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  • Review Article
  • Published:

Hallucinations in Parkinson disease

Nature Reviews Neurology volume 5, pages 331–342 (2009)Cite this article

Abstract

Patients with Parkinson disease (PD) can experience hallucinations (spontaneous aberrant perceptions) and illusions (misinterpretations of real perceptual stimuli). Of such phenomena, visual hallucinations (VHs) and illusions are the most frequently encountered, although auditory, olfactory and tactile hallucinations can also occur. In cross-sectional studies, VHs occur in approximately one-third of patients, but up to three-quarters of patients might develop VHs during a 20-year period. Hallucinations can have substantial psychosocial effects and, historically, were the main reason for placing patients in nursing homes. Concomitant or overlapping mechanisms are probably active during VHs, and these include the following: central dopaminergic overactivity and an imbalance with cholinergic neurotransmission; dysfunction of the visual pathways, including specific PD-associated retinopathy and functional alterations of the extrastriate visual pathways; alterations of brainstem sleep–wake and dream regulation; and impaired attentional focus. Possible treatments include patient-initiated coping strategies, a reduction of antiparkinson medications, atypical neuroleptics and, potentially, cholinesterase inhibitors. Evidence-based studies, however, only support the use of one atypical neuroleptic, clozapine, and only in patients without dementia. Better phenomenological discrimination, combined with neuroimaging tools, should refine therapeutic options and improve prognosis. The aim of this Review is to present epidemiological, phenomenological, pathophysiological and therapeutic aspects of hallucinations in PD.

Key Points

  • According to cross-sectional studies, one-third of individuals with Parkinson disease (PD) experience visual hallucinations; however, up to 75% of patients will develop such phenomona over a 20-year period

  • Hallucinations have substantial psychosocial effects and are a prominent factor influencing the placement of patients with PD in nursing homes

  • Hallucinations usually occur in the context of dopaminergic or anticholinergic drug therapy for PD

  • Multifaceted visual deficits, sleep–wake cycle dysregulation and cognitive dysfunction are increasingly recognized as contributory factors to hallucinations in PD

  • Treatments for hallucinations include atypical neuroleptics and, possibly, cholinesterase inhibitors

  • In the future, a more discriminative phenomenological exploration could delineate distinct types of hallucinations with differing pathophysiological mechanisms, treatment strategies, and prognoses

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Figure 1: Subject of visual illusions in PD.
Figure 2: Functional MRI in patients with PD and visual hallucinations.

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Authors and Affiliations

  1. Department of Neurology, Center Hospitalier de Luxembourg, Luxembourg City, Luxembourg

    Nico J. Diederich

  2. Department of Neurology, CHU Henri Mondor, Créteil, France

    Gilles Fénelon

  3. Department of Neurological Sciences, Rush University Medical Center, Chicago, USA

    Glenn Stebbins & Christopher G. Goetz

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  1. Nico J. Diederich
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  2. Gilles Fénelon
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  3. Glenn Stebbins
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  4. Christopher G. Goetz
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Correspondence to Nico J. Diederich.

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Competing interests

Gilles Fénelon acts as a consultant for Boehringer–Ingelheim and Novartis Pharmaceuticals. Christopher G. Goetz has served as a consultant and advisory board member to Novartis Pharmaceuticals. The other authors declare no competing interests.

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Diederich, N., Fénelon, G., Stebbins, G. et al. Hallucinations in Parkinson disease. Nat Rev Neurol 5, 331–342 (2009). https://doi.org/10.1038/nrneurol.2009.62

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