Hi Michael & Cheryl:
 
Here is an article on possibly the problems you are seeing in your mother.
 
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Hallucinations in Parkinson's Disease
by Robin Fross, MD
 
Editor's note:  Robin Fross, MD, is a neurologist specializing in movement
disorders with The Parkinson's Institute in Sunnyvale, CA.  She is also on
staff at Kaiser Permanente Medical Center in Hayward, CA.  Dr. Fross is
medical advisor to the Young Parkinson's Support Network of California.  This
article appeared as a two part series in the Peninsula Parkinson's Support
Groups newsletters, Volume VII, No. 3 and 4.  It is reproduced with their and
the author's permission.
 
People with Parkinson's disease may sometimes experience hallucinations.
 What are hallucinations and are they something to worry about?  A
hallucination is when one senses or perceives that an object or person is
present when that thing does not actually exist.  An example: I was sitting
quietly reading on my living room couch when I felt a presence and looked up
to see my late mother standing in the corner looking at me.  I was not
alarmed, but realized she wasn't really there, and then she was gone.  This
is similar to the typical hallucinations that can occur to people with
Parkinson's disease.  Sometimes these images are children, "little people,"
family pets or other small animals.  Occasionally they are images of ants or
bugs crawling on a surface or the appearance of inanimate objects such as
brooms or bicycles.  Rarely do these images speak or make sounds, although
they may be imbued with impish or contrary behaviors.,  Sometimes they do not
disappear quickly and persist whenever the mind is not otherwise occupied.
 They are rarely frightening or threatening and often are a source of some
amusement to the individual.
A hallucination by itself is not indicative of psychosis.  Often the
experience is easily recognized by the individual for its actual content   a
"waking dream."  However, in more extreme cases of hallucinosis other symptoms
 of psychosis can be present, such as delusions of persecution or
endangerment and unwarranted fearfulness.  The person may not be in touch
with the reality that these images are false.  In these situations it is diffi
cult for the person to separate the images that are imagined from the
delusions of circumstance that accompany these images.  For example, if I
were to see several people gathered in the yard outside my window, I might
also experience the delusion that they were going to set fire to my house.
 This delusion accompanies the hallucination, although the hallucination
itself does not image a fire.  Hallucinations can occur with full awareness
of the "unreality" of the image, or may be associated with symptoms of
psychosis, that is the loss of touch with reality and the experience of
delusions, disorientation and unwarranted fearfulness.
 
Causes of Hallucinations
 
Why do hallucinations happen in Parkinson's disease?  There are many possible
causes.  Some people experience hallucinations before they ever  take any
medications for Parkinson's.  This situation is usually related to the presenc
e of mild dementia that is sometimes seen in Parkinson's.  However, the most
common causes of hallucinations are (1) medications and (2) acute illness.
 The medications most likely to bring about hallucinations are, unfortunately,
 also those that are used to treat the motor symptoms of Parkinson's.  Every
drug that is now being used to treat Parkinson's can precipitate or aggravate
hallucinations.  However, some of these medications are more likely than most
to do so.  In my experience the worst offenders in causing hallucinations are
the anticholinergic agents   Artane, Cogentin, Kemadrin, Akineton.  Symmetrel
is also a predictable aggravator of hallucinations.  Also, the dopamine
agonists   Parlodel and Permax, can bring out hallucinations.  Eldepryl may
also trigger them, perhaps because of its breakdown product, methamphetamine.
 In my practice, the least likely culprit is Sinemet.  By itself it is the
safest and least hallucinogenic of all medications used to treat Parkinson's.
 
If a person with Parkinson's is experiencing worrisome hallucinations   that
is, not just the occasional simple shadowy image that the person has full
insight into, but constant and disorienting and disquieting images, I will
recommend that the most likely offending drug be discontinued (often Artane
or Symmetrel).  If the person is taking more than one of these drugs, then
both may need to be stopped.  I may try to get the person down to just taking
Sinemet alone.  In the majority of cases the person can do quite well on
Sinemet alone, without further hallucinations, although the dose of Sinemet
may have to be doubled.  It should be understood that, as a rule, no permanent
 damage to the mental state is caused by these drugs.
 
Other Conditions May Be Cause
 
Other medications, taken for associated conditions, can also bring about
hallucinations.  Common among them are the bladder medications, Ditropan
(oxybutynin), Levsin (hyoscyamine) and Urispas (falvoxate).  These agents are
similar to anticholinergics  such as Artane.  Pain medications such as
codeine, Vicodin (hydrocodone), Percocet (oxycodone), and morphine can bring
out confusion and hallucinations.  Sometimes even drugs used for sedation and
depression can aggravate the mental state (including such important
antidepressants as Elavil [amitripryline] and Desyrel [trazadone]).  My
general recommendations to persons already experiencing mental confusion,
early signs of dementia or a past history of hallucinations, is that they
should take these medications with caution after discussing their concerns
with their physicians.  After all, if only mild and infrequent hallucinations
occur, the benefit of pain relief or bladder management with these drugs may
far outweigh these relatively minor side effects.
It is also important not to blame medications for causing hallucinations
without first considering other possible causes.  A common cause of a change
in the mental state (confusion, hallucinations, disorientation) is as acute
illness, such as flu, a bladder infection or congestive heart failure.  Even
seemingly minor infections may precipitate mental deterioration.  Heat
exposure and dehydration can also lead to worsening of mental function.
 Undergoing the stress of a major illness, such as congestive heart failure
or bleeding ulcer, can cause trouble with the mental state.  General
anesthesia and the stress of recuperation from major surgery may also
precipitate a change in behavior, orientation and thinking processes.
 Medications given during hospitalization may also bring out the
hallucinating state.  In these circumstances the mental state generally
returns to normal in short order when the acute illness has run its course.
 
Dealing With Hallucinations
 
How does one deal with the person who is experiencing hallucinations?  My
advice is to, above all, remain calm and reassuring.  Do not argue with the
individual, but do reassure the person that you do not see these images and
so they must be "waking dreams," "little tricks of the mind that seem real
but aren't."  Never make the person feel at fault for seeing these things,
and never reinforce their fears that they are "crazy."  This is simply not
true and you should tell them so if they mention it.  Often it is better to
just distract the person away from their focus on these images and get them
thinking and doing other things.  When the person is occupied with a task or
engaged in conversation about something unrelated, the images will disappear
and be forgotten for the moment.  It may be as simple as having the person
discuss what should be prepared for the next meal, or what should be watched
on the television that night.  Sometimes a game of cards or a kitchen task
can distract the individual.  Sometimes, when the hallucinations occur at
night in the shadowy parts of a room, turning on a light to dispel the
shadows can help to reduce false imagery.
 
Clozaril May Help
 
Are there treatments to control hallucinations?  If all inciting medications
have been removed and hallucinations still occur to a worrisome degree
(interfering with the person's ability to function in the everyday
environment), then anti-psychotic medications may need to be used.  Most
anti-psychotic medications may aggravate the motor symptoms of Parkinson's
disease, causing more rigidity, tremor, and slowness.  These must be used
with caution.  I generally prefer to use Mellaril (thioridazine) at low doses
because it has the least propensity for worsening motor symptoms.  I stay
away from the stronger anti-psychotic agents, Haldol (haloperidol), Stelazine
(trifluoperazine) and Thorazine (chlorpromaine), because the motor symptoms
can worsen dramatically with these.  Recently, a new anti-psychotic drug has
been used for hallucinations in Parkinson's disease   Clozaril (clozapine).
 It does not aggravate the motor symptoms at all, but carries other risks
that make it difficult to administer.  The use of this drug is more tightly
regulated than other oral medication currently on the market.  Blood counts
(monitoring for potentially fatal anemia) must be done every week, and only
one week's supply of Clozaril is given at a time, pending the next week's
blood test.  This is done to prevent life-threatening complications, but it
makes it a complicated way to manage hallucinations.  In my practice, I only
use this drug as a last resort.  In general, hallucinations in Parkinson's
disease can be simply managed by understanding the underlying cause and
making small changes in medication if necessary.  Above all, hallucinations
should not be feared, but handled with understanding and reassurance.
 
END
 
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Regards,
Alan Bonander ([log in to unmask])