Treating Psychosis in Parkinson’s Disease – Out with the Old, In with the New?

The use of antipsychotic medications in Lewy body dementias is a known challenge. Up to 60% of people with Parkinson’s disease also experience psychosis. But are the medications helpful and safe? A recent study suggests there is reason for concern.

Using data from the Veteran’s Health Administration, Helen Kales, MD, Daniel Weintraub, MD and colleagues studied 7,877 pairs (each pair including one patient treated with an antipsychotic and the other not treated with an antipsychotic) of individuals with Parkinson’s disease who were matched by criteria such as age, sex, race, duration of Parkinson’s disease, and presence and duration of dementia, and controlling for presence of psychosis. The aim of the study was to determine if there was a difference in mortality rates over 180 days (i.e. 6 months), between those who were newly treated with antipsychotic medications and those who did not.

Those who had been hospitalized within the prior 14 days were excluded, to ensure individuals studied were medically stable. Individuals with schizophrenia or bipolar disorder were excluded from this study, as were people with dementia with Lewy bodies (DLB). Additionally, individuals who died within the first four weeks were excluded from the study in secondary analyses, as these medications are sometimes used for palliative care at end of life.

The use of antipsychotic medications had more than a two-fold “hazard ratio” (risk of death). Atypical antipsychotic medications had a lower hazard ratio than the older “typical’ antipsychotics. Quetiepine had the lowest hazard ratio of the atypical antipsychotics. The secondary analyses confirmed the primary analyses.

Dr. Weintraub is a member of the LBDA’s Scientific Advisory Council. This research paper was published in JAMA Neurology.

New treatment for psychosis in Parkinson’s disease, but can it be used in LBD?

The Food and Drug Administration (FDA) has just approved pimavanserin (brand name NUPLAIZID) for the treatment of psychosis in Parkinson’s disease. Occurring in up to 50% of people with Parkinson’s disease, hallucinations and delusions can be upsetting to both the person with Parkinson’s disease and caregivers. The full press release can be read here.

The Lewy Body Dementia Association submitted public comment in to the FDA advisory committee in March to express the urgency for safer treatments for psychosis in all Lewy body disorders. This new treatment has not yet been studied in dementia with Lewy bodies (DLB). Determining an appropriate dose for people with DLB is important due to the potential for severe medication sensitivities. A recent article reported on the advisory committee ruling and drew a cautionary response from Dr. Ian McKeith of Newcastle University and a member of LBDA’s Scientific Advisory Council about prescribing pimavanserin to DLB patients before such studies are done.