Management of Psychosis in Parkinson’s Disease: Emphasizing Clinical Subtypes and Pathophysiological Mechanisms of the Condition

Table 5

Proposed treatment strategies of acute, secondary psychosis in Parkinson’s disease.

Step	Action
I	General measures	Reestablishment of circadian rhythms
		Reestablishment of normal-level sensory inputs
		Hearing and vision aids
		Reestablishment of familial environment
II	Treatment of specific triggers	Treatment of infection, dehydration
		Balancing electrolytes, glucose, vitamins, hormones
		Treatment of heart insufficiency
III	Elimination of nonessential medication	Particularly anticholinergic, antiglutamatergic, sedating drugs
IV	Reduction of anti-Parkinson medication	Anticholinergics > amantadine > MAO-B-inhibitors > dopamine agonists > COMT-inhibitors > L-dopa retard > L-dopa nonretarded
V	Cholinesterase inhibitors in cognitively impaired patients	For example, rivastigmine 6–12 mg/d 2-3/d, or donepezil 5–10 mg/d 1/d (off-label), or galantamine 4–32 mg/d 2-3/d (off-label)
VI	Antipsychotic medication	Clozapine 12.5–62.5 mg/d (first-line), or quetiapine 12.5–75 mg/d (off-label)

COMT, catechol-O-methyltransferase; MAO-B, monoamine oxidase B; reference: Levin et al., 2016 [3], taken from Seppi et al., 2011 [122] and Connolly and Lang, 2014 [123].