Neuropsychiatric Complications of Parkinson’s Disease – Clinical Features and Management

Neuropsychiatric Complications of Parkinson’s Disease – Clinical Features and Management
Poewe Werner
SOLVAY PHARMACEUTICALS - EUROPEAN NEUROLOGICAL DISEASE 2007 SUPPLEMENT
Published: August 2007
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Abstract
Although idiopathic Parkinson’s disease (PD) is commonly regarded as a prototypic movement disorder, neuropsychiatric features are prominent and affect the majority of patients. They include disorders of affect and mood, cognitive dysfunction and complex behavioural disturbances, which are mostly induced by dopaminergic medications. Loss of initiative and assertiveness as well as anhedonia and anxiety are common in patients with PD. Their appearance may pre-date the manifestation of classic motor symptoms in up to one-third of patients, and recent studies have reported an increased risk of PD in subjects with a prior history of major depression or increased scores on anxiety scales. Depressive symptoms may be found in about 30–40% of patients with PD. Neuropsychological testing reveals subtle cognitive deficits in almost all PD patients, even those in the early stages. They relate to frontal executive dysfunction, including impaired problem-solving, and there is also impairment of learning and memory. Some 30–40% of patients with PD will develop clinically defined dementia, characterised by psychomotor slowing, apathy, memory deficits, poor visuospatial function, hallucinosis and fluctuations in attention and cognition, although language and praxis remain largely intact. Management of psychosis in PD is based on the elimination of contributing or triggering factors, including the treatment of electrolyte disturbances, infections, the reduction ofpolypharmacy and – commonly – the introduction of atypical neuroleptics. Recently, there has been growing concern about the incidence of impulse dyscontrol disorders in PD, including pathological gambling, shopping and hypersexuality. Recent surveys have shown that between 4 and 6% of outpatient populations may exhibit some form of impulse dyscontrol and there is a strong association with dopamine agonist therapy. Neuropsychiatric complications are one of the major therapeutic challenges in advanced PD, where they seem to affect at least 50% of patients. Their prevention and treatment is one of the major unmet needs in medical therapy for this disorder.

Neuropsychiatric symptoms are not purely complications of Parkinson’s disease (PD) – in reality, they are symptoms of it. However, they may also be complications or side effects of medication. As discussed in the previous paper (by Lesley Findley), many of the determinants of quality of life (QoL) in PD are non-motor symptoms (NMS), in particular neuropsychiatric symptoms. PD causes a range of changes in mood, affect and cognition, even at the behavioural level, that adversely affect a patient’s life. These changes are complex and can be perceived by the patient as threatening. They can be socially disruptive and endanger careers and family life. Therefore, while the tendency is to think of PD as a movement disorder, it is in effect a psychiatric disorder as well.

Depression
According to the Global PD Survey, depression is the major determinant of QoL, accounting for around 58% of the total QoL score.1 The frequency of depression in the Global PD Survey was around 50%, but there is little consensus across studies that have aimed to measure depression in PD. Such studies differ both in size and in the instrument they used to rate depression (see Table 1). Therefore, it is of little surprise that the prevalence also varies greatly in these studies, from quite rare – in the single digits – to more than 50% in others.

There are some problems in defining depression in PD. The nature of the biochemical changes inherent in PD induce disorders of affect and mood regulation that overlap with certain definitions of depression, such as that given in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). For example, the DSM-IV definition of depression includes anhedonia, which is an almost universal feature of PD; the same is true for apathy, which is also very common in PD, as are insomnia and fatigue. Therefore, the problem lies in deciding whether the PD depressive profile is the same as that in DSM-IV and is therefore the same as major depression without PD. There is currently no specific rating scale for depression in PD.

Keywords:
Neuropsychiatric Complications, Parkinson’s Disease, Depression, Cognitive Dysfunction,

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