EARLY DOPAMINERGIC DRUG-INDUCED HALLUCINATIONS IN PARKINSONIAN-PATIENTS

Objective: To characterize patients who develop hallucinations early i n the course of dopaminergic therapy for Parkinson's disease (PD) and contrast them with patients developing hallucinations after chronic dr ug treatment. Methods: Parkinsonian patients who met diagnostic criter ia for PD, experienced hallucinations, had a detailed hallucination in terview at the onset time of their first hallucination, and had a 5-ye ar clinical follow-up or an autopsy in those 5 years were identified a nd divided into two groups for comparison: 12 patients who developed e arly hallucinations within 3 months of starting levodopa therapy and 5 8 PD patients who developed hallucinations after 1 year of dopaminergi c therapy. We contrasted the quality, content, diurnal nature, and emo tional elements of the hallucinations, as well as the 5-year follow-up data on diagnosis, disease course, community home or nursing home out come, and mortality. Results: Both groups experienced a predominance o f visual hallucinations, visions of people and animals, and vivid colo rs and definition. Features distinctive to the early onset hallucinati ng patients included visions that persisted in daytime as well as nigh ttime, frightening content with paranoia, and accompanying nonvisual h allucinations, either auditory, olfactory, tactile, or combinations th ereof. At the 5-year follow-up, none of the early onset hallucinators had PD as their sole disorder. Four of the 12 had an underlying psychi atric illness that included hallucinations or psychosis preceding thei r parkinsonism by several years. In the other eight patients at the 5- year follow-up, their parkinsonism evolved to include additional signs that were no longer consistent with PD. The primary diagnoses were di ffuse Lewy body disease and Alzheimer's disease (AD) with extrapyramid al signs. Patients with early drug-induced hallucinations had signific antly greater placement to nursing homes and greater mortality. Conclu sions: Early onset drug-related hallucinations are not typical of PD. Their presence should signal an investigation of two alternative diagn oses, either a comorbid psychotic illness (often unrevealed by the pat ient initially) or an evolving parkinsonism-plus syndrome.