Pimavanserin: A Friend or Foe in Parkinson Disease Psychosis

Patients with Parkinson disease (PD) are at an increased risk of developing dementia and resulting behavioral abnormalities, including psychosis. The diagnostic criteria for PD psychosis recognize a spectrum of neuropsychiatric abnormalities that progressively worsen over time.1 Early in the disease, patients may experience illusions, passage, or the presence hallucinations and pareidolia often with preserved insight. As the disease progresses, well-formed visual hallucinations, delusions, and loss of insight create a challenge.2 A significant percentage of patients with PD experience dementia and psychosis. A prospective longitudinal study showed that 78% of patients with PD developed dementia over the 8-year observational period.3 Another prospective longitudinal study of community-dwelling patients with PD over 12 years found that 60% developed hallucinations and delusions.4 Symptoms of PD psychosis are challenging to manage, often lead to out-of-home placement, and are associated with an economic burden.5 Atypical antipsychotics such as clozapine, quetiapine, and others in this category were the only treatment options until the Food and Drug Administration (FDA) approved pimavanserin,6 a serotonin (2A) receptor inverse agonist.7 However, there have been concerns about an increased risk of mortality associated with this drug.

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