Objective: To examine if actual clinical practice of antipsychotic use in Parkinson’s Disease patients are consistent with published evidence-based reviews of treatment recommendations and discuss possible reasons for inconsistencies.

Background: Psychotic symptoms can occur in up to 40% of Parkinson’s Disease patients and are associated with major behavioral and functional problems. According to evidence-based reviews published by the American Academy of Neurology in 2006 and the Movement Disorders Society in 2011,  clozapine is efficacious, quetiapine may be useful, and olanzapine is not useful. However, actual clinical practice is challenging due to patient comorbidities, side-effects, other non-motor symptoms, practical logistics and caregiver preferences. For this reason, we hypothesize that patterns of antipsychotic prescriptions in patients with Parkinson’s Disease are incongruous with published evidence-based reviews of treatment, and discuss possible reasons.

Methods: Parkinson’s Disease patients were identified from a Movement Disorders database in a large tertiary hospital with a dedicated Movement Disorders service. Their prescription data for the years 2005 and 2013 were examined. Frequencies of usage of the different antipsychotics were calculated and compared. Patient demographic and clinical profiles were compared.

Results: In 2005, before the evidence-based reviews were published, frequency of antipsychotic use was haloperidol (35.82%), risperidone (23.54%), quetiapine (12.74%), olanzapine (9.37%) and clozapine (2.35%). In 2013, after the last published review in 2011, the frequency of antipsychotic use changed to haloperidol (16.2%), (23.77%), quetiapine (35.6%), olanzapine (14.24%) and clozapine (2.35%). The use of haloperidol decreased but the use of quetiapine and olanzapine increased. The use of clozapine and risperidone did not change. Additional data comparing patient profiles in 2005 and 2013 are still being analysed.

Conclusions: Practical challenges remain regarding the use of clozapine in the treatment of psychosis in Parkinson’s disease despite its efficacy, preventing more widespread use. Olanzapine and Quetiapine are preferred drug options despite evidence against its efficacy, likely due to differences in patient profiles and caregiver preferences. Current evidence base is still inadequate to transform clinical practice of treating psychosis in Parkinson’s Disease. 

References: 1. Seppi K, Weintraub D, Coelho M, Perez‐Lloret S, Fox SH, Katzenschlager R, Hametner EM, Poewe W, Rascol O, Goetz CG, Sampaio C. The Movement Disorder Society Evidence‐Based Medicine Review Update: Treatments for the non‐motor symptoms of Parkinson’s disease. Movement Disorders. 2011 Oct 1;26(S3):S42-80.

2. Miyasaki JM, Shannon K, Voon V, Ravina B, Kleiner-Fisman G, Anderson K, Shulman LM, Gronseth G, Weiner WJ. Practice Parameter: Evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006 Apr 11;66(7):996-1002.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/treatment-of-psychosis-in-parkinsons-disease-evidence-based-recommendations-versus-actual-clinical-practice/