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Longitudinal outcome of Parkinson’s disease patients with psychosis

S. A. Factor, DO, P. J. Feustel, PhD, J. H. Friedman, MD, C. L. Comella, MD, C. G. Goetz, MD, R. Kurlan, MD, M. Parsa, MD, R. Pfeiffer, MD and the Parkinson Study Group^*

*See the Appendix on page 1760 for a list of Group members.
Deceased.
From the Albany Medical Center (Drs. Factor and Feustel) and University of Rochester (Dr. Kurlan), NY; Memorial Hospital of Rhode Island (Dr. Friedman), Pawtucket; Rush–Presbyterian–St. Luke’s Medical Center (Drs. Comella and Goetz), Chicago, IL; Case Western University School of Medicine (Dr. Parsa), Cleveland, OH; and University of Tennessee Heath Science Center (Dr. Pfeiffer), Memphis.

Address correspondence and reprint requests to Dr. S.A. Factor, Parkinson’s Disease and Movement Disorders Center, Albany Medical Center, 215 Washington Ave. Ext., Albany, NY 12205; e-mail: factors{at}mail.amc.edu

Objectives: To examine the long-term outcome of PD patients with psychosis requiring antipsychotic therapy; to explore predictors of mortality, nursing home placement, dementia, and persistent psychosis; and to compare outcomes of those with persistent psychosis vs those whose psychosis resolved.

Methods: Baseline data available from 59 patients enrolled in the PSYCLOPS (PSychosis and CLOzapine in PD Study) trial included age, age at onset of PD, duration of PD and psychosis, character of psychosis, medications, living setting, and scores for Mini-Mental State Examination (MMSE), Unified Parkinson’s Disease Rating Scale, Hoehn and Yahr Scale, and Clinical Global Impression Scale. Longitudinal data were collected 26 months later regarding four outcomes: death, nursing home placement, diagnosis of dementia, and persistence of psychosis. Logistic regression was used to explore whether any baseline characteristics were associated with an increased likelihood of one of these outcomes.

Results: At baseline, 56% of patients had an MMSE score of <25, 12% were in a nursing home, 95% had hallucinations, and 60% had paranoia. On follow-up, 25% were dead, nursing home placement occurred in 42%, psychosis was persistent in 69%, and dementia was diagnosed in 68%. Select baseline characteristics predicted individual outcomes: Nursing home placement was associated with the presence of paranoia and older age; persistent psychosis was associated with younger age at onset of PD and longer disease duration; dementia was associated with older age at PD onset and lower initial MMSE score; no characteristics predicted death. Whether psychosis persisted or not had no significant effect on the development of the other three outcomes. The prevalence of hallucinations at follow-up was not different between groups currently receiving antipsychotics vs those on no treatment.

Conclusions: Psychosis in PD requiring antipsychotic therapy is frequently associated with death, nursing home placement, development and progression of dementia, and persistence of psychosis. Still, it appears the prognosis has improved with atypical antipsychotic therapy based on the finding that 28% of NH patients died within 2 years compared with 100% in a previous study done prior to availability of this treatment.

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