Impulse control disorders and related behaviors in Parkinson's disease: risk factors, clinical and genetic aspects, and management

Behavioral disorders in Parkinson disease: current view

Patients with Parkinson disease (PD) frequently experience several behavioral symptoms, such as anxiety, apathy, irritability, agitation, impulsive control and obsessive-compulsive or REM sleep behavior disorders, which can cause severe psychosocial problems and impair quality of life. Occurring in 30-70% of PD patients, these symptoms can manifest at early stages of the disease, sometimes even before the appearance of classic motor symptoms, while others can develop later. Behavioral changes in PD show distinct patterns of brain atrophy, dopaminergic and serotonergic deterioration, altered neuronal connectivity in frontostriatal, corticolimbic, default mode and other networks due to a cascade linking molecular pathologies and deficits in multiple behavior domains. The changes suggest a multi-system neurodegenerative process in the context of a specific α-synucleinopathy inducing a variety of biochemical and functional changes, the neurobiological basis and clinical relevance of which await further elucidation. This paper is intended to review the recent literature with focus on the main behavioral disturbances in PD patients, their epidemiology, clinical features, risk factors, animal models, neuroimaging findings, pathophysiological backgrounds, and treatment options of these deleterious lesions.

Excessive Daytime Sleepiness as a Risk Factor for Impulse Control Disorders in Parkinson's Disease

Purpose

Impulse control disorders (ICDs) and excessive daytime sleepiness (EDS) are common symptoms in Parkinson's disease (PD). Few longitudinal studies have focused on the association between EDS and ICDs. This longitudinal study aimed at assessing association between EDS and ICDs in PD.

Patients and Methods

Patients without ICDs were incorporated from the Parkinson's Progression Markers Initiative. All patients were followed until the onset of ICDs or the end of 4 years. A total of 260 PD patients were included. Univariable and multivariable logistic regression were used to explore association between EDS and ICDs.

Results

The overall frequency of ICDs at the end of follow-up was 23.8% (62 patients). The mean duration from dopamine replacement therapy to develop ICDs was 3.30 ± 2.42 years. Patients with ICDs had significantly higher Epworth Sleepiness Scale (ESS) score (P = 0.002) and higher proportion of EDS (P = 0.030) when compared to patients without ICDs. The multivariable logistic regression analysis indicated that high ESS (OR = 2.01, 95% CI 1.01-4.04, p = 0.049) score, high dopamine agonist equivalent daily dose (OR = 2.54, 95% CI 1.37-4.71, p = 0.003), high Geriatric Depression Scale (OR = 2.33, 95% CI 1.27-4.28, p = 0.006) score and postural instability (OR = 3.03, 95% CI 1.26-7.29, p = 0.013) were associated with ICDs occurrence.

Conclusion

Our results indicated that EDS acts as a risk for ICDs occurrence in PD. Clinicians should pay attention to EDS in clinical practice. This may be a promising new approach to better understand and therapy ICDs.

Impulse control disorder: Review on clinical, pharmacologic, and genetic risk factors

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor and non-motor symptoms, among which impulse control disorders behaviors (ICD) emerge as significant non-motor manifestations. ICD in PD patients, including pathological gambling, hypersexuality, compulsive buying, among others, lead to considerable impairment and reduced quality of life. This review aims to explore the multifaceted risk factors associated with ICD in PD patients, including clinical, pharmacological, and genetic aspects, to enhance early identification, prevention, and management strategies.

METHODS

A comprehensive review of literature was conducted to identify studies investigating risk factors for ICD in PD. Data from clinical, pharmacological, and genetic studies were analyzed to elucidate the complex interplay of factors contributing to ICD development.

RESULTS

Clinical risk factors such as young age, male gender, and specific personality traits were consistently associated with a higher incidence of ICD. Environmental factors such as cultural nuances and geographic location influence ICD prevalence. Disease characteristics include early PD onset, longer disease duration, motor fluctuations, anxiety, depression, sleep disorders, and apathy. Pharmaceutical risk factors involve dopaminergic drugs, with dopamine agonists showing a dose-dependent association with ICD. Genetic risk factors highlight the involvement of dopaminergic and serotoninergic systems, with various neurotransmitter pathways implicated.

CONCLUSIONS

ICDs are common and severe in PD. Understanding the multifaceted risk factors for ICD in PD is crucial for identifying patients at high risk to develop these adverse effects and developing targeted interventions to prevent their occurrence. Given their frequency and potential consequences for the patient and their family, the current strategy is to systematically screen for ICDs throughout patient follow-up, particularly when prescribing dopamine agonists.

Association between sleep problems and impulsivity mediated through regional homogeneity abnormalities in male methamphetamine abstainers

Sleep problems and impulsivity frequently occur in methamphetamine (MA) abstainers and are linked to aberrant brain function. However, the interplay between these factors remains poorly understood. This study aimed to investigate the relationship between sleep, impulsivity, and regional homogeneity (ReHo) through mediation analysis in MA abstainers. 46 MA abstainers and 44 healthy controls were included. Impulsivity and sleep problems were evaluated using the Barratt Impulsivity Scale and the Pittsburgh Sleep Quality Scale, respectively. ReHo, indicative of local brain spontaneous neural activity, was assessed using resting-state functional magnetic resonance imaging. Results unveiled correlations between different dimensions of impulsivity and ReHo values in specific brain regions. Motor impulsivity correlated with ReHo values in the left postcentral gyrus and left precentral gyrus, while non-planning impulsivity was only associated with ReHo values in the left precentral gyrus. Additionally, the need for sleep medications correlated with ReHo values in the left precentral gyrus and bilateral postcentral gyrus. Also, the need for sleep medications was positively correlated with cognitive impulsivity and motor impulsivity. Mediation analysis indicated that reduced ReHo values in the left precentral gyrus mediated the association between impulsivity and the need for sleep medications. These findings imply that addressing sleep problems, especially the need for sleep medications, might augment spontaneous neural activity in specific brain regions linked to impulsivity among MA abstainers. This underscores the importance of integrating sleep interventions into comprehensive treatment strategies for MA abstainers.

DRD4 gene polymorphism and impulse control disorder induced by dopamine agonists in Parkinson's disease

Impulse control disorders and their consequences display variability among individuals, indicating potential involvement of environmental and genetic factors. In this retrospective study, we analyzed a cohort of Parkinson's disease patients treated with dopamine agonists and investigated the influence of the dopamine D4 receptor gene polymorphism, DRD4 7R+, which is linked to psychiatric disorders, impulsive traits, and addictive behaviors. We found that DRD4 7R+ is a significant genetic risk factor associated with the severity of ICD.

Impulse control disorders and use of dopamine agonists in early onset Parkinson's disease

Introduction

Impulse control disorders (ICDs) are defined as excessive and repetitive behaviors that may affect Parkinson's disease (PD) patients exposed to dopamine agonists. Current data on ICDs in patients with early-onset Parkinson's disease (EOPD) is lacking. In this study we aim to assess the frequency of use of dopamine agonists, the prevalence of ICDs, and to explore potential factors associated with their development in patients with EOPD.

Methods

We used the Mayo Clinic Data Explorer system to investigate a population-based cohort of EOPD patients between 1990 and 2022 at Mayo Clinic, Rochester, MN. We used ICD coding for parkinsonism; then, we reviewed all the clinical records and included only those patients with a clinical diagnosis of PD with symptoms onset at or before the age of 50, and who developed ICDs after using therapeutic doses of dopamine agonists.

Results

A total of 831 (513 males and 318 females) patients with EOPD were included with a median age at symptom onset of 42 years of age (CI: 37-46). Dopamine agonists were used in 49.7% of all patients; of these, only 14.5% developed symptoms of one or more ICDs. Hypersexuality was the most commonly observed ICD (38.3%), and the only one having a statistically significant male predominance (p = 0.011).

Conclusion

ICDs are common in EOPD, particularly when associated with the use of dopamine agonists.

Prognosis of impulse control disorders in Parkinson's disease: a prospective controlled study

BACKGROUND

The long-term prognosis of impulsive compulsive disorders (ICD) remains poorly studied in Parkinson's disease (PD).

OBJECTIVE

Evaluating the natural history of ICD and its impact on PD symptoms including cognition and treatment adjustments.

MATERIALS AND METHODS

We assessed PD patients at baseline (BL) with (BL-ICD+) or without (BL-ICD-) ICD despite dopamine agonist (DA) exposure of > 300 mg levodopa-equivalent daily dose for > 12 months at baseline and after more than two years of follow-up. ICD were assessed using the Ardouin's Scale of Behaviors in PD (ASBPD), cognition using the Mattis scale, and PD symptoms using the UPDRS score. Treatment adjustments, DA withdrawal-associated symptoms, and ICDs social consequences were recorded.

RESULTS

149 patients were included (78 cases and 71 controls), mean duration of follow-up was 4.4 ± 1 years. At baseline, psychiatric disorders were more common among BL-ICD + (42.3 vs 12.3% among BL-ICD-, p < 0.01). At follow-up, 53.8% of BL-ICD + were not ICD-free while 21.1% of BL-ICD- had developed ICD. BL-ICD + more frequently experienced akinesia (21.8 vs 8.5%, p = 0.043) and rigidity worsening (11.5 vs 1.4%, p = 0.019) following therapeutic modifications. Decision to decrease > 50% DA doses (12.8 vs 1.4%, p = 0.019) or to withdraw DA (19.2 vs 5.6%, p = 0.025) was more frequently considered among BL-ICD+ . At follow-up, the prevalence of cognitive decline was lower among BL-ICD + (19.2 vs 37.1%, p = 0.025).

CONCLUSION

ICDs were associated with increased psychiatric burden at baseline and better cognitive prognosis. Most patients were still showing ICDs at the follow-up visit, suggesting ICD to be considered as a chronic, neuropsychiatric disorder.

Creative thinking and cognitive estimation in Parkinson's disease

BACKGROUND

Patients with Parkinson's disease (PD) have been reported to exhibit unusual bouts of creativity (e.g., painting, writing), in particular in the context of treatment with dopaminergic agents. Here we investigated divergent and convergent thinking thought to underlie creativity. In addition we assessed cognitive estimation.

METHOD

Twenty PD patients and 20 matched healthy control participants were subjected to the Guilford Alternate Uses task (divergent thinking), the remote associates task (convergent thinking) and two tests of cognitive estimation.

RESULTS

No group differences were found for the convergent thinking task, while the Guilford Alternate Uses task revealed a decreased number of correct responses and a reduced originality for PD patients. Originality in PD was correlated to total daily dose of dopaminergic medication. Moreover, both tasks of cognitive estimation showed an impairment in PD.

CONCLUSION

Only minor effects were found for psychometric indices of subprocesses of creative thinking, while estimation, relying on executive functioning, is impaired in PD. We suggest to take a product oriented view of creativity in further research on altered creative processes in PD.

Evaluation of risk factors for impulse control disorder in Parkinson's disease in northern China

INTRODUCTION

Impulse control disorder (ICD) is a common non-motor symptom of Parkinson's disease (PD), but its risk factors are still controversial. This study aimed to determine the prevalence of ICD in northern China and analyze the risk factors associated with ICD, multiple ICDs, and four subtypes.

METHODS

A total of 285 PD patients were enrolled in this study. Each patient was screened using the Questionnaire for Impulse and Compulsive Control Disorders (QUIP). Stepwise regression analysis was performed to identify independent risk factors, and a prediction model was developed.

RESULTS

The prevalence of ICD in the study population was 11.6%. Stepwise regression analysis showed that ICD was associated with disease duration, motor symptoms, dyskinesia, depression, REM sleep behavior disorder (RBD) and cognitive decline; multiple ICDs were related to coffee history, motor symptoms, dyskinesia, depression, apathy and RBD. The prediction model demonstrated good performance with AUC values of 0.93, 0.88, and 0.66 on the balanced train set, balanced test set, and the original imbalanced data set, respectively.

CONCLUSION

The risk factors for PD-ICD are complex and influenced by regional economic and cultural backgrounds. Clarifying these factors and developing predictive models can help to delay or even prevent the development of ICD through early screening and intervention.

The pharmacological management of the behavioral aspects of Parkinson's disease: an update

INTRODUCTION

Behavioural symptoms are common manifestations of Parkinson's disease and include depression, anxiety, impulse control disorders, hallucinations, psychosis, and cognitive dysfunction. They remain inadequately addressed in many patients despite their relevance for quality of life and disability. This applies also to impulse control disorders where the most common approach in recent literature is to refrain from using dopamine agonists without consideration about their potential benefit on motor complications.

AREAS COVERED

We conducted a narrative review searching for articles on behavioral symptoms in Parkinson disease and selected those which included involved neurotransmitters such as dopamine, noradrenaline, serotonin, acetylcholine. We specifically focused our search on open-label and randomized double-blind studies and biomarkers which could best characterize these clinical manifestations.

EXPERT OPINION

Management of Parkinson disease behavioural manifestations lacks clear guidelines and standardized protocols beside general suggestions of dose adjustments in dopamine replacement therapy and use of antidepressants or antipsychotic drugs with little consideration of patients' age, sex, comorbidities, and motor status. We suggest a pragmatic approach which includes education of affected patients and caring people, dealing with complex cases by experienced multidisciplinary teams, use of cognitive behavioural therapy, and psychological counselling to complement drug treatment.

Course of Impulse Control Disorder Symptoms in Parkinson's Disease: Deep Brain Stimulation Versus Medications

Background

The effect of surgery on impulse control disorders (ICDs) remains unclear in Parkinson's disease (PD) patients undergoing deep brain stimulation (DBS).

Objective

To examine changes in ICD symptoms in PD patients undergoing DBS compared to a medication-only control group.

Methods

The study was a 2-center, 12-month, prospective, observational investigation of PD patients undergoing DBS and a control group matched on age, sex, dopamine agonist use, and baseline presence of ICDs. Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease-Rating Scale (QUIP-RS) and total levodopa equivalent daily dose (LEDD) were collected at baseline, 3, 6, and 12 months. Linear mixed-effects models assessed changes in mean QUIP-RS score (sum of buying, eating, gambling, and hypersexuality items).

Results

The cohort included 54 participants (DBS = 26, controls = 28), mean (SD) age 64.3 (8.1) and PD duration 8.0 (5.2) years. Mean baseline QUIP-RS was higher in the DBS group at baseline (8.6 (10.7) vs. 5.3 (6.9), P = 0.18). However, scores at 12 months follow-up were nearly identical (6.6 (7.3) vs. 6.0 (6.9) P = 0.79). Predictors of change in QUIP-RS score were baseline QUIP-RS score (β = 0.483, P < 0.001) and time-varying LEDD (β = 0.003, P = 0.02). Eight patients (four in each group) developed de novo ICD symptoms during follow-up, although none met diagnostic criteria for an impulse control disorder.

Conclusions

ICD symptoms (including de novo symptoms) at 12 months follow-up were similar between PD patients undergoing DBS and patients treated with pharmacological therapy only. Monitoring for emergence of ICD symptoms is important in both surgically- and medication-only-treated PD patients.

Management of psychiatric and cognitive complications in Parkinson's disease

Neuropsychiatric symptoms (NPSs) such as affective disorders, psychosis, behavioral changes, and cognitive impairment are common in Parkinson's disease (PD). However, NPSs remain under-recognized and under-treated, often leading to adverse outcomes. Their epidemiology, presentation, risk factors, neural substrate, and management strategies are incompletely understood. While psychological and psychosocial factors may contribute, hallmark PD neuropathophysiological changes, plus the associations between exposure to dopaminergic medications and occurrence of some symptoms, suggest a neurobiological basis for many NPSs. A range of psychotropic medications, psychotherapeutic techniques, stimulation therapies, and other non-pharmacological treatments have been studied, are used clinically, and are beneficial for managing NPSs in PD. Appropriate management of NPSs is critical for comprehensive PD care, from recognizing their presentations and timing throughout the disease course, to the incorporation of different therapeutic strategies (ie, pharmacological and non-pharmacological) that utilize a multidisciplinary approach.

Psychiatric Symptoms in Parkinson's Disease Patients before and One Year after Subthalamic Nucleus Deep Brain Stimulation Therapy: Role of Lead Positioning and Not of Total Electrical Energy Delivered

Parkinson’s disease (PD) patients may experience neuropsychiatric symptoms, including depression, anxiety, sleep disturbances, psychosis, as well as behavioral and cognitive symptoms during all the different stages of the illness. Deep Brain Stimulation (DBS) therapy has proven to be successful in controlling the motor symptoms of PD and its possible correlation with the occurrence or worsening of neuropsychiatric symptoms has been reported. We aimed to assess the neuropsychiatric symptoms of 14 PD patients before and after one year of Subthalamic Nucleus (STN)-DBS and to correlate the possible changes to the lead placement and to the total electrical energy delivered. We assessed PD motor symptoms, depression, anxiety, apathy, impulsivity, and suicidality using clinician- and/or self-administered rating scales and correlated the results to the lead position using the Medtronic SuretuneTM software and to the total electrical energy delivered (TEED). At the 12-month follow-up, the patients showed a significant improvement in PD symptoms on the UPDRS (Unified Parkinson’s disease Rating Scale) (−38.5%; p < 0.001) and in anxiety on the Hamilton Anxiety Rating Scale (HAM-A) (−29%; p = 0.041), with the most significant reduction in the physiological anxiety subscore (−36.26%; p < 0.001). A mild worsening of impulsivity was detected on the Barratt Impulsiveness Scale (BIS-11) (+9%; p = 0.048), with the greatest increase in the attentional impulsiveness subscore (+13.60%; p = 0.050). No statistically significant differences were found for the other scales. No correlation was found between TEED and scales’ scores, while the positioning of the stimulating electrodes in the different portions of the STN was shown to considerably influence the outcome, with more anterior and/or medial lead position negatively influencing psychiatric symptoms.