Psychosis, hallucinations often part of Parkinson’s

What if your father reported seeing cats playing everywhere in the house, and then got upset because he "forgot" to feed them? Imagine if police were called repeatedly to your parent's home because your father was convinced that strangers had attacked your mother.

Las Vegas resident Susan — who asked that her last name not be used — and her mother spent years caring for her father, Gary, who lived with psychosis as a result of Parkinson's disease. He was diagnosed in the early 1990s.

At first, it was little things — Gary thought he saw a water leak in the bathroom and tried to repair a toilet that had nothing wrong with it. He broke it. He tried also to fix the lawnmower he perceived to be defective and busted it, too.

Then, a tumble escalated things.

"In August 2013, my dad fell and hit his head," Susan said. "... He ended up in the hospital and was there three weeks. After that was when the hallucinations went into full effect. It was scary and crazy. He saw naked people in the shower or in their bed, and he'd ask my mother, 'Why are you hanging out with weirdos?' "

One time, her mother was taking a nap and woke to find a policeman standing over her, concerned. Gary had called the police, claiming someone had sexually assaulted her.

"It seems most of the hallucinations (that Parkinson's patients experience) are motivated by illegal activity — stealing, poisoning, assaults," Susan said. "It's not easy to talk about even with the doctor."

Many people equate Parkinson's to tremors and stiffness given that it is a motor disorder. Yet, Parkinson's disease psychosis — known as PDP — will affect more than half of Parkinson's patients during the course of their illness.

"What happens is that they have to figure out the cocktail of your medications. How much of this medication can we give you to give you your motor skills back versus how much of a hallucination issue are you willing to deal with?" Susan said. "Do you want to walk or do you want to see things?"

Gary died in April 2014. He was 74.

Dr. Jeffrey L. Cummings, director of the Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W. Bonneville Ave., said the back part of the brain is engaged when patients see things that are not there.

"It's the part of the brain responsible for vision," he said, "so we believe these people are really seeing these things. They are figures that the brain produces, in the same way that I see you sitting here now. The credible accrual of scientific information supports the concept that when we see a stroke in that part of the brain, that hallucinations occur. In MRIs, that's the area activated."

The hallucinations are highly idiosyncratic to each individual, Cummings said.

"I don't believe we have scientific insights into why one person will see a naked person and another will see their long-dead mother standing in the doorway," he said. "We have no real insight into why one person sees one thing and another will see (something else)."

He said it's often very difficult for patients to be candid about seeing hallucinations, especially if they realize it is a highly unusual experience, something out of the norm.

When the patient doesn't perceive their experiences as possible hallucinations, how can a caregiver help that person understand that this is their brain showing things that are not there?

Maegan Caldrone, director of therapy operation at HealthSouth Desert Canyon Rehabilitation Hospital, 9175 W. Oquendo Road, weighed in.

"The caregiver can continue to educate the patient on what the neurologist has told them about the hallucinations and making sure to repeat that message to the patient so they understand it's part of the disease process," she said. " ... another thing we do at HealthSouth is the speech therapist is able to work with the Parkinson's patient and really elaborate about the hallucinations and what thoughts they may be having. The therapist can help them process through those thoughts and identify which ones are real and what ones are kind of unrealistic thoughts."

Why don't people like to admit to hallucinations?

"It speaks of mental illness," said Cummings, "and therefore it's frightening to people who think they may be institutionalized or labeled crazy. These are the fears they have, so it's very important for the doctor to approach this as a neutral topic (and say), 'We often see patients put on these drugs will see unusual experiences. Like, for instance, a dog in the road. Have you had any unusual experiences?' So you get the, 'It's due to the drug,' approach."

Depression also is common with Parkinson's disease. One form is psychotic depression in which hallucinations can occur. They're usually not vision-related, so the doctor interviews the patient to find out if he's hearing people saying accusatory things, such as, "Your life isn't worth living"; "You are responsible for that traffic accident"; or "If you had been a better son, your mother would still be alive.' "

"They'll have these auditory hallucinations," Cummings said. "... If they see something, that's much more what we see in Parkinson's psychosis. But it takes some experience to tease these things out."

Cummings is overseeing the clinical trials for Parkinson's patients taking the drug Pimavanserin, made by ACADIA Pharmaceuticals Inc. The drug has completed phase three trials and has shown to be effective for reducing hallucinations while not impacting motor control such as other Parkinson's medications.

"We're really excited about (the drug). It's the first time a drug has had a compelling effect," Cummings said.

He said the trial medication showed a nearly 50 percent reduction in hallucinations without the impaired motor skills of other drugs. Cummings said seeing the results from the clinical trial was encouraging.

"Very often with a trial," said Cummings, "one part will be positive, and one part will be negative, and you have to kind of interpret them. That wasn't the case with Pimavanserin. The data really lined up in a way we would like to see most trials line up. And it's the magnitude of (the effect), that's what we're seeking here. We really want to help our patients improve by a lot. You don't have very many of these ecstatic moments where the data line up the way this one did."

The company plans to file for FDA approval by end of 2015.

Visit my.clevelandclinic.org/services/neurological_institute/lou-ruvo-brain-health.

— To reach Summerlin Area View reporter Jan Hogan, email jhogan@viewnews.com or call 702-387-2949.