A Scoping Review of Palliative Care for Adults with Huntington's Disease: Current Practice and Future Directions

The pathobiology of depression in Huntington's disease: an unresolved puzzle

Huntington's disease (HD) is an autosomal-dominant progressive neurodegenerative disease that manifests with a triad of symptoms including motor dysfunctions, cognitive deficits, and prominent neuropsychiatric symptoms, the most common of which is depression, with a prevalence between 30 and 70%. Depressive symptoms occur in all stages of HD, beginning in presymptomatic HD gene carriers, and are strongly associated with suicidal ideation and suicidality, but their relationship with other clinical dimensions in HD is controversial and the underlying pathophysiology is poorly understood. Analysis of the available literature until November 2023 concerned the prevalence, clinical manifestations, neuroimaging, transgenic models, and treatment options of HD depression. While it was believed that depression in HD is due to psychosomatic factors in view of the fatal disease, studies in transgenic models of HD demonstrated molecular changes including neurotrophic and serotonergic dysregulation and disorders of the hypothalamic-pituitary-adrenal axis inducing depression-like changes. While relevant neuropathological data are missing, recent neuroimaging studies revealed correlations between depressive symptoms and dysfunctional connectivities in the default mode network, basal ganglia and prefrontal cortex, and changes in limbic and paralimbic structures related to the basic neurodegenerative process. The impact of response to antidepressants in HD patients is controversial; selective serotonin reuptake inhibitors are superior to serotonin-norepinephrine reuptake inhibitors, while electroconvulsive therapy may be effective for pharmacotherapy resistant cases. Since compared to major depressive disorder and depression in other neurodegenerative diseases, our knowledge of the molecular basis in HD depression is limited, further studies to elucidate the heterogeneous pathogenesis in this fatal disorder are warranted.

Efficacy of Electroconvulsive Therapy for the Treatment of Movement Disorders: A Literature Review

Electroconvulsive therapy (ECT) is a safe and effective treatment modality for various psychiatric disorders. However, evidence suggests a putative role of ECT in treating movement disorders that are refractory to less invasive modalities. ECT is primarily used in treatment-resistant psychiatric disorders. However, growing evidence exists for its use in movement disorders with and without psychiatric comorbidity.

The primary objective of this systematic review was to examine the efficacy of ECT as a primary treatment modality for movement disorders. Relevant, peer-reviewed publications were retrieved from PubMed, SCOPUS, CINAHL, and PsycINFO. Keywords related to ECT and movement disorders were used as search phrases to identify relevant articles. A total of 90 articles that met the inclusion criteria were included in this review. Core findings were subsequently appraised on the role of ECT in treating movement disorders.

Inclusion and exclusion criteria were developed to guide the search and selection process. Sources that met the inclusion criteria were those published between 2001 and January 2023. Additionally, peer-reviewed journals published in the English language covering the role of ECT in movement disorders were deemed appropriate for inclusion. Sources published before 2001, written in a non-English language, and not from peer-reviewed journals were excluded from this systematic review. The exclusion criteria also entailed eliminating duplicates from the review list.

Most reviewed sources revealed that ECT improved outcomes in symptoms associated with various movement symptoms. However, ECT does not have a long-lasting impact on neuroacanthocytosis symptoms. Additionally, ECT is negatively associated with aggression and agitation, two of the most critical movement symptoms of Alzheimer’s disease.

Evidence affirms the efficacy of ECT in providing symptomatic relief for movement disorders aside from psychiatric comorbidities. This positive association highlights the need for randomized controlled studies to identify movement disorder sub-populations that may respond to ECT.

Layers of Loss: A Scoping Review and Taxonomy of HD Caregivers' Spiritual Suffering, Grief/Loss and Coping Strategies

CONTEXT

Huntington's disease (HD), an incurable, multi-generational, autosomal dominant disorder, creating unique challenges and a myriad of spiritually-related stressors in those affected and their familial caregivers. Spiritual suffering, experiences of grief/loss, and coping strategies have not been systematically studied in HD caregivers.

OBJECTIVES

To comprehensively define spiritual suffering, grief/loss, and coping strategies used by HD caregivers.

METHODS

A PRISMA-ScR scoping literature review was conducted. Data from included research articles were organized thematically using induction and open coding. A grounded, deductive approach was used to delineate a demarcated taxonomy of themes, which encompasses all three over-arching domains. Four reviewers, employing a modified Delphi approach, ascertained which themes were demonstrated by research participants in each study.

RESULTS

36 of 583 articles met the review criteria; none were published in the palliative care literature. Investigations primarily focused on intrapersonal (self-image) distress and existential angst; only rarely looking deeper into divine/transpersonal suffering, disrupted religious relationships, or meaning distress. HD caregivers experience profound grief/loss, expressed as disenfranchised grief that is associated with the ambiguous loss of their loved one, loss of family structure, social connectedness, and personal losses. Half of the studies reported maladaptive HD caregiver coping strategies-characterized by dysfunctional escape schemes; in contrast, transcendent/creative strategies were often unexplored.

CONCLUSION

HD caregivers experience prolonged grief and other forms of spiritual suffering as they progressively lose their loved ones and disruption to their own lives. With an improved assessment tool, teams with spiritual and palliative care experts will better be able to support HD family caregivers.