The management of the psychotic PD patient begins by searching for correctable causes, including infection, metabolic derangements, social stress, and drug toxicity. Infections may not always cause fevers in the geriatric population, so a search for urinary tract infections or pneumonias is warranted. Some PD patients who did not manifest psychotic symptoms at home may decompensate upon moving into the hospital environment. In many of these cases, moving the patient into a secure familiar environment or treating the underlying medical illness may ameliorate psychotic symptoms (19). Finally, medications with CNS effects may cause or exacerbate psychosis in PD and are often overlooked. These medications include pain or sleeping medications such as narcotics, anxiolytics, hypnotics, and antidepressants.
If psychotic symptoms persist despite identification and correction of the above factors, antiparkinsonian medications are slowly reduced and if possible discontinued. Antiparkinsonian drugs should be reduced and discontinued in the following order: anticholinergic agents, selegiline, amantadine, dopamine agonists, catechol-O-methyltransferase inhibitors and, finally, levodopa (53). If psychosis improves, the patient is then maintained on the lowest possible dose of antiparkinsonian medications. If psychosis persists, and further reductions in antiparkinsonian medications cause intolerable motor function, the use of an atypical antipsychotic agent is warranted.
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