Cognitive-Behavioral Therapy for Anxiety in Parkinson's Disease

Feasibility and Acceptability of a Videoconferencing CBT Intervention for Anxiety in People with Parkinson's Disease

OBJECTIVES

In people with Parkinson's disease (PwPD), non-motor symptoms such as anxiety are common and have negative impacts on their quality of life. There are currently few interventions that address anxiety in PwPD, and access to diagnosis and treatment is often limited for those living in rural areas. The aim of this study was to evaluate the feasibility and acceptability of a telehealth videoconferencing CBT intervention for anxiety in PwPD.

METHODS

A pre- and post-test feasibility study (N = 10) was conducted and evaluated utilizing the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance).

RESULTS

Lack of access to the internet and videoconferencing technology were identified as barriers to participation. Physical health issues also impacted recruitment and retention. Non-completers were significantly older and less likely to have a carer involved in the intervention. Clinician adoption of the intervention was low while participant acceptability of videoconferencing technology varied and required carer support.

CONCLUSIONS

Providing access to technology and support to overcome technological issues, as well as telehealth training for clinicians, are recommended in future studies to improve recruitment, retention, and implementation.

CLINICAL IMPLICATIONS

Identification of barriers and facilitators provides future studies with the knowledge to tailorize their program to better suit PwPD.

Alprazolam Reduces Freezing of Gait (FOG) and Improves FOG-Related Gait Deficiencies

Background

Freezing of gait (FOG) is an intractable motor symptom in Parkinson's disease (PD) that increases fall risk and impairs the quality of life. FOG has been associated with anxiety, with experimental support for the notion that anxiety itself provokes FOG. We investigated the effect of acute anxiety reduction via alprazolam on FOG in PD.

Methods

In ten patients with PD, FOG, and normal cognition, we administered 0.25 mg alprazolam in one session and placebo in another, in counterbalanced order. At each session, on separate days, patients walked on a pressure-sensitive walkway. Using Oculus Rift virtual-reality goggles, patients walked along a plank that appeared to be (a) level with the floor, in the low-anxiety condition or (b) raised high above the ground, in the high-anxiety conditions. In this way, we assessed the impacts of anxiety and alprazolam (i.e., anxiety reduction) on FOG frequency and other gait parameters.

Results

FOG events appeared only in the high-anxiety conditions. Alprazolam significantly reduced subjective and objective measures of anxiety, as well as the prevalence of FOG (p = 0.05). Furthermore, alprazolam improved swing time (p < 0.05) and gait variability in all conditions, particularly during the elevated plank trials. Interpretation. Our results suggest that (1) anxiety induces FOG, and (2) alprazolam concomitantly reduces anxiety and FOG. Alprazolam further improved gait stability (i.e., swing time and gait variability). These findings reveal that anxiety triggers FOG in PD. Treating anxiety can reduce FOG and improve gait stability, potentially offering new therapeutic avenues for this intractable and disabling symptom in PD.

Delivering Multidisciplinary Rehabilitation Care in Parkinson's Disease: An International Consensus Statement

BACKGROUND

Parkinson's disease (PD) is a complex neurodegenerative disorder impacting everyday function and quality of life. Rehabilitation plays a crucial role in improving symptoms, function, and quality of life and reducing disability, particularly given the lack of disease-modifying agents and limitations of medications and surgical therapies. However, rehabilitative care is under-recognized and under-utilized in PD and often only utilized in later disease stages, despite research and guidelines demonstrating its positive effects. Currently, there is a lack of consensus regarding fundamental topics related to rehabilitative services in PD.

OBJECTIVE

The goal of the international Parkinson's Foundation Rehabilitation Medicine Task Force was to develop a consensus statement regarding the incorporation of rehabilitation in PD care.

METHODS

The Task Force, comprised of international multidisciplinary experts in PD and rehabilitation and people directly affected by PD, met virtually to discuss topics such as rehabilitative services, existing therapy guidelines and rehabilitation literature in PD, and gaps and needs. A systematic, interactive, and iterative process was used to develop consensus-based statements on core components of PD rehabilitation and discipline-specific interventions.

RESULTS

The expert-based consensus statement outlines key tenets of rehabilitative care including its multidisciplinary approach and discipline-specific guidance for occupational therapy, physical therapy, speech language pathology/therapy, and psychology/neuropsychology across all PD stages.

CONCLUSIONS

Rehabilitative interventions should be an essential component in the comprehensive treatment of PD, from diagnosis to advanced disease. Greater education and awareness of the benefits of rehabilitative services for people with PD and their care partners, and further evidence-based and scientific study are encouraged.

Cognitive status and sleep quality can explain the fear of falling and fall history in people with Parkinson's disease

Fear of falling (FOF) is highly prevalent in people with Parkinson's disease (PwPD) and contributes to high fall risk. Studies reporting on the relationship between falls, FOF, and non-motor factors such as cognitive function and sleep quality in Parkinson's disease are limited. This study aimed to investigate (1) the relationship of cognitive function and sleep quality with FOF, and history of falls in PwPD; (2) differences in cognitive function and sleep quality between Parkinson's disease fallers and non-fallers; and (3) a cut-off score for cognitive function and sleep quality to discriminate Parkinson's disease fallers from non-fallers. Fifty PwPD were assessed for FOF [Falls Efficacy Scale-International (FES-I)], cognition [Montréal Cognitive Assessment (MOCA)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], and falls history. The MOCA is significantly associated with FES-I scores ( R2  = 0.429, P  < 0.0001). Both MOCA ( P  = 0.012) and PSQI ( P  = 0.027) were associated with falls history even after adjusting for confounding factors (age, sex, L-dopa use, Parkinson's disease severity). Both MOCA and PSQI scores were able to distinguish fallers from non-fallers with cut-off scores of 15.5 and 7.5, respectively. Although our findings revealed that both cognitive function and sleep quality are important factors influencing falls and FOF in PwPD, it remains to be determined if addressing cognitive impairments and poor sleep quality may favorably impact balance before integrating such screenings into fall prevention programs.

Anxiety in Parkinson's Patients: What's Timing Got to Do with It?

Background: Parkinson's Disease (PD) affects over 10 million people worldwide. Many PD patients experience comorbid anxiety disorders, which have been correlated with reduced quality of life and can manifest at any time during the course of PD, including prior to motor symptom onset. Purpose: Prior work has demonstrated that patients diagnosed with depression following a PD diagnosis are less likely to receive depression treatment, but no such study has been conducted for anxiety. Research Design: A cross-sectional analysis of secondary electronhic health record data was conducted. Study Sample: Data was obtained through Optum® de-identified Electronic Health Record dataset, using ICD-9 and ICD-10 diagnosis codes to determine PD status and comparing index date of anxiety and PD diagnoses to classify patients by relative time of diagnosis. Data Analysis: Multivariate logistic regression was performed to assess factors associated with receipt of mental health treatment. Results: Of PD patients with anxiety, 52% documented a diagnosis of anxiety prior to PD. Overall, 69% documented some treatment, with 79% of those diagnosed with anxiety prior to PD receiving some treatment compared to 59% of those diagnosed with anxiety on or after PD (P < 0.001). Conclusion: Patients with PD and subsequent anxiety diagnoses are less likely to receive treatment. Further study could explore reasons for variations in mental health care within the context of an existing PD diagnosis.

Landing wise program: feasibility study protocol for Parkinson's disease

Regardless of the benefits of fall prevention programs, people with Parkinson's disease (PD) will still fall. Therefore, it is crucial to explore novel therapeutic approaches that are well-accepted and effective for addressing fall risk and the fear of falls among this population. The present study aims to assess the feasibility of the Landing Wise program as a therapeutic intervention for reducing the fear of falling in people with PD. A mixed-methods study will be conducted using convenience sampling to recruit 20 people with PD with a moderate concern of falling from a Parkinson's Patients Association. In addition to usual care, participants will attend 2 days per week, 90 min group sessions for 8 weeks. The intervention combines group cognitive behavioral intervention with the training of safe landing strategies. Feasibility will be assessed by six key domains (recruitment strategy and rates, enrollment, retention, acceptability, reasons for decline/withdrawal, and adverse events). Quantitative data will be analyzed using descriptive statistics to characterize the sample, followed by inferential statistics to evaluate differences in the Short Falls Efficacy Scale-International Scale, Movement Disorder Society Unified Parkinson's Disease Rating Scale, Timed Up Go, 6-Minutes Walking Distance, and fall frequency and severity scores between baseline and final assessment. Qualitative data will be analyzed using an inductive thematic analysis process. There is a growing interest in developing new effective therapeutic approaches for people with PD. If proven program feasibility, this study precedes a randomized controlled trial to establish the effectiveness of the Landing Wise program.

Reducing depression and anxiety symptoms in patients with Parkinson's disease: The effectiveness of group cognitive behavioral therapy

INTRODUCTION

/Objective: The aim of this study was to investigate the effectiveness of group cognitive behavioral therapy in depression and anxiety symptoms in patients with Parkinson's Tehran city.

METHODS

This quasi-experimental study was conducted with experimental and control groups at pretest, posttest, and follow-up. Patients 60-75 years old with Parkinson's disease centers and psychiatric services made up the study population. Based on a random sample of 90 people in Tehran city who scored highly on both the Beck Anxiety Inventory and the Beck Depression Scale, in two 45-person groups-the experimental group and the control group-were randomly assigned. The experimental group underwent group cognitive behavioral therapy for 8 weeks, while the control group just received training once per week. Methods of analysis of variance with repeated measures were employed to test the hypotheses.

RESULTS

The outcomes showed the independent variable is successful in lowering symptoms of anxiety and depression. Patients with Parkinson's disease who participated in group cognitive behavioral therapy for stress reduction showed a reduction in their anxiety and depressive symptoms.

CONCLUSION

Effective psychological interventions, like group cognitive behavioral therapy, can improve mood, lessen anxiety and depression, and help patients adhere more closely to treatment guidelines. As a result, these patients can help prevent the complications of Parkinson's disease and take effective action to raise their level of physical and mental health.

The Role of Telemedicine in the Treatment of Cognitive and Psychological Disorders in Parkinson’s Disease: An Overview

Background: This literature review evaluates the use and efficacy of telemedicine in cognitive and psychological treatment in Parkinson’s disease. Methods: Studies performed between 2016 and 2021 that fulfilled inclusion criteria were selected from PubMed, Scopus, Cochrane, and Web of Science databases. All articles were evaluated by title, abstract, and text. All studies that examined the cognitive and psychological/psychotherapy treatment of patients with Parkinson’s disease by telemedicine were included. Results: Telehealth improved cognitive status and emotional/behavioral disorders in this population, and had positive effects on the patients’ and caregivers’ quality of life. Conclusions: Our literature review supports the development and efficacy of cognitive and psychological treatment with telemedicine, but the methodology of the study must be reviewed considering its limitations so as to highlight the benefits and risks of treatment via telemedicine.

Neurobiology of depression in Parkinson's disease: Insights into epidemiology, molecular mechanisms and treatment strategies

Parkinson's disease (PD) is characterized mainly by motor dysfunctions due to the progressive loss of dopaminergic neurons. However, PD patients experience a multitude of debilitating non-motor symptoms, including depression, which may have deleteriously detrimental effects on life. Depression is multifactorial and exhibits a bimodal progression in PD, but its underlying molecular mechanisms are poorly understood. Studies demonstrating the pathophysiology of depression in PD and the specific treatment strategies for depression-like symptoms in PD patients are largely lacking, often underrated, under-recognized and, consequently, inadequately/under-treated. Nevertheless, reports suggest that the incidence of depression is approximately 20-30% of PD patients and may precede the onset of motor symptoms. Diagnosing depression in PD becomes difficult due to the clinical overlap in symptomatology between the two diseases, and the nigrostriatal dysfunction alone is insufficient to explain depressive symptoms in PD. Therefore, the current study provides an overview of the molecular mechanisms underlying the development of depression in PD and new insights into developing current antidepressant strategies to treat depression in PD. This review will identify and understand the molecular pathological mechanisms of depression in PD that will fundamentally help tailoring therapeutic interventions for depressive symptoms in PD.

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.

Telehealth Transdiagnostic Cognitive Behavioral Therapy for Depression in Parkinson's Disease: A Pilot Randomized Controlled Trial

Background

Cognitive behavioral therapy (CBT) is an effective treatment for depression in persons with Parkinson's disease (PwPD), but there are significant barriers preventing PwPD from receiving care in person. Telehealth CBT circumvents many of these barriers.

Objectives

We conducted a pilot randomized controlled trial evaluating the efficacy, feasibility, and acceptability of telehealth transdiagnostic CBT intervention for depression in PwPD.

Methods

Twelve PwPD with Major Depressive Disorder were enrolled, half randomly assigned to the treatment-immediate condition (TI) and half to the waitlist control condition (WLC). TI and WLC participants received 12 CBT sessions and assessments before treatment, immediately after treatment, and at the 6-week follow-up.

Results

The intervention was efficacious for treating depression in PwPD, with secondary benefits to anxiety, apathy, learning, memory, and quality of life. Improvements were largely maintained at follow-up. The intervention was highly feasible and acceptable.

Conclusions

Telehealth transdiagnostic CBT was an effective intervention for PwPD with depression.

Should patients with Parkinson’s disease only visit a neurologist’s office? - a narrative review of neuropsychiatric disorders among people with Parkinson’s disease

Introduction: Parkinson’s disease is a neurodegenerative disease that is often accompanied by disorders such as depression, psychotic disorders, cognitive disorders, anxiety disorders, sleep disorders, impulse control disorders. The aim of the study was to review the literature and present the characteristics of neuropsychiatric disorders occurring in people suffering from Parkinson’s disease, with the specification of the above-mentioned disorders.

Material and method: The literature available on the PubMed platform from 1986 to 2022 was reviewed using the following keywords: Parkinson’s disease, depression, anxiety disorders, psychotic disorders, sleep disorders, cognitive disorders, impulse control disorders. Original studies, reviews, meta-analyzes and internet sources were analyzed.

Results: The above-mentioned neuropsychiatric disorders appear with different frequency among people suffering from Parkinson’s disease and occur at different times of its duration or even precede its onset for many years. The non-motor symptoms in the form of depressed mood, energy loss or changes in the rhythm of the day may result in a delay of appropriate therapy and thus in complications. Neuropathological changes in the course of Parkinson’s disease as well as dopaminergic drugs used in its therapy influence the development of neuropsychiatric disorders.

Conclusions: In order to avoid misdiagnosis, practitioners should use, e.g. scales intended for patients with Parkinson’s disease. To prevent the consequences of the aforementioned disease entities, methods of early diagnosis, determination of risk factors and standardization of the treatment process must be determined. Consistent care for patients with Parkinson’s disease is significant, not only in the neurological field, but also in the psychiatric one.

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.

Possible association between the lrrk2 gene and anxiety behavior: a systematic literature review

Alterations to the LRRK2 gene have been associated with Parkinson's disease and alcohol consumption in animals and humans. Furthermore, these disorders are strongly related to anxiety disorders (ADs). Thus, we investigated how the LRRK2 gene might influence anxiety in humans and mice. We elaborated a systematic review based on the PRISMA Statement of studies that investigated levels of anxiety in animal or human models with alterations in the LRRK2 gene. The search was conducted in the PubMed, Scopus, and Web of Science databases, and in reference lists with descriptors related to ADs and the LRRK2. From the 62 articles assessed for eligibility, 16 were included: 11 conducted in humans and seven, in mice. Lrrk2 KO mice and the LRRK2 G2019S, LRRK2 R1441G, and LRRK2 R1441C variants were addressed. Five articles reported an increase in anxiety levels concerning the LRRK2 variants. Decreased anxiety levels were observed in two articles, one focusing on the LRRK2 G2019S and the other, on the Lrrk2 KO mice. Eight other articles reported no differences in anxiety levels in individuals with Lrrk2 alterations compared to their healthy controls. This study discusses a possible influence between the LRRK2 gene and anxiety, adding information to the existing knowledge respecting the influence of genetics on anxiety.

Psychological Factors Associated With Fear of Falling Avoidance Behavior in Parkinson's Disease: The Role of Depression, Anxiety, and Catastrophizing

PURPOSE

The purpose of this study was to examine the relationship between psychological factors (depression, anxiety, and catastrophizing) and fear of falling avoidance behavior (FFAB) among individuals with Parkinson's disease (PD).

METHODS

A secondary analysis of cross-sectional data from 59 individuals with PD using hierarchical multiple regression.

RESULTS

Disease severity (Movement Disorder Society - Unified PD Rating Scale) and catastrophizing (Consequences of Falling Questionnaire (CoF)) explained approximately 48.2% of the variance in the FFAB Questionnaire scores (P < .001). Catastrophizing was the only significant psychological variable (P < .001). The damage to identity subscale of the CoF was significant in the final model (P < .001).

CONCLUSIONS

Catastrophizing about the consequences of falls explained the largest portion of variability in FFAB after controlling for disease severity. Catastrophizing about the immediate consequences of falling may play a prominent role in FFAB and may be a potential treatment target for mitigating FFAB.

Anxiety predicts impulsive-compulsive behaviours in Parkinson's disease: Clinical relevance and theoretical implications

Patients with Parkinson's disease (PD) often present symptoms of anxiety, depression and apathy. These negative affect manifestations have been recently associated with the presence of impulsive compulsive behaviours (ICBs). However, their relation with the use of dopamine replacement therapy (DRT), a renewed risk factor for ICBs, is still not fully understood. Elucidating the role of these different ICBs predictors in PD could inform both prevention/intervention recommendations as well as theoretical models. In the present study, we have analysed data collected in 417 PD patients, 50 patients with Parkinsonian symptoms but with scan without evidence of dopaminergic deficit (SWEDD), and 185 healthy controls (HC). We examined each patient's clinical profile over a two-year time window, investigating the role of both negative affect and DRT on ICBs. Results confirmed the presence of higher levels of anxiety in both the clinical groups, and of higher level of ICBs in SWEDD patients, respect to both PD and HC. Mixed model analyses revealed a statistically significant association between anxiety and ICBs in the SWEDD patients who did not take any DRT. Findings suggest the independence between anxiety and DRT in ICBs development, and provide new evidence for the motivational opponency theoretical framework.

Cognitive dysfunction and neuropsychiatric aspects of Parkinson's disease

Movement abnormalities, by definition, and cognitive changes, to varying extents, affect every patient with Parkinson's disease (PD) and are attributed to the underlying neurodegenerative disease. Various psychiatric disorders occur in most patients at some point over the course of PD, including in the prodromal phase. Even though psychiatric disturbances tend to aggravate motor and cognitive deficits, they are under-recognized and under-treated, and the role of the underlying neurological disease is often minimized. To provide an integrated approach to understanding neuropsychiatric aspects of PD, this chapter reviews how cognitive changes in PD relate to the common psychiatric disturbances in PD along with the prevalence, phenomenology, pathophysiology, and treatment of each.

Cognitive and Physical Intervention in Metals’ Dysfunction and Neurodegeneration

Metals—especially iron, copper and manganese—are important elements of brain functions and development. Metal-dysregulation homeostasis is associated with brain-structure damage to the motor, cognitive and emotional systems, and leads to neurodegenerative processes. There is more and more evidence that specialized cognitive and motor exercises can enhance brain function and attenuate neurodegeneration in mechanisms, such as improving neuroplasticity by altering the synaptic structure and function in many brain regions. Psychological and physical methods of rehabilitation are now becoming increasingly important, as pharmacological treatments for movement, cognitive and emotional symptoms are limited. The present study describes physical and cognitive rehabilitation methods of patients associated with metal-induced neurotoxicity such as Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, Huntington’s disease and Wilson’s disease. In our review, we describe physical (e.g., virtual-reality environments, robotic-assists training) and psychological (cognitive training, cognitive stimulation, neuropsychological rehabilitation and cognitive-behavioral and mindfulness-based therapies) methods, significantly improving the quality of life and independence of patients associated with storage diseases. Storage diseases are a diverse group of hereditary metabolic defects characterized by the abnormal cumulation of storage material in cells. This topic is being addressed due to the fact that rehabilitation plays a vital role in the treatment of neurodegenerative diseases. Unfortunately so far there are no specific guidelines concerning physiotherapy in neurodegenerative disorders, especially in regards to duration of exercise, type of exercise and intensity, as well as frequency of exercise. This is in part due to the variety of symptoms of these diseases and the various levels of disease progression. This further proves the need for more research to be carried out on the role of exercise in neurodegenerative disorder treatment.

Designing Virtual Reality Assisted Psychotherapy for Anxiety in Older Adults Living with Parkinson's Disease: Integrating Literature for Scoping

Objective: This review integrates literature to discuss the potential use of virtual reality (VR) in treatment of anxiety in Parkinson's disease (PD) and inform next steps.Methods: A systematic search was performed to identify studies of VR use in PD, using four databases. Data were reported in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR).Results: Thirty-two studies met the inclusion criteria with four VR studies from the same study group directly assessing the effects of anxiety on motor symptoms in PD. Primary studies implementing a VR protocol in PD identified focus areas of understanding and alleviating freezing of gait (FOG), balance training, and cognitive and motor rehabilitation, and informed design considerations.Conclusion: VR in PD studies suggested established feasibility. With appropriate design considerations, a VR based protocol could improve anxiety outcomes in PD.Clinical implications: VR in PD provides control of a patient's field of view, which can be exploited to induce specific responses, provide visual feedback, analysis of patient actions, and introduce safe challenges in the context of training. VR assisted Cognitive Behavioral Therapy (CBT) tailored to suit subtypes of anxiety disorders in PD have the potential to improve the efficacy and effectiveness of psychotherapy in PD.

A theoretical framework for addressing fear of falling avoidance behavior in Parkinson's disease

Postural instability in Parkinson's disease (PD) is associated with several downstream consequences that ultimately lead to a greater risk of falling. Among the prominent downstream consequences is fear of falling (FOF), which is both common and problematic in PD. It can lead to a vicious cycle of FOF avoidance behavior that results in more sedentary behavior, physical deconditioning, and weakening of already impaired balance systems. This, in turn, may make the person with PD more susceptible to a future fall even with benign daily tasks. While FOF activity avoidance can be adaptive (appropriate), it can also be maladaptive (inappropriate or exaggerated). When this adaptive and maladaptive FOF avoidance behavior is contextualized to gait/balance performance, it provides a theoretical framework that can be used by clinicians to match patterns of behavior to a concordant treatment approach. In the theoretical framework proposed in this perspective, four different patterns related to FOF avoidance behavior and gait/balance performance are suggested: appropriate avoiders, appropriate non-avoiders, inappropriate avoiders, and inappropriate non-avoiders. For each of the four FOF avoidance behavior patterns, this paper also provides suggested treatment focuses, approaches and recommendations.

Noninvasive vagus nerve stimulation in Parkinson's disease: current status and future prospects

INTRODUCTION

Parkinson's disease (PD) is a common progressive neurodegenerative disorder with multifactorial etiology. While dopaminergic medication is the standard therapy in PD, it provides limited symptomatic treatment and non-pharmacological interventions are currently being trialed.

AREAS COVERED

Recent pathophysiological theories of Parkinson's suggest that aggregated α-synuclein form in the gut and spread to nuclei in the brainstem via autonomic connections. In this paper, we review the novel hypothesis that noninvasive vagus nerve stimulation (nVNS), targeting efferent and afferent vagal projections, is a promising therapeutic tool to improve gait and cognitive control and ameliorate non-motor symptoms in people with Parkinson's. We conducted an unstructured search of the literature for any studies employing nVNS in PD as well as for studies examining the efficacy of nVNS on improving cognitive function and where nVNS has been applied to co-occurring conditions in PD.

EXPERT OPINION

Evidence of nVNS as a novel therapeutic to improve gait in PD is preliminary, but early signs indicate the possibility that nVNS may be useful to target dopa-resistant gait characteristics in early PD. The evidence for nVNS as a therapeutic tool is, however, limited and further studies are needed in both brain health and disease.

Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand?

PURPOSE

To explore the heterogeneity of the literature on psychological interventions for psychological difficulties in people with Parkinson's disease (PD).

METHODS

A scoping review was performed across five major databases (MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library) up to June 2020.

RESULTS

From an initial return of 4911 citations, 56 studies were included, of which 21 were RCTs. A relatively wide range of therapeutic models have been adopted with people with PD, from common therapies such as cognitive behavioural therapy (CBT) and mindfulness, to less frequent approaches, for example, acceptance and commitment therapy (ACT) and psychodrama. The clinical implications of the findings are discussed, and suggestions are provided for future research on intervention studies and key psychological outcomes.

CONCLUSIONS

CBT appears to be effective in treating depression and sleep disorders in people with PD, while psychoeducation programmes alone should be avoided. The use of CBT to improve anxiety, quality of life, and impulse control, as well mindfulness-based interventions, should be undertaken with some caution because of insufficient research and inconsistent results. As we enter the new decade, more high-quality evidence is required for psychological interventions in people with PD in general and to corroborate preliminary positive findings on the adoption of less frequent approaches such as ACT.

PRACTITIONER POINTS

Parkinson's disease is a progressive neurodegenerative condition associated with several psychological difficulties which be targeted by psychological interventions. Currently, cognitive behavioural therapy (CBT) can be recommended to treat depression and sleep disorders in people with Parkinson's, while psychoeducation alone should be avoided. Caution is advised regarding the use of CBT and mindfulness-based interventions to improve anxiety, quality of life, and impulse control. Further evidence is required for less common approaches, such as acceptance and commitment therapy, psychodrama, and EMDR.

A New Era: The Growth of Video-Based Visits for Remote Management of Persons with Parkinson's Disease

The COVID-19 pandemic forced the abrupt and rapid expansion of an alternative care model that embraces the use of video-based visits in the care of persons with Parkinson's disease. Video-based visits not only eliminate the risk of infection but also reduce geography- and disability-related barriers to accessing specialist care. Research has established that they are feasible, acceptable to persons with Parkinson's disease and patient-centered. In the Unites States, the relaxation of licensure requirements, adoption of reimbursement parity and investment in telemedicine infrastructure has enabled the rapid growth of video-based visits during the COVID-19 pandemic. Now, we must turn our attention to ensuring that progress made in expanding access to video-based care is not lost and expanded worldwide. More work is needed to identify the optimal video-based care model, establish best practices, and ensure equitable access to care.

Individually Tailored Internet-Based Cognitive-Behavioral Therapy for Daily Functioning in Patients with Parkinson's Disease: A Randomized Controlled Trial

Background:

Parkinson’s disease (PD) is often associated with psychological distress and lowered daily functioning. The availability of psychological interventions tailored for people with Parkinson is very limited.

Objective:

To study if guided individually-tailored internet-based cognitive behavioral therapy (ICBT) provide additional value to standard medical treatment for PD.

Methods:

Seventy-seven individuals with PD and self-reported problems with general function measured with the Work and Social Adjustment Scale (WSAS > 15) were randomized to 10 weeks of either ICBT combined with standard medical treatment, or standard medical treatment plus being on waitlist to ICBT (CONTROL). Change in the main outcome WSAS, as well as secondary measures such as quality of life, depression, anxiety and insomnia symptoms were investigated post treatment.

Results:

Participants receiving ICBT reported significantly higher functioning after treatment (WSAS group difference –4.56, controlled effect size g = 0.69, significant group by time interaction, Wχ²= 26.23, p = 0.001). However, only around one third of participants in the treatment group were classified as treatment responders, defined as having a 30% reduction on the WSAS post treatment. Patient involvement and ratings of ICBT credibility were high. Symptoms of anxiety, depression and insomnia symptoms were significantly lower after treatment compared to CONTROL. There were also positive effects on Parkinson-specific function and quality of life in the treatment group.

Conclusions:

ICBT as an addition to standard medical treatment was credible and improved functioning for some individuals with PD. Still, the treatment needs further development in order to help a larger proportion of individuals with PD.

Trial registration number:

ClinicalTrials.gov NCT02627885.

Managing Advanced Parkinson Disease

Advanced Parkinson disease (PD) is associated with treatment-related motor fluctuations and reduced ability to perform activities of daily living. Progression of non-motor symptoms and medication-induced adverse effects complicate focused approach to motor symptom management, frequently accelerating reduced quality of life. It is thus critical for clinicians to consider disease progression versus therapeutic contributions when balancing management decisions. Such an approach requires careful recognition of inflection points resulting from therapeutic decisions and should prompt consideration of reduced pharmacologic burden and increased reliance on non-pharmacologic strategies in advanced disease. The successful approach to advanced PD requires a multidisciplinary effort focused on improving the patient's and family's quality of life, sometimes requiring sacrifice of motor symptom benefit. Here, we emphasize management strategies in advanced PD, focusing on the need to balance the therapeutic approach across advancing motor symptoms, progressive non-motor features, and potential pharmacologic adverse effects.

Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders in Medical Conditions: A Systematic Review

Emotional disorders are those that most commonly present comorbidly with medical conditions. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP), a cognitive-behavioral emotion-based intervention, has proven efficacy and versatility. The aim of this systematic review is to know the current (research studies) and future research interest (study protocols) in using the UP for the transdiagnostic treatment of emotional symptoms or disorders (EDs) in people with a medical condition. Using the PRISMA guidelines, a literature search was conducted in Web of Science, PubMed, Medline, and Dialnet. The nine research studies included in this review indicated that the UP is effective in treating emotional symptomatology in a population with a medical condition (effect sizes ranging from d = -3.34 to d = 2.16). The three included study protocols suggest interest in the future UP application to different medical conditions, and also in distinct application formats. Our review results are encouraging, and conducting more controlled studies is advised to recommend the UP to treat and/or prevent EDs in medical conditions, especially in children and youths.

Cognitive Behavioral Therapy for Anxiety in Parkinson's Disease: A Randomized Controlled Trial

Background

Anxiety disorders are among the most prevalent and disabling neuropsychiatric syndromes in patients with Parkinsonʼs disease (PD), but no randomized controlled treatment trials of anxiety have been published to date.

Objective

The aim of this study was to assess the effectiveness of cognitive behavioral therapy (CBT) in the treatment of anxiety in patients with PD.

Methods

Forty‐eight patients with PD with anxiety were randomized 1:1 between CBT and clinical monitoring only (CMO). The CBT program was developed to specifically address anxiety symptoms in PD and consisted of 10 weekly sessions. Assessments were conducted by blinded assessors at baseline, at the end of the intervention, after 3 months, and after 6 months (CBT group only). Main outcome measures were the Hamilton Anxiety Rating Scale (HARS) and the Parkinson Anxiety Scale (PAS).

Results

Both the CBT and CMO groups showed clinically relevant improvement. Although there was no between‐group difference in outcome on the Hamilton Anxiety Rating Scale (6.7‐point reduction in the CBT group versus 3.9‐point reduction in the CMO group; P = 0.15), there was both a statistically significant and a clinically relevant between‐group difference on the total PAS in favor of CBT (9.9‐point reduction in the CBT group versus 5.2‐point reduction in the CMO group; P = 0.012), which was due to improvement on the PAS subscales for episodic (situational) anxiety and avoidance behavior. This greater improvement was maintained at 3‐ and 6‐month follow‐ups.

Conclusion

CBT is an effective treatment for anxiety in patients with PD and reduces situational and social anxiety, as well as avoidance behavior. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Management of psychiatric disorders in Parkinson's disease : Neurotherapeutics - Movement Disorders Therapeutics

Affective disorders (depression and anxiety), psychosis, impulse control disorders, and apathy are common and sometimes disabling psychiatric conditions in Parkinson disease (PD). Psychiatric aspects of PD are associated with numerous adverse outcomes, yet in spite of this and their high frequency, there remains incomplete understanding of epidemiology, presentation, risk factors, neural substrate, and management strategies. Psychiatric features are typically co- or multimorbid, and there is great intra- and interindividual variability in presentation [1]. The neuropathophysiological changes that occur in PD, as well as the association between PD treatment and particular psychiatric disorders, suggest a neurobiological contribution to many psychiatric symptoms. There is evidence that psychiatric disorders in PD are still under-recognized and undertreated, and although psychotropic medication use is common, randomized controlled trials demonstrating efficacy and tolerability are largely lacking. Future research on neuropsychiatric complications in PD should be oriented toward determining modifiable correlates or risk factors, and most importantly, establishing efficacious and well-tolerated treatment strategies.

A new postural stability-indicator to predict the level of fear of falling in Parkinson's disease patients

BACKGROUND

Fear of falling (FoF) is defined as a lasting concern about falling that causes a person to limit or even stop the daily activities that he/she is capable of. Seventy percent of Parkinson's disease (PD) patients report activity limitations due to FoF. Timely identification of FoF is critical to prevent its additional adverse effects on the quality of life. Self-report questionnaires are commonly used to evaluate the FoF, which may be prone to human error.

OBJECTIVES

In this study, we attempted to identify a new postural stability-indicator to objectively predict the intensity of FoF and its related behavior(s) in PD patients.

METHODS

Thirty-eight PD patients participated in the study (mean age, 61.2 years), among whom 10 (26.32%) were identified with low FoF and the rest (73.68%) with high FoF, based on Falls Efficacy Scale-International (FES-I). We used a limit of stability task calibrated to each individual and investigated the postural strategies to predict the intensity of FoF. New parameters (FTRis; functional time ratio) were extracted based on the center of pressure presence pattern in different rectangular areas (i = 1, 2, and 3). The task was performed on two heights to investigate FoF-related behavior(s).

RESULTS

FTR1/2 (the ratio between FTR1 and FTR2) was strongly correlated with the FES-I (r = - 0.63, p < 0.001), Pull test (r = - 0.65, p < 0.001), Timed Up and Go test (r = - 0.57, p < 0.001), and Berg Balance Scale (r = 0.62, p < 0.001). The model of FTR1/2 was identified as a best-fitting model to predicting the intensity of FoF in PD participants (sensitivity = 96.43%, specificity = 80%), using a threshold level of ≤ 2.83.

CONCLUSIONS

Using the proposed assessment technique, we can accurately predict the intensity of FoF in PD patients. Also, the FTR1/2 index can be potentially considered as a mechanical biomarker to sense the FoF-related postural instability in PD patients.

Clinical experience of comprehensive treatment on the balance function of Parkinson's disease

To investigate the effect of multi-disciplinary teamwork on balance performance of Parkinson's disease (PD).Sixteen primary Parkinson's disease patients (8 male, 8 female) treated with bilateral subthalamic nucleus deep brain stimulation (STN-DBS) were included in the study. The median age of patients was 60.5 years; all patients were in the Hoehn&Yahr (H&Y) 3 stage; the median PD duration of the disease was 9 years. For each patient, multi-disciplinary teamwork treatment including DBS, medication, physical therapy and psychotherapy proceeded. levodopa equivalent daily dose (LEDD, mg/day), life quality (PDQ-39), Motor disability (MDS-UPDRSIII) and balance performance (MDS-UPDRS 3.12, Berg Balance Scale BBS, Limits of Stability LoS) were assessed in different time and status respectively: preoperation (Med-off, Med-on), postoperation (Stim-Off/Med-Off, Stim-On/Med-Off, Stim-On/Med-On), 6 months postoperation (Stim-On/ Med-Off, Stim-On/Med-On) and 12 months postoperation (Stim-On/Med-Off, Stim-On/Med-On).The LEDD, life quality (PDQ-39) continued to improve during the follow-up, statistical difference were found in both 6 months postoperation and 12 months postoperation compared with preoperation. The Motor disability (MDS-UPDRSIII), balance performance (MDS-UPDRS 3.12, BBS) and the LoS (target acquisition percentage, trunk swing angle standard deviation, time) showed significant improvement in Stim-On/med-Off 6 months postoperation and 12 months postoperation separately compared with Med-Off preoperation.Multi-disciplinary teamwork for PD patients with STN-DBS could improve balance performance.

Clinical practice guidelines based on evidence for cognitive-behavioural therapy in Parkinson's disease comorbidities: A literature review

The purpose of this review is to provide psychologists and other health care professional enough knowledge about available cognitive-behavioural interventions for comorbidities in Parkinson's disease that include depression, anxiety, impulsive disorder, pain, and sleep disturbances. This review has clear clinical practical suggestions how to adapt psychological interventions and techniques to the motor and/or cognitive impairments of patients with Parkinson's disease, based on earlier available research results. Every available research that could be found with the help of search engines from Medline, Springer, PsychINFO, and Google Scholar, which used cognitive-behavioural therapy to treat Parkinson's comorbidities, was cited and explained. Cognitive-behavioural interventions and techniques are presented based on available research results for Parkinson's comorbidities. It is recommended to use treatment plans and interventions that are earlier suggested as efficient in patients with Parkinson's disease. Strongest available research based recommendations are available for depression and anxiety. There are only few available research studies that used cognitive and/or behavioural interventions for pain, impulsive disorder, or sleeping disturbances, except insomnia in Parkinson's disease. Cognitive-behavioural therapy is safe to use and should be adapted to the specific needs of patients and with the scientific approved treatment interventions and techniques. Psychologists should be careful on how they adapt their treatment plan for patients.