Recognition and management of neuropsychiatric complications in Parkinson's disease

Global research trends and hotspots in Parkinson's disease psychosis: a 25-year bibliometric and visual analysis

Background

Parkinson's disease psychosis (PDP) is one of the most severe and disabling non-motor symptoms in the progression of Parkinson's disease (PD), significantly impacting the prognosis of PD patients. In recent years, there has been an increase in literature on PDP. However, bibliometrics has rarely been applied to PDP research. This study provides an overview of the current state of PDP research and predicts future trends in this field.

Methods

The literature search was conducted using the Web of Science Core Collection, with the search terms (Parkinson* AND (psychotic* OR hallucination* OR illusion* OR delusion* OR misperception* OR psychosis OR psychoses)). VOSviewer and CiteSpace software were employed to perform bibliometric analysis and visual representation of the search results.

Results

A total of 603 articles were effectively included. Since 2017, there has been a significant upward trend in publications related to PDP. The United States, the United Kingdom, and Canada were the top three contributing countries in terms of publication volume, with France also having a strong influence in this field. Movement Disorders and King's College London included and published the most articles on PDP. The paper titled "Hallucinations in Parkinson's Disease: Prevalence, Phenomenology, and Risk Factors" received the highest number of citations and average citations. Cluster analysis results identified brain, prevalence, connectivity, and atypical antipsychotics as key hotspots in this field. High-frequency keywords were grouped into three themes: neurobiology, therapeutic strategies, and symptom research. Among them, pimavanserin, risk, and functional connectivity have been the most studied areas in the past 7 years and are likely to remain key topics in future research.

Conclusion

Research on PDP has garnered increasing attention. This study visualizes PDP research over the past 25 years to analyze global hotspots and trends. It offers researchers a valuable perspective for identifying key topics and understanding research trajectories in this expanding field.

Cognitive Digital Intervention for Older Patients with Parkinson's Disease during COVID-19: A Mixed-Method Pilot Study

Mild cognitive impairment is frequent among people with Parkinson's disease. Cognitive training seems effective for cognitive status and for mitigating anxiety and depression. With the COVID-19 outbreak, such therapeutic interventions were delivered online. This longitudinal mixed-method study was aimed at evaluating the effectiveness of an online cognitive treatment, carried out during COVID times and based on Parkinson's-Adapted Cognitive Stimulation Therapy, on cognitive domains and mood of 18 older people with Parkinson's disease. After screening, the cognitive status and mood were assessed three times by Addenbrooke's Cognitive Examination-Revised scale and the Geriatric Depression Scale-Short Form. At the follow-up, patients were also interviewed for understanding their experience with the technology. Such treatment was effective on the participants' cognitive functions, but not on their mood. Despite some initial problems with the technology, the online intervention was experienced as a way of not being 'left behind', staying in contact with others, and being safe during the lockdown. This suggests that online cognitive treatment can be adopted to integrate face-to-face interventions by increasing their efficacy, accessibility, and long-term outcomes. Suggestions for future research are given.

Cognitive Behavioral Therapy Plus a Serious Game as a Complementary Tool for a Patient With Parkinson Disease and Impulse Control Disorder: Case Report

Background

Impulse control disorders (ICDs) are commonly developed among patients who take dopamine agonist drugs as a treatment for Parkinson disease (PD). Gambling disorder and hypersexuality are more frequent in male patients with PD, with a prevalence over 4% in dopamine agonists users. Although impulsive-compulsive behaviors are related to antiparkinsonian medication, and even though ICD symptomatology, such as hypersexuality, often subsides when the dopaminergic dose is reduced, sometimes ICD persists in spite of drug adjustment. Consequently, a multidisciplinary approach should be considered to address these comorbidities and to explore new forms of complementary interventions, such as serious games or therapies adapted to PD.

Objective

The aim of this study is to present the case of a patient with ICD (ie, hypersexuality) triggered by dopaminergic medication for PD. A combined intervention was carried out using cognitive behavioral therapy (CBT) for ICD adapted to PD, plus an intervention using a serious game—e-Estesia—whose objective is to improve emotion regulation and impulsivity. The aim of the combination of these interventions was to reduce the harm of the disease.

Methods

After 20 CBT sessions, the patient received the e-Estesia intervention over 15 sessions. Repeated measures, before and after the combined intervention, were administered to assess emotion regulation, general psychopathology, and emotional distress and impulsivity.

Results

After the intervention with CBT techniques and e-Estesia, the patient presented fewer difficulties to regulate emotion, less emotional distress, and lower levels of impulsivity in comparison to before the treatment. Moreover, the frequency and severity of the relapses also decreased.

Conclusions

The combined intervention—CBT and a serious game—showed positive results in terms of treatment outcomes.

Management strategies of sexual dysfunctions in Parkinson's disease

Sexual dysfunctions (SD) are frequent and highly disabling nonmotor manifestations of Parkinson's disease (PD) but are also potentially treatable. Neurologists should actively discuss, recognize and treat sexual health issues as an integral part of the management of the disease. In this chapter, we provide recommendations for managing and treating both primary and secondary SD in PD. Many sexual problems can be, at least partially, improved by adjusting the treatment of motor, nonmotor symptoms and comorbidities. Although some treatments of primary SD are evidence-based, many therapeutic options have not been yet systematically studied in patients with PD. The development of new treatments and repurposing of existing remedies in patients with PD remain an unmet need.

Hypomania, Depression, Euthymia: New Evidence in Parkinson's Disease

The field related to mood disorders in Parkinson's disease (PD) is fragmented. The aim of this cohort observational study was to evaluate whether the episodes of mood alteration could appear in different disease stages and to verify how nonmotor symptoms were led off into different stages. We enrolled 93 PD outpatients (three groups: drug naive—DN; not exhibiting motor fluctuations—n-MF; and exhibiting motor fluctuations—MF) and 50 healthy controls. Mood state was assessed through the Internal State Scale (ISS) while depressive symptoms were evaluated through the Beck Depression Inventory-II (BDI-II), nonmotor symptoms by means of the Non-Motor Symptoms Scale (NMSS), and the presence of impulse control disorders (ICDs) with the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP). Clinical and pharmacological data have also been recorded. No significant differences in mood state distribution between groups were observed. Nevertheless, as regards the mood state distribution within groups, in n-MF (47.6%) and MF patients (50%), (hypo)mania presence was significantly higher than other symptoms. In DN patients, hypomania showed a prevalence of 38.1% although it was not significant. At least one ICD was reported in 29.3% of n-MF and 50% of MF patients. In the MF group, a moderate positive correlation between ISS ACTivation subscale scores and the presence of ICDs and compulsive medication use emerged. Finally, MF patients reported higher BDI-II total scores than DN. Our results show that mood alterations in PD, considering both depressive symptoms and mood elevation, are related to the advanced stages of the disease as well as the presence of ICDs, and dopaminergic therapy would not always be able to restore a normal mood condition.

Poly (ADP-ribose) polymerase 1 inhibition prevents neurodegeneration and promotes α-synuclein degradation via transcription factor EB-dependent autophagy in mutant α-synucleinA53T model of Parkinson's disease

Poly (ADP‐ribose) polymerase 1 (PARP1) is a master regulator of diverse biological processes such as DNA repair, oxidative stress, and apoptosis. PARP1 can be activated by aggregated α‐synuclein, and this process in turn exacerbates toxicity of α‐synuclein. This circle is closely linked to the evolution of Parkinson's disease (PD) that characterized by progressive neurodegeneration and motor deficits. Here, we reported the PARP1, as a novel upstream molecular of transcription factor EB (TFEB), participates in regulation of autophagy in α‐synuclein aggregated cells and mice. PARP1 inhibition not only enhances the nuclear transcription of TFEB via SIRT1 mediated down‐regulation of mTOR signaling but also reduces nuclear export of TFEB by attenuating the TFEB‐CRM1 interaction. Our results revealed that PARP1 inhibition lessened the accumulation of α‐synuclein in PD models. Also, oral administration of PARP1 inhibitor Veliparib prevented neurodegeneration and improved motor ability in α‐synucleinA53T transgenic mice. These findings identify that PARP1 signaling pathway regulates TFEB‐mediated autophagy, pointing to potential therapeutic strategy of PD via enhancing protein degradation systems.

FDA Breakthrough Therapy Designation: Evaluating the Quality of the Evidence behind the Drug Approvals

The United States Food and Drug Administration (FDA) has created approval pathways and designations to accelerate access to medications indicated for serious or life-threatening conditions with limited treatment options. Implemented in 2012, the most recent of these is the breakthrough therapy designation (BTD). The purpose of this article was to review the evidence surrounding approval of medications with nononcology indications approved with the BTD designation from 2012 to 2016. Fifteen medications were identified for eight conditions, ranging from conditions that are relatively common, such as chronic hepatitis C infection, to those that are extremely rare, such as lysosomal acid lipase deficiency. The quality of evidence behind these approvals was highly heterogeneous. Much remains unknown about the safety and efficacy of many agents approved through the BTD. Health care professionals should be aware of these limitations to better educate patients and other providers appropriately.

Mental health in Parkinson's disease after receiving aquatic therapy: a clinical trial

Depression is a major determinant of quality of life in individuals with Parkinson's disease. The aim of this study was to evaluate the effects of a program of Ai Chi aquatic therapy on pain, depression and quality of life in people with Parkinson's disease. Participants were randomized to receive dry land physiotherapy treatment (control group) or aquatic Ai Chi sessions in the pool (experimental group). The outcome measures used included the VAS pain scale, the Geriatric Depression Scale and the SF-36 quality of life scale. In the experimental group treated with aquatic therapy, significant differences were found in the pain, depression and quality of life variables post-treatment (p < 0.001). In the control group, improvements were only observed in the VAS pain scale, and these were less significant than the changes found in the experimental group (p = 0.006). The significant changes registered in the experimental group at the post-treatment assessment were maintained 1 month after completing the experimental intervention program. In conclusion, these findings indicate that physical exercise performed in water has positive effects on some of the factors that influence mood and quality of life in people with Parkinson's disease.

The effects of relaxation training on depression and anxiety in people living with long-term neurological conditions

Purpose: The present study investigated the effects of a relaxation training program on self-reported depression and anxiety in participants living with long-term neurological conditions, including acquired brain injury, stroke, Parkinson's disease, and multiple sclerosis.Materials and methods: A five-session relaxation training program, plus a follow-up session was offered to people living with a long-term neurological condition as part of routine clinical practice, and was delivered in their own homes. A self-report measure (Hospital Anxiety and Depression Scale) was administered at the pre- and post-intervention time points and at follow-up, around 5 weeks after the final session. Participants also completed an individual assessment of change questionnaire at follow-up, reporting on subjective views of observed changes.Results: Statistically significant improvements were found on measures of both anxiety and depression following completion of the relaxation program. Scores at follow-up (mean = 5 weeks) revealed the improvement was maintained for anxiety, and there was further significant improvement for depression. Reliable change analyses from pre- to post-intervention demonstrated a clinically significant decrease in anxiety scores for 47% of participants and in depression scores for 30% of participants. No clinically significant increase in depression and anxiety was identified from pre- to post-intervention, and this was generally maintained at follow-up.Conclusion: Relaxation training is proposed as a clinically effective treatment for anxiety and depression in people living with long-term neurological conditions, which could in turn lead to better functional outcomes of neurorehabilitation. The program investigated here has additional benefits of being delivered in people's own homes, which overcomes barriers to attending hospital, and is consistent with trends towards home as opposed to hospital care. This program may also be less costly to administer as it can be delivered as part of a stepped-care program by therapy assistants under supervision from qualified staff, and encourages self-management over the longer term. Design limitations may reduce the generalisability of these findings, but are clinically encouraging and should stimulate further research.Implications for RehabilitationRelaxation training…• could be offered as an effective first-line intervention, as an alternative to medication to treat anxiety and depression to people living with Long-Term Neurological Conditionsis a self-management strategy which can be taught in people's own homes, if getting out of the house is difficultcan be delivered as a stepped-care intervention via therapy assistants, helping to reduce costs and demands on rehabilitation servicesmay help to improve the functional outcomes of wider rehabilitation interventions by addressing psychological issues which can be a barrier.

Rasagiline for the symptomatic treatment of fatigue in Parkinson's disease

BACKGROUND

Fatigue affects 40% to 50% of all PD patients and is a leading cause of disability, with no clearly established or efficacious established treatments.

METHODS

In this double-blinded, placebo-controlled, pilot trial, we investigated whether rasagiline improved fatigue among PD patients. Subjects were randomized to 1 mg daily of rasagiline or placebo for 12 weeks. The primary endpoint was a change in the Modified Fatigue Impact Scale from baseline to week 12.

RESULTS

Thirty PD subjects (16 men), with Modified Fatigue Impact Scale baseline score of 67 ± 15, were randomized (16 to rasagiline vs. 14 to placebo). Significant improvement was noted in the mean Modified Fatigue Impact Scale score of the rasagiline group (12 points) as compared to placebo (8.5 points) from baseline to week 12 (P = 0.003).

CONCLUSION

In this pilot study, rasagiline at a dose of 1 mg per day improved fatigue. Larger randomized studies are needed to confirm this finding.

A typology of care-giving across neurodegenerative diseases presenting with dementia

The purpose of this study is to develop and extend our understanding of dementia care-giving by introducing a typology of informal care-giving across four different diseases. Care-giving factors were examined with respect to specific dementia presentation in mild cognitive impairment, Alzheimer's disease, dementia with Lewy bodies and Parkinson's disease-associated dementia. Informal care-giving literature in the four diseases was systematically searched to identify specific disease symptoms and resultant care-giving strains and outcomes. Key concepts were extracted and grouped thematically. The first classification, ‘role-shift’, reflects care-giving where cognitive deterioration results in changing roles, uncertainty and relational deprivation among married partners. The second classification, ‘consumed by care-giving’, refers to those caring for persons with dementia-motor decline that greatly increases worry and isolation. Finally, in the ‘service use’ classification, formal support is needed to help care-givers cope with daily responsibilities and behaviour changes. In each case, the dementia presentation uniquely impacts care-giver strains. A major conclusion is that the same support to all care-givers under the umbrella term ‘dementia’ is unwarranted; the development of targeted support is required.

Effect of dopamine therapy on nonverbal affect burst recognition in Parkinson's disease

Background

Parkinson's disease (PD) provides a model for investigating the involvement of the basal ganglia and mesolimbic dopaminergic system in the recognition of emotions from voices (i.e., emotional prosody). Although previous studies of emotional prosody recognition in PD have reported evidence of impairment, none of them compared PD patients at different stages of the disease, or ON and OFF dopamine replacement therapy, making it difficult to determine whether their impairment was due to general cognitive deterioration or to a more specific dopaminergic deficit.

Methods

We explored the involvement of the dopaminergic pathways in the recognition of nonverbal affect bursts (onomatopoeias) in 15 newly diagnosed PD patients in the early stages of the disease, 15 PD patients in the advanced stages of the disease and 15 healthy controls. The early PD group was studied in two conditions: ON and OFF dopaminergic therapy.

Results

Results showed that the early PD patients performed more poorly in the ON condition than in the OFF one, for overall emotion recognition, as well as for the recognition of anger, disgust and fear. Additionally, for anger, the early PD ON patients performed more poorly than controls. For overall emotion recognition, both advanced PD patients and early PD ON patients performed more poorly than controls. Analysis of continuous ratings on target and nontarget visual analog scales confirmed these patterns of results, showing a systematic emotional bias in both the advanced PD and early PD ON (but not OFF) patients compared with controls.

Conclusions

These results i) confirm the involvement of the dopaminergic pathways and basal ganglia in emotional prosody recognition, and ii) suggest a possibly deleterious effect of dopatherapy on affective abilities in the early stages of PD.

Management of neuropsychiatric symptoms in long-term care residents with Parkinson's disease: a retrospective cohort study

BACKGROUND

The management of neuropsychiatric symptoms, including psychosis, in Parkinson's Disease (PD) is complicated by the fact that treatment with antipsychotics can worsen the movement disorder, which may necessitate changes to antiparkinsonian medications.

OBJECTIVES

The objectives of this study were to determine what antipsychotics are prescribed to residents in long-term care with PD and document subsequent changes in levodopa dosage.

METHODS

A retrospective cohort study using administrative health database information from Ontario, Canada, was conducted. PD diagnostic codes were obtained from the Ontario Health Insurance Plan (physician diagnostic codes) and the Canadian Institute of Health Information (hospitalization discharge diagnoses). The Ontario Drug Benefit database provided information on the use of antiparkinsonian medications and antipsychotics. Residents diagnosed with PD in long-term care were included if they were treated with stable doses of levodopa monotherapy and received a new prescription for an antipsychotic. The type of antipsychotic and the changes in levodopa dosage were determined.

RESULTS

There were 479 residents who met inclusion criteria. The prescribed antipsychotics were quetiapine (n = 192; 40 %), risperidone (n = 185; 39 %) and olanzapine (n = 81; 17 %), and only 21 (4 %) received a prescription for a typical antipsychotic. The first levodopa dosage change was a dose reduction in 469 (98 %) patients, and a dose increase in ten (2 %) patients.

CONCLUSIONS

Many PD patients in long-term care are treated with potentially inappropriate antipsychotic medications. However, there is no evidence that this treatment results in a prescribing cascade that leads to inappropriate increases in levodopa dosage.

Prefrontal dopamine signaling and cognitive symptoms of Parkinson's disease

Cognitive dysfunction is a common symptom of Parkinson's disease (PD) that causes significant morbidity and mortality. The severity of these symptoms ranges from minor executive symptoms to frank dementia involving multiple domains. In the present review, we will concentrate on the aspects of cognitive impairment associated with prefrontal dopaminergic dysfunction, seen in non-demented patients with PD. These symptoms include executive dysfunction and disorders of thought, such as hallucinations and psychosis. Such symptoms may go on to predict dementia related to PD, which involves amnestic dysfunction and is typically seen later in the disease. Cognitive symptoms are associated with dysfunction in cholinergic circuits, in addition to the abnormalities in the prefrontal dopaminergic system. These circuits can be carefully studied and evaluated in PD, and could be leveraged to treat difficult clinical problems related to cognitive symptoms of PD.

Management of sexual dysfunction in Parkinson's disease

Nonmotor symptoms, among them sexual dysfunction, are common and underrecognized in patients with Parkinson disease; they play a major role in the deterioration of quality of life of patients and their partners. Loss of desire and dissatisfaction with their sexual life is encountered in both genders. Hypersexuality (HS), erectile dysfunction and problems with ejaculation are found in male patients, and loss of lubrication and involuntary urination during sex are found in female patients. Tremor, hypomimia, muscle rigidity, bradykinesia, 'clumsiness' in fine motor control, dyskinesias, hypersalivation and sweating may interfere with sexual function. Optimal dopaminergic treatment should facilitate sexual encounters of the couple. Appropriate counselling diminishes some of the problems (reluctance to engage in sex, problems with ejaculation, lubrication and urinary incontinence). Treatment of erectile dysfunction with sildenafil and apomorphine is evidence based. HS or compulsive sexual behaviour are side effects of dopaminergic therapy, particularly by dopaminergic agonists, and should be treated primarily by diminishing their dose. Neurologists should actively investigate sexual dysfunction in their Parkinsonian patients and offer treatment, optimally within a multidisciplinary team, where a dedicated professional would deal with sexual counselling.

Nonpharmacological management of apathy in dementia: a systematic review

Apathy is one of the most challenging and prevalent behavioral symptoms of dementia. It is associated with increased disability and caregiver frustration as well as reduced quality of life, rehabilitation outcomes and survival after nursing home admission. A literature search to set criteria yielded 56 nonpharmacological intervention studies with outcomes relevant to apathy in dementia. Studies were rated according to quality and categorized into 7 groups: exercise, music, multisensory, animals, special care programming, therapeutic activities and miscellaneous. Despite a lack of methodological rigor, it is apparent that nonpharmacological interventions have the potential to reduce apathy. This review indicates that therapeutic activities, particularly those provided individually, have the best available evidence for effectiveness in dementia. Recommendations are provided for quality research.

Anxiety in Parkinson's disease: a critical review of experimental and clinical studies

Parkinson's disease (PD) is the second most common neurodegenerative disorder affecting about 1% of the population older than 60 years. Classically, PD is considered as a movement disorder, and its diagnosis is based on the presence of a set of cardinal motor signs that are the consequence of a pronounced death of dopaminergic neurons in the substantia nigra pars compacta. There is now considerable evidence showing that the neurodegenerative processes leading to sporadic PD begin many years before the appearance of the characteristic motor symptoms, and that additional neuronal fields and neurotransmitter systems are also involved in PD, including olfactory structures, amygdala, caudal raphe nuclei, locus coeruleus, and hippocampus. Accordingly, adrenergic and serotonergic neurons are also lost, which seems to contribute to the anxiety in PD. Non-motor features of PD usually do not respond to dopaminergic medication and probably form the major current challenge in the clinical management of PD. Additionally, most studies performed with animal models of PD have investigated their ability to induce motor alterations associated with advanced phases of PD, and some studies begin to assess non-motor behavioral features of the disease. The present review attempts to examine results obtained from clinical and experimental studies to provide a comprehensive picture of the neurobiology and current and potential treatments for anxiety in PD. The data reviewed here indicate that, despite their high prevalence and impact on the quality of life, anxiety disorders are often under-diagnosed and under-treated in PD patients. Moreover, there are currently few clinical and pre-clinical studies underway to investigate new pharmacological agents for relieving these symptoms, and we hope that this article may inspire clinicians and researchers devote to the studies on anxiety in PD to change this scenario. This article is part of a Special Issue entitled 'Anxiety and Depression'.

Psychiatric complications of dementia

Our paper describes the neuropsychiatric signs and symptoms of late-life disorders of cognitive impairment. Late-life cognitive disorders are associated with psychiatric symptoms in various ways-from apparent risk factors to pathognomonic features of particular dementias. They contribute greatly to the burden of illness, both in people with dementia, and in those who care for them. Here we consider specific dementia symptoms in relation to dementing illnesses and to the stages of dementia. Recognizing that no one drug is likely to successfully treat all dementia symptoms, we argue for a syndromic approach, which can lead to appropriately targeted therapy.

Impulse control and related disorders in Parkinson's disease patients treated with bilateral subthalamic nucleus stimulation: a review

Recently, impulse control and related disorders including punding and the dopamine dysregulation syndrome (DDS) have been increasingly recognized in treated patients with Parkinson's disease (PD). Especially the impulse control disorders (ICD) such as pathological gambling, hypersexuality, compulsive eating and buying may have dramatic repercussions on family, personal and professional life. Drug replacement therapy (DRT) is believed to play an important role in the onset of these behavioral disturbances. Although deep brain stimulation (DBS) of the subthalamic nucleus (STN) might be a therapeutic option for those patients with DRT-related behavior, it may also induce ICD. So far, little is known about the relationship between STN DBS and impulse control and related disorders. Our aim was to review the current knowledge on this relationship in PD patients. The available studies showed that stimulation of the STN is associated with both favorable and negative outcome in terms of impulse control and related disorders. Preoperative disorders may resolve or improve after STN DBS, but these can also worsen or show no change at all. Moreover, STN DBS can also reveal or even induce ICD. Possible explanations for this variability are proposed and suggestions for clinical management are given.

Neuropsychiatry of Parkinson's disease

Parkinson's disease (PD) is traditionally regarded as a movement disorder. In recent years, however, non-motor symptoms have been considered significant factors of disability at all stages of the illness. Behavioral and psychological symptoms or neuropsychiatric syndromes associated with PD are frequent and may represent a challenge in the management of these patients. They include anxiety, depression, psychosis, sleep, sexual and impulse control disorders, apathy and cognitive dysfunction. Their pathogenesis in PD is complex, involving neurodegenerative, drug-related and psychological mechanisms. We will review the current knowledge of this growing field, also focusing on the management of theses syndromes.

Depressive symptoms impacting on health-related quality of life in early Parkinson's disease: results from Chinese L-dopa exposed cohort

OBJECTIVE

To investigate the impact of depressive symptoms on health-related quality of life (HR-QOL) in a group of patients with early Parkinson's disease (PD).

METHODS

A 20-item scale, the Center for Epidemiologic Studies Depression Scale (CESD) and a 36-item questionnaire, the medical outcomes study short form (SF-36) were administered as part of baseline assessment of a clinical trial in PD, enrolling 391 early-stage, L-dopa exposed PD patients in China. We used multiple regression models to examine the relationship of depressive symptoms, measured by the CESD with HR-QOL, as measured by the SF-36. The SF-36 score of the depressed patients was compared with those non-depressed, as well.

RESULTS

A total of 146 (37.3%) patients screened positive for depression. Compared with those non-depressed, depressed patients had lower scores in all dimensions of SF-36 profile (p<0.001). Multiple regression analysis revealed that depressive symptoms, measured by CESD, increased our ability to explain the variance of SF-36 total score by 34.5%. Additionally, depressive symptom is the only variable which has the predictive value not only for total SF-36 total score, but also for each subdimension score of SF-36 profile.

CONCLUSION

Depressive symptoms are common early in the disease, having a substantial impact on patients' HR-QOL, affecting many areas other than the obvious mental health dimension of the HR-QOL profile. Our results highlight the broad importance of treating depression in this population.

Impact of cerebrovascular pathology on behavioural and neuropsychiatric symptoms in patients with Alzheimer's dementia: findings from a retrospective, naturalistic study

AIM

Cerebrovascular disease (CVD) has been associated with depression and a host of neuropsychiatric conditions including dementia. This study assessed the relationship between cerebrovascular findings reported on MRI brain scans and neuropsychiatric symptoms (NPS) and behavioural problems in patients with Alzheimer's disease (AD).

METHODS

Medical notes were retrospectively reviewed in patients undergoing brain MRI following referral for cognitive impairment to a memory clinic between January 2004 and June 2008. Patients with AD were graded into four categories of CVD severity based on neuroradiology reports and assessed for behavioural and NPS and activities of daily living using Neuropsychiatric Inventory (NPI), Geriatric Depression Scale (GDS) and Bristol Activities of Daily Living (BADL). Frontal lobe symptoms and parkinsonian features were also evaluated.

RESULTS

Of the initial 232 patients who underwent MRI 72% were diagnosed with AD. 89% of AD patients had CVD findings reported on MRI. Moderate-to-severe CVD was present in 47% of patients. None of the AD patients satisfied a diagnosis of vascular dementia. There was no significant relationship observed between level of MRI CVD findings and scores on NPI (p = 0.57), GDS (p = 0.26) and BADL (p = 0.46). The level of CVD severity did not appear to influence frontal lobe and parkinsonian assessments (p = 0.60).

CONCLUSION

The contribution of CVD to the pathogenesis of various NPS is still debated. Our study, based on patients diagnosed with AD in a memory clinic setting, suggests that there is no relationship between the extent of CVD pathology and neuropsychiatric and behavioural measures in AD patients. Further prospective quantitative studies are needed to assess the role of CVD, if any, in neuropsychiatric and behavioural symptoms in AD. It is possible that the relatively small pathological contribution of CVD to the development of these symptoms is obscured by the effect of the wider neurodegeneration encountered in AD.

The communicative effectiveness survey: preliminary evidence of construct validity

PURPOSE

To provide preliminary evidence of the construct validity of the Communicative Effectiveness Survey (CES) for individuals with dysarthria and idiopathic Parkinson's disease (PD).

METHOD

In a prospective, quasi-experimental design, 25 participants each were assigned to 3 groups (N = 75): PD and dysarthria, non-PD and no dysarthria, and PD significant others (SOs). Mean CES ratings were used to test for significant differences between the PD and non-PD group, and PD and SO rating of PD's communicative effectiveness. Multiple linear regression tested for significant predictors of CES ratings for PD group only using sentence intelligibility and spontaneous speech intelligibility scores as predictor variables.

RESULTS

The PD group rated their CES significantly lower than did the non-PD group. The PD group rated their CES significantly higher than their SOs rated them. Neither speech intelligibility score was a significant predictor of CES ratings. In follow-up analysis, the Hoehn and Yahr PD staging accounted for 47% of the variability in CES ratings for the PD group participants.

CONCLUSIONS

This study provides preliminary evidence of the CES's construct validity. Clinicians and researchers who assess and treat individuals with PD may consider adding an additional assessment to the traditional clinical measures (i.e., speech intelligibility) by obtaining a measure of communicative effectiveness.

Reward pathways in Parkinson's disease: clinical and theoretical implications

AIMS

The mesolimbic and mesocortical circuits are particularly involved in reward-related behavior in humans. Because these systems may be in some way altered in Parkinson's disease (PD), it is likely that some psychiatric manifestations of PD, such as hedonistic homeostatic dysregulation and pathological gambling, as well as impulsive decision making, may be ascribed to their involvement. The aim of the current article was to review recent literature on this topic in order to analyze whether these disturbances share a common ground and whether actual theoretical frameworks on addiction prove a useful tool for their interpretation.

METHODS

Data were identified on searches of MEDLINE/PubMed databases from relevant articles published up until March 2007.

RESULTS

All clinical manifestations (hedonistic homeostatic dysregulation, pathological gambling and impulsive decision making) seem to share a common multifaceted ground in which factors related to antiparkinsonian therapy, premorbid personality and progression of disease interact. Theoretical interpretations and conclusions drawn from experimental studies may help to shed light on the underlying pathological mechanisms.

CONCLUSIONS

Further studies are needed to analyze why, despite a common ground, only some patients develop those neuropsychiatric complications described here.

Is Parkinson's disease an autoimmune disorder of endogenous vasoactive neuropeptides?

Parkinson's disease (PD) is a motor disease including disorders of mobility, fine tremor, rigidity and posture caused by a relentless deterioration of dopaminergic cells in the substantia nigra (SN). Disorders of affect and a range of other symptoms including fatigue, cognitive dysfunction and mental confusion, sleep disorder and addictions are also seen as other CNS sites are also affected. Idiopathic and genetic causes together with inflammatory and degenerative disorders of ageing have been postulated as contributing to PD. Autoimmunity affecting certain vasoactive neuropeptides (VNs) has been postulated as contributing to certain fatigue-related conditions in humans and may be consistent with compromise of receptors associated with VNs and including receptors for vasoactive intestinal polypeptide (VIP) and pituitary adenylate cyclase-activating polypeptide (PACAP). Pro-inflammatory responses are seen in PD patients consistent with apoptotic neurodegeneration. Involvement of the Th1 directed cytokine interferon-gamma has been demonstrated and Th2 directed cytokines such as IL-10 protect against inflammation-mediated degeneration of dopaminergic neurons in the SN. Nitric-oxide dysregulation is also postulated in PD by fostering dopamine depletion via nitric-oxide synthase (iNOS). Both PACAP and VIP have neuroprotective effects in PD models by inhibiting the production of inflammatory mediators. PACAP specifically protects against the neurotoxicity induced by rotenone as well as protecting against oxidative stress-induced apoptosis. These findings suggest that a defect in VN function may act adversely on SN cells and hence contribute to a clinical presentation consistent with PD. The conclusion drawn from these findings is that PD may be an autoimmune disorder of VNs, specifically PACAP and VIP. Possibly unusual or anatomically specific receptors for these VNs may be involved. If proven, this hypothesis would have significant implications for immunological and pharmacological treatment and prevention of PD.