Dr. Grossberg (00:06): Hello, I'm Dr. George Grossberg. I'm a Professor and Director of the division of Geriatric Psychiatry in the Department of Psychiatry and Human Behavior at St. Louis University School of Medicine. Dr. Grossberg (00:20): I'd like to welcome you to the first episode of this podcast series, entitled Best Practices in Parkinson's Disease Psychosis. Joining me today, a real expert in the field, I'm very happy to have you join me, is Dr. Danielle Larson, who's a Movement Disorder Specialist at Northwestern University at the Feinberg School of Medicine in Chicago, Illinois. So welcome, Dr. Larson. Dr. Larson (00:50): Thank you. Thank you for having me today, and I'm glad to be here to talk about this very important aspect of Parkinson's disease care. Dr. Grossberg (00:59): Great. So in this episode, as I mentioned, this is a series... In this episode we're going to talk about why we should make Parkinson's disease psychosis a priority in our practices. We're going to focus on the symptoms, the epidemiology, as well as the burden on both patients as well as their caregivers. Dr. Grossberg (01:21): So Dr. Larson, let's start with how we defined Parkinson's disease psychosis. What are the diagnostic criteria? Dr. Larson (01:31): Well, thankfully, we have very specific and clear diagnostic criteria that were outlined by the National Institutes of Neurologic Disorders and Stroke and the National Institutes of Mental Health in 2007. So it's pretty clear to follow those criteria in order to make an accurate diagnosis. Dr. Larson (01:53): And the criteria starts with, first and foremost, that an individual has to be diagnosed with Parkinson's disease based on the UK Brain Bank criteria. Dr. Larson (02:03): And then that individual has to have at least one of four main symptoms of Parkinson's disease psychosis. And those four symptoms include hallucinations, delusions, illusions, and false sense of presence. Dr. Larson (02:20): Now, hallucinations are defined as abnormal perceptions without physical stimulus and in Parkinson's disease psychosis, these are commonly visual, such as seeing things that aren't there, like people or animals. And they're less likely to be auditory or tactile hallucinations. Dr. Larson (02:41): Delusions are defined as a false belief, despite evidence to the contrary. And in Parkinson's disease, delusions are commonly of a paranoid nature. For example, an individual might feel that someone is out to get them, like the FBI, or might feel that their partner has been unfaithful to them. Dr. Larson (03:03): Illusions are misperceptions of real stimuli and an example of that is if somebody looks at a tree and sees the leaves moving but sees a face amongst the leaves. Dr. Larson (03:16): And then lastly, a false sense of presence is when people with Parkinson's might feel that there is someone over their shoulder or behind them. But when they look, there's actually nobody there. Dr. Larson (03:30): And then another important aspect of the diagnostic criteria is that these symptoms have to occur after the Parkinson's disease diagnosis, and they must be recurrent or continuous for at least one month. And the symptoms can't have another explanation, such as another disease state or a toxic metabolic etiology contributing or causing them. Dr. Grossberg (03:58): That's very interesting. I was intrigued by what you said relative to visual hallucinations and the notion that it's not uncommon for patients with Parkinson's disease psychosis to see various animals. Dr. Grossberg (04:14): In fact, just last week I had one of my Parkinson's patients who's in the early to middle stages of Parkinson's disease came for follow up with his wife, and he was really, really bothered that he was seeing these rodents, mouse or rat-like creatures that were running around on the floor in his house. And that was quite disturbing and distracting. But it really got disturbing when he went to bed at night and these creatures were seen also in bed. Which of course made it hard for him to sleep and made it hard for his spouse to sleep. So these visual hallucinations and psychotic symptoms in general, I think as you pointed out, are not only common but can be quite distressing, quite disabling. Dr. Larson (05:06): Yes, they can definitely be distressing and especially as it sounds like, was the case with that patient, that the individual had lost insight into the fact that those rodents or those hallucinations were actually not real. So that's an important aspect of hallucinations to understand when we're asking our patients and their care partners whether or not they are aware that these are, in fact, hallucinations. Dr. Grossberg (05:34): And that's a really good point. So when are we likely to see Parkinson's disease psychosis? Dr. Larson (05:42): So the symptoms of Parkinson's disease psychosis can occur at any point during Parkinson's disease, but are more likely to occur in mid to later stages of the condition. But they are in some way dependent on what else is going on in that person's disease, what else is going on in their life, what medications they're on, what other comorbidities do they have that could be contributing to the onset of these Parkinson's disease psychosis symptoms. Dr. Larson (06:15): And typically when the symptoms start, they might start as minor symptoms, such as those illusions or false sense of presence or the minor visual misperceptions where the person retains insight and understands that they're not real. And then they do typically progress where they become more of those frank hallucinations like you described, where they're seeing animals, well formed animals, and they lose insight into the condition. They lose insight into the fact that those things aren't real. And that's when it becomes disturbing and frightening and very bothersome to patients and their care partners. Dr. Grossberg (06:59): Yeah, that's very interesting. I was also thinking, when you mentioned the false sense of presence, that is almost unique to Parkinson's disease patients as far as psychotic symptoms. As I think about other common disorders that can be associated with psychotic features or symptoms, you hardly ever hear about the false sense of presence, but it's actually a fairly big player in this population. Dr. Larson (07:31): It is. And it is something that I do see commonly and I see in people that are otherwise very cognitively intact and otherwise have no other Parkinson's disease psychosis manifestations, and might only have a false sense of presence for several years before they even develop any other symptoms. And it's something that I usually specifically ask about, because typically people don't think to offer that information or they think nothing of it. But when you specifically ask them if they see things over their shoulder or get a feeling that people are behind them, then that information will come to light. Dr. Grossberg (08:16): So I guess now that we've described the range of psychotic symptomatology, one of the questions our listening audience would and should have is what causes these symptoms? What triggers psychotic symptomatology against a background of Parkinson's disease? And we have to think about brain-related changes as well as things that are more extrinsic. You mentioned things that can contribute, or exacerbate, psychotic symptomatology. Dr. Grossberg (08:45): So as far as the brain-related disturbances, but we're looking at really are changes in several neurotransmitter pathways involving the dopaminergic, the serotonergic, and even the cholinergic pathways, which involve subcortical projections and synaptic and neuronal changes, both in the limbic as well as cortical structures. And we think that these changes trigger the psychotic symptomatology. But we also want to keep in mind, and you really alluded to this I think very nicely earlier, that there can be medications. Dr. Grossberg (09:23): So for example, dopaminergic agents, dopamine agonists in particular, can trigger psychotic symptoms or maybe exacerbate them, as can anticholinergic therapies that can also cause frank delirium, which can be accompanied by psychotic features. So in thinking about intervention down the road and treatment approaches, we want to make sure that we're also limiting potential insults by way of prescribed or even over-the-counter remedies. Dr. Grossberg (09:56): Now, I think at this juncture, we're moving to talk more about the burden of Parkinson's disease psychosis. And Dr. Larson, how common is this phenomenon and what impact does it have on our patients and their families? Dr. Larson (10:14): Well, as I believe we've already touched on, the symptoms of Parkinson's disease psychosis are much more common than I believe a lot of providers are aware. Actually about half of patients with Parkinson's disease will experience psychotic symptoms at some point during the course of their disease. One study in particular that looked at Parkinson's patients in a community dwelling found that nearly 50% of those people had some isolated minor symptoms like we talked about, such as those visual misperceptions or the false sense of presence. And then half of them, or about 25%, had current continuous psychotic symptoms. So that's nearly half of our patient population. And that might even be a false representation of what we see in the clinic because in these research studies, there's direct questions to find out whether these symptoms are happening. And I think in the clinical setting, unless we ask very direct questions, these symptoms might go unnoticed and undertreated and under-recognized for quite some time. Dr. Grossberg (11:34): There're under-reported, both by patients depending on the stage of the disease that they're in, as well as often I think by the care partners who may be reluctant or embarrassed to talk about these so-called psychiatric or behavioral symptoms, including psychosis. So what about the burden of Parkinson's disease psychosis? Dr. Larson (12:00): Yeah, the burden of Parkinson's disease psychosis can be great. It can definitely impact the individual with Parkinson's disease and also the care partner. So related to the individual with the Parkinson's disease, it can contribute to worsened disability in their activities of daily living. It can contribute to feelings of anxiety or depression, and just overall general lower quality of life. And then for the care partners, it does increase the burden on them. If an individual is more anxious, more depressed, and having bothersome hallucinations or delusions, then there is more burden on the care partner to address these issues. Dr. Larson (12:47): And then ultimately, Parkinson's disease psychosis symptoms can increase the likelihood of nursing home placement, hospitalization, morbidity, and even mortality. So as we discussed, that's why it's so important to understand if these symptoms are going on, as early as possible, so that they can be addressed appropriately for as long as possible. Dr. Grossberg (13:13): That sounds very good. I would want to go to you if I had a Parkinson's patient. But so you mentioned that the diagnostic criteria pretty much state that Parkinson's disease psychosis can occur with or without cognitive impairment, or with or without dementia. In fact, you even pointed out, I think very accurately that currently the only FDA-approved treatment for Parkinson's disease psychosis was actually studied in Parkinson's disease patients without dementia. But what about the added burden of dementia in this patient population? Dr. Larson (13:52): Yeah, I mean, that's a great point that we've talked about, that these symptoms can occur in people that are otherwise very cognitively intact. But having the extra burden of cognitive impairment, whether it's mild cognitive impairment or dementia, increases the strain on the care partner. It increases the likelihood that individual's going to lack insight into their hallucinations or their delusions and really understand that they need to take medications to address it, for example. And so that again, adds more burden onto the care partner to remind them to take their medications or be on top of their medications, their doctors visits, et cetera. Dr. Grossberg (14:36): That sounds good. So I think you and I both agree that we need to make Parkinson's disease psychosis a priority in our practice and in everyone's practice who sees these patients. I think the challenge is, and let me know what you think, that we tend to think of Parkinson's disease as a motor disorder disease. We tend to focus on the motor symptoms, and we don't routinely focus on the very disabling non-motor symptomatology and in particular, Parkinson's disease psychosis. So what can we do? How do we do that? How do we change practice? Dr. Larson (15:17): Yeah, that's a great question and definitely a very important question. And I do believe, at least in the Movement Disorders field, there has been a growing awareness and emphasis put on these non-motor symptoms and the burden that these non-motor symptoms have on Parkinson's disease patients. Dr. Larson (15:35): So I believe it's becoming more regularly addressed in clinical practice, but we do need to make it a point to ask about these symptoms, non-motor symptoms, but symptoms of Parkinson's disease psychosis at every visit. And there are certain ways that we can, if we want to leverage technology to help us do that, we can have templated notes in our electronic medical records where we have pre-written questions such as, "Are visual hallucinations present? Are delusions present?" Just to remind us that we need to be asking patients about this at every visit. Other people might have more formal questionnaires built into their electronic medical record to really get at these questions and again, remind us in our busy practice to focus on these aspects. Dr. Grossberg (16:30): I think that's a wonderful idea, and I think if more practitioners did that, we would indeed have, as you pointed out earlier, a recognition of Parkinson's disease psychosis early in the disease, during a time when we can intervene and make a tremendous difference. Dr. Grossberg (16:47): So I'm afraid, unfortunately, our limited time is up. But I do want to thank you, Dr. Larson, for the wonderful discussion. As I mentioned earlier, if I was living in Chicago, I would send all my patients to you. I think you have the empathy and the clinical skills and the personality to deal with these very troubling behaviors and to help our patients with Parkinson's disease psychosis and their loved ones and their caregivers. Dr. Grossberg (17:16): So I do want to also recognize and thank all of our listeners for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation. We look forward to seeing you at our next series.