Depression rating scales in Parkinson's disease: critique and recommendations

Exploratory evaluation of baseline cognition as a predictor of perceived benefit in a study of behavioral therapy for urinary incontinence in Parkinson disease

AIMS

While behavior-based pelvic floor muscle exercise therapy is an effective treatment for overactive bladder in Parkinson's disease (PD) patients, cognitive function may be a predictor of rehabilitation outcomes.

METHODS

In a planned exploratory analysis, participants who had a Montreal Cognitive Assessment (MoCA) with a score ≥18 who were randomized in a clinical trial to behavioral treatment were classified by perceived improvement (Benefit vs. No Benefit) as reported on a validated Satisfaction and Benefit Questionnaire. General cognition (MoCA), motor procedural learning (Serial reaction time task), verbal memory (Buschke delayed recall), spatial memory (Nonverbal/Spatial selective reminding test), and working memory (Wisconsin card sorting task) were compared between the two groups using Wilcoxon rank-sum test.

RESULTS

Of the 26 participants randomized to behavioral treatment (70% male, mean age 71 ± 6.1 years), 22 participants (85%) reported Benefit and four reported No Benefit. General cognition, motor procedural learning, verbal memory, spatial memory, and working memory did not differ between these groups. While the difference between the time to complete the final practiced series and the random series of the Serial Reaction Time Task (SRTT) was statistically similar between the groups, the Benefit group performed the random sequence more quickly (567.0 ± 136.5 ms) compared to the No Benefit group (959.4 ± 443.0 ms; p = 0.03) and trended toward faster performance in the final practiced series.

CONCLUSIONS

Perceived benefit from behavioral treatment for overactive bladder was not associated with measures of baseline cognition other than faster completion of the SRTT. This is noteworthy because many behavior-based therapy studies exclude participants with mild cognitive impairment. Additional studies may evaluate if domain-specific cognitive function, particularly the assessment of implicit memory, could lead to individualized behavioral therapy recommendations.

Evaluation of the Impact of Integrated Care and Self-Management After Deep Brain Stimulation in Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) is a progressive neurodegenerative disorder with a myriad of motor and non-motor symptoms. Although deep brain stimulation (DBS) has a dramatic impact in the lives of people with PD, care delivery remains complex. There is a lack of evidence on the implementation and role of integrated care and self-management support in people with PD with chronic DBS.

OBJECTIVE

To evaluate care needs, implementation and impact of a pragmatic network for PD care, the Integrated Parkinson Care Network (IPCN).

METHODS

This is a subgroup analyses of a 6-month, pre-post design, single-centre, phase 2 study to assess a patient-centred care model based on integrated care, self-management support (IPCN) in PD, focusing on those participants with chronic DBS.

RESULTS

We included 22 people with PD and chronic DBS (median time since DBS - 30 months). The mean age was 63.9 (7.6) years and mean disease duration was 15.2 (6.9) years. The top three care priorities were speech (54.5%), mobility (40.9%) and mood (31.8%). After the IPCN program, there was a positive change in the perception of support for chronic care (Patient Assessment of Chronic Illness Case: 0.85; 95% CI: 1.2 to -0.4) and self-management (5As: 0.77; 95% CI: 0.39 -1.15), along with quality of life (PDQ8 : 7.1, 95% CI:1.8 -12.4).

CONCLUSION

The IPCN is a care delivery model that addresses specific care needs of people with PD and chronic DBS. The current study showed its feasibility and warrants further evaluation.

Australian Parkinson's Genetics Study (APGS): pilot (n=1532)

PURPOSE

Parkinson's disease (PD) is a neurodegenerative disorder associated with progressive disability. While the precise aetiology is unknown, there is evidence of significant genetic and environmental influences on individual risk. The Australian Parkinson's Genetics Study seeks to study genetic and patient-reported data from a large cohort of individuals with PD in Australia to understand the sociodemographic, genetic and environmental basis of PD susceptibility, symptoms and progression.

PARTICIPANTS

In the pilot phase reported here, 1819 participants were recruited through assisted mailouts facilitated by Services Australia based on having three or more prescriptions for anti-PD medications in their Pharmaceutical Benefits Scheme records. The average age at the time of the questionnaire was 64±6 years. We collected patient-reported information and sociodemographic variables via an online (93% of the cohort) or paper-based (7%) questionnaire. One thousand five hundred and thirty-two participants (84.2%) met all inclusion criteria, and 1499 provided a DNA sample via traditional post.

FINDINGS TO DATE

65% of participants were men, and 92% identified as being of European descent. A previous traumatic brain injury was reported by 16% of participants and was correlated with a younger age of symptom onset. At the time of the questionnaire, constipation (36% of participants), depression (34%), anxiety (17%), melanoma (16%) and diabetes (10%) were the most reported comorbid conditions.

FUTURE PLANS

We plan to recruit sex-matched and age-matched unaffected controls, genotype all participants and collect non-motor symptoms and cognitive function data. Future work will explore the role of genetic and environmental factors in the aetiology of PD susceptibility, onset, symptoms, and progression, including as part of international PD research consortia.

Pingchan Granule for Motor Symptoms and Non-Motor Symptoms of Parkinson’s Disease: A Randomized, Double-Blind, Placebo-Controlled Study

Background: Pingchan granule (PCG) is a traditional Chinese medicine for treating Parkinson’s disease (PD).

Objective: This study aimed at evaluating the efficacy and safety of PCG for motor and non-motor symptoms of PD.

Methods: In this multicenter, randomized, double-blind, placebo-controlled trial, 292 participants with mild-to-moderate PD were included and followed for 36 weeks (24 week treatment, 12-week follow-up after intervention), randomly assigned at a 1:1 ratio to receive PCG or placebo. The primary outcomes included the severity of motor symptoms assessed by the Unified Parkinson’s disease Rating Scale (UPDRS) part 3 (UPDRS-III) score and the rate of disease progression assessed by the total UPDRS score. Secondary outcomes included non-motor symptoms assessed using the Scale for Outcomes in Parkinson’s Disease-Autonomic (SCOPA-AUT), Parkinson’s disease Sleep Scale (PDSS), 24-item Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating Scale for Anxiety (HAM-A), UPDRS part 2 (UPDRS-II), and 39-item Parkinson’s Disease Questionnaire (PDQ-39) scores. Assessments were done at baseline (T0), 12 weeks (T1), 24 weeks (T2), and 36 weeks (T3).

Results: Generalized estimating equation analyses revealed that the PCG group had significantly better improvement in UPDRS-III score at T1, T2, and T3 [time-by-group interaction, T1: β, −0.92 (95% CI, −1.59–−0.25; p = 0.01); T2: β, −2.08 (95% CI, −2.90–−1.27; p < 0.001); T3: β, −4.54 (95% CI, −5.37–−3.71; p < 0.001))]. The PCG group showed a greater decrease (rate of disease change) in the total UPDRS score between T0 and T2 [−2.23 (95% CI, −2.72–−1.73; p < 0.001) points per week vs. −0.21 (95% CI, −0.80–0.39; p = 0.50) points per week in the placebo group, p < 0.001]. Ameliorations of SCOPA-AUT, PDSS, HAM-D, HAM-A, UPDRS-II, and PDQ-39 scores were also observed.

Conclusion: PCG had a long-lasting and extensive symptomatic efficacy for both motor and non-motor symptoms of PD with good tolerance.

Trial registration: Chinese Clinical Trial Register, ChiCTR-INR-17011949.

Locus Coeruleus Shows a Spatial Pattern of Structural Disintegration in Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) causes a loss of neuromelanin-positive, noradrenergic neurons in the locus coeruleus (LC), which has been implicated in nonmotor dysfunction.

OBJECTIVES

We used "neuromelanin sensitive" magnetic resonance imaging (MRI) to localize structural disintegration in the LC and its association with nonmotor dysfunction in PD.

METHODS

A total of 42 patients with PD and 24 age-matched healthy volunteers underwent magnetization transfer weighted (MTw) MRI of the LC. The contrast-to-noise ratio of the MTw signal (CNR_MTw ) was used as an index of structural LC integrity. We performed slicewise and voxelwise analyses to map spatial patterns of structural disintegration, complemented by principal component analysis (PCA). We also tested for correlations between regional CNR_MTw and severity of nonmotor symptoms.

RESULTS

Mean CNR_MTw of the right LC was reduced in patients relative to controls. Voxelwise and slicewise analyses showed that the attenuation of CNR_MTw was confined to the right mid-caudal LC and linked regional CNR_MTw to nonmotor symptoms. CNR_MTw attenuation in the left mid-caudal LC was associated with the orthostatic drop in systolic blood pressure, whereas CNR_MTw attenuation in the caudal most portion of right LC correlated with apathy ratings. PCA identified a bilateral component that was more weakly expressed in patients. This component was characterized by a gradient in CNR_MTw along the rostro-caudal and dorso-ventral axes of the nucleus. The individual expression score of this component reflected the overall severity of nonmotor symptoms.

CONCLUSION

A spatially heterogeneous disintegration of LC in PD may determine the individual expression of specific nonmotor symptoms such as orthostatic dysregulation or apathy. © 2022 International Parkinson and Movement Disorder Society.

Tele-yoga for the management of Parkinson disease: A safety and feasibility trial

Objectives

Despite current standard treatments, persons with Parkinson disease (PD) still experience motor and non-motor symptoms that impact daily function and quality of life, warranting the investigation of additional interventions. Holistic complementary interventions such as yoga have been shown to be beneficial for persons with PD. However, there are multiple barriers to in-person interventions such as transportation difficulties and disease-related mobility impairments which may be mitigated by digital health applications. Therefore, this study’s purpose was to assess the safety and feasibility of a synchronous tele-yoga intervention for persons with PD.

Methods

Sixteen participants were enrolled in a single group safety and feasibility trial. The entire study was conducted remotely and consisted of a baseline assessment followed by a six-week waiting period, then a second assessment, a six-week tele-yoga intervention period, a post-intervention assessment, a six-week follow-up period, and lastly a follow-up assessment. During the tele-yoga period, participants completed two one-on-one 30-minute tele-yoga sessions weekly for a total of 12 sessions. Primary outcomes included adverse events, adherence, technological challenges, and usability. Secondary outcomes included enjoyment and clinically relevant outcome measures assessing both motor and non-motor symptoms.

Results

No severe adverse events were attributed to the intervention. Retention was 87.5%, assessment session adherence was 100%, and intervention session adherence was 97%. Technological challenges did not impact feasibility. The intervention was usable and enjoyable. While this study was not powered or designed to assess the efficacy of the intervention, preliminary improvements were shown for some of the clinically relevant outcome measures.

Conclusions

Overall, this study showed that the implementation of a synchronous one-on-one tele-yoga intervention was safe, feasible, usable, and enjoyable for persons with PD. Randomized control trials investigating its efficacy should be initiated. The study was registered with ClinicalTrials.gov (NCT04240899, https://clinicaltrials.gov/ct2/show/NCT04240899).

The impact of clinical scales in Parkinson’s disease: a systematic review

Background

Parkinson’s disease is one of the non-curable diseases and occurs by the prominent loss of neurotransmitter (dopamine) in substantia nigra pars compacta (SNpc). The main cause behind this is not yet identified and even its diagnosis is very intricate phase due to non-identified onset symptoms. Despite the fact that PD has been extensively researched over the decades, and various algorithms and strategies for early recognition and avoiding misdiagnosis have been published. The objective of this article is to focus on the current scenario and to explore the involvement of various clinical diagnostic scales in the detection of PD.

Method

An exhaustive literature review is conducted to synthesize the earlier work in this area, and the articles were searched using different keywords like Parkinson disease, motor/non-motor, treatment, diagnosis, scales, PPMI, etc., in all repositories such as Google scholar, Scopus, Elsevier, PubMed and many more. From the year 2017 to 2021, a total of 451 publications were scanned, but only 24 studies were chosen for a review process.

Findings

Mostly as clinical tools, UPDRS and HY scales are commonly used and even there are many other scales which can be helpful in detection of symptoms such as depression, anxiety, sleepiness, apathy, smell, anhedonia, fatigue, pain, etc., that affect the QoL of pateint. The recognition of non-motor manifests is typically very difficult than motor signs.

Conclusion

This study can give the beneficial research paths at an early stage diagnosis by focusing on frequent inspection of daily activities, interactions, and routine, which may also give a plethora of information on status changes, directing self-reformation, and clinical therapy.

Cognitive Influences in Parkinson's Disease Patients and Their Caregivers: Perspectives From an Australian Cohort

Objectives: Cognitive impairment impacts negatively on Parkinson's disease (PD) patient and caregiver quality of life (QoL). We examined cognitive impairment in PD patients and their caregivers to determine if caregiver cognition affected their PD relative. Methods: Validated cognition and clinical outcome measures were assessed in 103 PD patients and 81 caregivers. Results: PD patients showed more cognitive impairment than their carers, with 48.6% having possible Mild Cognitive Impairment (MCI) and 16.5% having PD dementia. Increasing age, male gender, lower education level, various non-motor symptoms and certain therapies, associated with poorer cognition in PD. Eighteen and a half percent of caregivers were found to have MCI, in association with a lower physical and mental QoL. This reflected in lower QoL and mood for the respective PD patients. Conclusion: Impaired cognition and QoL in caregivers was associated with decreased QoL and mood for respective PD patients, suggesting MCI in caregivers is an important consideration for the management of PD.

Prevalence of Burnout Syndrome and other psychiatric disorders among health professionals during the COVID-19 pandemic: A systematic review and meta-analysis protocol

INTRODUCTION

Studies carried out during previous pandemics revealed an increase in the prevalence of Burnout Syndrome and other psychiatric disorders among health professionals. A high prevalence of psychiatric disorders is also observed in some health categories, during the COVID-19 pandemic.

OBJECTIVE

This systematic review/meta-analysis study aims to assess the prevalence of Burnout Syndrome and other psychiatric disorders (depression, anxiety, stress, and insomnia) among health care professionals and other support professionals during the COVID-19 pandemic.

INCLUSION CRITERIA

Observational studies published from December 2019, without language restrictions in which the prevalence of Burnout Syndrome and other psychiatric disorders among health professionals during the COVID-19 pandemic will be assessed.

METHODS

PubMed, Web of Science, Embase, CINAHAL, PsycINFO, LILACS, SCOPUS, and The Cochrane Library will be searched for eligible studies. Two reviewers will independently screen and select studies, assess methodological quality, and extract data. A meta-analysis will be performed, if possible, and the Grading of Recommendations Assessment Development and Evaluation (GRADE).

ETHICS AND DISCLOSURE

This study will use secondary data. Thus, there is no need for submission to the ethics committee. The results of this systematic review will be published in a journal after a peer-review process.

TRIAL REGISTRATION

Systematic review registration number: CRD42020212036.

Symptom dimensions of anxiety in Parkinson's disease: Replication study in a neuropsychiatric patient population

INTRODUCTION

Anxiety disorders occur in approximately one third of people with Parkinson's disease (PD), and have a major impact on patient and caregiver wellbeing. In order to better understand and diagnose anxiety in PD patients, we investigated the generalizability of the results of a previous factor analysis on anxiety symptoms to a sample of PD patients with neuropsychiatric symptoms.

METHODS

In this cross-sectional study, anxiety symptoms were measured with the Beck Anxiety Inventory (BAI) in 123 PD patients who were referred for neuropsychiatric diagnostics and treatment. Subscales of anxiety were analyzed through principal component analysis of BAI items. The associations between BAI subscales and symptoms of motor and cognitive function and depression were assessed through regression analyses.

RESULTS

Similar to the previous factor analysis, we found one psychological (affective) and four somatic subscales of anxiety in the BAI. The affective subscale was the principal component explaining 35.9% of the variance. The scores on the total BAI and the affective subscale were significantly associated with depressive symptoms. In a post-hoc analysis, the affective subscale had equal power as compared to the total BAI in predicting whether or not participants were diagnosed with an anxiety disorder after psychiatric evaluation.

CONCLUSION

In this study, we replicated our previous findings of one affective and multiple somatic subscales of the BAI. The 7-item affective subscale of the BAI shows potential as a screening tool for non-episodic anxiety in PD. However, in clinical practice, we recommend evaluating anxiety symptoms in the context of other PD symptoms, including motor, autonomic, and other (neuro)psychiatric symptoms.

Longitudinal risk factors for developing depressive symptoms in Parkinson's disease

BACKGROUND

Despite the established importance of identifying depression in Parkinson's disease, our understanding of the factors which place the Parkinson's disease patient at future risk of depression is limited.

METHODS

Our sample consisted of 874 patients from two longitudinal cohorts, PPMI and PDBP, with median follow-up durations of 7 and 3 years respectively. Risk factors for depressive symptoms at baseline were determined using logistic regression. A Cox regression model was then used to identify baseline factors that predisposed the non-depressed patient to develop depressive symptoms that were sustained for at least one year, while adjusting for antidepressant use and cognitive impairment. Common predictors between the two cohorts were identified with a random-effects meta-analysis.

RESULTS

We found in our analyses that the majority of baseline non-depressed patients would develop sustained depressive symptoms at least once during the course of the study. Probable REM sleep behavior disorder (pRBD), age, duration of diagnosis, impairment in daily activities, mild constipation, and antidepressant use were among the baseline risk factors for depression in either cohort. Our Cox regression model indicated that pRBD, impairment in daily activities, hyposmia, and mild constipation could serve as longitudinal predictors of sustained depressive symptoms.

CONCLUSIONS

We identified several potential risk factors to aid physicians in the early detection of depression in Parkinson's disease patients. Our findings also underline the importance of adjusting for multiple covariates when analyzing risk factors for depression.

Cognition and motor learning in a Parkinson's disease cohort: importance of recall in episodic memory

Impaired motor learning in individuals with Parkinson's disease is often attributed to deficits in executive function, which serves as an important cognitive process supporting motor learning. However, less is known about the role of other cognitive domains and its association with motor learning in Parkinson's disease. The objective of this study was to investigate the associations between motor learning and multiple domains of cognitive performance in individuals with Parkinson's disease. Twenty-nine participants with Parkinson's disease received comprehensive neuropsychological testing, followed by practice of a bimanual finger sequence task. A retention test of the finger sequence task was completed 24 h later. Hierarchical linear regressions were used to examine the associations between motor learning (acquisition rate and retention) and cognitive performance in five specific cognitive domains, while controlling for age, sex, and years of Parkinson's disease diagnosis. We found that a higher acquisition rate was associated with better episodic memory, specifically better recall in visual episodic memory, in individuals with Parkinson's disease. No significant associations were observed between retention and cognitive performance in any domains. The association between motor acquisition and episodic memory indicates an increased dependency on episodic memory as a potential compensatory cognitive strategy used by individuals with Parkinson's disease during motor learning.

Disease-inclusive exercise classes improve physical fitness and reduce depressive symptoms in individuals with and without Parkinson's disease-A feasibility study

BACKGROUND AND PURPOSE

Exercise is an adjunctive treatment in the management of Parkinson's disease (PD), but barriers such as health status, fear of overexertion, and lack of transportation to the location prevent regular exercise participation. Disease-inclusive exercise classes may offer an opportunity to make exercise more accessible for older adults with and without diseases. However, the efficacy of such heterogenous exercise classes is still widely unknown. Therefore, it was the aim of this study to analyze the feasibility of disease-inclusive exercise classes in older adults with and without PD.

METHODS

Twenty-one older adults (healthy older adults (HOA): n = 13; PD: n = 8) completed an 8-week multimodal exercise intervention in supervised group sessions. Exercise classes lasted 60 min with the goal of two participations a week. We assessed physical fitness (timed up and go test [TUG], 6-minute walking test [6MWT], single leg stance), depressive symptoms and cognitive functions, and we determined growth factors (BDNF & IGF-1) before and after the intervention to determine the effects and by that, the feasibility of a disease-inclusive exercise program. Repeated measures ANOVA were used to establish changes.

RESULTS

TUG and 6MWT improved significantly after the training in both HOA (p = .008; p < .001) and individuals with PD (p = .024; p < .001). Furthermore, individuals with PD increased single leg stance left (p = .003). HOA (p = .003) and individuals with PD (p = .001) decreased their depressive symptoms between pre- and post-test significantly. Whereas growth factors tended to improve, no differences in cognitive functions were revealed.

CONCLUSION

Disease-inclusive multicomponent exercise improved physical functions and reduced depressive symptoms independent of health status. This should encourage exercise providers, researchers, and clinicians to further investigate disease-inclusive exercise, because they may have an important social impact and represent a more inclusive society.

Risk Factors for Apathy in Polish Patients with Parkinson's Disease

Apathy, a feeling of indifference or a general lack of interest and motivation to engage in activity, is one of the most common neuropsychiatric symptoms in Parkinson’s disease (PD). The large variation in prevalence and the underlying pathophysiological processes remain unclear due to heterogeneous PD populations. The purpose of this study was to identify risk factors for apathy, the modification or treatment of which may be clinically relevant and improve quality of life and caregiver burden for patients with Parkinson’s disease. Caucasian subjects with Parkinson’s disease were included in the study. Baseline demographics, neurological deficit, medications taken, cognitive and neuropsychiatric status, and the polymorphisms in the brain-derived neurotrophic factor gene were assessed. Apathy was diagnosed in 53 (50.5%) patients. They were less educated (OR 0.76 CI 0.64–0.89; p = 0.001), more frequently depressed (OR 1.08 CI 1.01–1.15; p = 0.018), and less frequently treated with inhibitors of monoamine oxidase-B (MAOB-I) (OR 0.07 CI 0.01–0.69; p = 0.023). Although apathetic patients were more likely to carry the Met/Met genotype, differences in the brain-derived neurotrophic factor BDNF rs6265 polymorphism between apathetic and non-apathetic PD patients were not statistically significant in multivariate analysis. Some risk factors for apathy may be clinically modifiable. Further studies are needed to assess whether modeling modifiable apathy risk factors will affect the prevalence of this neuropsychiatric symptom in patients with Parkinson’s disease.

Sleep apnea syndrome and subthalamic stimulation in Parkinson's disease

OBJECTIVES

Τhe association between Parkinson's disease (PD) and sleep apnea syndrome (SAS) is not fully elucidated and very few studies reported on SAS outcome after deep brain stimulation (DBS). Here, we compare the clinical profile of PD patients with and without SAS and assess, for the first time, the value of pre-DBS SAS as predictor of post-DBS outcome in PD.

METHODS

Fifty patients were grouped into PD with SAS (PD-SAS+,n = 22) and without (PD-SAS-,n = 28), based on the Apnea-Hypopnea-Index (AHI≥5) in polysomnography. We used novel multivariate statistical models to compare pre-DBS profiles and assess post-DBS motor, non-motor and quality of life (QoL) changes in both groups.

RESULTS

In the entire cohort, 44% of patients had at least mild SAS (AHI≥5), while 22% had at least moderate (AHI≥15). Mean AHI was 11/h (NREM-AHI = 10.2/h and REM-AHI = 13.5/h). The two groups had equal demographics and PD characteristics, and did not differ in respect to unified Parkinson's disease rating scale (UPDRS)-II_OFF, Body-Mass-Index, polysomnographic features, RBD, depression, sleepiness and QoL scores. The PD-SAS+ group had significantly higher scores in UPDRS-III_OFF (41.1 ± 17.7 vs. 30.9 ± 11.7,p < 0.05) compared to PD-SAS- group. The groups did not differ in respect to post-DBS change in UPDRS-II, UPDRS-III, Epworth sleepiness scale, Hamilton depression rating scale and PDQ39 scores. Positive airway pressure therapy had no impact on post-DBS outcome.

CONCLUSIONS

In patients with PD and candidates for DBS, the presence of SAS is associated with increased motor signs, but not with a specific non-motor, QoL or sleep-wake profile. The presence of SAS prior to STN-DBS is not associated with worse outcome after surgery.

A bidirectional relationship between anxiety, depression and gastrointestinal symptoms in Parkinson's disease

•

Gastrointestinal (GI) and mood symptoms are common in Parkinson’s disease.

•

Depression and anxiety are bidirectional risk factors for GI distress.

•

Association between GI and mood symptoms may reflect disrupted Gut-Brain axis.

Introduction

Anxiety, depression and gastrointestinal (GI) symptoms are common non-motor symptoms in Parkinson’s disease (PD). Past studies provide evidence of a disrupted microbiome-gut-brain axis in PD, which is associated with certain motor and non-motor symptoms in PD. Additionally, there is evidence of a bidirectional association between mental health and gut health among individuals with GI disorders. The current study examined the bidirectional association between GI symptoms and anxiety/depression among individuals newly diagnosed with PD.

Methods

We conducted a secondary data analysis of the Parkinson’s Progression Markers Initiative. This included 487 individuals newly diagnosed with PD and followed for up to 5 years. Participants completed questionnaires of anxiety, depression and GI symptoms (Scales for Outcomes in Parkinson’s Disease Autonomic; SCOPA-AUT) at each annual visit. Multilevel models examined the bidirectional-lagged relationship between GI symptoms and anxiety/depression.

Results

Models provided evidence for a bidirectional relationship between GI symptoms and anxiety/depression. Specifically, more severe GI symptoms predicted more severe anxious/depressive symptoms within the same year and at the following year. There was also evidence of the inverse directionality, meaning that more severe anxiety/depression predicted more severe GI symptoms concurrently and in the following year.

Discussion

Findings provide preliminary evidence for a cyclical relationship among gut health and mental health in PD. Future studies are needed to examine if the microbiome-gut-brain axis plays a mechanistic role.

Adverse effects of hypertension, supine hypertension, and perivascular space on cognition and motor function in PD

Dilated perivascular space (dPVS) has recently been reported as a biomarker for cognitive impairment in Parkinson’s disease (PD). However, comprehensive interrelationships between various clinical risk factors, dPVS, white-matter hyperintensities (WMH), cognition, and motor function in PD have not been studied yet. The purpose of this study was to test whether dPVS might mediate the effect of clinical risk factors on WMH, cognition, and motor symptoms in PD patients. A total of 154 PD patients were assessed for vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), autonomic dysfunction (orthostatic hypotension and supine hypertension [SH]), APOE ε4 genotype, rapid eye movement sleep-behavior disorder, motor symptoms, and cognition status. The degree of dPVS was evaluated in the basal ganglia (BG) and white matter using a 5-point visual scale. Periventricular, deep, and total WMH severity was also assessed. Path analysis was performed to evaluate the associations of these clinical factors and imaging markers with cognitive status and motor symptoms. Hypertension and SH were significantly associated with more severe BGdPVS, which was further associated with higher total WMH, consequently leading to lower cognitive status. More severe BGdPVS was also associated with worse motor symptoms, but without mediation of total WMH. Similar associations were seen when using periventricular WMH as a variable, but not when using deep WMH as a variable. In conclusion, BGdPVS mediates the effect of hypertension and SH on cognitive impairment via total and periventricular WMH, while being directly associated with more severe motor symptoms.

A Multisensory Deficit in the Perception of Pleasantness in Parkinson's Disease

BACKGROUND

There is growing interest in non-motor symptoms in Parkinson's disease (PD), due to the impact on quality of life. Anhedonia, the inability to experience joy and lust, has a prevalence of up to 46% in PD. The perception of pleasantness of an odor is reduced in anhedonia without PD. We previously showed a reduced hedonic olfactory perception in PD, i.e., patients evaluated odors as less pleasant or unpleasant compared to controls. This deficit correlated with anhedonia.

OBJECTIVE

We aimed to confirm these findings. Moreover, we hypothesized that the perception of pleasantness in PD is affected on a multisensory level and correlates with anhedonia. Therefore, we assessed olfactory, visual and acoustic evaluation of pleasantness in PD and healthy individuals.

METHODS

Participants had to rate the pleasantness of 22 odors, pictures, and sounds on a nine-point Likert scale. Depression, anhedonia, and apathy were assessed by means of questionnaires. Results of the pleasantness-rating were compared between groups and correlated to scores of the questionnaires.

RESULTS

In particular pleasant and unpleasant stimuli across all three modalities are perceived less intense in PD, suggesting that a reduced range of perception of pleasantness is a multisensory phenomenon. However, only a reduction of visual hedonic perception correlated with anhedonia in PD. A correlation of reduced perception of pleasantness with apathy or depression was not present.

CONCLUSION

We provide evidence for a multisensory deficit in the perception of pleasantness. Further studies should delineate the underlying neural circuity and the diagnostic value to detect neuropsychiatric symptoms in PD.

Assessment of Affective-Behavioral States in Parkinson's Disease Patients: Towards a New Screening Tool

BACKGROUND

Assessment of affective-behavioral states in patients with Parkinson's disease (PD) undergoing deep brain stimulation (DBS) is essential.

OBJECTIVE

To analyze well-established questionnaires as a pilot-study with the long term aim to develop a screening tool evaluating affective-behavioral dysfunction, including depression, anxiety, apathy, mania, and impulse control disorders, in PD patients screened for DBS.

METHODS

Two hundred ninety-seven inpatients with PD underwent standardized neuropsychiatric testing including German versions of Beck Depression Inventory-II, Hospital Anxiety and Depression Scale, Apathy Evaluation Scale, Self-Report Manic Inventory, and Questionnaire for Impulsive-Compulsive Disorders in PD-Rating Scale, to assess appropriateness for DBS. Statistical item reduction was based on exploratory factor analysis, Cronbach's alpha, item-total correlations, item difficulty, and inter-item correlations. Confirmatory factor analysis was conducted to assess factorial validity. An expert rating was performed to identify clinically relevant items in the context of PD and DBS, to maintain content validity. We compared the shortened subscales with the original questionnaires using correlations. To determine cutoff points, receiver operating characteristics analysis was performed.

RESULTS

The items of the initial questionnaires were reduced from 129 to 38 items. Results of confirmatory factor analyses supported the validity of the shortened pool. It demonstrated high internal consistency (Cronbach's alpha = 0.72-0.83 across subscales), and the individual subscales were correlated with the corresponding original scales (rs = 0.84-0.95). Sensitivities and specificities exceeded 0.7.

CONCLUSION

The shortened item pool, including 38 items, provides a good basis for the development of a screening tool, capturing affective-behavioral symptoms in PD patients before DBS implantation. Confirmation of the validity of such a screening tool in an independent sample of PD patients is warranted.

The Anterior Attentional-Intentional System in Patients with Parkinson's Disease-A Pilot and Feasibility Study

(1) Background: This study compared anterior attentional–intentional system performance between three groups: Parkinson’s disease (PD) patients with normal cognition (PD-NC), with mild cognitive impairment (PD-MCI), and a comparison group (CG). It also evaluated the feasibility of the recruitment and study procedures; (2) Methods: From 45 participants recruited, 39 were allocated (mean age 65.31; 43.59% men) to PD-NC, PD-MCI and CG (13 per group). To assess attention, we used three tasks from the ROtman–Baycrest Battery for Investigating Attention: Simple Reaction time (RT), Choice RT, and Prepare RT. We conducted a mixed-model analysis of variance with a 3 (groups) × 4 (tasks) design to compare reaction times; (3) Results: PD-MCI had slower reaction times than PD-NC (p = 0.028) and the CG (p = 0.052); there was no difference between PD-NC and CG. PD-MCI might perform worse on monitoring tasks than PD-NC, Z = −1.68, p = 0.092. Nearly half the volunteers from the CG and 87% of all eligible patients were enrolled in the study and completed all neuropsychological procedures; (4) Conclusions: General cognitive decline appears related to partial deficits in energization and tends to impair attentional monitoring. Furthermore, PD-NC exhibited similar reaction times to the CG. Results from the feasibility study contributed to the definitive study.

Frequency of suicidal ideation and associated clinical features in Lewy body dementia

INTRODUCTION

Neuropsychiatric disturbance is common in individuals with Lewy body dementia (LBD). Despite this, there is minimal research regarding suicide risks in this population.

METHODS

This study was a retrospective review of a prospectively-collected database at a tertiary movement disorders clinic. Database participants with an LBD diagnosis at their most recent visit and at least one complete Beck Depression Inventory-II (BDI-II) were included. Additional measures included demographics and measures of cognition, psychiatric symptoms, motor function, and the Parkinson Disease Questionnaire-39. The frequency of suicidal ideation was assessed using question 9 of the BDI-II. Features associated with a BDI-II score greater than zero were assessed using logistic regression.

RESULTS

The database included 95 individuals with LBD and at least one BDI-II (visit years 2010-2020). Most participants were older men who identified as white. Eighteen individuals (18.9%; 95% CI 12.3%-28.0%) reported thoughts of killing themselves without an intent to carry them out (BDI-II = 1). No participants reported a desire or plan to kill themselves. The presence of SI was associated with measures of depression, anxiety, and emotional well-being, but not with demographics, measures of disease severity, or other psychiatric concerns.

CONCLUSION

These findings emphasize the importance of routine screening for psychiatric symptoms in LBD and intervention when such concerns are identified. Interventions could include pharmacologic (e.g. depression treatment) and non-pharmacologic (e.g. firearm screening) approaches. More research is needed to assess suicidal ideation and suicide risks in large and more diverse LBD populations. Prospective studies should include measures of additional potential contributors to suicidality.

Study on the Regulation Effect of Optogenetic Technology on LFP of the Basal Ganglia Nucleus in Rotenone-Treated Rats

Background

Parkinson's disease (PD) is a common neurological degenerative disease that cannot be completely cured, although drugs can improve or alleviate its symptoms. Optogenetic technology, which stimulates or inhibits neurons with excellent spatial and temporal resolution, provides a new idea and approach for the precise treatment of Parkinson's disease. However, the neural mechanism of photogenetic regulation remains unclear.

Objective

In this paper, we want to study the nonlinear features of EEG signals in the striatum and globus pallidus through optogenetic stimulation of the substantia nigra compact part.

Methods

Rotenone was injected stereotactically into the substantia nigra compact area and ventral tegmental area of SD rats to construct rotenone-treated rats. Then, for the optogenetic manipulation, we injected adeno-associated virus expressing channelrhodopsin to stimulate the globus pallidus and the striatum with a 1 mW blue light and collected LFP signals before, during, and after light stimulation. Finally, the collected LFP signals were analyzed by using nonlinear dynamic algorithms.

Results

After observing the behavior and brain morphology, 16 models were finally determined to be successful. LFP results showed that approximate entropy and fractal dimension of rats in the control group were significantly greater than those in the experimental group after light treatment (p < 0.05). The LFP nonlinear features in the globus pallidus and striatum of rotenone-treated rats showed significant statistical differences before and after light stimulation (p < 0.05).

Conclusion

Optogenetic technology can regulate the characteristic value of LFP signals in rotenone-treated rats to a certain extent. Approximate entropy and fractal dimension algorithm can be used as an effective index to study LFP changes in rotenone-treated rats.

Mood Disorders and Anxiety in Parkinson's Disease: Current Concepts

Mood disorders and anxiety significantly impact the prognosis and disease course of Parkinson's disease. Non-motor symptoms of Parkinson's disease such as apathy, anhedonia, and fatigue overlap with diagnostic criteria for anxiety and depression, thus making accurate diagnosis of mood disorders in Parkinson's disease patients difficult. Furthermore, treatment options for mood disorders can produce motor complications leading to poor adherence and impaired quality of life in Parkinson's disease patients. This review aims to clarify the current state of diagnostic and treatment options pertaining to anxiety and mood disorders in Parkinson's disease. It explores both the pharmacologic and non-pharmacologic treatment modalities for various mood disorders in comorbid Parkinson's disease with a brief discussion of the future outlook of the field given the current state of the literature.

Increased Added Sugar Consumption Is Common in Parkinson's Disease

Objectives: There is limited information about the dietary habits of patients with Parkinson's Disease (PD), or associations of diet with clinical PD features. We report on nutritional intake in an Australian PD cohort.

Methods: 103 PD patients and 81 healthy controls (HCs) completed a validated, semi-quantitative food frequency questionnaire. Food and nutrient intake was quantified, with consideration of micronutrients and macronutrients (energy, protein, carbohydrate, fat, fibre, and added sugar). Participants also completed PD-validated non-motor symptom questionnaires to determine any relationships between dietary intake and clinical disease features.

Results: Mean daily energy intake did not differ considerably between PD patients and HCs (11,131 kJ/day vs. 10,188 kJ/day, p = 0.241). However, PD patients reported greater total carbohydrate intake (279 g/day vs. 232 g/day, p = 0.034). This was largely attributable to increased daily sugar intake (153 g/day vs. 119 g/day, p = 0.003) and in particular free sugars (61 g/day vs. 41 g/day, p = 0.001). PD patients who (1) experienced chronic pain, (2) were depressed, or (3) reported an impulse control disorder, consumed more total sugars than HCs (all p < 0.05). Increased sugar consumption was associated with an increase in non-motor symptoms, including poorer quality of life, increased constipation severity and greater daily levodopa dose requirement.

Conclusions: We provide clinically important insights into the dietary habits of PD patients that may inform simple dietary modifications that could alleviate disease symptoms and severity. The results of this study support clinician led promotion of healthy eating and careful management of patient nutrition as part of routine care.

Sexual Activity and Depressive Symptoms in Later Life: Insights from Jamaica

Objectives: To explore relationships between sexual activity and depressive symptoms in urology and gynecology out-patients aged 50 years and older.Methods: Depressive symptoms were assessed using Zung Self-Rating Depression Scale. Sexual activity was measured by interviewer-administered questionnaires assessing relationships, intimacy and sexual function (N = 557). Aging and sexual activity were discussed in focus groups (N = 52).Results: More men (51%) than women (41%) reported engagement in sexual intercourse and approximately 40% of men reported sexual activities in the past 4 weeks. The mean number of sex-related complaints per woman was 1.5 (Standard Deviation, 1.2). Approximately four of every ten men reported difficulty with erectile function. Men placed high value on sexual intercourse while women also embraced other activities. After controlling for demographic and health variables, men who reported sexual activity in the past 4 weeks had depressive symptom scores approximately five points lower than those who reported no sexual activity. Each additional sexual complaint was associated with a two-point increase in depressive symptoms scores in women.Conclusions: Higher depressive symptom scores are associated with reduced sexual activity in men and increased sexual complaints in women. Sexual activities remain important for older adults, despite declining sexual function and men place higher value on sexual intercourse than women.Clinical implications: Mental health assessments and sexual activity history should be included in routine healthcare consultations in persons 50 and over.

Mood in Parkinson's disease: From early- to late-stage disease

BACKGROUND

Although depression is known to be frequent in Parkinson's disease (PD), it is unclear how mood can change and/or impact on patient's quality of life (QoL) over time. Our aim was to analyze the frequency of depression, mood related factors and the contribution of mood to a patient's QoL perception in regard to disease duration.

METHODS

PD patients recruited from the COPPADIS cohort from January 2016 to November 2017 were included in this cross-sectional study. Three groups were defined: <5 years (Group A); from 5 to <10 years (Group B); ≥10 years (Group C). Analysis with well-planned linear regression models was conducted to determine how different factors contribute to mood (Beck Depression Inventory-II [BDI-II] as dependent variable), to health-related QoL (39-item Parkinson's Disease Questionnaire [PDQ-39SI] as dependent variable) and to global QoL (European Health Interview Survey - Quality of Life Eight-Item Index [EUROHIS-QOL8] as dependent variable).

RESULTS

Six hundred and sixty-three PD patients (62.6 ± 8.9 years old, 59.6% males) were included: Group A, 50.1% (n = 332); Group B, 33.3% (n = 221) and Group C, 16.6% (n = 110). There were no differences between the three groups in terms of the frequency of depressive symptoms nor the frequency of depression type (major vs. minor vs. subthreshold) (p = 0.729). However, the unique percent variance of PDQ-39SI and EUROHIS-QOL8 explained by BDI-II total score was 2 (23.7%) and threefold (26.9%), respectively, in Group C compared to the other two groups. EUROHIS-QOL8 total score provided the highest unique contribution to mood (16.8%).

CONCLUSIONS

Although depression-type frequency does not appear to change over time in PD; the contribution of mood on QoL perception is greater in patients with longer disease duration.

A Validation Study of PROMIS Sleep Disturbance (PROMIS-SD) and Sleep Related Impairment (PROMIS-SRI) Item Banks in Individuals with Idiopathic Parkinson's Disease and Matched Controls

BACKGROUND

Parkinson's disease (PD) is associated with sleep disturbance (SD) and sleep-related impairment (SRI). Validation of self-report measures of these problems is needed in PD. The Patient-Reported Outcomes Measurement Information System (PROMIS) includes tools that assess these problems (PROMIS-SD and PROMIS-SRI, respectively).

OBJECTIVE

This study aimed to further validate these measures in individuals with PD and matched controls.

METHODS

Individuals with early-stage PD (n=50) and matched controls (n=48) completed measures of SD including the PROMIS-SD, Pittsburgh Sleep Quality Index (PSQI), and Insomnia Severity Index (ISI). They also completed measures of daytime impairment including the PROMIS-SRI, Epworth Sleepiness Scale, State-Trait Anxiety Inventory, Beck Depression Inventory 2nd edition, and Parkinson's Disease Questionnaire-39. Internal consistency for the PROMIS measures were assessed using Cronbach's α coefficient and item-total correlations in the total sample. Convergent and divergent validity of the PROMIS item banks were assessed using Spearman correlations.

RESULTS

The PROMIS item banks had excellent internal consistency (α>0.94). Supporting convergent validity, the PROMIS-SD had strong correlations with other measures of SD (ρ>0.68, for PSQI and ISI) and the PROMIS-SRI had moderate to strong correlations with all measures of daytime impairment (ρ=0.41-0.72). Supporting divergent validity within the PD group, the PROMIS-SD correlated more strongly with SRI than with the Parkinson's Disease Questionnaire total score, a metric of PD related impairment.

CONCLUSION

In middle-aged and older adults, with and without early-stage PD, the PROMIS-SD and PROMIS-SRI are reliable and valid measures of SD and SRI, respectively.

A collaborative approach to exercise provision for people with Parkinson's - a feasibility and acceptability study of the PDConnect programme [version 2; peer review: 2 approved]

BACKGROUND

Exercise has been shown to be beneficial for people with Parkinson's (PwP), slowing the rate of decline of motor and nonmotor symptoms, with emerging evidence associating exercise with a neuroprotective effect. Current exercise provision is time-limited, and delivered in the absence of strategies to support long-term adherence to exercise. With a growing Parkinson's population, there is a need to develop long-term sustainable approaches to exercise delivery. The primary aim of this study is to assess the feasibility and acceptability of a multicomponent intervention (PDConnect) aimed at promoting physical activity, and self-management for PwP.

METHODS

A convergent fixed parallel mixed methods design study will be undertaken. The study aims to recruit 30 PwP, who will be randomly allocated into two groups: (i) the usual care group will receive physiotherapy once a week for six weeks delivered via Microsoft Teams. (ii) The PDConnect group will receive physiotherapy once a week for six weeks which combines exercise, education and behaviour change interventions delivered by NHS Parkinson's specialist physiotherapists via Microsoft Teams. This will be followed by 12 weekly sessions of group exercise delivered on Microsoft Teams by fitness instructors specially trained in Parkinson's. Participants will be then contacted by the fitness instructors once per month for three months by video conferencing to support exercise engagement. Primary feasibility data will be collected during the study, with acceptability assessed via semi-structured interviews at the end. Secondary outcomes encompassing motor, non-motor and health and well-being measures will be assessed at baseline, at six, 18, and 30 weeks.

DISCUSSION

This pilot study will establish whether PDConnect is feasible and acceptable to PwP. This will provide a platform for a larger evaluation to assess the effectiveness of PDConnect at increasing exercise participation and self-management within the Parkinson's Community.

TRIAL REGISTRATION

Registered on ISRCTN (ISRCTN11672329, 4th June 2020).

Anxiety in Parkinson's Disease: Correlation with Depression and Quality of Life

Introduction  Anxiety is common in patients with Parkinson's disease (PD). Its prevalence ranges from 20 to 40% but despite that, the high prevalence anxiety in PD is often undiagnosed and untreated. This research was aimed to study the pattern of anxiety with regard to its prevalence and risk factors and to establish the association of anxiety with depression and quality of life (QOL) in patients with PD. Methods  A total of 105 patients with PD were prospectively observed. Demographic and clinical variables were recorded and patients were assessed for anxiety (the Parkinson anxiety scale [PAS]), depression (geriatric depression scale [GDS]), and QOL (Parkinson's Disease Questionnaire-39 [PDQ-39]). Multiple forward logistic regression analysis was done for parameters showing association with anxiety. Pearson's correlation was used to calculate the strength of association of depression and QOL with anxiety. Results  Anxiety was present in 56 PD patients (53.3%). Episodic anxiety was noted in 50%, avoidance behavior in 35%, and persistent anxiety in 15% of these patients. There was significant association of anxiety with duration of disease ( p = 0.001), severity ( p < 0.005), levodopa equivalent dose (LED; p = 0.001), and tremor phenotype of PD ( p = 0.004). Anxiety coexisted with depression in 50 patients (79.4%), which was statistically significant in our cohort ( p = 0.001). There was significant linear relationship between the PAS and PDQ-39. Conclusion  Anxiety exerts a negative impact on the QOL as revealed by proportionately worsening PDQ-39 and PAS scores. Screening for anxiety will allow efficient delivery of support and treatment to patients with PD and their families.

Towards optimising experimental quantification of persistent pain in Parkinson's disease using psychophysical testing

People with Parkinson's disease (PD) may live for multiple decades after diagnosis. Ensuring that effective healthcare provision is received across the range of symptoms experienced is vital to the individual's wellbeing and quality of life. As well as the hallmark motor symptoms, PD patients may also suffer from non-motor symptoms including persistent pain. This type of pain (lasting more than 3 months) is inconsistently described and poorly understood, resulting in limited treatment options. Evidence-based pain remedies are coming to the fore but therapeutic strategies that offer an improved analgesic profile remain an unmet clinical need. Since the ability to establish a link between the neurodegenerative changes that underlie PD and those that underlie maladaptive pain processing leading to persistent pain could illuminate mechanisms or risk factors of disease initiation, progression and maintenance, we evaluated the latest research literature seeking to identify causal factors underlying persistent pain in PD through experimental quantification. The majority of previous studies aimed to identify neurobiological alterations that could provide a biomarker for pain/pain phenotype, in PD cohorts. However heterogeneity of patient cohorts, result outcomes and methodology between human psychophysics studies overwhelmingly leads to inconclusive and equivocal evidence. Here we discuss refinement of pain-PD paradigms in order that future studies may enhance confidence in the validity of observed effect sizes while also aiding comparability through standardisation. Encouragingly, as the field moves towards cross-study comparison of data in order to more reliably reveal mechanisms underlying dysfunctional pain processing, the potential for better-targeted treatment and management is high.

Distinct neural circuits are associated with subclinical neuropsychiatric symptoms in Parkinson's disease

BACKGROUND

Parkinson's disease (PD) can present with neuropsychiatric symptoms (here, anxiety, depression, and apathy) at any stage of the disease. We investigated the neural correlates of subclinical neuropsychiatric symptoms in relation to motor and cognitive symptoms in a high-functioning PD cohort.

METHODS

Brain morphometry of the cognitively intact, early-stage (Hoehn & Yahr 2) PD group (n = 48) was compared to matched controls (n = 37). Whole-brain, pairwise, resting-state functional connectivity measures were correlated with neuropsychiatric symptom, motor exam, and global cognitive scores of the PD group.

RESULTS

Factor analysis of highly collinear anxiety, depression, and apathy scores revealed a single principal component (i.e., composite neuropsychiatric symptom score) explaining 71.6% of variance. There was no collinearity between the neuropsychiatric, motor, and cognitive scores. Compared to controls, PD group showed only subcortical changes including amygdala and nucleus accumbens atrophy, and greater pallidal volume. Reduced functional connectivity in the limbic cortical-striatal circuits and increased functional connectivity between the cerebellum and occipito-temporal regions were associated with a more impaired neuropsychiatric profile. This functional connectivity pattern was distinct from those associated with motor deficits and global cognitive functioning. The individual components of the neuropsychiatric symptoms also exhibited unique connectivity patterns.

LIMITATIONS

Patients were scanned in "on-medication" state only and a control group with similar neuropsychiatric symptoms was not included.

CONCLUSION

Abnormal functional connectivity of distinct neural circuits is present even at the subclinical stage of neuropsychiatric symptoms in PD. Neuropsychiatric phenotyping is important and may facilitate early interventions to "reorganize" these circuits and delay/prevent clinical symptom onset.

Neuropsychiatric Symptoms Are Associated with Dementia in Parkinson's Disease but Not Predictive of it

Background

Neuropsychiatric symptoms in Parkinson's disease (PD) may increase dementia (PDD) risk. The predictive value of these symptoms, however, has not been compared to clinical and demographic predictors of future PDD.

Objectives

Determine if neuropsychiatric symptoms are useful markers of PDD risk.

Methods

328 PD participants completed baseline neuropsychiatric and MDS-Task Force-Level II assessments. Of these, 202 non-demented individuals were followed-up over a four-years period to detect conversion to PDD; 51 developed PDD. ROC analysis tested associations between baseline neuropsychiatric symptoms and future PDD. The probability of developing PDD was also modeled as a function of neuropsychiatric inventory (NPI)-total score, PD Questionnaire (PDQ)-hallucinations, PDQ-anxiety, and contrasted to cognitive ability, age, and motor function. Leave-one-out information criterion was used to evaluate which models provided useful information when predicting future PDD.

Results

The PDD group experienced greater levels of neuropsychiatric symptoms compared to the non-PDD groups at baseline. Few differences were found between the PD-MCI and PD-N groups. Six neuropsychiatric measures were significantly, but weakly, associated with future PDD. The strongest was NPI-total score: AUC = 0.66 [0.57-0.75]. There was, however, no evidence it contained useful out-of-sample predictive information of future PDD (delta ELPD = 1.8 (SD 2.5)); Similar results held for PDQ-hallucinations and PDQ-anxiety. In contrast, cognitive ability (delta ELPD = 36 (SD 8)) and age (delta ELPD = 11 (SD 5)) provided useful predictive information of future PDD.

Conclusions

Cognitive ability and age strongly out-performed neuropsychiatric measures as markers of developing PDD within 4 years. Therefore, neuropsychiatric symptoms do not appear to be useful markers of PDD risk.

Non-motor complications in late stage Parkinson's disease: recognition, management and unmet needs

Introduction: The burden of non-motor symptoms (NMS) is a major determinant of health-related quality of life in Parkinson's disease (PD), particularly at its late stage.Areas covered: The late stage is usually defined as the period from unstable advanced to the palliative stage, characterized by a combination of emerging treatment-resistant axial motor symptoms (freezing of gait, postural instability, falls and dysphagia), as well as both non-dopaminergic and dopaminergic NMS: cognitive decline, neuropsychiatric symptoms, aspects of dysautonomia, pain and sleep disturbances (insomnia and excessive day-time sleepiness). Here, the authors summarize the current knowledge on NMS dominating the late stage of PD and propose a pragmatic and clinically focused approach for their recognition and treatment.Expert opinion: The NMS progression pattern is complex and remains under-researched. While dopamine-dependent NMS may improve with dopamine replacement therapy, non-dopamine dependent NMS worsen progressively and culminate at the late stages of PD. Furthermore, some PD specific features could interact negatively with other comorbidities, multiple medication use and frailty - the evaluation of these aspects is important in the creation of personalized management plans in the late stage of PD.

Stopwatch training improves cognitive functions in patients with Parkinson's disease

Parkinson's disease (PD) impairs various cognitive functions, including time perception. Dysfunctional time perception in PD is poorly understood, and no study has investigated the rehabilitation of time perception in patients with PD. We aimed to induce the recovery of time perception in PD patients and investigated the potential relationship between recovery and cognitive functions/domains other than time perception. Sixty patients with PD (27 females) and 20 healthy controls (10 females) were recruited. The participants underwent a feedback training protocol for 4 weeks to improve the accuracy of subjective spatial distance or time duration using a ruler or stopwatch, respectively. They participated in three tests at weekly intervals, each comprising 10 types of cognitive tasks and assessments. After duration feedback training for 1 month, performance on the Go/No-go task, Stroop task, and impulsivity assessment improved in patients with PD, while no effect was observed after distance feedback training. Additionally, the effect of training on duration production correlated with extended reaction time and improved accuracy in the Go/No-go and Stroop tasks. These findings suggest that time perception is functionally linked to inhibitory systems. If the feedback training protocol can modulate and maintain time perception, it may improve various cognitive/psychiatric functions in patients with PD. It may also be useful in the treatment of diseases other than PD that cause dysfunctions in temporal processing.

Premotor Parkinson's disease: Overview of clinical symptoms and current diagnostic methods

Parkinson's disease (PD) is characterized by typical motor symptoms. However, recent studies show several non-motor features that may precede the development of the motor symptoms of PD. The best known premotor symptoms include hyposmia, REM sleep behavior disorder (RBD), constipation, and depression; other symptoms are excessive daytime somnolence, orthostatic hypotension and symptomatic hypotension, erectile or urinary dysfunction, musculoskeletal symptoms, pain, and global cognitive deficit. In this review, we summarize currently available diagnostic methods for these symptoms. We also briefly summarize neuroimaging, polyneuropathy, peripheral markers, and cerebrospinal fluid biomarkers that may be used in the early diagnosis of PD.

Effort-Based Decision-Making for Exercise in People with Parkinson's Disease

BACKGROUND

People with Parkinson's disease (PwPD) are less active than their age-matched peers. Non-motor symptoms, specifically, deficient motivation, may influence decision-making for exercise due to the impaired mesolimbic dopaminergic pathway.

OBJECTIVE

The purpose of this study was to determine if effort-based decision-making for physical effort was different in PwPD compared to healthy controls. We sought to determine the relationship between effort-based decision making for exercise and a discrete motor task as well as the impact of components of motivation on decision-making for physical effort in PwPD.

METHODS

An effort-based decision-making paradigm using a discrete motor task (button pressing) and a continuous exercise task (cycling) was implemented in 32 PwPD and 23 healthy controls. Components of motivation were measured using the Apathy Scale and the Temporal Experience of Pleasure Scale- Anticipatory Pleasure scale.

RESULTS

The presence of Parkinson's disease (PD) did not moderate decisions for either physical effort task. There was a moderate correlation between decisions for both tasks, within each group. The anticipation of pleasure and apathy were predictors of decisions for both physical effort tasks in PwPD, but not in healthy controls.

CONCLUSION

PwPD responded similarly to effort and reward valuations compared to those without PD. Individuals were consistent in their decisions, regardless of the physical effort task. The anticipation of pleasure and apathy were significant predictors of decisions for exercise in PwPD only. Increased anticipation of pleasure, reduction of apathy, and the use of rewards may enhance engagement in high effort exercise among PwPD.

Health-Related Quality of Life for Parkinson's Disease Patients and Their Caregivers

Objective

Motor and non-motor symptoms (NMS) negatively impact the health-related quality of life (HRQoL) for individuals with Parkinson’s disease (PD), as well as their caregivers. NMS can emerge decades prior to the manifestation of motor symptoms but often go unrecognized and therefore untreated. To guide clinical management, we surveyed differences and identified factors that influence HRQoL in a cohort of PD patients and family caregivers.

Methods

A total of 103 PD patients were compared with 81 caregivers. Outcome measures collected from validated questionnaires included generic and disease-specific HRQoL assessments, depression frequency and severity, constipation severity, upper and lower gastrointestinal symptoms, physical activity and motor symptom severity.

Results

PD patients reported significantly decreased physical and mental HRQoL compared to their caregivers (both p < 0.001). Unemployment, the need for social support services, rehabilitation use, REM sleep behavior disorder, impulse control disorders and features suggestive of increasing disease severity hallmarked by increasing PD duration, higher MDS UPDRS-III (Movement Disorder Society–Unified Parkinson’s Disease Rating Scale–Part III) scores, higher daily levodopa equivalence dose and motor fluctuations were consistent with a lower HRQoL in our PD cohort. Furthermore, decreased physical activity, chronic pain, depression, constipation and upper gastrointestinal dysfunction (particularly indigestion, excess fullness and bloating) suggested vulnerability to reduced HRQoL. Overall, PD patients perceived their health to decline by 12% more than their caregivers did over a 1-year period.

Conclusion

PD patients reported decreased HRQoL, with both motor symptoms and NMS negatively impacting HRQoL. Our findings support the routine clinical screening of HRQoL in PD patients to identify and address modifiable factors.

Apathy and Anxiety in De Novo Parkinson's Disease Predict the Severity of Motor Complications

Background

Neuropsychiatric and affective symptoms are prevalent in prodromal and clinical Parkinson's disease (PD). Some evidence suggests that they may also signify risk for motor complications (motor fluctuations and dyskinesias) of dopamine replacement therapy (DRT).

Objective

To determine whether neuropsychiatric symptoms present in de novo PD (ie, before DRT initiation) predict the severity of eventual motor complications of DRT.

Methods

We used clinical, demographic, neurobehavioral, and neuroimaging data from the Parkinson's Progression Markers Initiative (PPMI), a multicenter observational PD study. Participants were unmedicated at enrollment and 361 initiated DRT during PPMI follow-up. We used Cox proportional hazard and multivariate ordinal mixed-effects regression models to evaluate the relationship between baseline neuropsychiatric symptoms and motor complications as measured by the Movement Disorders Society-revised Unified Parkinson's Disease Rating Scale (MDS-UPDRS).

Results

The cumulative incidences of dyskinesias and motor fluctuations during follow-up (6.0 ± 1.5 years) were 34.3% and 59.9%, respectively. Both apathy and high trait-anxiety (top quartile) conveyed over two-fold increases in hazard for dyskinesia onset and for adverse impact on activities of daily living caused by both dyskinesias and motor fluctuations. The longitudinal severity of motor fluctuations and dyskinesias was significantly predicted by baseline trait-anxiety and apathy, but not depression. Models were adjusted for dimensionally related symptoms (eg autonomic dysfunction) and potential confounding variables (eg DRT dose).

Conclusions

Apathy and anxiety levels in de novo PD may be neuropsychiatric biomarkers of vulnerability to earlier and more disabling motor complications of DRT.

Emerging Perspectives in the Diagnosis and Management of Depression and Psychosis in Parkinson's Disease

Collapse

Efficacy of Cognitive Behavioral Therapy on Mood Disorders, Sleep, Fatigue, and Quality of Life in Parkinson's Disease: A Systematic Review and Meta-Analysis

Objective: The aim of this study was to perform a quantitative analysis to evaluate the efficacy of cognitive behavioral therapy (CBT) on mood disorders, sleep, fatigue, and its impact on quality of life (QOL) in Parkinson's Disease (PD). Methods: We searched for randomized controlled trials in three electronic databases. Fourteen studies, including 507 patients with PD, met the inclusion criteria. We determined the pooled efficacy by standard mean differences and 95% confidence intervals, using I ² to reveal heterogeneity. Results: The result showed CBT had a significant effect on depression [-0.93 (95%CI, -1.19 to -0.67, P < 0.001)] and anxiety [-0.76 (95%CI, -0.97 to -0.55, P < 0.001)]. Moderate effect sizes were noted with sleep disorders [-0.45 (95% CI, -0.70 to -0.20, P = 0.0004)]. There was no evident impact of CBT on fatigue or QOL. We found an intervention period >8 weeks was advantageous compared with <8 weeks, and CBT implemented in non-group was more effective than in group. Between the delivery methods, no significant difference was found. Conclusion: We found that CBT in patients with PD was an efficacious therapy for some non-motor symptoms in PD, but not efficacious for fatigue and QOL. These results suggest that CBT results in significant improvement in PD and should be used as a conventional clinical intervention.

Pingchan granule for depressive symptoms in parkinson's disease: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Depression in Parkinson's disease (dPD) is closely related to quality of life. Current studies have suggested that Pingchan Granule (PCG) might be effective for treating dPD.

OBJECTIVE

This study determines the efficacy of PCG for depressive symptoms in Parkinson's disease (PD).

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This was a randomized, double-blind, placebo-controlled trial, conducted in Longhua Hospital, Shanghai, China. Patients diagnosed with idiopathic PD and clinically significant depressive symptoms (defined by a 24-item Hamilton Rating Scale for Depression [HAM-D] score ≥ 8) were included in this study, randomly assigned to PCG or placebo group in a 1:1 ratio and followed for 24 weeks.

MAIN OUTCOME MEASURES

The primary outcome was the change from baseline to week 24 in HAM-D score among the set of patients who completed the study following the treatment protocol (per-protocol set). Secondary outcomes included changes in scores on the Unified Parkinson's Disease Rating Scale (UPDRS) part 2 (UPDRS-II), UPDRS part 3 (UPDRS-III), Parkinson's Disease Sleep Scale (PDSS) and Hamilton Rating Scale for Anxiety (HAM-A), between baseline and week 24.

RESULTS

Eighty-six patients were enrolled, and 85 patients were included in the per-protocol set. HAM-D scores decreased by an adjusted mean of 11.77 (standard error [SE] 0.25) in the PCG group and 3.86 (SE 0.25) in the placebo group (between-group difference = 7.91, 95% confidence interval [7.22, 8.80], P < 0.001), in the multivariable linear regression. Improvements in scores on the UPDRS-II, UPDRS-III, PDSS, and HAM-A scales were also observed.

CONCLUSION

Treatment with PCG was well tolerated and improved depressive symptoms and motor and other non-motor symptoms in PD.

TRIAL REGISTRATION

Chinese Clinical Trial Register: ChiCTR-INR-17011949.

Impulse control behavior in GBA-mutated parkinsonian patients

OBJECTIVE

To assess the prevalence and phenomenology of Impulse control behavior (ICB) in Parkinson's disease (PD) patients carrying mutations in the β-glucocerebrosidase (GBA) gene.

BACKGROUND

GBA mutations are a common genetic factor predisposing to PD. ICB is among the most disabling non-motor complications of PD. The occurrence of ICB in PD patients carrying GBA gene mutations (GBA-PD) has not been yet established.

METHODS

Forty-six patients with clinically definite PD (23 GBA-PD and 23 non-mutated patients, NM-PD) were screened for ICB. Diagnosis was clinically and rating based on a specific questionnaire (QUIP-RS). Other demographic and clinical variables did not differ between groups.

RESULTS

ICB occurred more frequently in GBA-PD patients (52.2%) compared to NM-PD (13%) and the total QUIP-RS score was higher in the GBA-PD group. Hypersexuality and compulsive shopping were the most prevalent ICB types occurring in GBA patients. ICB occurred only in one GBA-PD patient on levodopa monotherapy and in 11 patients taking dopamine agonists, either monotherapy or combined with levodopa (the corresponding figures in NM-PD patients were 0 and 3). Most GBA-PD patients were heterozygous for two common genetic variants, without appreciable difference in their ICB profile.

CONCLUSION

ICB is more common in GBA-PD patients compared to NM-PD. Dopamine agonist therapy may be synergic to GBA carrier status for ICB occurrence.

Dissonance in Music Impairs Spatial Gait Parameters in Patients with Parkinson's Disease

BACKGROUND

It is known that music influences gait parameters in Parkinson's disease (PD). However, it remains unclear whether this effect is merely due to temporal aspects of music (rhythm and tempo) or other musical parameters.

OBJECTIVE

To examine the influence of pleasant and unpleasant music on spatiotemporal gait parameters in PD, while controlling for rhythmic aspects of the musical signal.

METHODS

We measured spatiotemporal gait parameters of 18 patients suffering from mild PD (50%men, mean±SD age of 64±6 years; mean disease duration of 6±5 years; mean Unified PD Rating scale [UPDRS] motor score of 15±7) who listened to eight different pieces of music. Music pieces varied in harmonic consonance/dissonance to create the experience of pleasant/unpleasant feelings. To measure gait parameters, we used an established analysis of spatiotemporal gait, which consists of a walkway containing pressure-receptive sensors (GAITRite®). Repeated measures analyses of variance were used to evaluate effects of auditory stimuli. In addition, linear regression was used to evaluate effects of valence on gait.

RESULTS

Sensory dissonance modulated spatiotemporal and spatial gait parameters, namely velocity and stride length, while temporal gait parameters (cadence, swing duration) were not affected. In contrast, valence in music as perceived by patients was not associated with gait parameters. Motor and musical abilities did not relevantly influence the modulation of gait by auditory stimuli.

CONCLUSION

Our observations suggest that dissonant music negatively affects particularly spatial gait parameters in PD by yet unknown mechanisms, but putatively through increased cognitive interference reducing attention in auditory cueing.

Depression in Parkinson's disease: Perspectives from an Australian cohort

INTRODUCTION

Depression is often an under-recognised feature of Parkinson's disease (PD). It is detrimental to physical and interpersonal functioning, negatively impacting a patient's clinical management, quality of life and well-being. We aimed to identify clinical predictors and management implications of depression in Australian PD patients.

METHODS

103 PD and 81 Healthy Control (HC) subjects were evaluated using the Beck Depression Inventory (BDI) and other validated PD motor and non-motor symptom (NMS) tools.

RESULTS

Nearly twice as many PD patients were depressed, (38.9% vs 20.1%, p = 0.009), with a corresponding increase in depression severity on the BDI (11.9; standard deviation (SD) 8.8 vs 5.2; SD 5.5, p<0.001), and an odds ratio of 2.4 (95% confidence interval 1.2 - 4.7). Employment appeared to be a relative protective factor for depression, whilst patients requiring support services seemed to be more vulnerable to depression. Rapid Eye Movement Sleep Behaviour Disorder, dyskinesias, impulse control disorder, higher daily levodopa equivalent dose, increased motor severity, as well as catechol-O-methyltransferase inhibitor and amantadine use, all showed associations with depression (p<0.05). Chronic pain, decreased physical activity, constipation and upper gastrointestinal dysfunction presented with an apparent increase in risk for developing depression and increased depression severity. Other NMS were also found to be associated with PD-related depression.

LIMITATIONS

Potential selection bias of self-reporting data collection from specialist PD clinics in a single metropolitan area.

CONCLUSION

Our findings provide novel insight into the prevalence of depression in PD, possible contributory factors and future treatment strategies targeting depression in PD.

High-Intensity Interval Cycle Ergometer Training in Parkinson's Disease: Protocol for Identifying Individual Response Patterns Using a Single-Subject Research Design

Background: People with Parkinson's disease (PD) experience not only motor problems but also non-motor problems that seriously impede their daily functioning and quality of life. The current pharmacologic treatment of PD is symptomatic, and alternative rehabilitation treatments, which preferably also have a disease-modifying effect and promote neuroplasticity, are needed. Recent studies suggest that high-intensity interval training (HIIT) is promising for promoting neuroplasticity in human PD, with short training time and reduced burden. Biomarkers for neuroplasticity such as brain-derived neurotrophic factor (BDNF) and neurodegeneration (including neurofilament NfL and α-synuclein) may play a role, but their response to HIIT is not well-investigated.

Objectives: The aims of this study were (1) to study the effects of 4 weeks of HIIT compared with 4 weeks of continuous aerobic exercise on motor and non-motor outcomes of PD and (2) to investigate the association between HIIT, motor/non-motor performances changes, and blood biomarker levels for neuroplasticity and neurodegeneration.

Study Design: Single-subject research design with alternating treatment setup (ABACA) and frequent repeated measurements was used. Each participant received different intervention conditions (B/C) interspersed with baseline periods (A, i.e., ABACA or ACABA), and frequent repeated assessment of outcome measures is done to quantify within-subject, individual response patterns with sufficient power for data analysis. Blood samples were collected once a week in the baseline and training phases (A1 and B/C) and once every 2 weeks in the washout phases (A2 and A3).

Intervention: Four subjects with PD on stable dopaminergic medication, two in Hoehn–Yahr stage 1–2, and two in Hoehn–Yahr stage 2.5–3 followed an ABACA or ACABA schedule, consisting of blocks with 30-min sessions of “B” (HIIT) or 50-min sessions of “C” [continuous aerobic exercise (CAE)] 3×/week for 4 weeks, separated by baseline “A” periods of 8 weeks for a total duration of 28 weeks.

Outcome Measures: Outcome measures include disease status [Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS)], blood biomarkers (BDNF, Nfl, and α-synuclein), measures for functional mobility (including an activity tracker), and activities of daily living, as well as cognition, mood, biorhythm (sleeping problems), and quality of life.

Data Analysis: Visual analysis of trends in level, slope, and variability in response patterns was carried out, confirmed by longitudinal regression analysis with phase (ABACA) as the independent variable.

The use of vortioxetine for depression in patients with Parkinson's disease in the early and advanced stages of the disease

Depression is one of the most common non-motor manifestations of Parkinson's disease (PD), which largely determines both the severity of the course of the disease and the life expectancy of patients, as well as the compliance of patients to and the efficiency of antiparkinsonian therapy. In this connection, the search for a safe and effective antidepressant for patients with PD is of particular relevance.

Objective: to evaluate the efficacy and safety of vortioxetine in patients with PD complicated by mild to moderate depression.

Patients and methods. Examinations were made in 150 patients with PD in its early and advanced stages (Hoehn-Yahr stages: 1.0 to 3.0). All the patients were treated with vortioxetine at a dose of 15 or 20 mg/day for 8 months. The investigators used clinical and psychopathological rating scales, such as the Hospital Depression Scale (HADS-D), the Hospital Anxiety Scale (HADS-A), the Beck Depression Inventory (BDI), and the Montgomery-Asberg Depression Rating Scale (MADRS). The severity of PD motor manifestations was assessed according to the Unified PD Rating Scale (UPDRS) Part III.

Results and discussion. During the follow-up period corresponding to 12 weeks of vortioxetine use, all the patients showed a significant decrease in MARDS, HADS-A and HADS-D, and BDI scores for depression and anxiety (p < 0.001). Vortioxetine demonstrated an optimal balance between tolerability and clinical efficacy in correcting affective disorders in this patient group. In addition, analysis of the dynamics of motor disorders yielded data on the improvement of movement functions while correcting depression as lower UPDRS Part III total scores (p < 0.001).

Conclusion. The findings suggest that vortioxetine has a significant effect on depression and anxiety in patients with PD in its early and advanced stages, good tolerability, and a rapid-onset effect.

Pilot Evaluation of a Pragmatic Network for Integrated Care and Self-Management in Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) is a chronic neurodegenerative disorder that challenges care provision. A multidisciplinary care model needs to be impactful, feasible, and viable economically for widespread utilization. Supportive evidence is lacking.

OBJECTIVE

The objective of this study was to evaluate the implementation and impact of a pragmatic network for PD care, the Integrated Parkinson Care Network (IPCN).

METHODS

A 6-month, pre-post design, single-center, phase 2 study for complex interventions for patients with newly diagnosed (<1 year) and advanced (diagnosis >8 years) PD was used to assess a patient-centered care model based on integrated care, self-management support, and technology-enabled care. We comprehensively assessed the implementation of care paths, change in selected health and care quality outcomes after the Integrated Parkinson Care Network program, and costs analyses.

RESULTS

We recruited 100 participants in 6 months. Overall, the top care priorities were speech and communication (33.7%), anxiety and depression (31.6%), and mobility, balance, and falls (29.6%), and the most commonly (>45%) used resources were speech-language pathology, community seniors services, and physiotherapy. Care priorities were met successfully in 90.6% of the cases, and there was a positive change in the Parkinson's Disease Questionnaire-8 (2.7; 95% confidence interval, 0.4-5.0; statistically significant in the advanced group), the perception of support for chronic care (Patient Assessment of Chronic Illness Case score, 1.1; 95% confidence interval, 0.9-1.4), and self-management (5As score, 1.2; 95% confidence interval, 1.0-1.4). The total cost of the Integrated Parkinson Care Network was C$1367 per patient.

CONCLUSIONS

A pragmatic development of a care delivery network based on integrated care and self-management support is promising for its feasibility, impact, and a sustainable cost. © 2020 International Parkinson and Movement Disorder Society.

Rationale and Design of the PAIRED Trial: Partnered Dance Aerobic Exercise as a Neuroprotective, Motor, and Cognitive Intervention in Parkinson's Disease

Parkinson's disease (PD), an intractable condition impairing motor and cognitive function, is imperfectly treated by drugs and surgery. Two priority issues for many people with PD are OFF-time and cognitive impairment. Even under best medical management, three-fourths of people with PD experience “OFF-time” related to medication-related motor fluctuations, which severely impacts both quality of life and cognition. Cognitive deficits are found even in newly diagnosed people with PD and are often intractable. Our data suggest that partnered dance aerobic exercise (PDAE) reduces OFF-time on the Movement Disorders Society Unified Parkinson Disease Rating Scale-IV (MDS-UPDRS-IV) and ameliorates other disease features, which motivate the PAIRED trial. PDAE provides AE during an improvisational, cognitively engaging rehabilitative physical activity. Although exercise benefits motor and cognitive symptoms and may be neuroprotective for PD, studies using robust biomarkers of neuroprotection in humans are rare. We propose to perform a randomized, controlled trial in individuals with diagnosed mild–moderate PD to compare the efficacy of PDAE vs. walking aerobic exercise (WALK) for OFF-time, cognition, and neuroprotection. We will assess neuroprotection with neuromelanin-sensitive MRI (NM-MRI) and iron-sensitive (R2^*) MRI sequences to quantify neuromelanin loss and iron accumulation in substantia nigra pars compacta (SNc). We will use these biomarkers, neuromelanin loss, and iron accumulation, as tools to chart the course of neurodegeneration in patients with PD who have undergone long-term (16 months) intervention. We will randomly assign 102 individuals with mild–moderate PD to 16 months of PDAE or WALK. The 16-month intervention period will consist of Training (3 months of biweekly sessions) and Maintenance (13 months of weekly sessions) phases. We will assess participants at baseline, 3 months (immediately post-Training), and 16 months (immediately post-Maintenance) for OFF-time and behaviorally and physiologically measured cognition. We will acquire NM-MRI and R2^* imaging data at baseline and 16 months to assess neuroprotection. We will (1) examine effects of Training and Maintenance phases of PDAE vs. WALK on OFF-time, (2) compare PDAE vs. WALK at 3 and 16 months on behavioral and functional MRI (fMRI) measures of spatial cognition, and (3) compare PDAE vs. WALK for effects on rates of neurodegeneration.

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.