From the FDA Drug Label
Hallucinations and psychotic-like behavior have been reported with dopaminergic medications. In general, hallucinations present shortly after the initiation of therapy and may be responsive to dose reduction in levodopa Hallucinations may be accompanied by confusion and to a lesser extent sleep disorder (insomnia) and excessive dreaming. Carbidopa and levodopa orally disintegrating tablets may have similar effects on thinking and behavior This abnormal thinking and behavior may present with one or more symptoms, including paranoid ideation, delusions, hallucinations, confusion, psychotic-like behavior, disorientation, aggressive behavior, agitation, and delirium Ordinarily, patients with a major psychotic disorder should not be treated with carbidopa and levodopa orally disintegrating tablets, because of the risk of exacerbating psychosis. In some cases, although not all, these urges were reported to have stopped when the dose was reduced or the medication was discontinued
Delirium Management:
- The development of delirium in patients taking Levodopa may require dose reduction.
- Dopaminergic medications, such as Rotigotine, may also contribute to delirium.
- It is essential to consider dose reduction or stopping the medication if a patient develops delirium while taking these medications 1.
- Patients with a major psychotic disorder should not be treated with these medications due to the risk of exacerbating psychosis.
From the Research
Parkinson's disease medications like Prolopa (levodopa) and Rotigotine often need adjustment when patients develop delirium, with a focus on simplifying medication regimens and balancing motor symptom control with cognitive function 2, 3. When delirium occurs, it's essential to consider the potential impact of dopaminergic medications on cognitive function and the risk of worsening delirium.
- Dopamine agonists like Rotigotine should be used cautiously or temporarily reduced as they have a higher risk of causing or worsening confusion and hallucinations 2.
- For levodopa preparations, consider maintaining the same total daily dose but administering smaller doses more frequently to reduce fluctuations.
- Anticholinergic medications should be discontinued entirely if possible. The goal is to balance motor symptom control with cognitive function, as dopaminergic medications can worsen delirium through their effects on dopamine receptors, particularly in the limbic system and frontal cortex, while abrupt withdrawal can precipitate severe parkinsonism or even neuroleptic malignant syndrome-like presentations 4, 5. Regular reassessment of both motor symptoms and cognitive status is essential to guide ongoing medication adjustments until the delirium resolves 6. It's also crucial to be aware of patient comorbidities before prescribing a medication to treat delirium, and to consider the potential benefits and risks of each medication option 3.