From the Guidelines
For Parkinson's disease patients experiencing hallucinations, the most appropriate medication option is pimavanserin (Nuplazid), which is specifically FDA-approved for Parkinson's disease psychosis and can be prescribed at 34 mg once daily. When considering treatment options, it's crucial to prioritize medications that do not worsen motor symptoms, a common issue with traditional antipsychotics. According to the provided evidence, atypical antipsychotic agents like quetiapine (Seroquel) can be used for control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness 1. However, the evidence from 1 is outdated, and more recent guidelines recommend pimavanserin as the first-line treatment for Parkinson's disease psychosis due to its efficacy and safety profile. Key considerations in managing hallucinations in Parkinson's disease include:
- Ruling out other causes of hallucinations such as infections, metabolic disturbances, or medication side effects
- Simplifying the Parkinson's medication regimen by reducing anticholinergics or amantadine to minimize potential contributors to hallucinations
- Monitoring treatment closely for effectiveness and side effects, aiming to use the lowest effective dose to control psychotic symptoms while minimizing adverse effects. In the context of real-life clinical practice, prioritizing the patient's quality of life, morbidity, and mortality is essential, and thus, the choice of medication should be guided by the most recent and highest-quality evidence available.
From the FDA Drug Label
NUPLAZID is an atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. NUPLAZID is indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis [see Clinical Studies (14)]. NUPLAZID is an atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. (1)
The medication for Parkinson’s with hallucinations is pimavanserin (PO), also known as NUPLAZID.
- The recommended dose is 34 mg taken orally once daily, without titration 2.
- Key warnings include increased mortality in elderly patients with dementia-related psychosis and QT interval prolongation 3.
- Common adverse reactions include peripheral edema and confusional state 3.
From the Research
Medication Options for Parkinson's Disease with Hallucinations
- Acetylcholinesterase inhibitors are recommended as a first-line treatment for well-formed visual hallucinations in Parkinson's disease 4
- Atypical antipsychotics, such as Pimavanserin and Clozapine, can be effective in managing hallucinations associated with Parkinson's disease psychosis (PDP) 5, 6
- Quetiapine may also be used, but its support is not as substantial as other antipsychotics, and research studies are still emerging 5, 7
- Antidepressants may be beneficial in the appropriate setting 4
- Cholinesterase inhibitors, such as rivastigmine, can improve visual hallucinations in Parkinson's disease patients with dementia 7
Considerations for Medication Management
- Treatment of hallucinations in Parkinson's disease should be individualized and multifaceted 4
- Screening, education, medication review, and avoidance of common triggers are important 4
- Antipsychotic medications can have potential risks, such as extrapyramidal symptoms, somnolence, hypotension, constipation, and cognitive impairment 5
- Pimavanserin has a lower number of side-effects compared to other atypical antipsychotics and may be a protective factor for the risk of falls in individuals with Parkinson's disease 6
- Clozapine carries a risk of agranulocytosis, necessitating close monitoring of blood counts 5, 8