Hallucinations and confusion in Parkinson’s disease
A parkinsonian patient can see some familiar person or animal which are not present at that time. It is a visual hallucination; rarely they hear voices or music ( auditory hallucination) Visual hallucination can be distressing, in particular, if the patient is seeing a relative who is dead for many years and has not the full insight of the unreality of the vision. Visual hallucinations can happen during the day or at night. Nocturnal hallucinations can be terrifying and threaten for the patient, occur as part of vivid nightmares in the second part of the night; it’s called REM behavior disorder (or RBD as an acronym). RBD has to be diagnosed as it required as the specific therapeutic strategy (some drugs are worsening RBD and have to be stopped) and a specific treatment of the sleep disorder.has to be started. Visual hallucinations related to a RBD phenomenon. can occur also after an afternoon nap, when the patient wakes up.
Daytime hallucinations can be due to the high doses of antiparkinsonian drugs ( the dopaminergic psychosis). It’s usually related to the Dopaminergic agonist, the anticholinergic drugs or the Amantadine; usually, the patient is also confused. It’s very important to recognise this psychosis as the antiparkinsonian drugs have to be decreased very cautiously.
Daytime visual hallucinations can also occur very early in the disease, at the same time that the patient slows down, even without being treated;. The patients sometimes mentioned the feeling of a presence behind or beside them ( called extra-campines hallucinations because occurring outside the visual field, so not seen but felt). Often, in addition, these patients developed nocturnal RBD. It’s often marked the onset of Lewy body dementia.
Acute and sudden confusion and agitation with hallucinations in an advanced PD can be the sign of an infection, such as urinary tract infection or pulmonary infection, which will respond well to antibiotics.
Parkinsonian patients are prone to develop anxiety and depression.
Depression is not easy to diagnose because signs of motor and mental slowness, poor sleep, weight loss can be related to both the depression and the Parkinson disease. Also mood can fluctuate with the motor state. Mood swings are responsible for depression and panic attacks when the patient is Off ( very slow ) and of excitation or euphoria when the patient is On dyskinetic (involuntary movements.)
Impulse control disorders with the dopaminergic agonists.
- It’s more frequent in young male patients with a past history of depression or addiction, but can affect any parkinsonian patients. Patients become addicted to gambling or shopping; they put on weight as they are sweet craving and /or become obsessed by sexuality, watching porn movies and browsing on a porn website, sometimes cross-dressing or having a compulsion for exhibitionism.
- All these addictions need early interventions from the neurologists to protect the patient and his family.
Parkinsonian patients can become addict to their antiparkinsonian treatment, increasing sometimes secretly the daily doses of levodopa or dopaminergic agonists. They feared so much to be Off that they keep taking tablets, despite being mobile and often too mobile with wild and permanent involuntary movements (dyskinesias)). It is exhausting physically for the patient and psychologically for the family around him. It can end up in a psychotic state due to the very high total daily doses, taken by the patient.
Parkinsonian patients may feel the need to repetitively classify papers, to work endlessly on the computer forgetting lunch, to dismantle some devices, to organise collections of objects, labeling them, pulling them in and out. This repetitive active is nonproductive and has to be performed by the patient, every day, often at night , the patient, being carried away by the activity. and forgetting the time for going to bed. It is important to recognise this abnormal behavior before an inversion of the sleep cycle and an exclusion of the patient from normal daily life.
Hypersexual behavior and pathological jealousy in severe advanced Parkinson’s disease
Severely affected Parkinsonian patients who have developed cognitive decline and are treated with dopaminergic agonist can have disturbing hypersexual behavior, despite sometimes a sexual impotence. which is extremely distressing for the partner, usually also quite senior.
Pathological jealousy is also not rare at that stage, the patient being convinced that his/her partner has an affair. Both the patient and the partner who is the target of the delusional belief are distressed.
All these psychiatric and cognitive complications represent the more severe and complex issues to deal when treating Parkinsonian patients.
Dr MH Marion is an experienced neurologist with knowledge of both neuropsychiatry and Parkinson’s disease. Dr MH Marion worked in the psychiatric department in Salpetriere Hospital in Paris as an interne and also graduated in neuro- psycho-pharmacology, testing the drugs acting on the dopaminergic system.