Apathy in Parkinson's disease

Oral Health and Dental Health Care Experiences of Patients From the Netherlands With Parkinson's Disease: A Qualitative Study

BACKGROUND

Parkinson's disease patients have poorer oral health than their healthy peers. Insight into their own experiences is vital for improving dental care.

OBJECTIVE

To better understand the experiences of Parkinson's disease patients' with their oral health and dental care.

MATERIALS AND METHODS

Eleven semistructured interviews with Parkinson's disease patients from the Netherlands were conducted. Data were analysed using thematic analysis to identify recurring themes and patterns.

RESULTS

Participants' narratives revealed challenges in accessing dental treatment, primarily due to motor and communication difficulties. They also highlighted organisational barriers, such as appointment scheduling and awareness of care practitioners about Parkinson's disease patients' oral health. Furthermore, they expressed the urgent need for Parkinson's disease-specific dental education to (dental) care practitioners and research initiatives that focus on Parkinson's disease patients' oral health and dental care.

CONCLUSION

Parkinson's disease patients' experiences highlight the need for tailored care interventions and improvements in dental care systems.

Community Choir Improves Vocal Production Measures in Individuals Living with Parkinson's Disease

OBJECTIVES

Parkinson's disease (PD) is a neurodegenerative disease leading to motor impairments and dystonia across diverse muscle groups including vocal muscles. The vocal production challenges associated with PD have received considerably less research attention than the primary gross motor symptoms of the disease despite having a substantial effect on quality of life. Increasingly, people living with PD are discovering group singing as an asset-based approach to community building that is purported to strengthen vocal muscles and improve vocal quality.

STUDY DESIGN/METHODS

The present study investigated the impact of community choir on vocal production in people living with PD across two sites. Prior to and immediately following a 12-week community choir at each site, vocal testing included a range of vocal-acoustic measures, including lowest and highest achievable pitch, duration of phonation, loudness, jitter, and shimmer.

RESULTS

Results showed that group singing significantly improved some, though not all, measures of vocal production. Group singing improved lowest pitch (both groups), duration (both groups), intensity (one group), jitter (one group), and shimmer (both groups).

CONCLUSIONS

These findings support community choir as a feasible and scalable complementary approach to managing vocal production challenges associated with PD.

A Comparison of In-Person and Telehealth Treatment Modalities using the SpeechVive Device

Telehealth is increasing popular as a treatment option for people with Parkinson disease (PD). The SpeechVive device is a wearable device that uses the Lombard effect to help patients speak more loudly, slowly, and clearly. This study sought to examine the effectiveness of the device to improve communication in people with PD, delivered over a telehealth modality as compared to in-person, using implementation science design. 66 people with PD were enrolled for 12 weeks with 34 choosing the in-person group and 32 in the telehealth group. Participants were assessed pre-, mid-, and post-treatment. Participants produced continuous speech samples on and off the device at each timepoint. Sound pressure level (SPL), utterance length, pause frequency, and total pause duration were measured. Psychosocial surveys were administered to evaluate the effects of treatment on depression, self-efficacy, and participation. The in-person group increased SPL when wearing the device while the telehealth group did not. Both groups paused less often while wearing the device. Utterance length increased post-treatment for the telehealth group, but not for the in-person group. An increase in communication participation ratings in the telehealth group, but not the in-person group, was the only significant change in the psychosocial metrics. The in-person group showed similar treatment effects as previous studies. The device was not as effective in the telehealth group. One limitation was data loss due to recording issues that impacted the telehealth group more than the in-person group.

Caregiver perspectives enable accurate diagnosis of neurodegenerative disease

BACKGROUND

The history from a relative or caregiver is an important tool for differentiating neurodegenerative disease. We characterized patterns of caregiver questionnaire responses, at diagnosis and follow-up, on the Cambridge Behavioural Inventory (CBI).

METHODS

Data-driven multivariate analysis (n = 4952 questionnaires) was undertaken for participants (n = 2481) with Alzheimer's disease (typical/amnestic n = 543, language n = 50, and posterior cortical n = 50 presentations), Parkinson's disease (n = 740), dementia with Lewy bodies (n = 55), multiple system atrophy (n = 55), progressive supranuclear palsy (n = 422), corticobasal syndrome (n = 176), behavioral variant frontotemporal dementia (n = 218), semantic (n = 125) and non-fluent variant progressive aphasia (n = 88), and motor neuron disease (n = 12).

RESULTS

Item-level support vector machine learning gave high diagnostic accuracy between diseases (area under the curve mean 0.83), despite transdiagnostic changes in memory, behavior, and everyday function. There was progression in CBI subscores over time, which varied by diagnosis.

DISCUSSION

Our results highlight the differential diagnostic information for a wide range of neurodegenerative diseases contained in a simple, structured collateral history.

HIGHLIGHTS

We analyzed 4952 questionnaires from caregivers of 2481 participants with neurodegenerative disease. Behavioral and neuropsychiatric manifestations of neurodegenerative disease had overlapping diagnostic boundaries. Simple questionnaire response patterns were sufficient for accurate diagnosis of each disease. We reinforce the value of a collateral history to support a diagnosis of dementia. The Cambridge Behavioural Inventory is sensitive to change over time and suitable as an outcome measure in clinical trials.

Greater Apathy Associated With Selective Serotonin Reuptake Inhibitor Use in Parkinson's Disease

OBJECTIVE

Apathy, a motivational disorder, is common in Parkinson's disease (PD) and often misdiagnosed as depression. Use of selective serotonin reuptake inhibitors (SSRIs) has been associated with increased apathy in adolescents and adults with depression. Based on observations that serotonin may downregulate dopaminergic systems, we examined the relationship between apathy and SSRI use in individuals with PD.

METHODS

Medications, mood/motivation scales, and clinical data were collected from a convenience sample of 400 individuals with PD. Depression and apathy were measured using the Beck Depression Inventory-II (BDI-Il) and the Apathy Scale (AS). Antidepressant medications were grouped by mechanism type.

RESULTS

Of the 400 PD patients, 26% were on SSRIs. On standard mood/motivation scales, 38% of the sample exceeded clinical cut-offs for apathy and 28% for depression. Results of hierarchical regression analyses revealed that SSRIs were the only antidepressant that were significantly associated with higher apathy scores (β = .1, P = .02). Less education (β = -.1, P = .01) worse cognition (β = -.1, P = .01), and greater depressive symptoms (β = .5, P < .001) were also significant predictors of apathy.

CONCLUSION

These findings suggest that use of SSRIs, but not other antidepressants, is associated with greater apathy in PD. Given the interactive relationship between serotonin and dopamine, the current findings highlight the importance of considering apathy when determining which antidepressants to prescribe to individuals with PD. Similarly, switching a SSRI for an alternative antidepressant in individuals with PD who are apathetic may be a potential treatment for apathy that needs further study.

Motivators and Barriers Affecting Exercise in Patients With Parkinson's Disease

BACKGROUND AND PURPOSE

Parkinson's disease (PD) significantly impacts the quality of life via both motor and nonmotor symptoms. Exercise is a valuable nonpharmacological intervention that can alleviate PD symptoms and slow disease progression. Understanding the factors that motivate and restrict exercise in PD patients is essential for promoting engagement. This study aimed to identify the motivators and barriers affecting exercise in PD patients.

METHODS

This cross-sectional study assessed exercise habits, motivators, and barriers among PD patients with a modified Hoehn and Yahr stage of ≤2.5. Participants were categorized into non-, low-, and high-exercise groups based on the World Health Organization guidelines. The International Physical Activity Questionnaire, the Korean version of the Sport Motivation Scale, and a barriers-to-exercise questionnaire were utilized.

RESULTS

Data from 165 of 196 enrolled patients were analyzed: 28 (17.0%), 88 (53.3%), and 49 (29.7%) in the non-, low-, and high-exercise groups, respectively. The nonexercise group demonstrated higher levels of fatigue and apathy, and more-severe cardiovascular, mood, intellectual, attention, gastrointestinal, and urinary symptoms. While all groups recognized the benefit of exercise, those in the nonexercise group viewed PD symptoms and depressive mood as major barriers, whereas those in the high-exercise group were primarily motivated by personal satisfaction.

CONCLUSIONS

This study highlights the importance of enjoyment and personal satisfaction to the maintenance of exercise habits among PD patients. By enhancing specific motivators and overcoming barriers, particularly PD symptoms and related nonmotor symptoms, tailored interventions can be implemented to increase exercise adherence and, eventually, improve the quality of life of PD patients.

A Cognitive-Behavioral Model of Apathy in Parkinson's Disease

Apathy is recognized to be a common, disabling syndrome that occurs across a range of psychiatric and neurological conditions, including Parkinson's disease. It can have a significant impact on quality of life, both for people affected and those around them. Currently, there are no established, evidence-based treatments for this debilitating syndrome. Assessment and treatment have been complicated by overlaps with depression and anhedonia, as well as a lack of understanding of the underlying mechanisms. Emerging lines of evidence conceptualize apathy as a reduction of motivation associated with disordered effort-based decision-making and dysfunction of distinct neural circuitry between the basal ganglia and medial prefrontal cortex. Here, we introduce a novel cognitive-behavioral framework that can inform a clinician's conceptualization and treatment of apathy, using cognitive-behavioral therapy (CBT) techniques. We focus on people with Parkinson's disease in our model, but our approach is transdiagnostic and can be applied to other conditions. It considers both individual targets for therapy as well as maintenance and intervention at a systemic level. The generalizability and parsimony of the framework provides a structured assessment and formulation of apathy, while also allowing clinicians to remain sensitive to other neuropsychiatric symptoms that can occur alongside apathy, such as depression and anxiety.

Association between the functional connectivity of ventral tegmental area-prefrontal network and pure apathy in Parkinson's disease: a cross-sectional study

Background

Apathy, characterized by diminished goal-directed behaviors, frequently occurs in patients with Parkinson's disease (PD). The dopamine-releasing neurons of the ventral tegmental area (VTA) have been closely related to this behavioral disruption and project widely to the corticolimbic areas, yet their functional and structural connectivity in regard to other brain regions remain unknown in patients with PD and pure apathy (PD-PA). This study thus aimed to characterize the alterations of functional connectivity (FC) of the VTA and white matter structural connectivity in PD-PA.

Methods

In this study, 29 patients with PD-PA, 37 with PD but not pure apathy (PD-NPA), and 28 matched healthy controls (HCs) underwent T1-weighted, resting state functional magnetic resonance imaging, and diffusion tensor imaging scans. Patients of this cross-sectional retrospective study were consecutively recruited from The First Affiliated Hospital of Nanjing Medical University between April 2017 and October 2021. Meanwhile, HCs were consecutively recruited from the local community and the Health Examination Center of our hospital. An analysis of covariance and a general linear model were respectively conducted to investigate the functional and structural connectivity among three groups. The tract-based spatial statistics (TBSS) approach was used to investigate the white matter structural connectivity.

Results

Patients with PD-PA showed reduced FC of the VTA with the left medial superior frontal gyrus (SFGmed) when compared to the patients with PD-NPA [t=-3.67; voxel-level P<0.001; cluster-level family-wise error-corrected P (PFWE)<0.05]. Relative to the HCs, patients with PD-PA demonstrated reduced FC of the VTA with the left SFGmed (t=-4.98; voxel-level P<0.001; cluster-level PFWE<0.05), right orbital superior frontal gyrus (SFGorb) (t=-5.08; voxel-level P<0.001; cluster-level PFWE<0.05), and right middle frontal gyrus (MFG) (t=-5.08; voxel-level P<0.001; cluster-level PFWE<0.05). Moreover, the reductions in VTA FC with the left SFGmed were associated with severe apathy symptoms in patients with PD-PA (r=-0.600; P=0.003). However, a TBSS approach did not reveal any significant differences in fiber tracts between the three groups.

Conclusions

This study identified reduced FC within the mesocortical network (VTA-SFGmed) of patients with PD-PA. These findings may provide valuable information for administering neuromodulation therapies in the alleviation of apathy symptoms in those with PD.

Impaired value-based decision-making in Parkinson's disease apathy

Apathy is a common and disabling complication of Parkinson's disease characterized by reduced goal-directed behaviour. Several studies have reported dysfunction within prefrontal cortical regions and projections from brainstem nuclei whose neuromodulators include dopamine, serotonin and noradrenaline. Work in animal and human neuroscience have confirmed contributions of these neuromodulators on aspects of motivated decision-making. Specifically, these neuromodulators have overlapping contributions to encoding the value of decisions, and influence whether to explore alternative courses of action or persist in an existing strategy to achieve a rewarding goal. Building upon this work, we hypothesized that apathy in Parkinson's disease should be associated with an impairment in value-based learning. Using a four-armed restless bandit reinforcement learning task, we studied decision-making in 75 volunteers; 53 patients with Parkinson's disease, with and without clinical apathy, and 22 age-matched healthy control subjects. Patients with apathy exhibited impaired ability to choose the highest value bandit. Task performance predicted an individual patient's apathy severity measured using the Lille Apathy Rating Scale (R = -0.46, P < 0.001). Computational modelling of the patient's choices confirmed the apathy group made decisions that were indifferent to the learnt value of the options, consistent with previous reports of reward insensitivity. Further analysis demonstrated a shift away from exploiting the highest value option and a reduction in perseveration, which also correlated with apathy scores (R = -0.5, P < 0.001). We went on to acquire functional MRI in 59 volunteers; a group of 19 patients with and 20 without apathy and 20 age-matched controls performing the Restless Bandit Task. Analysis of the functional MRI signal at the point of reward feedback confirmed diminished signal within ventromedial prefrontal cortex in Parkinson's disease, which was more marked in apathy, but not predictive of their individual apathy severity. Using a model-based categorization of choice type, decisions to explore lower value bandits in the apathy group activated prefrontal cortex to a similar degree to the age-matched controls. In contrast, Parkinson's patients without apathy demonstrated significantly increased activation across a distributed thalamo-cortical network. Enhanced activity in the thalamus predicted individual apathy severity across both patient groups and exhibited functional connectivity with dorsal anterior cingulate cortex and anterior insula. Given that task performance in patients without apathy was no different to the age-matched control subjects, we interpret the recruitment of this network as a possible compensatory mechanism, which compensates against symptomatic manifestation of apathy in Parkinson's disease.

Apathy scores in Parkinson's disease relate to EEG components in an incentivized motor task

Apathy is one of the most prevalent non-motor symptoms of Parkinson's disease and is characterized by decreased goal-directed behaviour due to a lack of motivation and/or impaired emotional reactivity. Despite its high prevalence, the neurophysiological mechanisms underlying apathy in Parkinson's disease, which may guide neuromodulation interventions, are poorly understood. Here, we investigated the neural oscillatory characteristics of apathy in Parkinson's disease using EEG data recorded during an incentivized motor task. Thirteen Parkinson's disease patients with apathy and 13 Parkinson's disease patients without apathy as well as 12 healthy controls were instructed to squeeze a hand grip device to earn a monetary reward proportional to the grip force they used. Event-related spectral perturbations during the presentation of a reward cue and squeezing were analysed using multiset canonical correlation analysis to detect different orthogonal components of temporally consistent event-related spectral perturbations across trials and participants. The first component, predominantly located over parietal regions, demonstrated suppression of low-beta (12-20 Hz) power (i.e. beta desynchronization) during reward cue presentation that was significantly smaller in Parkinson's disease patients with apathy compared with healthy controls. Unlike traditional event-related spectral perturbation analysis, the beta desynchronization in this component was significantly correlated with clinical apathy scores. Higher monetary rewards resulted in larger beta desynchronization in healthy controls but not Parkinson's disease patients. The second component contained gamma and theta frequencies and demonstrated exaggerated theta (4-8 Hz) power in Parkinson's disease patients with apathy during the reward cue and squeezing compared with healthy controls (HCs), and this was positively correlated with Montreal Cognitive Assessment scores. The third component, over central regions, demonstrated significantly different beta power across groups, with apathetic groups having the lowest beta power. Our results emphasize that altered low-beta and low-theta oscillations are critical for reward processing and motor planning in Parkinson's disease patients with apathy and these may provide a target for non-invasive neuromodulation.

Study of molecular patterns associated with ferroptosis in Parkinson's disease and its immune signature

Parkinson's disease is the second most common neurodegenerative disease in the world. We downloaded data on Parkinson's disease and Ferroptosis-related genes from the GEO and FerrDb databases. We used WCGAN and Random Forest algorithm to screen out five Parkinson's disease ferroptosis-related hub genes. Two genes were identified for the first time as possibly playing a role in Braak staging progression. Unsupervised clustering analysis based on hub genes yielded ferroptosis isoforms, and immune infiltration analysis indicated that these isoforms are associated with immune cells and may represent different immune patterns. FRHGs scores were obtained to quantify the level of ferroptosis modifications in each individual. In addition, differences in interleukin expression were found between the two ferroptosis subtypes. The biological functions involved in the hub gene are analyzed. The ceRNA regulatory network of hub genes was mapped. The disease classification diagnosis model and risk prediction model were also constructed by applying hub genes based on logistic regression. Multiple external datasets validated the hub gene and classification diagnostic model with some accuracy. This study explored hub genes associated with ferroptosis in Parkinson's disease and their molecular patterns and immune signatures to provide new ideas for finding new targets for intervention and predictive biomarkers.

Dimensions of apathy in Parkinson's disease

INTRODUCTION

Apathy is one of the most common neuropsychiatric manifestations in Parkinson's disease (PD). Recent proposals consider apathy as a multidimensional construct, which can manifest in behavioral, cognitive, emotional, and/or social dimensions. Apathy also overlaps conceptually and clinically with other non-motor comorbidities, particularly depression. Whether all of these dimensions are applicable to the apathetic syndrome experienced by people with PD is unclear. In the present study, we investigated the multidimensional pattern of apathy associated with PD, using the recently developed Apathy Motivation Index (AMI) which probes behavioral, emotional, and social apathy dimensions. We then examined the relationship between these dimensions and other features of PD commonly associated with apathy, including depression, anxiety, cognition, and motor state.

METHODS

A total of 211 participants were identified from the New Zealand Brain Research Institute (NZBRI) longitudinal PD cohort. One hundred eight patients and 45 controls completed the AMI, administered as an online questionnaire, and additional assessments including neuropsychiatric, neuropsychological, and motor scores. The pattern of dimensional apathy in PD was assessed using a repeated-measured analysis of variance, while simple linear regressions were performed to evaluate relationships between these dimensions and other variables.

RESULTS

We found a significant interaction between group (PD versus control) and apathy subscale, driven mainly by higher levels of social and behavioral-but not emotional-apathy in those with PD. This result was strikingly similar to a previous study investigating social apathy in PD. Distinct patterns of dimensional apathy were associated with depression and anxiety, with social and behavioral apathy positively associated with depression, and emotional apathy negatively associated with anxiety.

CONCLUSION

This work provides further evidence for a distinct pattern of apathy in people with PD in which deficits manifest in some-but not all-dimensions of motivated behavior. It emphasizes the importance of considering apathy as a multidimensional construct in clinical and research settings.

Cholinergic nucleus 4 grey matter density is associated with apathy in Parkinson's disease

Objective: The generation and maintenance of goal-directed behavior is subserved by multiple brain regions that receive cholinergic inputs from the cholinergic nucleus 4 (Ch4). It is unknown if Ch4 degeneration contributes to apathy in Parkinson's disease (PD). Method: We analyzed data from 106 pre-surgical patients with PD who had brain MRIs and completed the Frontal Systems Behavior Scales (FrSBe). Eighty-eight patients also completed the Beck Depression Inventory-2nd Edition. Cholinergic basal forebrain grey matter densities (GMD) were measured by applying probabilistic maps to T1 MPRAGE sequences processed using voxel-based morphometry methods. We used linear and hierarchical regression modelling to examine the association between Ch4 GMD and the FrSBe Apathy subscale scores. We used similar methods to assess the specificity of this association and potential associations between Ch4 target regions and apathy. Results: Ch4 GMD (p = .021) and Ch123 GMD (p = .032) were significantly associated with Apathy subscale scores on univariate analysis. Ch4 GMD, but not Ch123 GMD, remained significantly associated with apathy when adjusting for age, sex, levodopa equivalent doses, and disease duration. Centromedial amygdala GMD, which receives cholinergic inputs from Ch4, was also associated with apathy. Ch4 GMD was not associated with depression or disinhibition, nor was it associated with executive dysfunction when adjusting for clinical and demographic variables. Conclusions: Ch4 GMD is specifically associated with apathy in PD. Ch4 degeneration results in cholinergic denervation of multiple cortical and limbic regions, which may contribute to the cognitive and emotional-affective processing deficits that underlie the behavioral symptoms of apathy.

The Differential Role of Executive Apathy in Alzheimer's Disease Dementia, Mild Cognitive Impairment and Healthy Cognitive Ageing

The objective of the present work was to compare the levels of executive, emotional, and initiation apathy in individuals with mild cognitive impairment (MCI), mild Alzheimer's disease dementia (ADD), and cognitively intact healthy controls (HCs). Fifty-two patients with mild ADD, 40 individuals with MCI, and 37 cognitively intact individuals were included in the current study. The participants were consecutive visitors to the Outpatient Memory Clinic of "Nestor" Alzheimer's Center. The symptoms of apathy were measured with the dimensional apathy scale. Analyses showed that ADD patients had significantly higher degrees of executive, emotional, initiation, and overall apathy compared with both the MCI group and the HCs. Additionally, a significant difference was observed in the dimension of executive apathy between individuals with MCI and the HCs. In conclusion, the dimension of executive apathy was the most sensitive measure regarding the differentiation of individuals with mild ADD or MCI and HCs. Hence, detailed evaluation of executive apathy in older individuals referred to a memory clinic may provide useful information contributing to their diagnostic categorization and to the differentiation between neurocognitive disorders and healthy cognitive ageing.

The Possible Role of Apathy on Conflict Monitoring: Preliminary Findings of a Behavioral Study on Severe Acquired Brain Injury Patients Using Flanker Tasks

The diagnosis of apathy, one of the most common behavioral changes after acquired brain injury (ABI), is important for improving clinical understanding and treatment of persons with ABI. The main aim of this study was to determine the possible role of apathy in conflict monitoring, by using choice reaction time tasks. Methods: We examined behavioral responses of conflict monitoring during three different flanker tasks in 10 severe ABI patients with or without diagnosis of apathy (3 M, mean age = 56.60; 3 M, mean age ± SD = 58.60, respectively), and 15 healthy controls (9 M, mean age = 54.46) Reaction times (RTs), accuracy, and global index of performance (GIP) were analyzed for each task. Results: Only apathetic ABI patients showed a significant difference from healthy subjects (p-value ≤ 0.001), while the performance of patients without apathy was not significantly different from that of healthy controls (p-value = 0.351). Healthy participants had higher accuracy in comparison to both ABI patients with (p < 0.001) and without (p-value = 0.038) apathy, whilst slower RTs were shown by ABI patients without apathy in comparison to both healthy subjects (p-value = 0.045) and apathetic ABI patients (p-value = 0.022). Only patients with apathy exhibited a significantly higher number of missing trials (p-value = 0.001). Conclusions: Our results may suggest a potential link between apathy following severe ABI and conflict monitoring processes, even though further investigations with larger sample size are needed.

Changes in Apathy, Depression, and Anxiety in Parkinson's Disease from before to during the COVID-19 Era

Apathy, depression, and anxiety are common non-motor symptoms of Parkinson's disease (PD). Tracking the changes in such symptoms over time would be valuable not only to determine their natural course during the disease, but also to establish the effects of unusual historical events interacting with the natural course. Having collected data on apathy (Apathy Scale), depression (Beck Depression Inventory-II), and anxiety (Parkinson's Anxiety Scale) in a large sample of persons with PD (PwPD) before the beginning of the COVID-19 era, we followed up with these individuals to investigate the changes in their prevalence of apathy, depression, and anxiety across two timepoints (T1 and T2). Of the original 347 participants, 111 responded and provided complete data at T2. The data collection at T1, before COVID-19, occurred between 2017-2018. The data collection at T2 occurred in 2021 and included the same measures, with the addition of the Coronavirus Impact Scale to assess the effects of the pandemic on the individual participants. Over this period, there was a significant increase in apathy, but not in depression or anxiety. Anxiety and depression, but not apathy, were correlated with the impact of COVID-19.

Differential contributions of depression, apathy, and anxiety to neuropsychological performance in Parkinson's disease versus essential tremor

INTRODUCTION

Mood symptoms are common features of Parkinson's disease (PD) and essential tremor (ET) and have been linked to worse cognition. The goals of the present study were to compare the severity of anxiety, apathy, and depressive symptoms in PD, ET, and healthy controls (HC) and to examine differential relationships between mood and cognition.

METHOD

Older adults with idiopathic PD (N = 448), ET (N = 128), or HC (N = 136) completed a multi-domain neuropsychological assessment consisting of memory, executive function, and attention/working memory domains. Participants also completed self-reported mood measures. Between-group differences in mood and cognition were assessed, and hierarchical regression models were conducted to examine relationships between mood and cognition in each group.

RESULTS

Relative to the HC group, the PD and ET groups reported more mood symptoms and scored lower across all cognitive measures. There were no differences between the two movement disorder groups. Mood variables explained 3.9-13.7% of the total variance in cognitive domains, varying by disease group. For PD, apathy was the only unique predictor of executive function (β = -.114, p = .05), and trait anxiety was the only unique predictor of attention/working memory (β = -.188, p < .05). For ET, there were no unique predictors, though the overall models significantly predicted performance in the executive function and attention/working memory domains.

CONCLUSIONS

In a large cohort of ET and PD, we observed that the two groups had similar self-reported mood symptoms. Mood symptoms were differentially associated with cognition in PD versus ET. In PD, increased apathy was associated with worse executive function and higher trait anxiety predicted worse attention/working memory. For ET, there were no unique predictors, though the overall mood symptom severity was related to cognition. Our study highlights the importance of considering the relationship between mood and neuropsychological performance in individuals with movement disorders.

On the association between apathy and deficits of social cognition and executive functions in Huntington's disease

OBJECTIVE

To investigate if executive and social cognitive dysfunction was associated with apathy in a large cohort of Huntington's disease gene expansion carriers.

METHOD

Eighty premanifest and motor-manifest Huntington's disease gene expansion carriers (Mini-Mental State Examination score ≥ 24 and Montreal Cognitive Assessment score ≥ 19) and thirty-two controls were examined with the Lille Apathy Rating Scale (LARS), a tailored and quantitative measure of apathy, and a comprehensive cognitive battery on executive functions and social cognition (emotion recognition, theory of mind and sarcasm detection), as well as general correlates like demographic variables, and neuropsychiatric and cognitive screening tests.

RESULTS

The motor-manifest Huntington's disease gene expansion carriers had significantly different scores on most measures of social cognition and executive functions, compared to premanifest and control participants. Apathy was significantly correlated with most executive test scores, but the Emotion Hexagon was the only social cognitive test score significantly correlated with apathy. We found that the motor score and the depression score were the only significant predictors of the apathy score, when the social cognitive and executive tests with the strongest association with the global LARS score were entered into a multiple stepwise regression model. No cognitive test score could significantly predict apathy. The model explained 21 % of the total variance.

CONCLUSION

Despite being significantly correlated with apathy neuropsychological variables did not have a significant impact on apathy when variables as depression and motor symptoms were taken into account. Apathy should be considered an independent symptom of Huntington's disease that requires specific examination.

Early Parkinson's Disease Phenotypes Tailored by Personality, Behavior, and Motor Symptoms

BACKGROUND

Previous studies described a parkinsonian personality characterized as rigid, introverted, and cautious; however, little is known about personality traits in de novo Parkinson's disease (PD) patients and their relationships with motor and neuropsychiatric symptoms.

OBJECTIVE

To investigate personality in de novo PD and explore its relationship with PD symptoms.

METHODS

Using Cloninger's biosocial model, we assessed personality in 193 de novo PD patients. Motor and non-motor symptoms were measured using several validated scales. Cluster analysis was conducted to investigate the interrelationship of personality traits, motor, and non-motor symptoms.

RESULTS

PD patients showed low novelty seeking, high harm avoidance, and normal reward dependence and persistence scores. Harm avoidance was positively correlated with the severity of depression, anxiety, and apathy (rs = [0.435, 0.676], p < 0.001) and negatively correlated with quality of life (rs = -0.492, p < 0.001). Novelty seeking, reward dependence, and persistence were negatively correlated with apathy (rs = [-0.274, -0.375], p < 0.001). Classification of patients according to personality and PD symptoms revealed 3 distinct clusters: i) neuropsychiatric phenotype (with high harm avoidance and low novelty seeking, hypodopaminergic neuropsychiatric symptoms and higher impulsivity), ii) motor phenotype (with low novelty seeking and higher motor severity), iii) benign phenotype (with low harm avoidance and high novelty seeking, reward dependence, and persistence traits clustered with lower symptoms severity and low impulsivity).

CONCLUSION

Personality in early PD patients allows us to recognize 3 patients' phenotypes. Identification of such subgroups may help to better understand their natural history. Their longitudinal follow-up will allow confirming whether some personality features might influence disease evolution and treatment.

Clinical uses of Bupropion in patients with Parkinson's disease and comorbid depressive or neuropsychiatric symptoms: a scoping review

OBJECTIVE

Bupropion, an antidepressant inhibiting the reuptake of dopamine and noradrenaline, should be useful to treat depressive symptoms in patients with Parkinson's disease (PD). Limited and conflicting literature data questioned its effectiveness and safety in depressed PD patients and extended its use to other neuropsychiatric symptoms associated with this disorder.

DESIGN

The databases PubMed, Embase, Web of Sciences, Cochrane Library, and the grey literature were searched. Following a scoping review methodology, articles focusing on Bupropion uses in PD patients who manifested depressive or other neuropsychiatric alterations were reviewed.

RESULTS

Twenty-three articles were selected, including 7 original articles, 3 systematic reviews or meta-analyses, 11 case reports, 1 clinical guideline, and 1 expert opinion. Bupropion showed considerable effectiveness in reducing depressive symptoms, particularly in relation to apathy. Solitary findings showed a restorative effect on compulsive behaviour secondary to treatment with dopamine as well as on anxiety symptoms. The effect on motor symptoms remains controversial. The safety profile of this medication seems positive, but additional precautions should be used in subjects with psychotic symptoms.

CONCLUSION

The available literature lacks good evidence to support the use of Bupropion in PD patients presenting depressive symptoms. Further investigations are needed to extend and confirm reported findings and to produce accurate clinical guidelines.

Apathy-Related Symptoms Appear Early in Parkinson's Disease

BACKGROUND

Apathy, often-unrecognized in Parkinson's Disease (PD), adversely impacts quality-of-life (QOL) and may increase with disease severity. Identifying apathy early can aid treatment and enhance prognoses. Whether feelings related to apathy (e.g., loss of pleasure) are present in mild PD and how apathy and related feelings increase with disease severity is unknown.

METHODS

120 individuals (M age: 69.0 ± 8.2 y) with mild (stages 1-2, n = 71) and moderate (stages 2.5-4; n = 49) PD were assessed for apathy and apathy-related constructs including loss of pleasure, energy, interest in people or activities, and sex. Correlations were used to determine the association of apathy with apathy-related constructs. Regression models, adjusted for age, cognitive status, and transportation, compared groups for prevalence of apathy and apathy-related feelings.

RESULTS

Apathy-related constructs and apathy were significantly correlated. Apathy was present in one in five participants with mild PD and doubled in participants with moderate PD. Except for loss of energy, apathy-related constructs were observed in mild PD at a prevalence of 41% or greater. Strong associations were noted between all apathy-related constructs and greater disease severity. After adjustment for transportation status serving as a proxy for independence, stage of disease remained significant only for loss of pleasure and loss of energy.

CONCLUSION

People with mild PD showed signs of apathy and apathy-related feelings. Loss of pleasure and energy are apathy-related feelings impacted by disease severity. Clinicians should consider evaluating for feelings related to apathy to enhance early diagnosis in individuals who might otherwise not exhibit psychopathology.

No Higher Risk-Seeking Tendencies or Altered Self-Estimation in a Social Decision-Making Task in Patients with Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) has been associated with a tendency towards more risky decisions. However, the commonly used paradigms typically neglect the social context.

OBJECTIVE

Here, we investigated social decision-making and self-estimation in a competitive experimental task.

METHODS

A computerized experimental setting was used in which 86 PD patients (age = 66.5 [50-79], 62.8% male, H&Y = 2 [1.5-3]) and 44 healthy controls (HC; age = 67 [54-79], 54.4% male) in groups of four performed mathematical addition tasks in which they were asked to calculate as many sums as possible in five minutes. Participants had to choose their preferred compensation scheme ("piece rate" versus "tournament") and retrospectively rank their performance in comparison to the suspected performance of the others. A comprehensive neuropsychological test battery was also conducted.

RESULTS

No significant difference was found in overall social decision-making and self-estimation between PD patients and HC. However, for those individuals who made inadequate decisions, PD patients engaged in significantly more risk-averse and HC in more risky decisions. Concerning those inadequate decisions, the PD patients made more extreme decisions (severity of social decision-making) in both directions (risk-averse, risk-seeking).

CONCLUSION

Our data indicate that social decision-making behavior and self-estimation are largely intact in PD patients with mild to moderate disease stages and intact global cognition, executive functions, and social cognition. Future studies with more heterogeneous PD samples regarding their neuropsychological profile will have to examine at which state social decision-making may be affected and by which factors this behavior might be influenced.

Changes in Self- and Informant-Reported Frontal Behaviors in Parkinson's Disease: A Longitudinal Study

OBJECTIVE

Frontal behaviors (i.e., executive dysfunction, disinhibition, apathy) are common in Parkinson's disease (PD). However, it is unclear if patient and informant reports of patient frontal behaviors are in agreement over time.

METHOD

Sixty-two PD patients without dementia and their informants (87% spouses/partners) completed the self- and informant-versions of the Frontal Systems Behavior Scale at baseline and 2-year follow-up. Dyad ratings were compared and predictors of behavior ratings were examined.

RESULTS

Patient and informant reports at baseline and follow-up were in agreement, with significant increases in overall frontal behaviors, executive dysfunction, and apathy. Higher levels of baseline patient depression and caregiver burden predicted decrements in patient-reported executive function; worse patient cognition at baseline predicted worsening apathy as rated by informants.

CONCLUSIONS

PD patients and their informants are concordant in their ratings of worsening frontal behaviors over time. Targeting patient depression, cognition, and caregiver burden may improve decrements in frontal behaviors (executive dysfunction and apathy) in PD.

Anhedonia in Neurodegenerative Diseases

Neurodegenerative diseases are increasingly recognised to be an important cause of brain disorders, particularly in late age. Associated with a wide range of pathologies, they lead to progressive loss of neurons in different regions of the nervous system. Although anhedonia is common in a variety of neurodegenerative diseases, to date it has not been extensively studied in most of these conditions. Here we review the current literature on studies assessing the association between anhedonia and neurodegenerative diseases including Parkinson's Disease, Dementia with Lewy Bodies, Parkinson's Plus Syndromes, Alzheimer's Disease, Vascular Dementia, Frontotemporal Dementia, Amyotrophic Lateral Sclerosis and Huntington's Disease. Much of the research has been conducted in Parkinson's disease where it is evident that there are strong links between apathy (loss of motivation) and anhedonia, although the two syndromes can be dissociated. Intriguingly, drugs that improve apathy can also lead to amelioration of anhedonia in some cases. Overlaps between the two syndromes may also exist across other neurodegenerative conditions, including Frontotemporal Dementia in which imaging has revealed atrophy of both common brain regions associated with anhedonia and apathy, as well as a set of unique brain regions associated with anhedonia. A transdiagnostic perspective might be helpful to investigate whether a common network of brain regions is dysfunctional with anhedonia across neurodegenerative conditions.

Health care professionals' perspectives on self-management for people with Parkinson's: qualitative findings from a UK study

BACKGROUND

Parkinson's disease is a long-term, complex health condition. To improve or maintain quality of life, people with Parkinson's can have an active involvement in their care through self-management techniques. Given the complexity and individualization of self-management, people with Parkinson's will need support and encouragement from their healthcare professionals (HCPs). Despite the key role HCPs have in this, research has seldom explored their perspectives and understanding of self-management for people with Parkinson's.

METHODS

Multi-disciplinary teams providing care for people with Parkinson's across London, Coventry and Hertfordshire were approached and took part in either one of four focus groups or individual interviews. Forty-two HCPs, including a range of specialist doctors, general practitioners, allied health professionals, nurses, and social workers, took part in this study. Interviews were transcribed and analysed using thematic analysis to identify themes.

RESULTS

Four themes were developed from the data: 1) Empowerment of patients through holistic care and being person-centred; 2) Maximising motivation and capability for patients, for example using asset based approaches and increasing opportunities; 3) importance of empowerment of carers to support self-management and 4) contextual barriers to self-management such as the social context.

CONCLUSIONS

This study is the first to explore the perspectives of HCPs on self-management in people with Parkinson's. Our findings have identified important considerations surrounding empowerment, motivation, carers and contextual barriers to better understand how we enable effective self-management techniques in people with Parkinson's. Research should build on these findings on to develop acceptable and effective self-management tools for use in practice with people affected by Parkinson's.

Apathy in Parkinson's Disease: A Retrospective Study of Its Prevalence and Relationship With Mood, Anxiety, and Cognitive Function

Apathy is thought to be an important clinical feature of Parkinson's disease (PD). However, its prevalence ranges greatly across studies because of differing definitions, assessment tools, and patient inclusion criteria. Furthermore, it remains unclear how the presentation of apathy in PD is related to mood disorder and/or cognitive impairment. This study sought to examine the prevalence of a pure apathy syndrome in PD, distinct from both depression and anxiety, and reveal its associated cognitive profile. A retrospective study was performed on 177 PD patients who had completed measures of apathy [Apathy Evaluation Scale (AES)] and mood functioning [Hospital Anxiety and Depression Scale (HADS)] and had undergone extensive neuropsychological assessment, using measures of intellectual functioning, memory, executive function, attention, language, visual processing, and cognitive speed; 14.7% of the sample indicated clinically significant levels of apathy, but this nearly always co-presented with depression and/or anxiety, with cases of "pure" apathy very rare (2.8%). On extensive cognitive assessment, patients with mood disorder performed worse on a measure of non-verbal intellectual functioning, but patients with additional apathy or apathy only demonstrated no further losses. The syndrome of apathy in PD greatly overlaps with that of depression and anxiety, suggesting that apathy in PD may be in large an epiphenomenon of mood disorder, with no specific neuropsychological features.

Influence of Clinical Markers of Dopaminergic Behaviors on Depressive Symptoms During Withdrawal in Cocaine Users

Background: During cocaine withdrawal, transient depressive symptoms that do not meet the criteria for depression, but promote relapse, are frequently observed. Their temporality could evoke a role of dopamine, especially since the underlying mechanism of these depressive symptoms is not well understood. We hypothesized that variation in the dopaminergic activity profile, modeled from clinical markers, could be implicated in the development of depressive symptoms during cocaine withdrawal. Methods: We compared patients reporting depressive symptoms (RDS+) or not (RDS-) during cocaine withdrawal. We evaluated dopaminergic activity through indirect clinical markers based on the known dopaminergic behaviors. A combined criterion was constructed for hyper and hypo dopaminergic models according to the O'Brien method and illustrated by the Hedges' effect-size and forest-plot graph. A multidimensional factorial analysis was carried out to determine which parameters discriminate RDS+/RDS- patients. Results: 313 patients were included, and 77% reported depressive symptoms during cocaine withdrawal. Hyperdopaminergic variables used to discriminate the two groups had a large overall effect size (-0.669) and included psychotic symptoms (-0.524), hallucinations (-0.548), and delusions (-0.528). The overall effect of the hypodopaminergic component was considerable (-0.604) with a large effect size for the severity of dependence (-0.616), withdrawal symptoms (-0.578), and anhedonia (-0.528). The combined model including hyperdopaminergic and hypodopaminergic components had the largest effect size (-0.785). Conclusion: The dopaminergic activities profile, assessed by indirect clinical markers, seems to characterize patients with depressive symptoms very well during cocaine withdrawal. RDS+ patients reported moreover higher levels of psychotic symptoms and more severe cocaine use disorder than RDS-.

Psychometric properties of the Beck Depression Inventory-II in progressive supranuclear palsy

OBJECTIVES

Depression is one of the most common neuropsychiatric symptoms in progressive supranuclear palsy (PSP). Yet, few studies have examined the ability of available instruments to detect depressive symptoms in PSP. Aims of the present study were to (I) report psychometric properties of the Beck Depression Inventory Second Edition (BDI-II) in PSP, (II) establish the BDI-II cut-off indicating the presence of depression in PSP and (III) describe clinical correlates as well as correlation with quality of life of depressive symptoms in PSP.

DESIGN, SETTING AND PARTICIPANTS

At the Center for Neurodegenerative Diseases of the University of Salerno, Italy, the BDI-II was validated in 62 PSP patients diagnosed according to the Movement Disorder Society criteria. Patients underwent a clinical interview, a motor evaluation, extensive cognitive and behavioral testing.

RESULTS

The mean BDI-II total score was 15.92 ± 10.31. The internal consistency was high (Cronbach's alpha = 0.868); corrected item-total correlation was >0.40 for the majority of items. The significant and moderate correlation of the BDI-II with other tools evaluating depressive symptoms indicated adequate convergent validity of the scale. The satisfactory cut-off to identify patients with clinically significant depression was >14.5. We also showed a correlation between higher scores on BDI-II and lower quality of life, irrespective of motor and cognitive burden.

CONCLUSION

In conclusion, the BDI-II is a reliable and valid tool for the assessment of depression symptoms in PSP. Such data are useful to standardize studies of depression in PSP and to quantify the effectiveness of any interventions on this disabling symptom.

The Apathy Evaluation Scale (AES-C): Psychometric Properties and Invariance of Italian Version in Mild Cognitive Impairment and Alzheimer's Disease

Apathy is a neuropsychiatric symptom observed in different neurological and psychiatric disorders. Although apathy is considered a symptom, it has been recently reconsidered as a syndrome characterised by three dimensions: cognitive symptoms, affective symptoms and behavioural symptoms. Recent studies have shown that apathy can be considered as a prodromal symptom of Alzheimer's disease (AD), but also an indicator of the transition from mild cognitive impairment to AD. According to this scenario, an early detection of apathy in subjects with Mild Cognitive Impairment (MCI) and Mild AD can be a valid psychometric strategy to improve an early diagnosis and promote a prompt intervention. The Apathy Evaluation Scale is a validated tool composed of 18 items that assess and quantify emotional, behavioural and cognitive aspects of apathy. The aim of this study is to assess the specific reliability and validity of the Italian version of the Apathy Evaluation Scale-Clinician Version (AES-C) to detect apathy both in amnestic MCI and mild AD patients. In the present paper, we therefore examined the psychometric properties and the invariance of the Italian Version of the AES-C conducted on a sample composed of an experimental group of amnestic MCI and AD patients (N = 107) and a control group (N = 107) constituted by Age- and Sex-matched healthy controls. Results confirm the goodness of the scale. Confirmatory factory analysis confirmed that the AES-C Italian Version presents the same stability of one second-order factor and three first-order factors identified in the original version, and all items are predicted by a single general factor. Moreover, the scale was found to be invariant across both populations. Moreover, reliability and discriminant analysis showed good values. We found in the experimental group a negative correlation between the AES-C and Frontal Assessment Battery (FAB) (rs = -0.21, p < 0.001) and Mini Mental State Examination (MMSE) (rs = -0.04, p < 0.001), while a positive correlation was found between the AES-C and Hamilton psychiatric Rating scale for Depression (HAM-D) scores (rs = 0.58, p < 0.001) Overall, our data demonstrated the validity of the Italian version of the AES-C for the assessment of apathy both in MCI and in AD patients.

Apathy and Anhedonia: Clinical and Neurophysiological Assessment of a Romanian Cohort

Background: Patients with Parkinson’s disease (PD) often have, besides the characteristic motor manifestations, a wide variety of non-motor symptoms. These include apathy and anhedonia, common issues in PD, which can be quantified with the help of evaluation scales recommended by the literature. There are sensory non-motor manifestations of PD, some of which are easy to detect through electrophysiological studies. Our aim was to investigate the possible association of apathy and anhedonia with the severity of the motor status in a sample of PD patients in Romania. We also examined the prevalence of latency changes in the P100 wave of visual evoked potentials (VEPs) and how they correlated with motor status, apathy, and anhedonia in PD patients. Methods: Thirty-four patients with PD participated in this study. All were assessed for motor status using the Unified Parkinson’s Disease Rating Scale (UPDRS) and were rated on the Hoehn and Yahr scales. The presence and severity of apathy and anhedonia were assessed using the Apathy Evaluation Scale (AES), the Dimensional Apathy Scale (DAS), the Lille Apathy Rating Scale (LARS), and the Snaith–Hamilton Pleasure Scale (SHAPS). The latency of the P100 wave of the VEP was measured in all the patients. Results: Apathy and anhedonia were common among the patients with PD (35% and 58.8%, respectively). The presence of apathy/anhedonia was correlated with the severity of motor symptoms, as assessed using the UPDRS scale (p < 0.001), and with the stage of the disease according to the Hoehn and Yahr scale (p < 0.001). A prolonged latency of the P100 wave of the VEP was observed among apathetic (p < 0.001)/anhedonic (p < 0.01) patients and those with increased disease severity (p < 0.001). Conclusion: Apathy and anhedonia are common in PD and may correlate with the severity of motor symptoms. There may be visual impairment in these patients, evidenced by a prolonged P100 latency, which correlates with the severity of disease. Significance: Scales for assessing apathy and anhedonia, as well as measuring VEP latency, could be useful in assessing the severity of disease.

A Single Session of Whole-Body Electromyostimulation Increases Muscle Strength, Endurance and proNGF in Early Parkinson Patients

Parkinson's disease (PD) patients lead a sedentary lifestyle, being unable or unwilling to exercise conventionally, due to physical and mental limitations. The aim of this study was to assess the acute effects of a single session of whole-body electromyostimulation (WB-EMS) on the physical performances and serum levels of the neurotrophic factors in PD patients. Ten subjects (aged 72.60 ± 6.82) underwent 20 min of physical activity with superimposed WB-EMS and, after four weeks, the same protocol with no WB-EMS. WB-EMS was conducted with intermittent stimulation, with 4 s WB-EMS/4 s rest, at 85 Hz, 350 μs. A physical fitness assessment and blood samples collection, to evaluate neurotrophic factors' levels (BDNF, FGF21, proNGF, mNGF), were collected before and after the intervention. The RM-ANOVA showed significant improvements in sit-to-stand (p < 0.01), arm curl (p < 0.01), handgrip (p < 0.01) and soda pop test (p < 0.01) after the WB-EMS intervention. Higher proNFG serum levels were observed in the WB-EMS condition compared to the no WB-EMS after 60 min post-intervention (p = 0.0163). The effect of WB-EMS confirmed the electrostimulation ability to modulate the proNGF quantity. The positive impact of the WB-EMS protocol on physical functioning, and eye-hand coordination, makes this intervention a promising strategy to improve motor and non-motor symptoms in PD patients.

Defining Atypical Anxiety in Parkinson's Disease

BACKGROUND

Anxiety is a major complication in Parkinson's disease (PD). Many PD patients experience clinically significant anxiety not meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) anxiety disorder criteria. This atypical anxiety (anxiety disorder not otherwise specified [NOS]) is often under-recognized and its diagnosis is underdeveloped.

OBJECTIVES

This study aimed to identify the demographic, psychiatric, and clinical characteristics of anxiety disorder NOS in PD.

METHODS

A cross-sectional design studied a convenience sample of 184 PD patients without dementia recruited from neurology outpatient clinics. A semi-structured interview using DSM-IV criteria categorized PD patients into current anxiety disorder NOS (n = 28), DSM-IV anxiety disorders (n = 42) or no anxiety (n = 86) groups. Logistic regression modeling identified characteristics associated with the anxiety disorder NOS group compared to DSM-IV anxiety and no anxiety groups.

RESULTS

The anxiety disorder NOS group was associated with motor complications of PD therapy, episodic, persistent and social anxiety symptoms, depression, non-motor experiences of daily living, poor quality of life, and female sex compared to the no anxiety group. Compared to DSM-IV anxiety, those with anxiety disorder NOS demonstrated greater global cognitive impairment, more severe motor complications of PD therapy, a greater severity and functional impact of dyskinesias, and greater complexity of motor fluctuations. Persistent, episodic, and social anxiety symptoms did not significantly differ between anxiety disorder NOS and DSM-IV anxiety groups.

CONCLUSIONS

These findings suggest that PD-specific symptoms characterize anxiety in a subgroup of PD patients who do not fulfill DSM-IV criteria for anxiety disorders.

Reward sensitivity and action in Parkinson's disease patients with and without apathy

Clinical apathy results in dysfunction of goal directed behaviour, a key component of which is the initiation of action. Previous work has suggested that blunting of reward sensitivity is an important mechanism underlying apathy. However, an additional component might be impoverished initiation of action itself. This study aims to investigate the link between motivation and motor output and its association with apathy and dopamine. An oculomotor task that measures pupillary and saccadic response to monetary incentives was used to assess reward sensitivity, first in 23 young and 18 elderly controls, and then in 22 patients with Parkinson's disease tested ON and OFF dopaminergic medication. To distinguish between pupillary responses to anticipated reward alone versus responses associated with motor preparation, a saccadic 'go/no-go' task was performed. Half of the trials required a saccade to be initiated to receive a reward and in the remaining trials no action was required but reward was still obtained. No significant difference in pupil response was demonstrated between the two conditions in all groups tested, suggesting pupillary responses to rewards are not contingent upon motor preparation in Parkinson's disease. Being ON or OFF dopamine did not influence this response either. Previous work demonstrated associations between apathy and pupillary reward insensitivity in Parkinson's disease. Here we observed this effect only when an action was required to receive a reward, and only in the ON state. These findings suggest that apathy in Parkinson's disease is linked to reduced reward sensitivity and that this is most prominently observed when actions have to be initiated to rewarding goals, with the effect modulated by being ON dopaminergic medication. OFF medication, there was no such strong relationship, and similarly in the 'no-go' conditions, either ON or OFF dopaminergic drugs. The results provide preliminary data which suggest that apathy in Parkinson's disease is associated with a reduction in reward sensitivity and this is most evident when associated with initiation of goal directed actions in the presence of adequate dopamine.

Patterns of brain activity during a set-shifting task linked to mild behavioral impairment in Parkinson's disease

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PD with mild behavioral impairment revealed deficits in cognitive flexibility.

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Brain activities during a set-shifting task linked with MBI in PD was evaluated.

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PD-MBI revealed reduced activity in the prefrontal and posterior parietal cortices.

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The prefrontal activity was associated with cognitive impairment in PD-MBI.

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High MBI-C score was associated with reduced deactivation in the hippocampus.

Mild behavioral impairment (MBI) is a neurobehavioral syndrome characterized by later life emergence of sustained neuropsychiatric symptoms, as an at-risk state for incident cognitive decline and dementia. Prior studies have reported that neuropsychiatric symptoms are associated with cognitive abilities in Parkinson’s disease (PD) patients, and we have recently found a strong correlation between MBI and cognitive performance. However, the underlying neural activity patterns of cognitive performance linked to MBI in PD are unknown. Fifty-nine non-demented PD patients and 26 healthy controls were scanned using fMRI during performance of a modified version of the Wisconsin card sorting task. MBI was evaluated using the MBI-checklist, and PD patients were divided into two groups, PD-MBI and PD-noMBI. Compared to the PD-noMBI group and healthy controls, the PD-MBI group revealed less activation in the prefrontal and posterior parietal cortices, and reduced deactivation in the medial temporal region. These results suggest that in PD, MBI reflects deficits in the frontoparietal control network and the hippocampal memory system.

Rotigotine Transdermal Patch for Motor and Non-motor Parkinson's Disease: A Review of 12 Years' Clinical Experience

Motor and non-motor symptoms (NMS) have a substantial effect on the health-related quality of life (QoL) of patients with Parkinson's disease (PD). Transdermal therapy has emerged as a time-tested practical treatment option, and the rotigotine patch has been used worldwide as an alternative to conventional oral treatment for PD. The efficacy of rotigotine on motor aspects of PD, as well as its safety and tolerability profile, are well-established, whereas its effects on a wide range of NMS have been described and studied but are not widely appreciated. In this review, we present our overall experience with rotigotine and its tolerability and make recommendations for its use in PD and restless legs syndrome, with a specific focus on NMS, underpinned by level 1-4 evidence. We believe that the effective use of the rotigotine transdermal patch can address motor symptoms and a wide range of NMS, improving health-related QoL for patients with PD. More specifically, the positive effects of rotigotine on non-motor fluctuations are also relevant. We also discuss the additional advantages of the transdermal application of rotigotine when oral therapy cannot be used, for instance in acute medical emergencies or nil-by-mouth or pre/post-surgical scenarios. We highlight evidence to support the use of rotigotine in selected cases (in addition to general use for motor benefit) in the context of personalised medicine.

The Mechanism of Physical Activity-induced Amelioration of Parkinson's Disease: A Narrative Review

Physical activity, together with its ameliorative effects on Parkinson's disease (PD) symptoms, remains a relatively unappreciated factor which may be beneficial for the treatment outcome. Contemporary evidence supports the positive effects of non-pharmacological approaches to PD symptom management, in particular the effects of the exercise on both, motor and non-motor symptoms. The aim of the study was to review the mechanisms of exercise-induced amelioration of PD symptoms. Methods: Electronic databases (PubMed, Web of Science and Google Scholar) were searched using the following key words: "Parkinson and physical activity" OR "Parkinson disease and exercise" OR "Parkinson disease and lifestyle factors" OR "Parkinson disease and longevity". A total of 97 studies which investigated PD genetics and various forms of exercise and their etiologic impact on PD were reviewed. The studies were subdivided into four topic groups: 1) genetics of PD, 2) exercise and the brain, 3) physical activity and PD, 4) mind-body interventions, and discussed accordingly. Adequate levels of physical activity are associated with higher quality of life in PD patients. Physical activity may have protective and stimulatory effects for better functional efficiency in higher-level cognitive networks. It can also improve balance and motor functions by improving muscle strength. Given the etiologic evidence of the beneficial effects of physical activity on PD, albeit tentative, a concerted effort to elucidate the processes and outcomes of physical activity on ameliorating symptoms of PD must be undertaken.

Aerobic Exercise and Healthy Nutrition as Neuroprotective Agents for Brain Health in Patients with Parkinson's Disease: A Critical Review of the Literature

Parkinson’s disease (PD) is characterized by motor and nonmotor features that have an influence on patients’ quality of life at different levels. To date, some evidences have arisen on the effectiveness of physical trainings and nutrients intake in ameliorating functional and cognitive outcomes in PD patients. Physical activity is effective in improving both motor and nonmotor features and recent epidemiological investigations have revealed the pivotal role that dietary patterns may play in reducing the risk of PD highlighting the pathogenesis of the neurodegeneration. Specifically, aerobic exercise shows beneficial effects in improving motor functions and executive control in PD patients, as well as proper nutrition may help in improving neuroprotective agents counteracting neurodegeneration and allows patients to better interact with the medication. Our narrative review critically focused on aerobic exercise and nutrition in PD in order to point out the best prescriptions for brain health of affected patients. Implications for a therapeutic plan and rehabilitation for these patients are also discussed.

A neurally plausible schema-theoretic approach to modelling cognitive dysfunction and neurophysiological markers in Parkinson's disease

The cognitive mechanisms underlying sequential action selection in routine or everyday activities may be understood in terms of competition within a hierarchically organised network of action schemas. We present a neurobiologically plausible elaboration of an existing schema-based cognitive model of action selection in which the basal ganglia implements an activation-based selection process that mediates between assumed cortical representations of rule-based schemas. More specifically, the model employs a network of basal ganglia units with computations performed by individual BG nuclei, embedded in a corticothalamic loop that disinhibits schemas according to the received feedback. We provide bridging assumptions for linking the operation of the model with ERP components that describe the error-related negativity (ERN) and the parietal switch positivity (PSP), and evaluate the model against behavioural and neural markers of performance of the Wisconsin Card Sorting Test by healthy control participants and Parkinson's Disease patients.

Autonomic dysfunction is associated with neuropsychological impairment in Lewy body disease

OBJECTIVE

This study aimed to analyze the association of autonomic dysfunction with cognition, depression, apathy, and fatigue in Lewy body disease (LBD).

METHODS

We included 61 patients [49 with idiopathic Parkinson's disease, 7 with dementia with Lewy bodies, and 5 E46K-SNCA mutation carriers] and 22 healthy controls. All participants underwent a comprehensive battery of neuropsychological and clinical measures, autonomic symptom assessment with the SCOPA-AUT, analysis of non-invasive hemodynamic parameters during deep breathing, the Valsalva maneuver, and a 20-min tilt test, and electrochemical skin conductance measurement at rest (Sudoscan). Student's t tests were used to assess group differences, and bivariate correlations and stepwise linear regressions to explore associations between autonomic function, cognition, depression, apathy, and fatigue.

RESULTS

Compared to controls, patients who had significant impairment (p < 0.05) in cognition, higher depression, apathy, and fatigue, more autonomic symptoms and objective autonomic dysfunction, reduced deep breathing heart rate variability [expiratory-to-inspiratory (E/I) ratio], prolonged pressure recovery time, and lower blood pressure in Valsalva late phase II and phase IV, while 24.1% had orthostatic hypotension in the tilt test. Autonomic parameters significantly correlated with cognitive and neuropsychiatric outcomes, systolic blood pressure during the Valsalva maneuver predicting apathy and depression. The E/I ratio was the main predictor of cognitive performance (17.6% for verbal fluency to 32.8% for visual memory).

CONCLUSION

Cardiovascular autonomic dysfunction is associated with cognitive and neuropsychiatric impairment in LBD, heart rate variability during deep breathing and systolic blood pressure changes during the Valsalva procedure are the main predictors of neuropsychological performance and depression/apathy symptoms, respectively.

Performance and Symptom Validity Assessment in Patients with Apathy and Cognitive Impairment

OBJECTIVE

Performance and symptom validity tests (PVTs and SVTs) measure the credibility of the assessment results. Cognitive impairment and apathy potentially interfere with validity test performance and may thus lead to an incorrect (i.e., false-positive) classification of the patient's scores as non-credible. The study aimed at examining the false-positive rate of three validity tests in patients with cognitive impairment and apathy.

METHODS

A cross-sectional, comparative study was performed in 56 patients with dementia, 41 patients with mild cognitive impairment, and 41 patients with Parkinson's disease. Two PVTs - the Test of Memory Malingering (TOMM) and the Dot Counting Test (DCT) - and one SVT - the Structured Inventory of Malingered Symptomatology (SIMS) - were administered. Apathy was measured with the Apathy Evaluation Scale, and severity of cognitive impairment with the Mini Mental State Examination.

RESULTS

The failure rate was 13.7% for the TOMM, 23.8% for the DCT, and 12.5% for the SIMS. Of the patients with data on all three tests (n = 105), 13.5% failed one test, 2.9% failed two tests, and none failed all three. Failing the PVTs was associated with cognitive impairment, but not with apathy. Failing the SVT was related to apathy, but not to cognitive impairment.

CONCLUSIONS

In patients with cognitive impairment or apathy, failing one validity test is not uncommon. Validity tests are differentially sensitive to cognitive impairment and apathy. However, the rule that at least two validity tests should be failed to identify non-credibility seemed to ensure a high percentage of correct classification of credibility.

Curcumin-Activated Mesenchymal Stem Cells Derived from Human Umbilical Cord and Their Effects on MPTP-Mouse Model of Parkinson's Disease: A New Biological Therapy for Parkinson's Disease

Background

The aim of this study was to investigate the effects of human umbilical cord mesenchymal stem cell activated by curcumin (hUC-MSCs-CUR) on Parkinson's disease (PD). hUC-MSCs can differentiate into many types of adult tissue cells including dopaminergic (DA) neurons. CUR could protect DA neurons from apoptosis induced by 6-hydroxydopamine (6-OHDA). Therefore, we used the hUC-MSCs activated by CUR for the treatment of PD in an animal model.

Methods

The hUC-MSCs-CUR was transplanted into the MPTP-induced PD mouse models via the tail vein. We found that hUC-MSCs-CUR significantly improved the motor ability, increased the tyrosine hydroxylase (TH), dopamine (DA), and Bcl-2 levels, and reduced nitric oxide synthase, Bax, and cleaved caspase 3 expression in PD mice. The supernatant of hUC-MSCs-CUR (CM-CUR) was used to stimulate the SH-SY5Y cellular model of PD; cell proliferation, differentiation, TH, and neuronal-specific marker microtubular-associated protein 2 (MAP2) expressions were examined.

Results

Our data showed that CM-CUR significantly promoted cell proliferation and gradually increased TH and MAP2 expression in SH-SY5Y PD cells. The beneficial effects could be associated with significant increase of rough endoplasmic reticulum in the hUC-MSCs-CUR, which secretes many cytokines and growth factors beneficial for PD treatment.

Conclusions

Transplantation of hUC-MSCs-CUR could show promise for improving the motor recovery of PD.

Relationship of Movement Disorders Society-Unified Parkinson's Disease Rating Scale Nonmotor Symptoms to Cognitive Functioning in Patients with Parkinson's Disease

Background

Few studies assess the relationships between nonmotor aspects of experiences of daily living and cognitive functioning in Parkinson's disease (PD).

Objective

To evaluate the relationships among the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part I items and neuropsychological tests in PD.Methods: We assessed 151 PD patients with the MDS-UPDRS part I and a battery of cognitive tests focused on the following 5 cognitive domains: attention/working memory, executive functioning, recent memory, language, visuoperception. Raw scores for individual cognitive tests were transformed to z scores, and cognitive domain scores were calculated by averaging z scores within each domain. Individual items from the MDS-UPDRS part I were entered in a stepwise linear regression analysis assessing item contribution to cognitive domain scores.

Results

The MDS-UPDRS part I item scores for hallucinations and psychosis and light headedness on standing predicted attention/working memory domain scores (P = 0.004). These same item scores, along with apathy, depressed mood, and dopamine dysregulation syndrome, predicted executive functioning (P = 0.044). The apathy and dopamine dysregulation syndrome items predicted language (P = 0.006). In addition, the cognitive impairment and sleep items were predictors of recent memory (P = 0.031). None of the items were predictors of visuoperception (P = 0.006). Other part I items were not significantly related to cognitive domain scores.

Conclusions

Specific nonmotor MDS-UPDRS part I items, particularly mood, behavior, and autonomic-related items, exhibited significant relationships with cognitive domains. The highest number of items were predictive of the executive functioning domain, which is the hallmark cognitive dysfunction in PD.

Drug Choices and Advancements for Managing Depression in Parkinson's Disease

Depression is a frequent non-motor symptom of Parkinson’s disease (PD), and may even precede the onset of motor symptoms of parkinsonism. Beyond its negative influence on mood, depression in PD is frequently associated with other neuropsychiatric symptoms and with late-stage complications such as dementia. Despite its profound impact on the quality of life and cognitive functioning in PD, depression in PD is often under-recognized and poorly treated.

Pathophysiological studies demonstrated that depression in PD is associated with global dysfunction of interactions between discrete brain areas rather than focal structural or functional abnormalities, and that it is sustained by pathological changes of several neurotransmitter/receptor complexes.

In general, all traditional antidepressants and some dopamine agonists have been found to be safe and well-tolerated to treat depressive symptoms in PD, despite initial warning on worsening of parkinsonism. Available data suggest that the time-course of response differs among antidepressants. Efficacy results from clinical trials with antidepressant in PD are, however, rather uncertain, although pooled analysis suggests a moderate benefit. Several issues may critically impact the results of clinical trials with antidepressants in PD, including the correct psychiatric diagnosis, the overlap of symptoms between depression and PD, and the selection of appropriate end-points and rating scales.

Clinimetric approach to rating scales for the assessment of apathy in Parkinson's disease: A systematic review

A number of rating scales for the assessment of apathy in Parkinson's disease (PD) were developed. Unfortunately, previous studies focused mainly on psychometric criteria rather than on clinimetric principles to develop these assessment instruments. In the clinimetric approach, the clinical validity of a rating scale, rather than its statistical significance, has the priority. The aim of the present systematic review was to capture the clinimetric properties of these rating scales and to identify the measures, which display clinical validity for the assessment of apathy in PD. The systematic search was conducted on Scopus, PsycINFO, PubMed, Web of Science, ScienceDirect, and Medline following the PRISMA guidelines. A total of 44 studies were included and analyzed in this systematic review. The apathy rating scales, which were found to be psychometrically robust and reliable, were actually clinically questionable. The apathy measures, which displayed clinimetric properties, were the Starkstein Apathy Scale (SAS), the 5-item version of the World Health Organization Well-Being Index (WHO-5), the Neurasthenia Scale and the Lille Apathy Rating Scale (LARS). The SAS was found to be clinically valid at a macro-analytic level, particularly when used either to exclude the presence of symptoms of apathy or to evaluate the side effects of medications. The WHO-5 and the Neurasthenia Scale were found to be clinically valid only at a micro-analytic level and can be used as screening measures for the assessment of the severity of symptoms of apathy. The LARS was a clinically valid instrument to be used for the diagnosis of apathy.

A Stage-Based Approach to Therapy in Parkinson's Disease

Parkinson’s disease (PD) is a neurodegenerative disorder that features progressive, disabling motor symptoms, such as bradykinesia, rigidity, and resting tremor. Nevertheless, some non-motor symptoms, including depression, REM sleep behavior disorder, and olfactive impairment, are even earlier features of PD. At later stages, apathy, impulse control disorder, neuropsychiatric disturbances, and cognitive impairment can present, and they often become a heavy burden for both patients and caregivers. Indeed, PD increasingly compromises activities of daily life, even though a high variability in clinical presentation can be observed among people affected. Nowadays, symptomatic drugs and non-pharmaceutical treatments represent the best therapeutic options to improve quality of life in PD patients. The aim of the present review is to provide a practical, stage-based guide to pharmacological management of both motor and non-motor symptoms of PD. Furthermore, warning about drug side effects, contraindications, as well as dosage and methods of administration, are highlighted here, to help the physician in yielding the best therapeutic strategies for each symptom and condition in patients with PD.

Detecting Apathy in Individuals with Parkinson's Disease: A Systematic Review

BACKGROUND

Individuals experiencing apathy in Parkinson's disease (PD) have a lack of emotion and motivation. Apathy often overlaps with comorbidities such as depression, and is sometimes difficult to detect.

OBJECTIVE

To examine diagnostic accuracy of apathy-screening tools compared with a gold standard (clinician diagnosis) among adult outpatients with PD.

METHODS

A systematic review was conducted. Six research databases were searched to May 23, 2018. Diagnostic accuracy measures, including sensitivity and specificity were gathered.

RESULTS

1,007 full-text articles were reviewed with seven full-text articles included. The gold standard was considered a clinician diagnosis as apathy is not defined in the DSM/ICD. Diagnostic accuracy measures were reported for the Lille Apathy Rating Scale (LARS) both informant- and observer-rated, Unified Parkinson's Disease Rating Scale (UPDRS), Apathy Scale (AS), Apathy Evaluation Scale (AES), Non-Motor Symptoms Questionnaire (NMS-Q), and Dimensional Apathy Scale (DAS). The AES had the best reported sensitivity and specificity values, both 90%. The AS had the highest reported specificity at 100%, with 66% sensitivity. Pooled prevalence of apathy was 29.1% (95% CI 21.5%-36.6%).

CONCLUSIONS

While 18 screening tools exist to screen for apathy in PD, only six have been validated against clinician diagnosis. The AES had the highest reported sensitivity and specificity and is a brief, easy to use tool. The AS was designed specifically for use in PD populations and has the highest reported specificity. Future research should focus on the development of an accepted gold standard, to further understand accuracy measures of all available apathy screening tools.

Insensitivity to loss predicts apathy in huntington's disease

BACKGROUND

Apathy is a deficit in goal-directed behavior that significantly affects quality of life and function. It is common in Huntington's disease and other disorders affecting corticostriatal pathways. Deficits in processing of reward, altered effort, and executive dysfunction are associated with apathy in other disorders, but the cognitive processes leading to apathy in Huntington's disease remain largely unknown. A previously reported deficit in learning from losses in Huntington's disease raises the possibility of a hitherto unrecognized mechanism leading to apathy. This study's objective was to delineate the cognitive processes associated with apathy in HD.

METHODS

We tested 51 Huntington's disease participants and 26 controls on a battery of novel and established measures to assess the contribution to apathy in Huntington's disease of executive function, reward value, reward-effort calculations, instrumental learning, and response to reward and loss.

RESULTS

Huntington's disase participants had deficits in instrumental learning with impaired response to loss, but no evidence to suggest altered reward-related behavior or effort. We also saw an executive dysfunction contribution to apathy in Huntington's disease.

DISCUSSION

We report the novel finding that apathy in Huntington's disease is associated with blunted responses to losses and impaired instrumental learning. This association is consistent with the known early degeneration of the indirect pathway and amygdala involvement in apathy in Huntington's disease, but is previously unreported in any disorder. In keeping with the comparative preservation of the ventral striatum and orbitofrontal cortex in Huntington's disease, reward valuation and reward-effort calculations did not contribute to apathy. © 2019 International Parkinson and Movement Disorder Society.

Memory, Subjective Memory and Motor Functioning in Non-Demented Elders With and Without Parkinson's Disease

Parkinson's Disease (PD) is a progressive neurological condition characterized by motor and non-motor symptoms impacting life quality. The main aim of the current study was to investigate the effect of PD on objective (i.e., working memory and semantic memory) and subjective memory (i.e., self-reported seriousness of forgetting, mnemonic usage and actual memory efficiency) controlling for the effect of depressive symptomatology. The relationship of working memory performance to gait and mobility indices was also examined, as well as the factors predicting subjective memory were explored. Fifty-four community-dwelling adults (mean age = 72.3 years, SD = 8.8) were recruited in Sardinia, an Italian island located in the Mediterranean Sea. Specifically, 27 non-demented adults with mild, early-stage PD were matched for years of education, age, and gender with a sample of healthy individuals. Participants completed a test battery assessing objective memory, subjective memory, and depressive symptoms, and an instrumental analysis of gait and functional mobility was performed. Participants with PD had poorer objective memory across all indices measured and displayed a restricted set of gait and posture impairments. Working memory performance was selectively related to gait and posture measures. Moreover, participants with PD had lower trust in their memory efficiency relative to the past than the control healthy group. Finally, 22% of the variance in seriousness of the consequences of forgetting was predicted by education and general cognitive efficiency. Overall, the present findings confirm the presence of changes in both objective and subjective memory in PD, independent from depressive symptoms.