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Hi Michael & Cheryl: Here is an article on possibly the problems you are seeing in your mother. ======== 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 =================== Regards, Alan Bonander ([log in to unmask])