NeuroVoices: Ruth Schneider, MD, on Addressing Psychosis in Lewy Body Diseases

Ruth Schneider, MD

Parkinson disease psychosis (PDP) a common feature of PD, encompasses minor phenomena, including illusions, passage hallucinations, and presence hallucinations, as well as visual and nonvisual hallucinations and delusions. More than half of all patients with PD eventually develop symptoms over the course of their disease. For clinicians, understanding effective and early treatment strategies for PDP can be critical to improving long-term quality of life.

At the recently concluded 2023 American Neurological Association (ANA) Annual Meeting, held September 9-12 in Philadelphia, Pennsylvania, Ruth Schneider, MD, gave a talk on the management of psychosis in PD and other Lewy body diseases. Schneider, an associate professor in the department of neurology at the University of Rochester, specializes in the care of patients with movement disorders, with a research focus in the development of digital measures of disease, and the neuropsychiatric manifestations of PD.

Schneider sat down with NeurologyLive^® at the meeting to discuss her presentation, including some of the differences of psychosis among patients with dementia with Lewy bodies and PD. As part of a new iteration of NeuroVoices, Schneider gave thoughts on the impact of pimavanserin (Nuplazid; Acadia), the only FDA-approved medication to treat PDP, and whether there is hesitancy with certain off-label medications in the toolbox.

NeurologyLive^®: Could you provide an overview of your presentation and explain why this topic interested you?

Ruth Schneider, MD: Certainly. My presentation focused on the epidemiology and presentation of psychosis in Lewy Body diseases, highlighting the differences between psychosis in Parkinson's disease and dementia with Lewy bodies. This topic intrigued me because psychosis is quite common and has a significant impact. It's associated with increased disability, leading to outcomes like nursing home placement, dementia, and mortality in Parkinson's disease. So, it's crucial that we actively screen for it and address it appropriately as clinicians.

Could you elaborate on the differences observed in psychosis between dementia with Lewy bodies and Parkinson's disease?

Ruth Schneider, MD: Certainly. Psychosis is prevalent in both conditions, but it tends to be associated with more advanced stages in Parkinson's disease. The prevalence of hallucinations and delusions increases as Parkinson's disease progresses. In contrast, dementia with Lewy bodies often presents with visual hallucinations as a core clinical diagnostic criterion, so the prevalence is higher, even at the earliest stages. Moreover, hallucinations in dementia with Lewy bodies tend to be multimodal, involving visual and other sensory components. While this can also occur in Parkinson's disease as it advances, it's less common.

Could you discuss the differences in the management and treatment of psychosis in these two patient groups? Specifically, how has the treatment landscape changed since the approval of pimavanserin, and how is it integrated with other medications?

Ruth Schneider, MD: Certainly. In both conditions, we start by educating and providing support to patients and their families. We also consider removing medications that may precipitate or worsen psychosis, such as anticholinergics or opioids. However, our treatment paths diverge. In Parkinson's disease, treatment with antipsychotics is somewhat standard, with options like pimavanserin and Clozapine. In contrast, there has been historical concern about neuroleptic sensitivity in dementia with Lewy bodies, making us more cautious about initiating antipsychotics in this population.

Are there any specific hesitations or considerations when it comes to using certain antipsychotics, such as a particular drug, timing, or patient characteristics?

Ruth Schneider, MD: In Parkinson's disease, it's important to remember that not all forms of psychosis necessarily require treatment. Milder forms like illusions or misperceptions don't necessarily need intervention, especially if the individual has insight and no safety concerns. Before prescribing medication, I explore potential medication reductions or other adjustments. When choosing a medication, I consider factors like side effect profiles, the expected time frame for benefits, and any barriers that patients might face. For example, Clozapine, while effective, requires routine blood monitoring, which can be burdensome.

In the context of dementia with Lewy bodies, what research gaps exist regarding psychosis, and what unanswered questions are still present?

Ruth Schneider, MD: The most significant gap, in my opinion, lies in finding the best approach to treatment. There has been a lack of clinical trials and research studies focusing on psychosis in dementia with Lewy bodies compared to Parkinson's disease. I would love to see more research and clinical trials exploring different antipsychotics and treatment approaches for psychosis in dementia with Lewy bodies.

Transcript edited for clarity by artificial intelligence.