Visual Hallucinations in PD: What do they look like? by Dr. De Leon

Someone asked not long ago if Parkinson’s hallucinations had a particular pattern or flavoring to them? The truth is that there are common trends seen in PD patients who experience hallucinations. First, a hallucination is a strong perception of something that is not real or does not exist. Any and all of the senses can be involved in a hallucination meaning that one can feel, taste, touch, see or hear something that is not real. Hallucinations are purely imaginary as opposed to illusions which are distortions of real things/ objects/ people/ and sounds. The second most common hallucination in my experience is olfactory (smell) hallucinations …I frequently think something is burning. other people have told me same thing. this may be related to olfactory neurons dying out.

It is estimated that at some point up to 75% of PD individuals will experience this phenomena of hallucinations particularly-visual.

It is also important to note that the timing of such events can be a huge diagnostic clue. In typical PD, these symptoms do not occur until more than 10 years into diagnosis and can be exacerbated by medications but are a part of the disease itself. So, if symptoms present at onset or within a few years of Parkinson’s symptoms then we are most likely NOT dealing with regular garden variety PD but rather a disease in the spectrum of Parkinson family like Lewy body dementia or CBGD ( corticobasalganglia degeneration) to name a few.

The most common type of hallucination in PD individuals is a visual one, as I stated earlier.  These can be either black and white or in full color and typically involve children or animals. The perceptions can last a brief period of time or hours. however, important to note that usually the images do not speak or make sounds and thus are not ordinarily distressing to the individual who for the most part remain aware that this is a hallucination (not real). In fact, a lot of my patients, as do many other PD individuals, rather enjoy seeing the children and find comfort in these images. However, although it is usually not the norm some patients can find the hallucinations distressing, anxiety provoking, and even frightening at times, these typically occur with more violent or frightening images- typically of demons and such.  When a person cannot distinguish reality from make- belief or if the images are too frightening or causing distress, this is the time for intervention.

What can you do to help?

1)  Make note as to when hallucinations are more likely to occur to try to prevent. Confusion, hallucinations and a full moon usually go hand in hand! So, keep those neuroleptic drugs handy just in case you may need during a full moon or lunar eclipse. In my experience, more patients were brought to ER because of psychosis during these days.  Typically, I would recommend pre-medicating a patient during those days if I knew they were prone to hallucinate and get distressed over the event.

2)  People that sleep a lot during the day seem to be more prone to visual hallucinations. Try to maintain normal sleep wake cycle as much as possible and prevent excess daytime sleep. On the other hand, sleep deprivation can also trigger these episodes. Therefore it is important  to discuss with your physician any sleep problems.

3)  Also be aware that certain medications like anti- cholinergics (e.g.amantadine), anti- histamines (Benadryl), anti- anxyolitics (e.g. klonopin)  even dopamine medications, more the agonists than levodopa, can induce hallucinations.

4) Other triggers for hallucinations are acute infections. In the elderly population urinary infection is the number one culprit. So maintain your loved ones well hydrated.

Even though, PD individuals may experience auditory hallucinations this is not the norm and if this is highly prevalent, one must consider other causes triggering these events, such as brain tumors, strokes, medications, etc.

Often, my grandmother who had Parkinson’s in her final stages would hallucinate. She frequently saw children playing and thought of them as the children she had lost when they were infants or toddlers. Seeing them made her happy. In this scenario I did not need to give her any type of medication for psychosis or hallucinations for its not always necessary to medicate a loved one just on the basis that they are having hallucinations. However,  there were times when she thought the house was being flooded and caused a great deal of distress thinking that she and we were going to drown especially my daughter who was only a toddler then.  At those times, I would have to give medication to decrease her anxiety.

How to handle patient when hallucinating?

1) You never want to be confrontational or argumentative or even try to change their belief about their hallucination; it would only escalate to violence.

2)  Also do not try to give medication when they are agitated or again will only cause you the caregiver increased heartache.

3) Best to walk away if they are not in imminent danger let them settle down then bring a medication best if it’s something quick acting like an orally disintegrating compound. Another good technique that works unless extremely agitated is distraction with books, pictures, coloring, games, etc.

Fortunately, we now have a new medication on the market just for PD psychosis from Acadia called Nuplazid (Pimavanserin). Medications which I frequently employed for this problem were atypical antipsychotics( neuroleptics) such as Seroquel and Clozaril since they would not interfere with motor symptoms of PD, there are other medications which can be given in smaller quantities but used because they are IV or orally disintegrating.

Finally, since rarely do hallucinations in PD occur in absence of dementia this needs to be treated.  Look for other underlying causes such as strokes, or vitamin B12 deficiency. Adjust dopamine levels and best to remove Amantadine and dopamine agonists which can exacerbate problem and start treatment with an anticholinesterase inhibitor, like Aricept. In my experience combination treatment with Namenda and Exelon or another one of its class went along way to curbing dementia and hence hallucinations.

Make sure you consult your physician regarding any changes in mental status including hallucinations.





Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at you can also learn more about Parkinson’s disease at or at;, All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at contributor Contributor


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