Neurological Awareness
A Story from the Shadow of Parkinson’s
Mr. Mehmet is a retired teacher. The knowledge and memories he accumulated over the years had flowed from his trembling hands into his memoirs. However, recently, he started saying—much to the bewilderment of his family—that his late life partner was sitting at the edge of the bed. But his wife had passed away years ago. At first, the family thought, “maybe he’s dreaming.” But when it became clear that Mr. Mehmet was seeing these images during the day while awake, concern grew. For many patients and their families, just like Mr. Mehmet, the images that invade the mind, the whispering voices, or the unrealistic beliefs are as wearing as the tremors and slow movements associated with Parkinson’s. In this article, we will discuss in a scientific yet human-centered manner why hallucinations and psychotic symptoms occur in Parkinson's disease, how to cope with them, and what families can do.
Frequency of Hallucinations and Psychotic Symptoms in Parkinson’s
Although Parkinson’s is mostly recognized for its motor symptoms, hallucinations or psychotic symptoms (loss of touch with reality, delusions, etc.) occur in 20-40% of patients at some stage of life.Source Especially in the advanced stages of the disease, this rate rises to 60%. This means that 6 out of every 10 people with Parkinson’s may experience such episodes at some point in their lives.
Visual hallucinations: The most common type. Patients see things that are not there, usually in the form of people or animals.
Auditory hallucinations: Hearing sounds, like bells, or someone calling their name.
Delusions: For example, believing their spouse is cheating or that the house is being robbed.
These can be frightening for both the patient and their loved ones, as these moments—where reality and imagination intertwine—often lead to a silent sense of loneliness and helplessness.
Causes: What Happens in the Brain of a Person with Parkinson’s
In Parkinson’s, the main issue is not just dopamine loss. Over time, other neurotransmitters such as acetylcholine and serotonin also decrease. Several factors play a role in the emergence of hallucinations and psychotic symptoms:
Medications: Some drugs used in the treatment of Parkinson’s—like levodopa or dopamine agonists—increase dopamine and thus the risk of psychosis. The risk is higher in cases of sleep disturbances, advanced age, or dementia.
Brain Degeneration: Over time, there is increased degeneration in the brain, especially in the frontal and temporal lobes. This impairs perception and reality monitoring.
Cognitive Decline (Dementia): Dementia develops in 30-50% of individuals with Parkinson’s. As dementia progresses, susceptibility to hallucinations increases.
The patient’s general health: Fever, infections, dehydration, or metabolic disturbances can trigger sudden psychotic episodes.
Interesting fact: The risk of hallucinations in people with Parkinson’s increases with age, number of medications, and duration of the disease.
The Burden of Hallucinations and Delusions on Patients and Loved Ones
These symptoms deeply impact not just the patient, but also their family. One day, seeing "playful children" in the house, and the next fearing "someone is poisoning me"—all disrupt the patient’s peace and often leave family members feeling helpless, sad, and sometimes angry. Some studies show that when psychosis begins in a person with Parkinson’s, social isolation increases and the caregiving burden can rise by up to 40%.Source
Sometimes, hallucinations are silent and cause no distress, but they can occasionally turn into fear or aggression. It’s vital for families to understand this is not a "personality change," but a natural extension of the disease.
Types and Diagnosis of Hallucinations
Visual hallucinations: Objects, animals, people, shadows. They are generally detailed and "realistic."
Auditory hallucinations: Less common. Hearing voices, melodies, whispers that are not really there.
Tactile hallucinations: Rare, but may include sensations like insects crawling on the skin.
Delusions: The patient begins to believe their loved ones are trying to harm them or that someone has broken into the home.
Usually, patient and family interviews are sufficient for diagnosis. However, in cases of rapid onset, with fever or loss of consciousness, infections or other neurological conditions need to be excluded.
What Happens in the Brain?
In Parkinson’s, especially the visual pathways (occipital lobe) and frontal lobe are affected. When the visual pathways deteriorate, information from the eyes can no longer be filtered by the brain as “real or imaginary?” The frontal lobe is the center for logic and testing reality. Research shows Parkinson’s patients who experience hallucinations have reduced blood flow and tissue loss specifically in these areas.Source
Parkinson’s Medications and Psychotic Symptoms
Many Parkinson’s medications ease motor symptoms by increasing dopamine in the brain but can also stimulate the "reality checkpoint." The following medications carry a higher risk:
Levodopa (especially in high doses)
Dopamine agonists (pramipexole, ropinirole, bromocriptine...)
MAO-B inhibitors and COMT inhibitors
Note: The risk increases with high doses and long-term use. Although reducing medication may be challenging for motor symptom control, once psychotic symptoms begin, medications should be reviewed.
What to Do If Hallucinations Occur?
Don’t panic. Hallucinations are a possible part of the disease. This doesn’t mean your loved one is "crazy." Responding with anger, warnings, or trying to persuade the patient will rarely work and can lead to conflict.
Observe the situation. If hallucinations are calm and not disturbing the patient, just keep a note. If anxiety, fear, or danger appears, consult a doctor.
Assess medications. Never stop or reduce medications on your own! Get in touch with your neurologist. Your doctor may decrease dopaminergic drugs if possible or add an antipsychotic medication.
Minimize environmental factors. Ensure the room is well-lit, and use glasses or hearing aids if needed. Shadows and darkness can worsen hallucinatory images.
Living with Parkinson’s Psychosis: Tips for Families
Listen. Instead of denying what your loved one sees or feels, say “I can’t see it, but would you like to tell me about it?” for safer communication.
Maintain daily routines. Regular meal times, brief walks, and conversation help create mental stability.
Don’t be afraid to take breaks. Caregivers can experience burnout too. Build a support network.
Optimize auditory and visual cues for the patient. Glasses, hearing aids, and good lighting make a difference.
Don’t leave the patient alone during psychotic episodes, but avoid needless arguments. Tension is exhausting for both sides.
5 Major Steps in Treatment
Review medications: The first step is to reduce or discontinue current Parkinson’s drugs, especially dopamine agonists and anticholinergics—as directed by a neurologist.
Rule out environmental and medical causes: Other factors like fever, infections, and dehydration should be excluded, as they can trigger acute episodes.
Non-pharmacological approaches: Ensure good room lighting, reduce visual stimuli, include short daytime walks, and add light entertainment.
Antipsychotic treatment: If delusions or hallucinations continue after reducing other drugs, "Parkinson’s-friendly" atypical antipsychotics (clozapine, quetiapine, pimavanserin) are preferred.
Clozapine is very effective at low doses but requires regular blood testing.
Quetiapine has fewer side effects, though not effective in every patient.
Pimavanserin is a new-generation drug with less effect on dopamine.
Caregiver and family support: Work as a team, join support groups, and seek psychological counseling when needed.
Important Considerations on Antipsychotic Medications
Many typical antipsychotics (haloperidol, risperidone, olanzapine) can worsen Parkinson’s motor symptoms and are therefore avoided.
Clozapine and pimavanserin are FDA-approved for Parkinson’s.Source
Dosage and selection must always be determined by a specialist, as side effects and drug interactions require supervision.
Emotional Support for Patients and Families
Remember: For someone experiencing hallucinations, these episodes feel very “real.” They may sometimes be frightening, sometimes strange, and sometimes even pleasant. Direct denial, confrontation, or anger can worsen the situation. Being present with empathy—saying things like, “I can imagine how tough this must be for you, let’s talk about how we can overcome this together”—can make the process easier. Studies show that when patients receive family support, the severity of these episodes can decrease by up to 30%.
Your loved one’s behaviors are not intentional; they are a result of the disease. Blaming yourself isn’t helpful; what matters is rediscovering the strength to move forward together.
When to Consult a Physician?
If hallucinations are frequent, intense, and cause fear
If there is an obvious risk of harm to self or others
If sudden confusion develops
If delusions become increasingly fixed or there is clear detachment from reality
If symptoms persist despite medications
Don’t delay seeking neurological or psychiatric support. Early intervention can often restore calm and relief.
Hope for the Future: New Treatment Options
Ongoing research is exploring new drugs for Parkinson’s psychosis. Pimavanserin, which targets the serotonin 2A receptor in the brain, has been shown to reduce hallucinations without causing motor impairment.Source In the future, more targeted and side-effect-free treatments may help families better manage this process.
Conclusion: Together, It’s Possible
Psychotic symptoms are among the toughest aspects of Parkinson’s. But you are not alone. Every hallucination and every difficult night is part of adapting to a new life. Knowledge and understanding are the best medicine. Don’t hesitate to consult your doctor. With the guidance of science and compassion, you can manage this process with confidence and empathy.
Resources
Bir Sonraki Okuma
