: A Systematic Review of the Phenomenology of Olfactory Hallucinations

Olfactory dysfunction is a prevalent non-motor symptom in Parkinson's disease (PD), affecting approximately 65-90% of subjects. PD patients may also report odor perception in the absence of any external source, often referred to as olfactory hallucinations (OHs) or phantosmia. This study aims to explore the current understanding of OHs in PD and offer a comprehensive overview of their prevalence and characteristics. We conducted a systematic search of the literature published on PubMed from inception to July 2023 regarding OHs in PD, following PRISMA guidelines. From the 2875 studies identified through database searching, 29 studies fulfilled the necessary criteria and underwent data extraction. The frequency of OHs in PD patients varies widely, ranging from 0.5% to 18.2%, with female prevalence ranging from 36% to 75% of the patients. Olfactory experiences may vary widely, ranging from pleasant scents to unpleasant odors. Several studies have indicated the concurrent presence of other types of hallucinations alongside phantosmia, especially visual and auditory hallucinations. OHs in PD are a type of hallucination that has been largely overlooked. To gain a deeper understanding of OHs in PD patients, the next crucial step should involve the development and validation of a dedicated questionnaire.

The challenges in managing co-occurring Parkinson's and schizophrenia spectrum disorders

This article explores the relationship between Parkinson's and schizophrenia spectrum disorders, discussing not only the possibility that they can be comorbid conditions but that the presence of one could increase the chances of developing the other. They are rarely documented together, other than in relation to medication-induced side effects, and this could be due to diagnostic overshadowing, or the widely held belief that these conditions are not able to co-exist. It also briefly discusses treatment options available and gaps identified for future research.

The Self-Administered Screening Questionnaire for Parkinson's Disease-Associated Psychosis (SASPAP)

BACKGROUND

Psychosis is a common manifestation of Parkinson's disease (PD), and a major source of caregiver burden, nursing home placement, and mortality. Psychosis symptoms are often not volunteered during the clinic visit because of embarrassment or lack of insight, and there is no validated screening scale. We compare a new self-administered psychosis screening questionnaire against the Parkinson's Disease Psychosis Scale (PDPS) and physician interview as the gold standard assessments.

OBJECTIVE

To create and validate the Self-Administered Screening Questionnaire for PD-Associated Psychosis (SASPAP).

METHODS

The questionnaire was developed through a modified Delphi method by a committee of two neurologists, a psychiatrist, a patient, and patient advocate and underwent several rounds of revisions, including patient β-testing. It was provided by staff at intake to 250 consecutive patients diagnosed with PD, at the Methodist Hospital Movement Disorders Clinic, and separately to their caregivers when available. Later, the PDPS and a general psychosis interview were administered by PD specialists without knowledge of the screening questionnaire responses.

RESULTS

Two hundred and fifty consecutive patients with PD (mean age, 68.6 ± 7.0; mean age of PD onset, 62.7 ± 10.5 years; 35.2% female) were included. The screening questionnaire was positive for psychosis (any of the four questions positive) in 33.6% of patients. Compared to the gold standard, the SASPAP sensitivity was 87.8% and the specificity 92.3%.

CONCLUSION

This four-question self-administered screening questionnaire for PD psychosis demonstrated high diagnostic accuracy compared with the gold standard assessments and can be self-completed at visit intake. © 2023 International Parkinson and Movement Disorder Society.

Pimavanserin treatment increases plasma brain-derived neurotrophic factor levels in rats

Background

Pimavanserin, a serotonin 5HT-2A receptor inverse agonist is the first-line, FDA-approved treatment of hallucinations and delusions associated with Parkinson's Disease psychosis (PDP), which occurs in up to 50% of PD patients. The neurobiological mechanism underlying the therapeutic effectiveness of Pimavanserin in PDP remains unknown. Several earlier studies have shown that treatment with 5HT-2A antagonists and other drugs acting on the serotonergic system such as SSRIs increase Brain derived neurotrophic factor (BDNF) levels in rodents. BDNF is synthesized as the precursor proBDNF, that undergoes cleavage intra or extracellularly to produce a mature BDNF (mBDNF) protein. mBDNF is believed to play a key role in neuroplasticity and neurogenesis. The present study tested the hypothesis that treatment with Pimavanserin is associated with higher and sustained elevations of mBDNF.

Methods

Adult Sprague-Dawley male rats were treated with Pimavanserin, Fluoxetine or vehicle for 4 weeks (chronic) or 2 h (acute). BDNF levels were determined by enzyme-linked Immunosorbent assay (ELISA).

Results

We found significant increases in plasma mBDNF levels in rats following chronic Pimavanserin treatment, but not in Fluoxetine-treated rats. No significant changes in mBDNF levels were found in the prefrontal cortex or hippocampus following Pimavanserin or Fluoxetine treatment.

Conclusion

These findings suggest that increase in mBDNF levels could be a contributing mechanism for the neuroprotective potential of Pimavanserin.

Pimavanserin: A Truly Effective Treatment for Parkinson's Disease Psychosis? A Review of Interventions

Parkinson's disease (PD) is the second-most common neurodegenerative disorder with a long-term 60% cumulative prevalence of PD psychosis. Medical treatment is limited to few atypical antipsychotic drugs with low affinity to dopamine D2 receptors. In 2016, pimavanserin, a selective 5-HT2A inverse agonist/antagonist, was approved by the US Food and Drug Administration (FDA) as the only treatment for PD psychosis (PDP). This article provides an overview of the epidemiology, pathophysiology, and treatment options for PDP and illuminates the mode of action and therapy options with pimavanserin and the current study data.

Illusory Responses across the Lewy Body Disease Spectrum

OBJECTIVE

This study was undertaken to study pareidolias, or perceived meaningful objects in a meaningless stimulus, in patients across the Lewy body (LB) disease spectrum, where most do not report hallucinations or delusions.

METHODS

We studied illusory responses on the Noise Pareidolia Task in 300 participants (38 cognitively impaired LB, 65 cognitively unimpaired LB, 51 Alzheimer disease spectrum [AD-s], 146 controls). Pairwise between-group comparisons examined how diagnosis impacts the number of illusory responses. Ordinal regression analysis compared the number of illusory responses across diagnosis groups, adjusting for age, sex, and education. Analyses were repeated after removing participants with reported hallucinations or delusions.

RESULTS

Cognitively impaired LB participants were 12.3, 4.9, and 4.6 times more likely than control, cognitively unimpaired LB, and AD-s participants, respectively, to endorse illusory responses. After adjusting for age, sex, and education, the probability of endorsing 1 or more illusory responses was 61% in the cognitively impaired LB group, compared to 26% in AD-s, 25% in cognitively unimpaired LB, and 12% in control participants. All results were similar after repeated analysis only in participants without hallucinations or delusions. In LB without hallucinations or delusions, 52% with mild cognitive impairment and 66.7% with dementia endorsed at least 1 illusory response.

INTERPRETATION

We found illusory responses are common in cognitively impaired LB patients, including those without any reported psychosis. Our data suggest that, prior to the onset of hallucinations and delusions, the Noise Pareidolia Task can easily be used to screen for unobtrusive pareidolias in all LB patients. ANN NEUROL 2023;93:702-714.

Grey matter volume loss in Parkinson's disease psychosis and its relationship with serotonergic gene expression: A meta-analysis

BACKGROUND

Neuroanatomical alterations underlying psychosis in Parkinson's Disease (PDP) remain unclear. We carried out a meta-analysis of MRI studies investigating the neural correlates of PDP and examined its relation with dopaminergic and serotonergic receptor gene expression.

METHODS

PubMed, Web of Science and Embase were searched for MRI studies (k studies = 10) of PDP compared to PD patients without psychosis (PDnP). Seed-based d Mapping with Permutation of Subject Images and multiple linear regression analyses was used to examine the relationship between pooled estimates of grey matter volume (GMV) loss in PDP and D1/D2 and 5-HT1a/5-HT2a receptor gene expression estimates from Allen Human Brain Atlas.

RESULTS

We observed lower grey matter volume in parietal-temporo-occipital regions (PDP n = 211, PDnP, n = 298). GMV loss in PDP was associated with local expression of 5-HT1a (b = 0.109, p = 0.012) and 5-HT2a receptors (b= -0.106, p = 0.002) but not dopaminergic receptors.

CONCLUSION

Widespread GMV loss in the parieto-temporo-occipital regions may underlie PDP. Association between grey matter volume and local expression of serotonergic receptor genes may suggest a role for serotonergic receptors in PDP.

Non-visual hallucinations in Parkinson's disease: a systematic review

BACKGROUND

Non-visual hallucinations in Parkinson's disease (PD) can be prevalent and distressing. Most existing research has however, focused on visual hallucinations as well as related risk factors. The current study thus conducted a systematic review to collate existing evidence on non-visual hallucinations in PD, focusing on their prevalence, phenomenology, and clinical-cognitive correlates.

METHODS

Ninety-one relevant studies were included from a systematic search across PsycINFO APA, PubMed, and Web of Science, for peer-reviewed publications in the English language, from 1970 to the present. These comprised a mix of case (30 studies; n = 56) and group design (62 studies; n = 7346) studies, divided into three somewhat overlapping collections to address our three research foci.

RESULTS

Prevalence estimates for hallucinations were: auditory 1.5-72.0%, olfactory 1.6-21.0%, somatic-tactile 0.4-22.5%, gustatory 1.0-15.0%, and sensed presence 0.9-73.3%. Phenomenological inquiries revealed descriptions of vivid, consuming events replete with elaborate detail, adversely affecting PD patients in different ways. Overt experiences of multisensory hallucinations were also highly variable (0.4-80%) but exceedingly common, reported by almost half of the 45 included prevalence studies. There was some evidence for modality-specific hallucination predictors, but this was largely tentative, pending robust replication.

CONCLUSIONS

Marked prevalence figures coupled with phenomenological descriptions implicating distress denote that non-visual and multisensory hallucinations in PD are of clinical significance. More direct research and clinical attention need to be devoted to the study and management of such hallucinatory experiences.

Mortality in Patients with Parkinson's Disease-Related Psychosis Treated with Pimavanserin Compared with Other Atypical Antipsychotics: A Cohort Study

INTRODUCTION

Pimavanserin is approved in the USA to treat hallucinations and delusions associated with Parkinson's disease psychosis (PDP).

OBJECTIVES

We evaluated mortality in patients with PDP after initiation of pimavanserin or comparator atypical antipsychotics, overall, over time, and across subgroups.

METHODS

A cohort of patients aged ≥65 years in the USA with PDP newly initiating pimavanserin or a comparator atypical antipsychotic (clozapine, quetiapine, risperidone, olanzapine, aripiprazole, brexpiprazole) was identified in 2016-2019 Medicare claims data. All-cause mortality in the propensity score-matched treatment groups was compared with hazard ratios (HRs) and 95% confidence intervals (CIs) estimated with Cox-proportional hazards models. Cumulative incidence curves and time period-specific models evaluated risk over time. Subgroup and sensitivity analyses were performed, including a sub-cohort of long-term care (LTC) or skilled nursing facility (SNF) residents.

RESULTS

We identified 2892 pimavanserin initiators and 19,083 comparator initiators (overall 47% female, mean age = 80.9 years, LTC/SNF residents = 30%). Before matching, pimavanserin users had fewer severe comorbidities and more anti-Parkinson medication use than comparators. Matching resulted in 2891 patients in both groups, and all covariates were well balanced. In the matched cohort, the HR for mortality for pimavanserin versus comparator was 0.78 (95% CI 0.67-0.91), with the lowest time period-specific HRs in the first 180 days. Hazard ratios were similar across sensitivity analyses and subgroups. In LTC/SNF residents, the HR was 0.78 (95% CI 0.60-1.01).

CONCLUSION

The observed mortality rates were lower among patients treated with pimavanserin compared with those treated with other atypical antipsychotics.

STUDY REGISTRATION

European Union Post-authorization Study (EU PAS) register number 46331.

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.

Motor- and cognition-related safety of pimavanserin in patients with Parkinson's disease psychosis

Background

Pimavanserin, a selective 5-HT_2A inverse agonist/antagonist, is the only treatment approved by the US Food and Drug Administration for hallucinations and delusions associated with Parkinson's disease (PD) psychosis.

Aim

We aimed to evaluate motor- and cognition-related safety in pimavanserin-treated patients with PD psychosis.

Methods

This analysis included patients with PD psychosis treated with pimavanserin 34 mg from a pooled analysis of 3 randomized, double-blind, placebo-controlled, 6-week studies [NCT00477672 (study ACP-103-012), NCT00658567 (study ACP-103-014), and NCT01174004 (study ACP-103-020)] and a subgroup of patients with PD dementia with psychosis from HARMONY (NCT03325556), a randomized discontinuation study that included a 12-week open-label period followed by a randomized double-blind period of up to 26 weeks. Motor- and cognition-related safety were examined.

Results

The pooled analysis included 433 randomized patients (pimavanserin, 202; placebo, 231). Least squares mean (standard error [SE]) change from baseline to week 6 Unified Parkinson's Disease Rating Scale (UPDRS) II + III score was similar for pimavanserin [−2.4 (0.69)] and placebo [−2.3 (0.60)] (95% Confidence Interval [CI]:−1.9, 1.6). The change from baseline to week 6 for UPDRS II and UPDRS III scores was similar between groups. In the HARMONY open-label period, 49 patients with PD dementia with psychosis were treated with pimavanserin 34 mg, 36 of whom were randomized in the double-blind period (pimavanserin, 16; placebo, 20). In the open-label period, the mean (SE) change from baseline to week 12 (n = 39) Extra-Pyramidal Symptom Rating Scale (ESRS-A) score was −1.7 (0.74); in the double-blind period, the results were generally comparable between the pimavanserin and placebo arms. The change from baseline in Mini-Mental State Examination (MMSE) score was also comparable between pimavanserin- and placebo-treated patients in HARMONY [open-label (n = 37): mean (SE) change from baseline to week 12, 0.3 (0.66)]. Rates of motor- and cognition-related adverse events were similar between pimavanserin and placebo in both analyses.

Conclusions

Pimavanserin 34 mg was well tolerated and did not yield a negative impact on motor- or cognition-related function in patients with PD psychosis.

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.

High frequency of psychosis in late-stage Parkinsońs disease

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55.4% of late-stage Parkinsońs disease (LSPD) patients have psychotic symptoms.

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72.5% of LSPD patients present a comorbid psychiatric diagnosis.

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Clinical diagnostic interview increases detection of psychosis.

Background

Psychosis is a frequent non-motor symptom in Parkinson’s disease (PD). Estimates of the frequency of Parkinsońs disease psychosis (PDP) vary widely. Knowledge about the frequency and phenomenology of psychosis in late-stage (LS) PD patients is limited.

This study aimed to determine the frequency of psychosis in LSPD patients through clinical diagnostic interview (CDI) (gold standard), according to NINDS/NIMH diagnostic criteria for PDP. The secondary objectives were to characterize the phenomenology, to test selected instruments and assess their adequacy in comparison to CDI, and to assess the psychiatric comorbidities.

Methods

A cross-sectional study including LSPD patients (patients with ≥ 7 years from symptoms onset and Hoehn and Yahr scale score > 3 or a Schwab and England scale score < 50% in the ON condition) was conducted. Patients were subjected to psychiatric, neurological, and neuropsychological evaluations. Each patient was interviewed by a psychiatrist who performed a CDI.

Results

92 LSPD patients were included. 55.4% experienced psychotic symptoms according to NINDS/NIMH diagnostic criteria for PDP. Hallucinations were present in 94.1% and delusions in 29.4% of the psychotic patients. Visual hallucinations were the most common (88.23%) psychotic symptom. 72.5% of LSPD patients with psychotic symptoms had at least one comorbid psychiatric diagnosis. Lower frequency of psychosis was found when the assessment was performed only through selected instruments rather than CDI.

Conclusions

A high frequency (55.4%) of psychotic symptoms and comorbid psychiatric (72.5%) diagnosis were found in LSPD patients. The use of CDI, in addition to structured scales may increase the sensitivity of detecting psychotic symptoms.

Frequency and Characteristics of Psychosis in Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Psychotic symptoms are highly frequent in Parkinson's disease (PD) patients and are associated with poor prognosis. They include hallucinations, delusions, and minor psychotic phenomena, including sense of presence, passage hallucinations, and illusions.

OBJECTIVE

To evaluate the frequency of psychosis in PD patients.

METHODS

A systematic review and meta-analysis of clinical trials, prospective and retrospective cohort studies, case-control studies, and cross-sectional studies reporting the frequency of psychosis, hallucinations, and delusions in PD.

RESULTS

Electronic database search wielded 3536 articles, an additional 91 were identified through citation chaining. Of these, 163 were fully inspected, 57 removed, and 106 included as relevant for neuropsychiatric events frequency, with 32 meeting our inclusion criteria (psychosis and/or specific psychotic phenomena). The pooled frequency of psychosis was 20.7% (95% CI 14.5 to 28.6; I2 = 94%, 15 studies; combined n = 2919). None of the pre-defined meta-regressions or subgroup analyses were statistically significant or helped explain the statistical heterogeneity. The pooled frequency of any form of hallucination was 21.6% (95% CI 14.7 to 30.6; I2 = 95%; 18 studies; combined n = 3161). Duration of PD at baseline and mean baseline Hoehn & Yahr stage helped explain the statistical heterogeneity in the meta-analysis of hallucinations.

CONCLUSION

Based on the available evidence, around a fifth of PD patients experience psychosis or hallucinations. The risk of developing hallucinations is likely moderated by the disease duration, Hoehn & Yahr stage, and the cognitive status.

Incidence, Prevalence, and Mortality of Psychosis Associated with Parkinson's Disease (1991-2010)

BACKGROUND

Parkinson's disease (PD)-associated psychosis is a well-known non-motor complication, occurring years after diagnosis of PD. Incidence data vary across different studies highlighting a need for long-term observation and clinical definition.

OBJECTIVE

To determine the incidence of psychosis in patients with PD and to investigate their survival in an incident cohort study from 1991-2010 in Olmsted County, MN.

METHODS

We used the Rochester Epidemiology Project to define an incident-cohort study of parkinsonism (1991-2010) in Olmsted County, MN. A movement-disorder specialist reviewed the electronic medical records and applied diagnosis criteria to PD. Psychosis was diagnosed using of NINDS/NIMH unified criteria.

RESULTS

We identified 669 cases of parkinsonism; 297 patients were clinically diagnosed with PD. 114/297 (38.4%) patients had evidence of psychosis (60% male); the median onset age of psychosis was 79.4 years. The incidence of Parkinson's disease psychosis (PDP) was 4.28/100 person-years. PDP patients had a 71% increased risk of death compared to PD patients. In PD patients without psychosis, men had 73.4% increased risk of death compared to women, whereas no significant sex difference was observed among PDP men vs. women. Of 114 patients diagnosed with psychosis, 59 were treated with antipsychotics. There was no significant difference in survival between treated and untreated patients.

CONCLUSION

PDP increased the odds of death compared to PD patients. Men with PD without psychosis had greater odds of death compared to women; however, in PD with psychosis the odds of death were comparable among sexes. Lastly, treatment with anti-psychotics did not significantly affect survival.

Psychiatric Comorbidities Affect the Hospitalization Course of Parkinson's Disease Patients: A Cross-Sectional Inpatient Study

Objectives

We aim to delineate the differences in demographic characteristics and hospitalization outcomes including the severity of illness, hospitalization length of stay (LOS) and cost, utilization of deep brain stimulation (DBS), and disposition in Parkinson’s disease (PD) inpatients with psychiatric comorbidities versus without psychiatric comorbidities.

Methods

We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS), included 56,844 PD inpatients (age ≥40 years), and subdivided them by inpatients into those without psychiatric comorbidities (N = 38,629) and with psychiatric comorbidities (N = 18,471). We compared the distributions of demographic characteristics and hospitalization outcomes (severity of illness, utilization ofDBS, and disposition) by performing Pearson’s chi-square test, and we measured the differences in continuous variables (i.e., age, LOS, and cost) by using the independent samples t-test. 

Results

A significantly higher proportion of PD inpatients with psychiatric comorbidities were female (44.4%) and white (83%) and had a moderate loss of functioning (48.8%) compared to those without psychiatric comorbidities. PD inpatients with psychiatric comorbidities had an increased mean LOS (4.7 days vs. 3.7 days, P <0.001) but a lower mean cost ($37,445 vs. $ 41,957, P <0.001). Also, there was a significantly lower utilization of DBS in PD inpatients with psychiatric comorbidities (19.2% vs. 26.9%, P <0.001) compared to those without psychiatric comorbidities, and an adverse disposition of transfer to a skilled nursing facility/intermediate care facility (47.1% vs. 39.6%, P <0.001) compared to PD inpatients without psychiatric comorbidities.

Conclusion

Although PD patients with psychiatric comorbidities had a moderate loss of functioning, there was significant underutilization of DBS. Meanwhile, psychiatric comorbidities among PD patients led to increased LOS and transfer to skilled facilities.

Exploring Nonmotor Neuropsychiatric Manifestations of Parkinson Disease in a Comprehensive Care Setting

Parkinson disease (PD) is a debilitating neurological condition that includes both motor symptoms and nonmotor symptoms (NMS). Psychiatric complaints comprise NMS and are collectively referred to as neuropsychiatric manifestations. Common findings include atypical depressive symptoms, anxiety, psychosis, impulse control disorder, deterioration of cognition, and sleep disturbances. Quality of life (QoL) of patients suffering from NMS is greatly impacted and many times can be more debilitating than motor symptoms of PD. We expand on knowledge gained from treatment models within a comprehensive care model that incorporates multidisciplinary specialists working alongside psychiatrists to treat PD. Insight into background, clinical presentations, and treatment options for patients suffering from neuropsychiatric manifestations of PD are discussed. Identifying symptoms early can help improve QoL, provide early symptom relief, and can assist tailoring treatment plans that limit neuropsychiatric manifestations.

Efficacy results of pimavanserin from a multi-center, open-label extension study in Parkinson's disease psychosis patients

INTRODUCTION

Pimavanserin, a selective 5-HT_2A inverse agonist/antagonist, was approved for hallucinations and delusions associated with Parkinson's disease psychosis (PDP). We present durability of response with pimavanserin in patients with PDP for an additional 4 weeks of treatment.

METHODS

This was an open-label extension (OLE) study in patients previously completing one of three double-blind, placebo-controlled (Core) studies. All patients received pimavanserin 34 mg once daily. Efficacy assessments included the Scale for the Assessment of Positive Symptoms (SAPS) PD and H + D scales, Clinical Global Impression (CGI) Improvement and Severity scales and Caregiver Burden Scale (CBS), through 4 weeks in the OLE. Safety assessments were conducted at each visit.

RESULTS

Of 459 patients, 424 (92.4%) had a Week 4 efficacy assessment. At Week 4 (10 weeks total treatment), SAPS-PD mean (standard deviation) change from OLE baseline was -1.8 (5.5) and for SAPS-H + D was -2.1 (6.2) with pimavanserin 34 mg. Patients receiving placebo during the Core studies had greater improvements (SAPS-PD -2.9 [5.6]; SAPS-H + D -3.5 [6.3]) during the OLE. For participants treated with pimavanserin 8.5 or 17 mg during the Core studies, further improvement was observed during the OLE with pimavanserin 34 mg. The mean change from Core Study baseline for SAPS-PD score was similar among prior pimavanserin 34 mg and prior placebo-treated participants (-7.1 vs. -7.0). The CGI-I response rate (score of 1 or 2) at Week 4 was 51.4%. Adverse events were reported by 215 (46.8%) patients during the first 4 weeks of OLE. The most common AEs were fall (5.9%), hallucination (3.7%), urinary tract infection (2.8%), insomnia (2.4%), and peripheral edema (2.2%) CONCLUSIONS: Patients previously on pimavanserin 34 mg during three blinded core studies had durability of efficacy during the subsequent 4 week OLE SAPS-PD assessment. Patients previously on blinded placebo improved after 4 weeks of OL pimavanserin treatment. These results in over 400 patients from 14 countries support the efficacy of pimavanserin for treating PDP.

Movement Disorder Emergencies

Acute presentation of new movement disorders and acute decompensation of chronic movement disorders are uncommon but potentially life-threatening. Inadvertent or purposeful overdose of many psychiatric medications can result in acute life-threatening movement disorders including serotonin syndrome, neuroleptic malignant syndrome, and malignant catatonia. Early withdrawal of potentiating medications, treatment with benzodiazepines and other diagnosis-specific drugs, and providing appropriate supportive care including airway and breathing management, hemodynamic stabilization, fluid resuscitation, and renal support including possible hemodialysis are the mainstays of acute management. Many of these conditions require admission to the neurologic intensive care unit.

Delusion and Delirium in Neurodegenerative Disorders: An Overlooked Relationship?

Delusions are part of the neuropsychiatric symptoms that patients suffering from neurodegenerative conditions frequently develop at some point of the disease course and are associated with an increased risk of cognitive and functional decline. Delirium is a syndrome characterized by acute onset of deficits in attention, awareness, and cognition that fluctuate in severity over a short time period. Delusions and delirium are frequently observed in the context of neurodegeneration, and their presence can easily mislead clinicians toward a misdiagnosis of psychiatric disorder further delaying the proper treatment. Risk factors for developing delusion and delirium in neurodegenerative conditions have been investigated separately while the possible interplay between these two conditions has not been explored so far. With this study, we aim to achieve a more comprehensive picture of the relationship between delusions and delirium in neurodegeneration by analyzing prevalence and subtypes of delusions in different neurodegenerative disorders; providing an overview of clinical tools to assess delusions in neurodegenerative patients and how delusions are covered by delirium assessment tools and discussing the possible common pathophysiology mechanisms between delusion and delirium in neurodegenerative patients. A more extensive characterization of the relationship between delusions and delirium may help to understand whether delusions may constitute a risk factor for delirium and may ameliorate the management of both conditions in patients with neurodegenerative disorders.

Management of psychiatric disorders in Parkinson's disease : Neurotherapeutics - Movement Disorders Therapeutics

Affective disorders (depression and anxiety), psychosis, impulse control disorders, and apathy are common and sometimes disabling psychiatric conditions in Parkinson disease (PD). Psychiatric aspects of PD are associated with numerous adverse outcomes, yet in spite of this and their high frequency, there remains incomplete understanding of epidemiology, presentation, risk factors, neural substrate, and management strategies. Psychiatric features are typically co- or multimorbid, and there is great intra- and interindividual variability in presentation [1]. The neuropathophysiological changes that occur in PD, as well as the association between PD treatment and particular psychiatric disorders, suggest a neurobiological contribution to many psychiatric symptoms. There is evidence that psychiatric disorders in PD are still under-recognized and undertreated, and although psychotropic medication use is common, randomized controlled trials demonstrating efficacy and tolerability are largely lacking. Future research on neuropsychiatric complications in PD should be oriented toward determining modifiable correlates or risk factors, and most importantly, establishing efficacious and well-tolerated treatment strategies.

Evaluating rates of reporting symptoms of Parkinson's disease psychosis: provider versus targeted questionnaire

PURPOSE/AIM

A targeted questionnaire may help increase rates of reporting Parkinson's disease psychosis (PDP) symptoms. Despite the need for a rapid patient- and/or caregiver-administered screening tool for PDP symptoms, an appropriate tool is not yet available. This study developed a targeted PDP questionnaire and examined rates of reporting psychosis symptoms in response to the questionnaire compared to rates of reporting symptoms to healthcare providers during a routine visit.

MATERIALS AND METHODS

This was a single-center, cross-sectional observational study of patients at an outpatient neurology practice. Medical charts were screened for eligibility, and patients were contacted by telephone for informed consent.

RESULTS

A total of 25 patients (24%, N = 104) newly reported PDP symptoms in response to the targeted questionnaire. The frequency of reporting new symptoms in response to the questionnaire was statistically significantly greater compared to frequency of reporting symptoms without use of a targeted questionnaire (p < 0.0001).

CONCLUSIONS

A targeted questionnaire increases rates of reporting PDP symptoms, and based on frequency, severity, and distress ratings, may allow for capture of PDP symptoms earlier in the course of the disease. By using a questionnaire, patients reported symptom onset an average of 1.4 years earlier than patients who reported symptoms to their providers according to patient medical records.

Neuropsychiatric symptoms in Parkinson's disease: aetiology, diagnosis and treatment

Historically, Parkinson's disease was viewed as a motor disorder and it is only in recent years that the spectrum of non-motor disorders associated with the condition has been fully recognised. There is a broad scope of neuropsychiatric manifestations, including depression, anxiety, apathy, psychosis and cognitive impairment. Patients are more predisposed to delirium, and Parkinson's disease treatments give rise to specific syndromes, including impulse control disorders, dopamine agonist withdrawal syndrome and dopamine dysregulation syndrome. This article gives a broad overview of the spectrum of these conditions, describes the association with severity of Parkinson's disease and the degree to which dopaminergic degeneration and/or treatment influence symptoms. We highlight useful assessment scales that inform diagnosis and current treatment strategies to ameliorate these troublesome symptoms, which frequently negatively affect quality of life.

Hallucinations, Delusions and Impulse Control Disorders in Parkinson Disease

Psychotic and compulsive symptoms in Parkinson disease are highly prevalent and associated with poor outcomes and greater caregiver burden. When acute, delirium should be ruled out or treated accordingly. When chronic, comorbid systemic illnesses, dementia, and psychiatric disorders should be considered. Reduction and discontinuation of anticholinergics, amantadine, dopamine agonists, and levodopa as tolerated, as well as adjunctive clozapine or quetiapine are frequently effective to manage Parkinson disease psychosis. Pimavanserin appears effective but is not widely available, and more experience is needed. Dopamine agonist discontinuation is usually successful for impulse control disorders, but requires frequent monitoring, documentation, and caregiver involvement.

The Neuropsychiatry of Parkinson Disease: A Perfect Storm

Affective disorders, cognitive decline, and psychosis have long been recognized as common in Parkinson disease (PD), and other psychiatric disorders include impulse control disorders, anxiety symptoms, disorders of sleep and wakefulness, and apathy. Psychiatric aspects of PD are associated with numerous adverse outcomes, yet in spite of this and their frequent occurrence, there is incomplete understanding of epidemiology, presentation, risk factors, neural substrate, and management strategies. Psychiatric features are typically multimorbid, and there is great intra- and interindividual variability in presentation. The hallmark neuropathophysiological changes that occur in PD, plus the association between exposure to dopaminergic medications and certain psychiatric disorders, suggest a neurobiological basis for many psychiatric symptoms, although psychological factors are involved as well. There is evidence that psychiatric disorders in PD are still under-recognized and undertreated and although psychotropic medication use is common, controlled studies demonstrating efficacy and tolerability are largely lacking. Future research on neuropsychiatric complications in PD should be oriented toward determining modifiable correlates or risk factors and establishing efficacious and well-tolerated treatment strategies.

Advances in Management of Neuropsychiatric Syndromes in Neurodegenerative Diseases

PURPOSE OF REVIEW

Neuropsychiatric syndromes (NPS) are common in neurodegenerative disorders (NDD). This review describes the role of NPS in the diagnosis of NDD, criteria for the diagnosis of NPS, management of NPS, and agents in clinical trials for NPS.

RECENT FINDINGS

NPS play an increasingly important role in the diagnosis of NDD. Consensus diagnostic criteria have evolved for psychosis, depression, agitation, and apathy in NDD. With one exception-pimavanserin is approved for the treatment of hallucinations and delusions in Parkinson's disease-there are no drugs approved by the FDA for treatment of NPS in NDD. Trials show that atypical antipsychotics reduce psychosis in AD and in Parkinson's disease, although side effect concerns have constrained their use. Antidepressants show benefit in treatment of Parkinson's disease with depression. Several agents are in clinical trials for treatment of NPS in NDD. Neuropsychiatric syndromes play a major role in NDD diagnosis. Clinical criteria allow recognition of NPS in NDD. Psychotropic medications are often useful in the treatment of NPS in NDD; efficacious, safe, and approved agents are needed.

Minor hallucinations in Parkinson disease: A subtle symptom with major clinical implications

OBJECTIVE

Psychosis is one of the most debilitating complications of Parkinson disease (PD). Although research on PD psychosis has been focused on the study of well-structured visual hallucinations (VH), currently accepted National Institute of Neurological Disorders and Stroke-National Institute of Mental Health diagnostic criteria emphasize minor hallucinations (MH) as the most common psychotic phenomena in PD. The objective of this review is to comprehensively describe the clinical and research advances on the understanding of MH and to provide future directions for obtaining further insights into their potential major implications for PD management and prognosis.

METHODS

A PubMed search was done in November 2018 to identify articles on minor psychotic phenomena in PD.

RESULTS

MH often precede the onset of well-structured VH and are associated with other nonmotor symptoms such as REM sleep behavior disorder and depression. The pattern of functional brain connectivity changes associated with MH involve visual-processing areas and attention control networks, which overlap with abnormalities described in patients with well-structured VH. The dysfunction of cortical networks in patients with MH may be an early indicator of a more widespread form of the disease.

CONCLUSION

Although called "minor," MH may have major clinical and prognostic implications. Further research is needed to establish whether MH are associated with a higher risk of disabling psychotic complications, cognitive deterioration, or a more accelerated disease progression. Understanding the early neurobiological underpinnings of MH may provide the background for future studies to identify the progressive dysfunction of neural circuits leading to more severe forms of psychosis in PD.

Advances in Management of Psychosis in Neurodegenerative Diseases

PURPOSE OF THE REVIEW

Psychosis is broadly defined as a disengagement from reality. It describes syndromes that impair both thought content and thought process. Psychosis negatively impacts an individual's quality of life, in addition to the families caring for them. Psychosis with different types of hallucinations and delusions occurs in the context of delirium. Neuropsychiatric symptoms (NPS) are almost universal in the course of common neurodegenerative disorders (NDD) like Alzheimer's disease (AD) or Parkinson's disease (PD). In this paper, the authors took an effort to characterize AD and PD psychosis with a special focus on the most diagnostically reliable features. Effectiveness and limitations of pharmacological interventions are discussed.

RECENT FINDINGS

Consensus diagnostic criteria have evolved for psychosis secondary to AD as well as psychosis in PD. Psychotropic medications can be effective in the treatment of NPS in NDD; however, clinicians must be mindful of the side effects. There is a consensus on benefit of initiating any acetylcholinesterase inhibitor (ACHI: donepezil, rivastigmine, and galantamine) as a first line of treatment for psychosis in AD, as it may reduce and/or avoid the need for the use antipsychotics. Pimavanserin, a selective-serotonin inverse agonist that preferentially targets 5-HT2A receptors, while avoiding activity at dopamine and other receptors commonly targeted by antipsychotics had recently been approved by FDA to treat hallucinations and delusions in PD. Quetiapine is widely prescribed for the treatment of psychosis in different NDD, but the data remains equivocal. Psychosis with different types of hallucinations and delusions may occur in the context of delirium and is almost universal as a neuropsychiatric symptom in the course of PD and AD. Currently, pimavanserin remains the only pharmacologic agent approved for treatment of psychosis in PD. In cases of other NPS in other than Parkinson's diseases, atypical antipsychotics are commonly used off-label. More research is greatly needed to advance this field and address NPS especially psychosis in geriatric population.

Psychotic disorders in late life: a narrative review

Psychotic disorders are not uncommon in late life. These disorders often have varied etiologies, different clinical presentations, and are associated with significant morbidity and mortality among the older adult population. Psychotic disorders in late life develop due to the complex interaction between various biological, psychological, social, and environmental factors. Given the significant morbidity and mortality associated with psychotic disorders in late life, a comprehensive work-up should be conducted when they are encountered. The assessment should not only identify the potential etiologies for the psychotic disorders, but also recognize factors that predicts possible outcomes for these disorders. Treatment approaches for psychotic disorders in late life should include a combination of nonpharmacological management strategies with the judicious use of psychotropic medications. When antipsychotic medications are necessary, they should be used cautiously with the goal of optimizing outcomes with regular monitoring of their efficacy and adverse effects.

Comprehensive identification of delusions and olfactory, tactile, gustatory, and minor hallucinations in Parkinson's disease psychosis

INTRODUCTION

Psychotic symptoms are underdiagnosed in Parkinson's disease (PD), and there is a need for a comprehensive PD psychosis rating scale.

METHODS

Cross-sectional analysis of 199 consecutive PD outpatients. After a routine clinical visit that included the Unified Parkinson's Disease Rating Scale (UPDRS) and Non-Motor Symptoms Questionnaire (NMS-Quest), subjects completed the enhanced Scale for the Assessment of Positive Symptoms in PD (eSAPS-PD), a structured clinical interview that included the standard SAPS-PD with additional prompts for delusions and olfactory, gustatory, and minor hallucinations. Based on the combined results of these assessments, subjects were categorized as having major psychotic symptoms (hallucinations or delusions; PDP-major), isolated minor psychotic symptoms (passage hallucinations, presence hallucinations, or illusions; PDP-minor), or no psychotic symptoms (PD-controls).

RESULTS

We identified 58 subjects (29%) with psychotic symptoms, including 28 (14%) with major psychotic symptoms and 30 (15%) with isolated minor psychotic symptoms. Hallucinations were present in 56 subjects (28%); most commonly visual (24%, of which 21% were minor only), followed by olfactory (6%), tactile (4%), auditory (2%), and gustatory (1%). The eSAPS-PD detected psychotic symptoms in more subjects (n = 55, 28%) than all other assessments combined (clinical visit, UPDRS part 1, and NMS-Quest) (n = 22, 11%). Compared with PD-controls, PDP-minor subjects had a higher burden of other non-motor symptoms on the Non-Motor Symptoms Scale (37 [27-51] vs. 18 [9-36], p < 0.001) and lower quality of life scores on the PD Quality of Life Questionnaire (138 [125-151] vs. 149 [137-165], p = 0.01).

CONCLUSION

The eSAPS-PD can markedly improve detection of psychotic symptoms in PD.

Delusional Jealousy (Othello Syndrome) in 67 Patients with Parkinson's Disease

Othello syndrome (OS) is a type of paranoid delusional jealousy, characterized by the false absolute certainty of the infidelity of a partner. Because OS has infrequently occurred in patients with Parkinson’s disease (PD), the characteristics of OS in PD remain unclear. We reviewed the clinical characteristics of this syndrome in PD. We reviewed 67 patients who had PD with OS. OS was more common in men (45 patients) than in women (22 patients), and it frequently occurred in middle-aged patients. Until the onset of OS, the duration of PD (range, 2–19.8 years) and the duration of treatment with PD medications (range, 2 months to 18.5 years) varied. At the onset of OS, cognition was preserved in most patients. 42 of 47 patients had other psychiatric disorders in addition to OS, and 5 patients had isolated OS. Persecutory or other paranoid delusions developed in 34 patients with OS. OS was associated with PD medication in 25 of 26 patients, especially in patients, used the dopamine agonists. The dose of the PD medication associated with OS was decreased or these drugs were withdrawn to facilitate the treatment of OS. In most patients, OS disappeared or the severity of OS was reduced. OS is infrequent in patients with PD, but is likely to be easily detected because OS is commonly accompanied by persistent paranoid and sexual delusions. When clinicians encounter such patients, the withdrawal or reduction of dopamine agonists should be attempted, and if necessary, additional treatment with clozapine is recommended.

Treating Hallucinations and Delusions Associated With Parkinson's Disease Psychosis

PURPOSE OF REVIEW

We discuss features of Parkinson's disease psychosis (PDP) including symptomology and pathophysiology. Treatment options, including non-pharmacologic strategies, dose reduction of offending agents, and the addition of non-dopaminergic antipsychotics, are addressed. The efficacy of second-generation antipsychotics and novel agents is examined.

RECENT FINDINGS

Pimavanserin, a 5-HT_2A/C receptor inverse agonist with no other receptor activity, has shown efficacy and tolerability and is now FDA approved for PDP treatment. Research into novel targets is ongoing. PDP is a morbid complication of Parkinson's disease with complex incompletely understood mechanisms. Treatment is directed towards mitigation of psychosis without worsening of motor features.

Parkinson's disease psychosis: presentation, diagnosis and management

Parkinson's disease is a neurodegenerative disorder characterized by motor and nonmotor symptoms. Psychosis is a common feature of Parkinson's disease. Parkinson's disease psychosis (PDP) encompasses minor phenomena (illusions, passage hallucinations and presence hallucinations), visual and nonvisual hallucinations and delusions. PDP is associated with reduced function and quality of life. The initial management approach should focus on identification and treatment of any contributory medical factors, reduction or discontinuation of medications with potential to induce or worsen psychosis, nonpharmacological strategies and consideration of acetylcholinesterase inhibitor treatment in the setting of dementia. Pimavanserin, quetiapine and clozapine may all be considered for use in PDP. In this review, we discuss the presentation, diagnosis and management of PDP.

Caregiver Burden in Parkinson Disease: A Critical Review of Recent Literature

Burden is a negative psychological state induced in caregivers by the demands of providing care to a person with an illness or a disability. Managing caregiver burden in Parkinson disease (PD) is significant because informal caregivers make a substantial contribution to the well-being of persons with PD, incurring financial, social, and personal losses. Failure to recognize and manage caregiver burden may lead to burnout and premature institutionalization of the person with PD. We conducted a comprehensive literature review to identify and summarize factors that may amplify burden, including motor and nonmotor symptoms of PD, caregiver psychiatric symptoms, and caregiver coping style. We review instruments designed to sample the construct of burden among caregivers and evaluate interventions that may reduce burden, either by directly targeting caregivers or by treating PD symptoms associated with burden. We aim to provide a concise synopsis of these issues for the clinician or researcher working with this population in order to facilitate recognition of caregiver burden, provide accurate assessment, administer appropriate interventions, and stimulate further research in this area.

Somatization in Parkinson's Disease: A systematic review

The current systematic review study is aimed at critically analyzing from a clinimetric viewpoint the clinical consequence of somatization in Parkinson's Disease (PD). By focusing on the International Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive electronic literature research strategy on ISI Web-of-Science, PsychINFO, PubMed, EBSCO, ScienceDirect, MEDLINE, Scopus, and Google Scholar databases. Out of 2.926 initial records, only a total of 9 studies were identified as clearly relevant and analyzed in this systematic review. The prevalence of somatization in PD has been found to range between 7.0% and 66.7%, with somatoform disorders acting as clinical factor significantly contributing to predict a progressive cognitive impairment. We highlighted that somatization is a highly prevalent comorbidity affecting PD. However, the clinical consequence of such psychiatric symptom should be further evaluated by replacing the clinically inadequate diagnostic label of psychogenic parkinsonism with the psychosomatic concept of persistent somatization as conceived by the Diagnostic Criteria for Psychosomatic Research (DCPR).

The role of neurotransmitters in the development of Parkinson's disease-related psychosis

Psychotic symptoms are common, disabling non-motor features of Parkinson's disease (PD). Despite noted heterogeneity in clinical features, natural history and therapy response, current dogma posits that psychosis generally progresses in a stereotypic manner through a cascade of events that begins with minor hallucinations and evolves to severe hallucinations and delusions. Further, the occurrence of psychotic symptoms is believed to indicate a poor prognosis. Here we propose a classification scheme that outlines the pathogenesis of psychosis as it relates to dysfunction of several neurotransmitter systems. We hypothesize that several subtypes exist, and that PD psychosis is not consistently indicative of a progressive cascade and poor prognosis. The literature was reviewed from 1990 to 2017. An overview of the features of PD psychosis is followed by a review of data indicating the existence of neurotransmitter-related subtypes of psychosis. We found that ample evidence exists to demonstrate the presence of multiple subtypes of PD psychosis, which are traced to dysfunction of the following neurotransmitter systems: dopamine, serotonin and acetylcholine. Dysfunction of each of these systems is recognizable through their clinical features and correlates, and the varied long-term prognoses. Identifying which neurotransmitter system is dysfunctional may help to develop targeted therapies. PD psychosis has various subtypes that differ in clinical features, underlying pathology and pathophysiology, treatment response and prognosis. A novel classification scheme is presented that describes the clinical subtypes with different outcomes, which could lead to the development of targeted therapies. Future research should focus on testing the viability of this classification.

Psychosis in parkinsonism: an unorthodox approach

Psychosis in Parkinson's disease (PD) is currently considered as the occurrence of hallucinations and delusions. The historical meaning of the term psychosis was, however, broader, encompassing a disorganization of both consciousness and personality, including behavior abnormalities, such as impulsive overactivity and catatonia, in complete definitions by the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Our review is aimed at reminding that complex psychotic symptoms, including impulsive overactivity and somatoform disorders (the last being a recent controversial entity in PD), were carefully described in postencephalitic parkinsonism (PEP), many decades before dopaminergic treatment era, and are now described in other parkinsonisms than PD. Eminent neuropsychiatrists of the past century speculated that studying psychosis in PEP might highlight its mechanisms in other conditions. Yet, functional assessments were unavailable at the time. Therefore, the second part of our article reviews the studies of neural correlates of psychosis in parkinsonisms, by taking into account both theories on the narrative functions of the default mode network (DMN) and hypotheses on DMN modulation.

Psychosis in Parkinson's Disease: Epidemiology, Pathophysiology, and Management

Psychotic symptoms are common in Parkinson's disease (PD) and are associated with poorer quality of life and increased caregiver burden. PD psychosis is correlated with several factors, such as more advanced disease, cognitive impairment, depression, and sleep disorders. The underlying causes of psychosis in PD thus involve a complex interplay between exogenous (e.g., drugs, intercurrent illnesses) and endogenous (e.g., PD disease pathology) factors. Current theories of the pathophysiology of PD psychosis have come from several neuropathological and neuroimaging studies that implicate pathways involving visual processing and executive function, including temporo-limbic structures and neocortical gray matter with altered neurotransmitter functioning (e.g., dopamine, serotonin, and acetylcholine). Treatment of PD psychosis requires a step-wise process, including initial careful investigation of treatable triggering conditions and a comprehensive evaluation with adjustment of PD medications and/or initiation of specific antipsychotic therapies. Clozapine remains the only recommended drug for the treatment of PD psychosis; however, because of regular blood monitoring, quetiapine is usually first-line therapy, although less efficacious. Emerging studies have focused on agents involving other neurotransmitters, including the serotonin 5-HT2A receptor inverse agonist pimavanserin, cholinesterase inhibitors, and antidepressants and anxiolytics.

Validation of the National Institute of Neurological Disorders and Stroke Criteria for Psychosis in Parkinson Disease

OBJECTIVES

Parkinson disease (PD) psychosis is a condition associated with several negative outcomes. Despite its impact, there is a lack of validated diagnostic tools for this condition. In this study, we aim to verify the validity of the proposed NINDS criteria for PD psychosis and explore its possible applications in clinical practice.

DESIGN, SETTINGS, PARTICIPANTS

We prospectively selected 104 subjects with idiopathic PD referred to a movement disorder clinic for a cross-sectional evaluation.

MEASUREMENTS

A neurological evaluation confirmed idiopathic PD and classified PD psychosis according to the NINDS criteria. A psychiatrist then classified the subject according to DSM-IV-TR criteria for psychosis, considered the reference standard. We used Cohen's kappa (κ) to quantify reliability between methods. Finally, we designed models assigning a weighted score to each characteristic psychotic symptom from the NINDS criteria (criterion A), and plotted receiver operating curves for each model.

RESULTS

Of the total sample, 52 (50%) met proposed criteria for NINDS PD psychosis and 16 (15.6%) met reference standard criteria. Inter-rater reliability showed only a fair agreement (κ = 0.30). By using a scoring approach for each NINDS criteria item and a cutoff total score for the diagnosis of PD psychosis, we significantly increased the agreement for diagnosis reliability (κ = 0.72), with sensitivity of 94% and specificity of 91%.

CONCLUSIONS

Although the NINDS criteria had limited reliability for diagnosing PD psychosis, a scoring approach for symptoms showed good reliability, with sensitivity and specificity above 90%. This scoring approach may be an accurate tool for identifying patients with PD psychosis.

Neuropsychiatric symptoms in untreated Parkinson's disease

Neuropsychiatric and cognitive symptoms are common in Parkinson's disease (PD) and may precede and exceed motor symptoms as major factors impacting disease course and quality of life. Neuropsychiatric symptoms (NPS) in PD are various and are attributed to pathologic changes within multiple brain regions, to psychological stress, and to adverse effects of dopamine replacement therapy. Sleep disorders and mood symptoms such as apathy, depression, and anxiety may antedate the development of motor symptoms by years, while other NPS such as impulse control disorders, psychosis, and cognitive impairment are more common in later stages of the disease. Few studies report on NPS in the early, untreated phase of PD. We reviewed the current literature on NPS in PD with a focus on the early, drug-naive stages of PD. Among these early disease stages, premotor and early motor phases were separately addressed in our review, highlighting the underlying pathophysiological mechanisms as well as epidemiological characteristics, clinical features, risk factors, and available techniques of clinical assessment.

Cost-Utility Model of Rasagiline in the Treatment of Advanced Parkinson's Disease in Finland

Background:

The economic burden of Parkinson's disease (PD) is high, especially in patients experiencing motor fluctuations. Rasagiline has demonstrated efficacy against symptoms of PD in early and advanced stages of the disease.

Objective:

To assess the cost-utility of rasagiline and entacapone as adjunctive therapies to levodopa versus standard levodopa care in PD patients with motor fluctuations in Finland.

Methods:

A 2 year probabilistic Markov model with 3 health states: “25% or less off-time/day,” “greater than 25% off-time/day,” and “dead” was used. Off-time represents time awake with poor or absent motor function. Model inputs included transition probabilities from randomized clinical trials, utilities from a preference measurement study, and costs and resources from a Finnish cost-of-illness study. Effectiveness measures were quality-adjusted life years (QALYs) and number of months spent with 25% or less off-time/day. Uncertainty around parameters was taken into account by Monte Carlo simulations.

Results:

Over 2 years from a societal perspective, rasagiline or entacapone as adjunctive therapies to levodopa showed greater effectiveness than levodopa alone at no additional costs. Benefits after 2 years were 0.13 (95% CI 0.08 to 0.17) additional QALYs and 5.2 (3.6 to 6.7) additional months for rasagiline and 0.12 (0.08 to 0.17) QALYs and 5.1 (3.5 to 6.6) months for entacapone, both in adjunct to levodopa compared with levodopa alone.

Conclusions:

The results of this study support the use of rasagiline and entacapone as adjunctive cost-effective alternatives to levodopa alone in PD patients with motor fluctuations in Finland. With a different mode of action, rasagiline is a valuable therapeutic alternative to entacapone at no additional charge to society.

Current Understanding of Psychosis in Parkinson's Disease

Psychosis in Parkinson's disease (PD) is one of the greatest determinants of nursing home placement and caregiver stress. Traditionally associated with medications with dopaminergic effect, it has now been linked to other medications and other stressors e.g. systemic illnesses. The development of hallucinations in a PD patient can herald the onset of dementia and usually predicts increased mortality risk. Medication reduction in PD psychosis usually reduces the symptoms; however, this comes at the cost of worsening motor function. If gradually decreasing the patient's medications does not resolve the psychosis, the treatment of choice is an atypical antipychotic. Though only clozapine has level A recommendation for this indication, other atypicals like quetiapine continue to get used for this purpose on account of the logistics involved with clozapine use. Cholinesterase inhibitors are also increasingly being used for PD psychosis on account of the association with dementia. The treatment of PD psychosis is an unmet need in PD management and search for suitable agents constitutes an active area of research in PD.