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Parkinson’s disease as a neuropsychiatric disorder: focus ... · Parkinson’s disease as a...

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Marianna Amboni Centro Malattia di Parkinson e disturbi del movimento, CEMAND, Salerno, Italy IDC Hermitage-Capodimonte, Napoli, Italy Parkinson’s disease as a neuropsychiatric disorder: focus on non-motor symptoms
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Page 1: Parkinson’s disease as a neuropsychiatric disorder: focus ... · Parkinson’s disease as a neuropsychiatric disorder: focus on non-motor symptoms ... anxiety) Psychosis and impulse

Marianna Amboni

Centro Malattia di Parkinson e disturbi del movimento, CEMAND, Salerno, Italy

IDC Hermitage-Capodimonte, Napoli, Italy

Parkinson’s disease as a neuropsychiatric disorder: focus on non-motor symptoms

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Cognitive impairment in PD (mild cognitive impairment and dementia)

Affective disorders in PD (depression and anxiety)

Psychosis and impulse control disorders in PD

Outlines

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Cognitive dysfunction in non-demented PD patients

Cognitive impairment can be detected in patients with newly

diagnosed PD, and there is significant decline in cognitive

function in the first few years following diagnosis.

Cognitive domains affected in PD include executive function

(affecting planning, decision making and concept formation),

memory, visuospatial processing, attention and language

The pattern of presentation of cognitive impairment is

heterogeneous in terms of the domains affected. Many patients

show deficits in multiple domains.

There is some evidence that deficits in certain domains may be

associated with an increased risk of developing dementia.

Aarsland et al 2009a;

Foltynie et al, 2004;

Muslimovic et al, 2005

Kandiah et al 2009;

Muslimovic et al 2009

Cronin-Golomb et al

1997; Dujardin et al

1999; Lewis et al 2003;

Siegert et al 2008;

Barone et al 2008

Green et al 2002;

reviewed by Dubois &

Pillon 1997

Foltynie et al 2004;

Williams-Gray et al 2009

Levy et al 2002

(From Barone et al, 2011)

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Clinical diagnostic criteria for Dementia associated with Parkinson’s disease

Emre et al, 2007

→Typical cognitive profile

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DIAGNOSTIC ALGORHYTHM FOR PDD

PD +

DEMENTIA

TYPICAL COGNTIVE PROFILE

YES NO

FEATURES THAT MAKE

THE DIAGNOSIS UNCERTAINPOSSIBLE PDD

NO YES

PROBABLE PDD

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PD PD + CI PD-MCI PDD

Cognitive

dysfunction- + + +

Subjective

complaints- - + +

Functional

decline- - - +

Defining cognitive impairment, MCI and dementia in PD

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Cognitive impairment in PD (mild cognitive impairment and dementia)

Affective disorders in PD (depression and anxiety)

Psychosis and impulse control disorders in PD

Outlines

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Implications of Depression in PD

• Depression is the strongest predictor of poor quality of life in PD1; it can occur many years prior to PD onset

• Depression is associated with:

-Faster disease progression and greater reduction in activity of daily living functions 2,3

-Reduced quality of life of patient4 and caregiver5

-Impaired cognitive functioning6

-Increased mortality7

• Depression may be more disabling than motor symptoms

1. Schrag A, et al. J Neurol Neurosurg Psychiatry2000;69:308-12.

2. Starkstein SE, et al. J Neurol Neurosurg Psychiat1992;55(5):377-8.

3. Liu CY, et al. J Neurol 1997;244:493-8.4. Hobson P, et al. Age Ageing 1999;28:2341-6.

5. Tröster AI, et al. Arch Neurol 1995;52:1164-9.6. Aarsland D, et al. Int J Geriat Psychiat 1999;14:866-

74.7. Hughes et al. Acta Neurol Scand 2004;110(2):118-23.

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The average prevalence were:Major Depressive D.: 17%Minor Depressive D.: 22%Dysthymia : 13%

Clinical relevant depressive symptoms: 36.1 %%

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Properties of depression scales in Parkinson’s disease

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Anxiety in PD

• Up to 40% of PD patients experience anxiety symptoms (GAD, panic attacks etc)1-4

• Increased anxiety has been associated with motor fluctuations (off periods)3,4

• Similar to depression, anxiety disorders can occur up to 20 years prior to PD onset5,6

• Despite depression, anxiety has received scant attention to date

1. Richard et al. J Neuropsychiatry Clin Neurosci, 1996

2. Kummer et al. Mov Disord, 2008

3. Pontone et al. Mov Disord, 2009

4. Dissanayaka et al. Mov Disord, 2010

5. Gonera et al. Mov Disord, 1997

6. Shiba et al. Mov Disord, 2000

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Cognitive impairment in PD (mild cognitive impairment and dementia)

Affective disorders in PD (depression and anxiety)

Psychosis and impulse control disorders in PD

Outlines

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Criteria for Diagnosis of Psychosis in PD

1 Ravina B, Marder K, Fernandez HH, et al. Diagnostic Criteria for Psychosis in Parkinson’s disease: Report of an NINDS/NIMH Work Group. Mov Disord. 2007;22(8):1061-1068.

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Impulse Control Disorders (ICDs)

• ICDs include pathological gambling, compulsive shopping and eating, sexual preoccupations, punding and medication abuse [Voon, 2007]. These behavioral disorders are usually problematic for patient and caregiver, but because they are often embarrassing, medical staff should pose focused questions regarding their presence

• ICDs appear to be more common in treated PD patients than in the general population

• The overall prevalence of these behaviors appears to be 13.6% of treated PD patients [Weintraub, DOMINION study, 2010]

• 0.7-7.2% in patients with levodopa treatment alone; 13.5-14.0% in patients with dopamine agonists treatment [Voon, 2007; Weintraub, 2010]

• ICDs are associated with younger age and depend on gender [Singh et al, 2007; Voon et al, 2007];

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Diagnosis of ICD

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(From Voon & Fox, 2007)

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Conclusions • Cumulative prevalence of most psychiatric disorders in PD

is much higher than previously thought

• Nonmotors mental symptoms of PD are associated with greater disability, poorer quality of life and caregiver burden

• Most psychiatric disturbances in PD are associated with worse motor progression and cognitive impairment

• The neural substrate of neuropsychiatric symptoms is a complex interaction of deficits in several neurotransmitters and neural networks, pathological changes and genetic factors

• PD treatment has a complex and varied effect on psychiatric symptoms, in some cases being an etiological factor and in others representing a treatment option


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