Parkinson’s Disease And Delusions

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Olfactory Tactile And Gustatory Hallucinations

People with Parkinsons disease can also experience olfactory , tactile , and gustatory hallucinations. These types of hallucinations are less common than visual and auditory hallucinations.

Smelling cigarette smoke is an olfactory hallucination several members of MyParkinsonsTeam describe:

• I have, over the past few months, been having the issue of smelling smoke occasionally when there is none. Its subtle and will last for about an hour.
• I can smell cigarette smoke smelled it all day today and there is no one anywhere who smokes.
• Its nice to hear Im not alone in this. Its just my hubby and me and neither of us smoke, nor does anyone we know, unless my cat is secretly lighting one up without my knowledge. LOL!

What Are Parkinsons Disease

Delusions are false beliefs that are not based on reality. These beliefs are fixed. People experiencing them are unlikely to change or abandon these beliefs, even when presented with evidence that they are false.

Delusions experienced by people with Parkinsons disease are usually of a common theme. These may include:

• Spousal infidelity
• Thinking that people are stealing their belongings
• Thinking people are trying to harm them
• Thinking people may put poison in their food
• Thinking people are switching out or substituting their medications
• Other beliefs based on paranoia

Pdps Impact On Caregivers

As Susans story demonstrates, PDP is difficult for both the patient and their caregivers, particularly because it is impossible to convince someone that their delusions are not real. Logic does not penetrate. In fact, accusations of spousal infidelity are often the last straw when caregivers find caring for their loved one too overwhelming. One of the major problems in dealing with PDP is that the patient and the family often try to hide the problem the patient for fear of being thought crazy and the caregiver due to embarrassment. The reality is that when a Parkinsons Disease patient has psychotic symptoms, his or her mental abilities will be otherwise normal. The patient may not be disoriented, can still balance their checkbook and recall everything theyre supposed to know. When hallucinations or delusions occur, the treating doctor should be notified. No irreversible harm will occur if treatment is delayed, but it is unlikely the problem will go away on its own.

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What Are The Treatment Options For Parkinsons Psychosis

Because Parkinsons drugs can cause psychosis, your doctor will likely start by taking you off your medications, one at a time, or adjusting the dose. Changing your medication may make your movement symptoms worse.

Your doctor will keep adjusting your medication. The goal is to get you to a dose that improves your movement without causing hallucinations and delusions.

If changing your medication doesnt work, the next step is to go on an antipsychotic medication. These drugs prevent psychosis symptoms by altering levels of chemicals in your brain.

Older antipsychotic drugs can make Parkinsons movement symptoms worse. Newer drugs, called atypical antipsychotics, are less likely to affect your movement. These drugs are off-label, meaning theyre not approved to treat Parkinsons specifically. They include:

• clozapine
• quetiapine

In 2016, the Food and Drug Administration approved pimavanserin . Its the first drug designed specifically to treat Parkinsons disease psychosis. Nuplazid reduces the number of hallucinations and delusions without affecting movement.

Nuplazid and other newer antipsychotic drugs do carry a black box warning. They can increase the risk of death in older people who have psychosis related to dementia. Your doctor will consider this and other risks before prescribing one of these drugs.

What Triggers Psychosis In Parkinsons Disease

Psychosis in Parkinsons disease is believed to be due to long term use of parkinsonian medications especially dopaminergic and anticholinergic drugs . However, significant medication exposure is no longer a pre-requisite in Parkinsons disease psychosis . The continuum hypothesis states that medication-induced psychiatric symptoms in Parkinsons disease starts with sleep disturbances accompanied by vivid dreams, and then develops into hallucinations and delusions, and ends in delirium. However this theory is now being challenged .

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Theory Of Pd Progression: Braaks Hypothesis

The current theory is that the earliest signs of Parkinsons are found in the enteric nervous system, the medulla and the olfactory bulb, which controls sense of smell. Under this theory, Parkinsons only progresses to the substantia nigra and cortex over time.

This theory is increasingly borne out by evidence that non-motor symptoms, such as a loss of sense of smell , sleep disorders and constipation may precede the motor features of the disease by several years. For this reason, researchers are increasingly focused on these non-motor symptoms to detect PD as early as possible and to look for ways to stop its progression.

Page reviewed by Dr. Ryan Barmore, Movement Disorders Fellow at the University of Florida, a Parkinsons Foundation Center of Excellence.

Hallucinations According To The Duration Of The Disease

We found that the prevalence of hallucinations of all types and of visual hallucinations in the 3 months preceding inclusion in the study increased with the duration of the disease. Moreover, the duration of Parkinson’s disease was an independent predictor of visual hallucinations in the multivariate analysis. Other studies gave conflicting results on the relationship between hallucinations and disease duration. In a retrospective study of 100 patients, logistic regression analysis also showed an association between `psychosis’ and an increased duration of the disease . An association between the duration of the disease and the occurrence of hallucinations was also found by some investigators but not by others .

Table 1

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How Are They Treated

Your medical team should be aware of non-motor issues, just like your physical symptoms. Internists, neurologists, and psychiatrists together can help determine the right course for each person.

There are antipsychotic medications that are safe and can help to reduce the symptoms of Parkinson’s disease psychosis, but there are even more antipsychotics that are contraindicated for PD.

Let a medical provider know you have Parkinson’s when seeking emergency care or treatment for something by doctors who are not a part of your regular medical team.

There is only one drug, pimavanserin, approved in 2016 by the FDA specifically for PD. It has a mechanism of action that doesn’t block dopamine. This has made it a safer drug for people with Parkinson’s.2

Two other medications, quetiapine and clozapine, that have been used for a longer time, are also considered safe for treating hallucinations and delusions in people with PD.2

How To Care For Someone Who Experiences Delusions

If the person youre caring for experiences confusion or delusions, heres what you can do in the moment:

• Stay as calm and patient as you can and remember that this belief has nothing to do with you and only with what is going on in their mind
• Remove any objects in the room that could pose a danger to them or to anyone else
• Clear space so there are no tripping hazards and its easy for the person to move around
• Do not try to reason with the person or convince them why their belief is false
• Reassure them that everything is going to be okay
• If the person becomes aggressive, minimize your movements and remain calm
• Ask the person to talk to you about what they are feeling and really listen to them so they dont feel threatened
• If you feel like you or they are in danger, call 911

Here are a few actions you can take once the delusion has passed:

• Inform their doctor immediately
• Educate others who may care for the person how to handle the situation if it happens
• If the person is open to it, discuss it with them and ask them to explain what the experience is like for them and if theres anything different you could do next time
• Seek expert advice if you feel like you need support in managing these episodes

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Hallucinations And Rem Sleep Disorders In Parkinson’s Disease

At timestamp 1:58 in this recording of Thrive: HAPS 2020 Caregiver Conference, you will find a one hour talk by neurologist Joohi Jimenez-Shahed, MD. In it she delves into what REM sleep behavior disorder is and is not, and the distinctions between hallucinations, delusions, and delirium. Managment options for RBD and hallucinations are included.

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Practical Tips For Caregivers Of People With Parkinson’s Psychosis

This 2-page tip sheet has bullet point suggestions for what to do if the person you care for experiences hallucination, delusions or confusion, or becomes agitated or aggressive. In addition, there are tips for how to best be prepared for a doctors appointment when you bring this behavior to the attention of your medical team.

The Cause Of Parkinsons Delusions And Hallucinations

Some risk factors associated with the development of psychosis in Parkinsons disease include:

• Age: Parkinsons disease usually occurs in people over age 60.
• Duration and severity of Parkinsons disease: Psychosis is more common in advanced or late-stage Parkinsons disease.
• Later onset: Occurring later in life
• Hyposmia: A decreased sense of smell
• Cognitive impairment: Problems with thinking, including trouble remembering, difficulty learning new things, difficulty concentrating, problems making decisions that affect everyday life
• Depression: People who have both depression and Parkinsons disease are at a greater risk of developing psychosis.
• Diurnal somnolence: Daytime sleepiness
• REM sleep behavior disorder: A sleep disorder in which you physically act out dreams involves making vocal sounds and sudden, often extreme, arm and leg movements during REM sleep
• Visual disorders: Impaired vision
• Severe axial impairment: Speech, swallowing, balance, freezing of gait
• Autonomic dysfunction: Impairment of the autonomic nervous system , which controls involuntary or unconscious actions such as heart rate, breathing, body temperature, blood pressure, digestion, and sexual function
• High medical comorbidity: The existence of more than one condition or illness in the same person at the same time with Parkinsons disease, may include conditions such as dementia, depression, and sleep disorders

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Types Of Hallucinations In People With Parkinsons Disease

Hallucinations involve the five senses: sight, smell, touch, hearing, and taste.

People with hallucinations have sensory experiences that feel real to them, but are not actually happening and are not apparent to anyone else.

Types of hallucinations include:

• Auditory: Hearing things
• Gustatory: Tasting things

For people who experience Parkinsons-related hallucinations, the hallucinations are usually visual. They are typically non-threatening, but less commonly they can be of a threatening nature.

Often people with Parkinsons disease psychosis see small people or animals, or loved ones who have already died. They are not interacting with them, just being observed.

Auditory hallucinations are more common in people with schizophrenia, but can happen with Parkinsons disease. With Parkinsons disease, auditory hallucinations are usually accompanied by visual hallucinations.

More specific types of hallucinations experienced by people with Parkinsons disease include:

Parkinsons Disease And Psychosis: Hallucinations Delusions

Parkinson’s disease psychosis occurs in around 50% of PD patients. In Parkinson’s disease, hallucinations and confusion are relatively common, often occurring as side-effects of Parkinson’s medications. These symptoms can also be indicative of Parkinson’s disease psychosis, however, so it’s important to consult your doctor if you think you might be delusional or psychotic. In the meantime, here is everything you need to know about Parkinson’s disease psychosis, including symptoms and treatment.

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Demystifying Hallucinations Night Terrors And Dementia In Parkinsons

This two-hour webinar includes extensive discussion about hallucinations, delusions, illusions and other examples of Parkinsons psychosis in Parkinson’s. Presenters: Rohit Dhall, MD, MSPH and Vergilio Gerald H. Evidente, Director, Movement Disorders Center of Arizona in Scottsdale. Pay particular attention to Dr. Rohit Dhalls description of the causes of PD psychosis as well as treatment options and what to discuss with your movement disorder specialist. Dr. Evidente gives a clear description on differences in PD dementia, Alzheimer’s and other dementias.

Phenomenology Of The Hallucinations

Minor hallucinations/illusions

We grouped together in this category three types of phenomena. The most frequent type was presence hallucinations . The patient had the vivid sensation of the presence of somebody either somewhere in the room or, less often, behind him or her. In all cases, the presence was that of a person, and in one case it was also occasionally the presence of an animal . In seven cases, the presence was that of a relative . In all the other cases the presence was unidentified. The presence hallucinations were commonly as vivid as a hallucinated scene and were described as a `perception’. For instance, one patient said: `the image is behind me’, a second said: `I see someone arriving I turn back but nobody is there’, a third said: `I take a look I don’t see anything, but it is engraved in my mind’, and another said: `I have the impression that my mother is always there, that she is about to come into sight’. The passage hallucinations consisted of brief visions of a person or an animal passing sideways. If an animal was seen, the species was almost invariably specified , and in two instances it was a dog previously owned by the patient. Illusions occurred in nine patients . In five cases the illusion consisted of the transformation of an object into an animal .

Case 1 .

Case 2 .

Formed visual hallucinations

Case 3

Auditory hallucinations

Case 4

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Parkinson’s Disease Psychosis: The What When Why And How

Psychosis is a psychiatric term used in neurology to refer to a spectrum of abnormalities. Parkinsons disease psychosis is where people experience hallucinations or delusions. Hallucinations is seeing, hearing, or smelling things that dont exist. With tactile hallucinations, one can feel a presence that isnt there. Delusions are believing something that is not true, like that a spouse is being unfaithful or caregivers are stealing. In this one-hour talk, movement disorder specialist Christopher Goetz, MD, focuses on hallucinations and spends a little time on delusions.

Talk About Your Hallucinations And Delusions

Your hallucinations or delusions can be distressing for those around you. They may be unsure how to react so let them know what you are going through and how best they can help you. They will be more able to support you if you share your experiences with them, particularly if you know what the most common triggers are and what can be done to make the hallucinations or delusions go away.

Counselling can sometimes be helpful, particularly if the hallucinations or delusions strain relationships. Your doctor will be able to advise on the available types of counselling.

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Keep Your Home Well Lit

A dark environment may be associated with increased hallucinations, says Dr. Barrett. For some people, increased lighting may help, he says. However, this could also have a negative effect on sleep, so it should be approached with that in mind. After all, adequate sleep can help you feel better, he says. Talk with your doctor about adjustments that might work for you.

Recognizing Symptoms Of Delusions

People with Parkinsons delusions frequently believe they are being mistreated. As a result, people experience paranoia, mistrust, anger, and anxiety. Jealousy delusions usually a belief that a spouse is being unfaithful are very common. Persecutory delusions the false belief that someone is cheating or conspiring against you are also common. Persecutory delusions are often directed at someone the person with Parkinsons interacts with regularly, like a spouse, family member, or caregiver.

Caregivers on MyParkinsonsTeam share their experiences with jealousy and persecutory delusions:

• Husband still thinks Im slipping out at night, which I understand is the number one delusion for a spouse!
• He is saying I am lying to him, and he is showing signs of being paranoid.
• They provoke severe anxiety in my husband and sometimes he believes men are after him. He can become distrustful of me and his health care aide, whom he likes very much. These bad episodes can last one hour or six hours.
• My mom tells me I don’t feed her or I make her eat things that she doesn’t like.

Some delusions are more general confusions of reality. As one caregiver described, He mixes reality and old memories and TV programs and fantasy to create a different kind of reality. Another caregiver shared, He is POSITIVE we are not where we are, that he has two cats, etc.

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Examples Of Delusions In Pd

• Jealousy
• Belief: Your partner is being unfaithful.
• Behavior: Paranoia, agitation, suspiciousness, aggression.

How Delusions May Affect You

When delusions are mild, the person with Parkinsons may know what is happening and can be helped to overcome their false beliefs. A GP or specialist may just monitor the situation.

However, when delusions make people suspicious and distrusting, they can cause problems in relationships, medications and treatments.

With a serious delusion, there is a chance the person could accuse your partner or a family member of something they havent done. They may no longer be able to tell whether things are real or not, which can make them feel very anxious or irritable.

Some people with Parkinsons experience a mixture of hallucinations and delusions. This could lead them to feeling confused and can have an impact on day-to-day life.

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