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Parkinson disease psychosis — ABIM Board MCQ

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HardNeurologyParkinson disease psychosisABIM Board

A 74-year-old with Parkinson disease develops formed visual hallucinations while taking carbidopa-levodopa and pramipexole. Infection, metabolic disturbance and delirium have been excluded; motor symptoms are acceptable. Which medication adjustment should be considered first?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Gradually reduce or discontinue the dopamine agonist before reducing necessary levodopa

The best answer is “Gradually reduce or discontinue the dopamine agonist before reducing necessary levodopa”. Dopamine agonists have a high hallucination and impulse-control burden, so they are commonly reduced before essential levodopa when motor function allows. Dopamine-blocking drugs such as haloperidol and metoclopramide can markedly worsen parkinsonism, abrupt levodopa withdrawal can be dangerous, and anticholinergics worsen cognition.

Reference: AAN Practice Guideline: Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease: https://www.aan.com/Guidelines/home/GuidelineDetail/1048