hallucinations associated with Parkinson's disease

Etiology: 1) excessive medications 2) cognitive impairment Clinical manifestations: 1) may be associated with nightmares & paranoia 2) often worse in the evening Management: 1) reduce adjunctive medications (step 1) a) selegiline b) anticholinergics c) amantadine 2) reduce dopaminergic agonists (step 2) a) reduce dose at time of day hallucinations occur b) evening dose reduction most likely of benefit 3) atypical antipsychotic may be needed if 1 & 2 fail a) quetiapine (Seroquel) agent of choice b) clozapine - most effective agent to control hallucinations without worsening motor function - begin 12.5 mg QD & increase slowly - monitor CBC weekly c) avoid risperidone; worsens parkinsonism in most patients

References

Bronstein J, In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004