Prevalence of anxiety in Parkinson's disease: A systematic review and meta‐analysis

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.

The Relationship Between Anxiety Disorders and Parkinson's Disease: Clinical and Therapeutic Issues

PURPOSE OF REVIEW

This paper seeks to describe anxiety's different symptomatologic presentations in Parkinson's disease (PD), its longitudinal course and predictors, as well as its motor and non-motor correlates. It also reviews the available screening tools and different treatment modalities.

RECENT FINDINGS

In PD, longitudinal predictors of anxiety are mostly non-motor non-dopaminergic symptoms. The longitudinal course of anxiety is mainly a stable one. The Parkinson Anxiety Scale and the Geriatric Anxiety Scale are the 2 recommended screening tools. A third of PD patients suffer from an anxiety disorder at any time point. It can precede or follow PD motor symptoms. Anxiety is associated with demographic, disease-related motor and non-motor features. There is a lack of studies evaluating psychotropic treatment of anxiety in PD. Adjustment of dopaminergic treatment is indicated when anxiety is associated with motor fluctuations. DBS can be useful as well as CBT and body-mind interventions.

Omega-3 and polyunsaturated fat for prevention of depression and anxiety symptoms: systematic review and meta-analysis of randomised trials

BACKGROUND

There is strong public belief that polyunsaturated fats protect against and ameliorate depression and anxiety.

AIMS

To assess effects of increasing omega-3, omega-6 or total polyunsaturated fat on prevention and treatment of depression and anxiety symptoms.

METHOD

We searched widely (Central, Medline and EMBASE to April 2017, trial registers to September 2016, ongoing trials updated to August 2019), including trials of adults with or without depression or anxiety, randomised to increased omega-3, omega-6 or total polyunsaturated fat for ≥24 weeks, excluding multifactorial interventions. Inclusion, data extraction and risk of bias were assessed independently in duplicate, and authors contacted for further data. We used random-effects meta-analysis, sensitivity analyses, subgrouping and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment.

RESULTS

We included 31 trials assessing effects of long-chain omega-3 (n = 41 470), one of alpha-linolenic acid (n = 4837), one of total polyunsaturated fat (n = 4997) and none of omega-6. Meta-analysis suggested that increasing long-chain omega-3 probably has little or no effect on risk of depression symptoms (risk ratio 1.01, 95% CI 0.92-1.10, I2 = 0%, median dose 0.95 g/d, duration 12 months) or anxiety symptoms (standardised mean difference 0.15, 95% CI 0.05-0.26, I2 = 0%, median dose 1.1 g/d, duration 6 months; both moderate-quality evidence). Evidence of effects on depression severity and remission in existing depression were unclear (very-low-quality evidence). Results did not differ by risk of bias, omega-3 dose, duration or nutrients replaced. Increasing alpha-linolenic acid by 2 g/d may increase risk of depression symptoms very slightly over 40 months (number needed to harm, 1000).

CONCLUSIONS

Long-chain omega-3 supplementation probably has little or no effect in preventing depression or anxiety symptoms.

DECLARATION OF INTEREST

L.H. and A.A. were funded to attend the World Health Organization Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Diet and Health meetings and present review results. The authors report no other conflicts of interest.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Neuroimaging of Anxiety in Parkinson's Disease: A Systematic Review

BACKGROUND

The aim of this systematic review was (1) to identify the brain regions involved in anxiety in Parkinson's disease (PD) based on neuroimaging studies and (2) to interpret the findings against the background of dysfunction of the fear circuit and limbic cortico-striato-thalamocortical circuit.

METHODS

Studies assessing anxiety symptoms in PD patients and studies using magnetic resonance imaging, positron emission tomography, or single-photon emission computed tomography were included.

RESULTS

The severity of anxiety was associated with changes in the fear circuit and the cortico-striato-thalamocortical limbic circuit. In the fear circuit, a reduced gray-matter volume of the amygdala and the anterior cingulate cortex (ACC); an increased functional connectivity (FC) between the amygdala and orbitofrontal cortex (OFC) and hippocampus and between the striatum and the medial prefrontal cortex (PFC), temporal cortex, and insula; and a reduced FC between the lateral PFC and the OFC, hippocampus, and amygdala were reported. In the cortico-striato-thalamocortical limbic circuit, a reduced FC between the striatum and ACC; a reduced dopaminergic and noradrenergic activity in striatum, thalamus, and locus coeruleus; and a reduced serotoninergic activity in the thalamus were reported.

CONCLUSION

To conclude, anxiety is associated with structural and functional changes in both the hypothesized fear and the limbic cortico-striato-thalamocortical circuits. These circuits overlap and may well constitute parts of a more extensive pathway, of which different parts play different roles in anxiety. The neuropathology of PD may affect these circuits in different ways, explaining the high prevalence of anxiety in PD and also the associated cognitive, motor, and psychiatric symptoms. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Modifiable Comorbidities Associated with Cognitive Decline in Parkinson's Disease

Background

Cognitive impairment (CI) is one of the most feared and debilitating complications of PD. No therapy has been shown to slow or prevent CI in PD.

Objective

To determine associations between modifiable comorbidities, including cardiovascular disease risk factors, mood disorders, and sleep characteristics, and rate of cognitive decline in Parkinson's disease (PD).

Methods

Data from the Parkinson's Progression Markers Initiative (PPMI) cohort was queried for baseline cardiovascular disease risk factors, mood disorders, and sleep characteristics. Linear mixed- effects models (LME) were used to examine the association between baseline factors and change in cognition, evaluated by the Montreal Cognitive Assessment (MoCA) over time. Baseline comorbidities found to affect MoCA decline were assessed for an association with focal cognitive domains using LME.

Results

Higher Body Mass Index (BMI) (β = -0.009, P = 0.039), State Trait Anxiety Inventory (STAI) (β = -0.005, P < 0.001), Geriatric Depression Scale (GDS) (β = -0.034, P < 0.001), Epworth Sleepiness Scale (ESS) (β = -0.017, P = 0.003), and REM Sleep Behavior Disorder Screening Questionnaire (RBDSQ) (β = -0.037, P < 0.001) were associated with faster rates of MoCA decline. Using established cut-offs for clinically significant symptoms, being overweight, or the presence of depression, excessive day time sleepiness (EDS), and possible REM sleep behavior disorder (pRBD), were all associated with faster rate of cognitive decline.

Conclusion

Several modifiable baseline comorbidities are associated with faster rate of CI over time in patients with PD. These associations identify potential opportunities for early intervention that could influence CI in PD.

Stress and mindfulness in Parkinson's disease - a survey in 5000 patients

Many Parkinson’s disease (PD) patients notice that motor symptoms worsen during stress, and experience stress-related neuropsychiatric symptoms such as anxiety and depression. Here we investigated which personal and disease characteristics are associated with perceived stress in PD, which PD symptoms are sensitive to stress, and we assessed self-reported benefits of stress-reducing strategies such as mindfulness. We sent an online survey to the Fox Insight cohort (n = 28,385 PD patients, n = 11,413 healthy controls). The survey included specific questions about the influence of stress on PD symptoms, use of stress-reducing strategies, and several validated scales measuring perceived stress, anxiety, dispositional mindfulness, rumination, and self-compassion. We received completed surveys from 5000 PD patients and 1292 controls. Patients perceived more stress than controls. Among patients, stress was correlated with increased rumination (R = 0.65), lower quality of life (R = −0.56), lower self-compassion (R = −0.65), and lower dispositional mindfulness (R = −0.48). Furthermore, patients indicated that stress significantly worsened both motor symptoms – especially tremor – and non-motor symptoms. Physical exercise was most frequently used to reduce stress (83.1%). Mindfulness was practiced by 38.7% of PD respondents, who noticed improvement in both motor and non-motor symptoms. Among non-users, 43.4% were interested in gaining mindfulness skills. We conclude that PD patients experience greater levels of stress than controls, and that stress worsens both motor and non-motor symptoms. Mindfulness may improve PD symptom severity, with the strongest effects on anxiety and depressed mood. These findings justify further controlled studies to establish the merits of mindfulness and other stress-alleviating interventions.

Metabolomics profiling reveals altered lipid metabolism and identifies a panel of lipid metabolites as biomarkers for Parkinson's disease related anxiety disorder

OBJECTIVES

Anxiety disorder is a common non-motor symptom in patient with Parkinson's disease (PD). We aimed to explore its pathogenesis and identify plasma biomarkers using untargeted metabolomics analysis.

METHODS

Consecutive PD patients and healthy controls were recruited. Clinical data were assessed and patients with Parkinson's disease related anxiety disorder (PDA) were recognized. Fast plasma samples were obtained and untargeted liquid chromatography-mass spectrometry-based metabolomics analysis was performed. Based on the differentially expressed metabolites from the above metabolomics analysis, correlation analyses and receiver operating characteristic curves (ROC) were further employed.

RESULTS

According to the clinical data, PDA patients had lower plasma levels of total cholesterol, triglyceride, low-density lipoprotein cholesterol, and apolipoprotein B. There were thirty-nine differentially expressed metabolites in PDA patients when compared with the other two groups from the metabolomics analysis, respectively. Fourteen lipid metabolites were simultaneously altered between these two groups, and all of them were significantly decreased. They can be further subcategorized into fatty acyls, glycerolipids, sterol lipids, sphingolipids, and prenol lipids. The plasma levels of thirteen metabolites were negatively correlated with HAMA scores except 10-oxo-nonadecanoic acid. Based on the ROC curves, the fourteen lipid metabolites can be diagnostic biomarkers for PDA patients separately and the areas under the curve of the fourteen lipid metabolites ranged from 0.681 to 0.798.

CONCLUSIONS

Significantly lower plasma lipoproteins can be found in PDA patients. A panel of fourteen lipid metabolites were also significantly decreased and can be clinical biomarkers for the diagnosis of PDA patients.

Anxiety in Parkinson's disease: Abnormal resting activity and connectivity

Anxiety is a very common yet poorly understood symptom of Parkinson's disease. We investigated whether Parkinson's disease patients experiencing anxiety share neural mechanisms described in the general population with involvement of critical regions for the control of behaviour and movement. Thirty-nine patients with PD were recruited for this study, 20 with higher anxiety scores and 19 with lower anxiety scores. They all underwent a resting-state fMRI scan, while they were on medication. The amplitude of low-frequency fluctuation (ALFF) and seed-based connectivity were investigated to reveal the changes of the spontaneous activity and the interaction among different related regions. The results provided evidence that anxiety in Parkinson's disease is associated with the over-activation of the amygdala and impaired inter-relationship of regions involved in behavior (i.e. medial prefrontal cortex, insula) and motor control (i.e. basal ganglia).

Risk and Protective Factors Associated With Health-Related Quality of Life of Parents With Mental Illness

Purpose: Health-related quality of life (HRQoL) can be reduced in parents with mental illness (mental illness) who face the dual demands of disabling symptoms and their impact on family, social, and occupational life. This study aimed at analyzing the influence of various factors on HRQoL in parents with mental illness. Method: Baseline data of the German randomized controlled multicenter project CHIMPS (children of parents with mental illness) was used for analyses. The final sample consisted of n = 208 parents with mental illness and n = 197 children and adolescents aged 8-18 years. HRQoL was assessed with the EQ-5D. Results: Parents with mental illness reported significantly lower global and specific HRQoL than the German reference population. They were least satisfied with aspects that relate to anxiety and depression followed by usual activities, pain and discomfort. Better global HRQoL was primarily associated with self-reported physical and mental health, as well as adaptive coping behavior. Associations with mobility, self-care, usual activity, pain and discomfort, anxiety and depression were analyzed and discussed. Conclusions: HRQoL in parents with mental illness is reduced. Clinical interventions should focus on the alleviation of mental health symptoms and probably somatic symptoms and promote adaptive coping skills.

Mood and emotional disorders associated with parkinsonism, Huntington disease, and other movement disorders

This chapter provides a review of mood, emotional disorders, and emotion processing deficits associated with diseases that cause movement disorders, including Parkinson's disease, Lewy body dementia, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, frontotemporal dementia with parkinsonism, Huntington's disease, essential tremor, dystonia, and tardive dyskinesia. For each disorder, a clinical description of the common signs and symptoms, disease progression, and epidemiology is provided. Then the mood and emotional disorders associated with each of these diseases are described and discussed in terms of clinical presentation, incidence, prevalence, and alterations in quality of life. Alterations of emotion communication, such as affective speech prosody and facial emotional expression, associated with these disorders are also discussed. In addition, if applicable, deficits in gestural and lexical/verbal emotion are reviewed. Throughout the chapter, the relationships among mood and emotional disorders, alterations of emotional experiences, social communication, and quality of life, as well as treatment, are emphasized.

Annual Prevalence of Use of Potentially Inappropriate Medications for Treatment of Affective Disorders in Parkinson's Disease

OBJECTIVE

To examine the national prevalence of pharmacological treatment of affective disorders in older adults with Parkinson's disease (PD), and determine the prevalence and risk factors for receipt of an American Geriatrics Society Beers Criteria® defined potentially inappropriate medication (PIM) for affective disorder treatment.

DESIGN

Cross-sectional analysis of 2014 Medicare data.

SETTING

Research Identifiable File data from the Centers for Medicare and Medicaid Services.

PARTICIPANTS

Individuals ≥65 years of age with PD whose inpatient, outpatient, and prescription care is administered through the U.S. Medicare Program.

MEASUREMENTS

The 2014 prevalence of affective (i.e., depressive and anxiety) disorders was calculated. We assessed prescription fills for affective disorder treatment and classified prescriptions according to PIM status. Patient and clinician factors associated with PIM prescriptions were determined.

RESULTS

Of 84,323 beneficiaries with PD, 15.1% had prevalent depression only, 7.5% had anxiety only, and 8.5% had comorbid depression and anxiety. Among those with depression only, 80.7% were treated in 2014 (12.8% of treated received at least one PIM). The annual treatment prevalence was 62.9% (75.9% PIM) and 93.1% (63.9% PIM) in the anxiety only and comorbid group, respectively. In most groups, PIM use was less likely among men and those with dementia; geriatricians were less likely to prescribe PIMs.

CONCLUSION

Treatment of affective disorders in persons diagnosed with PD is high. PIM use is also common, particularly in persons with anxiety. Future research will quantify the potential effects of these PIMs on clinical and patient outcomes.

Stress and Mindfulness in Parkinson's Disease: Clinical Effects and Potential Underlying Mechanisms

Patients with Parkinson's disease (PD) are very vulnerable to the negative effects of psychological distress: neuropsychiatric symptoms, such as anxiety and depression, are highly prevalent in PD; motor symptoms (such as tremor) typically worsen in stressful situations; and dopaminergic medication is less effective. Furthermore, animal studies of PD suggest that chronic stress may accelerate disease progression. Adequate self-management strategies are therefore essential to reduce the detrimental effects of chronic stress on PD. Mindfulness-based interventions encourage individuals to independently self-manage and adapt to the challenges created by their condition. In PD, emerging clinical evidence suggests that mindfulness-based interventions may reduce psychological distress and improve clinical symptoms, but insight into the underlying mechanisms is lacking. In this viewpoint, we provide a systematic overview of existing mindfulness trials in PD. Furthermore, we discuss the cerebral mechanisms involved in acute and chronic stress, and the impact of mindfulness-based interventions on these networks. In addition, we delineate a hypothetical mechanistic framework of how chronic stress may increase the susceptibility for neuropsychiatric symptoms in PD and may potentially even influence disease progression. We end with offering recommendations for future research. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Altered cerebellum functional network on newly diagnosed drug-naïve Parkinson's disease patients with anxiety

Introduction

Damage to the cerebellar functional network may underlie anxiety symptoms in patients with Parkinson’s disease (PD). Herein we investigated the regional homogeneity (ReHo) and functional connectivity (FC) patterns of cerebellar and clinical correlates in PD patients with anxiety and explored their clinical significance.

Methods

We enrolled 50 newly diagnosed drug-naïve PD patients and 30 normal controls (NCs). Twenty-six PD patients with anxiety symptoms (PD-A) and 24 PD patients without anxiety symptoms (PD-NA) were sorted into groups based on the Hamilton Anxiety Scale (HAMA). All included participants underwent rest-state functional magnetic resonance imaging (rs-fMRI) scanning. Cerebellar FC based on the seed-based method was used to investigate regional and whole brain function in PD-A, PD-NA, and NCs, and the relationship between the abnormal brain function and anxiety symptoms in PD patients was also detected.

Results

Compared with the PD-NA group and the NCs, the ReHo value of the PD-A group was significantly decreased in the left medial frontal gyrus and increased in the left cerebellum. Further, left-cerebellum-based FC patterns were used to detect the decreased FC in the right cerebellum, while FC was increased in the right caudate nucleus, and the right anterior cingulate cortex (ACC) in the PD-A group was compared with that in the PD-NA group. Further, the altered FC between the left cerebellum and the right cerebellum was significantly associated with anxiety symptoms in the PD-A group.

Conclusion

The present study found abnormal regional cerebellum function as well as disruptions in the connectivity network within the cerebellum, caudate, and ACC in patients with PD-A. In addition, the FC between the left cerebellum and the right cerebellum was associated with anxiety symptoms in patients with PD. The present study indicated that cerebellar functional damage may be associated with anxiety symptoms in PD patients.

Depression and anxiety among patients with Parkinson’s disease: frequency, risk factors, and impact on quality of life

Background

Depression and anxiety are non-motor symptoms of Parkinson’s disease (PD) that are often overlooked and underrated. This study aimed to highlight the frequency and risk factors of depression and anxiety among subjects with PD.

Methods

Sixty-four patients with PD who were diagnosed according to United Kingdom Parkinson’s Disease Society (UKPDS) Brain Bank Criteria and 50 sex- and age-matched healthy control subjects are evaluated for depression and anxiety. PD severity and staging were assessed using Unified Parkinson’s Disease Rating Scale (UPDRS) and Hoehn and Yahr scale. Depression and anxiety were diagnosed using DSM-IV TR criteria and scored using Hamilton Depression and Hamilton Anxiety Rating Scales (HAM-D and HAM-A). The World Health Organization Quality of Life (WHOQOL)-BREF was used to assess impact of depression and anxiety on quality of life.

Results

31.25% of patients with PD had depression while 40.6% of patients had anxiety disorder. Depression was higher in females and patients with history of depression and low socioeconomic status (SES). Anxiety was common in young patients and those who had history of anxiety. Overlap between depression and anxiety was recorded in 23.4%. Total UPDRS and Hoehn and Yahr scale accounted for 33.4% of variance for depression. Total UPDRS and earlier age of onset accounted for 39% of variance for anxiety. Advanced disease stage and severity were independent predictors for depression while disease severity and younger age of onset were the main predictors for anxiety. Depression and anxiety have a negative impact on the overall quality of life of PD patients especially on physical and psychosocial domains.

Conclusion

Depression and anxiety are relatively common in PD. Female gender, low SES, and history of depression were the main risk factors for developing depression. Young age and history of anxiety were risk factors for anxiety. Both had negative impact on quality of life.

Searching for Peripheral Biomarkers in Neurodegenerative Diseases: The Tryptophan-Kynurenine Metabolic Pathway

Neurodegenerative diseases are multifactorial, initiated by a series of the causative complex which develops into a certain clinical picture. The pathogenesis and disease course vary from patient to patient. Thus, it should be likewise to the treatment. Peripheral biomarkers are to play a central role for tailoring a personalized therapeutic plan for patients who suffered from neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, and multiple sclerosis, among others. Nevertheless, the use of biomarkers in clinical practice is still underappreciated and data presented in biomarker research for clinical use is still uncompelling, compared to the abundant data available for drug research and development. So is the case with kynurenines (KYNs) and the kynurenine pathway (KP) enzymes, which have been associated with a wide range of diseases including cancer, autoimmune diseases, inflammatory diseases, neurologic diseases, and psychiatric disorders. This review article discusses current knowledge of KP alterations observed in the central nervous system as well as the periphery, its involvement in pathogenesis and disease progression, and emerging evidence of roles of microbiota in the gut-brain axis, searching for practical peripheral biomarkers which ensure personalized treatment plans for neurodegenerative diseases.

Yoga Improves Balance and Low-Back Pain, but Not Anxiety, in People with Parkinson's Disease

Individuals with Parkinson's disease (PD) experience postural instability, low-back pain (LBP), and anxiety. These symptoms increase the risk of falls and decrease quality of life. Research shows yoga improves balance and decreases LBP and anxiety in healthy adults, but its effects in PD are poorly understood. All participants were part of a larger intervention study. Participants received pretest and posttest evaluations, including the Balance Evaluation Systems Test (BESTest), Beck Anxiety Inventory (BAI), and Revised Oswestry Disability Index (ROSW). Total scores for each measure, as well as individual balance system section scores from the BESTest (biomechanical constraints, stability limits/verticality, transitions/anticipatory, reactive, sensory orientation, and stability in gait) were compared within groups pre- to posttest. Participants in the yoga group (n = 13) completed a twice-weekly 12-week yoga interve n t i o n , whereas controls (n = 13) continued their usual routines for 12 weeks. Both the yoga (Z = -3.20, p = 0.001) and control (Z = -2.10, p = 0.040) groups improved on the BESTest total score. The control group showed no changes in individual balance systems, whereas the yoga group improved in stability limits/verticality (Z = -2.3, p = 0.020), transitions/ anticipatory (Z = -2.50, p = 0.010), reactive (Z = -2.70, p = 0.008), and sensory orientation (Z = -2.30, p = 0.020). ROSW decreased in the yoga group only (Z = -2.10, p = 0.030). BAI did not change in either group. Yoga is a nonpharmacological intervention that can improve balance and LBP in people with PD. This study demonstrated that yoga is feasible for people with PD, and participants reported high levels of enjoyment and intent to practice yoga after the study.

Nonpharmacological interventions for respiratory health in Parkinson's disease: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Respiratory dysfunction in Parkinson's disease (PD) is often an underdiagnosed and untreated impairment associated with the disease. Clinically, a reactive approach to respiratory morbidity is taken, rather than preventative approaches that address underlying impairment/s. This systematic review identifies the current evidence to support nonpharmacological interventions to improve respiratory impairments in individuals with PD.

METHODS

The relevant literature was searched using a customised and systematic strategy. Randomised and nonrandomised control trials of nonpharmacological interventions targeting respiratory outcome measures in PD were included. Outcomes of interest were respiratory morbidity and mortality, respiratory muscle strength, spirometry measures, lung volumes, peak cough flow, and perception of dyspnoea.

RESULTS

Nonpharmacological interventions included: functional training, generalised strength training, respiratory muscle strength training, aerobic exercise, qigong, yoga, breath stacking, incentive spirometry and singing. Methodological quality of included studies varied. Meta-analyses of nonpharmacological interventions demonstrated significant effects for inspiratory muscle strength (mean difference [MD] 19.68; confidence interval [CI] 8.49, 30.87; z = 3.45; p = 0.0006; I²  = 2%), expiratory muscle strength (MD 18.97; CI 7.79, 30.14; z = 3.33; p = 0.0009; I²  = 23%) and peak expiratory flow (MD 72.21; CI 31.19, 113.24; z = 3.45; p = 0.0006; I²  = 0%). Best-evidence synthesis identified level 1 evidence supporting nonpharmacological interventions for improving peak cough flow and perceived dyspnoea. No studies were identified reporting outcomes of respiratory rate, inspiration:expiration ratio or respiratory morbidity or mortality in PD.

CONCLUSIONS

Nonpharmacological interventions improved respiratory muscle strength and peak expiratory flow in PD. Additional trials targeting respiratory dysfunction and longitudinal studies examining the relationship between respiratory dysfunction and morbidity and mortality rates in PD are required.

The association of occupational stress and sleep duration with anxiety symptoms among healthy employees: A cohort study

The aim of this study is to identify occupational stress associated with the development of new-onset anxiety symptoms and the dose-response relationship between sleep duration and the onset of anxiety symptoms. Data from 29,251 healthy employees who had undergone at least two comprehensive health examinations at Kangbuk Samsung Hospital Health Screening Center were analysed. Anxiety symptoms were assessed using the Beck Anxiety Inventory. Occupational stress and sleep duration were measured using a self-reported questionnaire about total sleep time and the Korean Occupational Stress Scale-Short Form (KOSS-SF), respectively. Flexible parametric proportional hazards model used to estimate the hazard ratios. Compared with the groups without case-level anxiety, discomfort in an organizational climate, high job demands, job insecurity, organizational injustice and lack of reward were associated with the onset of case-level anxiety. Compared with less than 6 hr of sleep per day, the beneficial level of sleep duration was 7 ≤ to <9 hr a day. Almost all subscales of job stress were associated with the development of anxiety symptoms. In addition, the efficacious level of sleep duration for reducing the onset of future anxiety symptoms was 7 ≤ to <9 hr a day.

A trial of buspirone for anxiety in Parkinson's disease: Safety and tolerability

INTRODUCTION

In Parkinson's disease (PD), anxiety is common, associated with lower health-related quality of life, and undertreated. The primary objective of this study was to determine the tolerability of buspirone for the treatment of anxiety in PD.

METHODS

Individuals with PD and clinically significant anxiety were randomized 4:1 to flexible dosage buspirone or placebo for 12 weeks. Treatment was initiated at 7.5 mg twice daily and titrated based on response and tolerability to an optimal dosage (maximum 30 mg twice daily). The primary outcome was the proportion of participants who failed to complete the study on study drug. Secondary outcomes included adverse events, dosage reductions, motor function, dyskinesias, and anxiety.

RESULTS

A total of 21 participants enrolled, 4 were randomized to placebo and 17 to buspirone (mean (SD) age 65.5 (9.8), 76.5% male, 88% on concomitant antidepressant or anxiolytic). In the buspirone group, 7 (41%) failed to complete the study on drug, 5 due to intolerability. The median buspirone dosage was 7.5 mg twice daily. No serious adverse events occurred. A total of 9 (53%) buspirone participants experienced adverse events consistent with worsened motor function. In the buspirone group, mean (SD) improvement from baseline to week 12 in Hamilton Anxiety Rating Scale was -3.9 (3.8) and Parkinson Anxiety Scale -7.1 (6.4).

CONCLUSION

Tolerability concerns do not support moving immediately forward with a large-scale efficacy trial. However, concomitant anxiolytics may have affected tolerability and a signal of efficacy was seen suggesting that future studies of buspirone monotherapy be considered.

Theta and gamma connectivity is linked with affective and cognitive symptoms in Parkinson's disease

BACKGROUND

The progression of Parkinson's disease (PD) can often exacerbate symptoms of depression, anxiety, and/or cognitive impairment. In this study, we explore the possibility that multiple brain network responses are associated with symptoms of depression, anxiety and cognitive impairment in PD. This association is likely to provide insights into a single multivariate relationship, where common affective symptoms occurring in PD cohorts are related with alterations to electrophysiological response.

METHODS

70 PD patients and 21 healthy age-matched controls (HC) participated in a high-density electroencephalography (EEG) study. Functional connectivity differences between PD and HC groups of oscillatory activity at rest and during completion of an emotion-cognition task were examined to identify key brain oscillatory activities. A canonical correlation analysis (CCA) was applied to identify a putative multivariate relationship between connectivity patterns and affective symptoms in PD groups.

RESULTS

A CCA analysis identified a single mode of co-variation linking theta and gamma connectivity with affective symptoms in PD groups. Increases in frontotemporal gamma, frontal and parietal theta connectivity were related with increased anxiety and cognitive impairment. Decreases in temporal region theta and frontoparietal gamma connectivity were associated with higher depression ratings and PD patient age.

LIMITATIONS

This study only reports on optimal dosage of dopaminergic treatment ('on' state) in PD and did not investigate at "off" medication".

CONCLUSIONS

Theta and gamma connectivity during rest and task-states are linked to affective and cognitive symptoms within fronto-temporo-parietal networks, suggesting a potential assessment avenue for understanding brain-behaviour associations in PD with electrophysiological task paradigms.

Suicide in Parkinson's Disease: A Systematic Review

Psychiatric disorders and suicide have been reported in patients suffering from Parkinson's disease. The aims of the present paper were to determine whether patients with Parkinson's disease have an increased rate of suicide and to identify the clinical features possibly associated with suicide risk in Parkinson's disease. We also reviewed the studies on suicide risk in Parkinson's disease in patients after deep brain stimulation. We performed a Medline, Excerpta Medica, PsycLit, PsycInfo and Index Medicus search to identify all articles published on this topic from 1970 to 2019. The following search terms were used: suicide OR suicide attempt OR suicidal ideation OR suicide risk AND Parkinson's disease AND Parkinson's disease and deep brain stimulation. The studies we identified that assessed the suicide rate associated with Parkinson's disease yielded contrasting results, although an increase in suicidal ideation did emerge. The studies on the effect of deep brain stimulation on suicide risk in Parkinson's disease also reported mixed findings. Psychiatric symptoms, including depression, appear to be associated with suicide risk in patients with Parkinson's disease undergoing medical and after surgical treatment. The studies reviewed suggest that suicidal ideation is increased in Parkinson's disease. Further longitudinal studies designed to assess suicidality in this condition are still needed.

Anxiety in Parkinson's disease is associated with changes in the brain fear circuit

BACKGROUND

Anxiety is frequent in Parkinson's disease (PD) and has a negative impact on disease symptoms and quality of life. The underlying mechanisms remain largely unknown. The aim of this study was to identify anatomical and functional changes associated to PD-related anxiety by comparing the volume, shape and texture of the amygdala, the cortical thickness as well as the functional connectivity (FC) of the fear circuit in patients with and without clinically relevant anxiety.

METHODS

Non-demented PD patients were recruited, and anxiety was quantified using the Parkinson Anxiety Scale. Structural MRI was used to compare cortical thickness and amygdala structure and resting-state functional MRI to compare FC patterns of the amygdala and resting-state functional networks in both groups.

RESULTS

We included 118 patients: 34 with (A+) and 84 without (A-) clinically relevant anxiety. Clusters of cortical thinning were identified in the bilateral fronto-cingulate and left parietal cortices of the A+ group. The texture and the shape of the left amygdala was different in the A+ group but the overall volume did not differ between groups. FC between the amygdala and the whole brain regions did not differ between groups. The internetwork resting-state FC was higher between the "fear circuit" and salience network in the A+ group.

CONCLUSION

Anxiety in PD induces structural modifications of the left amygdala, atrophy of the bilateral fronto-cingulate and the left parietal cortices, and a higher internetwork resting-state FC between the fear circuit and the salience network.

A feasibility trial of an internet-delivered psychological intervention to manage mental health and functional outcomes in neurological disorders

OBJECTIVE

Mental health and cognitive difficulties are highly prevalent across neurological disorders and significantly contribute to poorer patient outcomes. Unfortunately, access to effective psychological services for these comorbidities are limited. To determine whether a novel transdiagnostic internet-delivered psychological intervention, the Wellbeing Neuro Course, was feasible, acceptable and efficacious a single-group feasibility open trial was employed.

METHODS

The Wellbeing Neuro Course, targets mental health and cognitive difficulties, across a variety of neurological disorders. It is comprised of six online lessons, based on Cognitive Behavioural Therapy and Compensatory Cognitive Rehabilitation, delivered over 10 weeks and provided with weekly support from a mental health professional via email and telephone. 105 adults with diagnoses of either epilepsy, multiple sclerosis, Parkinson's disease and/or acquired brain injury, underwent the intervention.

RESULTS

The intervention was found to be highly acceptable with high intervention completion and levels of satisfaction (>95%). There was evidence of clinically significant improvements in primary outcomes (within-group Cohen's d; average reductions) of depression (d = 0.93; avg. reduction ≥36%), anxiety (ds = 0.66, avg. reduction ≥36%), and disability (ds ≥ 0.49; avg. reduction ≥23%) at post-intervention, maintained at 3-month follow-up. For secondary outcomes there were significant improvements in fatigue severity and perceived cognitive difficulties of attention, planning and prospective memory. Findings were achieved with minimal clinician time, highlighting its public health potential.

CONCLUSION

This open trial provides preliminary evidence the Wellbeing Neuro Course is acceptable and reduces symptoms of depression, anxiety and disability in neurological disorders. Future controlled trials of the intervention are now needed.

TRIAL REGISTRATION

ACTRN12617000581369.

Deep Brain Stimulation Impact on Social and Occupational Functioning in Parkinson's Disease with Early Motor Complications

Background

Deep brain stimulation (DBS) improves motor symptoms and quality of life in patients with Parkinson's disease (PD) and early motor complications, suggesting that DBS could be prescribed to the working‐age PD population.

Objectives

To investigate the effect of DBS compared with best medical therapy (BMT) on social, psychosocial, and occupational functioning in patients with PD ≤60 years of age with early motor complications, its correlates, and possible underlying rationale.

Methods

Methods included analyses of the Social and Occupational Functioning Assessment Scale, Scales for Outcomes for Parkinson's–Psychosocial, Professional Fitness, Starkstein Apathy Scale, and Schwab and England Activities of Daily Living Scale from the EARLYSTIM study.

Results

Compared with BMT, DBS resulted in significantly greater improvements from baseline through 24 months in social,occupational, and psychosocial functioning. Yet, work status in the 2 groups did not differ at baseline and 24 months. Physicians reported a significantly higher percentage of patients in the BMT group unable to work at 24 months relative to baseline compared with the DBS group. Apathy was significantly worse in patients for whom physicians overrated ability to work when compared with patients’ own ratings than in the group of patients who physicians' ability to work ratings were comparable to, or worse than, patients' self‐ratings of ability to work.

Conclusions

For patients aged ≤60 years with PD and early motor complications, DBS provided significant improvements in social, occupational, and psychosocial function, but not in the actual work engagement compared with BMT at 2 years. Apathy may impact ability to work.

Parkinson Anxiety Scale: A Validation Study for the Brazilian Population

Objective

The Parkinson Anxiety Scale (PAS) was developed to measure the severity of anxiety symptoms in patients with Parkinson’s disease (PD), and it has not yet been adapted and validated in Portuguese. Thus, this study evaluated the reliability and validity of a translated and adapted version of the PAS for the Brazilian population of PD patients.

Methods

The Parkinson Anxiety Scale – Brazilian Version (PAS-BV) was completed by 55 patients with PD. The reliability (test-retest reliability, interrater reliability and internal consistency) and construct validity of the PAS-BV were assessed by comparing it with the Beck Anxiety Inventory (BAI), the Parkinson’s Disease Fatigue Scale (PFS) and the Unified Parkinson Disease Rating Scale (UPDRS) part III.

Results

Patients with PD had an average age of 64.51 ± 9.20 years and had PD for an average of 6.98 ± 5.02 years. The reliability of the PAS-BV was 0.83, and the intraclass correlation coefficient (ICC) (retest-test) was 0.88. The scale presented good convergent validity with the BAI (r_s = 0.82, p < 0.05). It also presented good divergent validity with the PFS (r_s = 0.24, p > 0.05) and the UPDRS part II (r_s = -0.10, p > 0.05), part III (r_s = -0.21, p > 0.05), and part IV (r_s = 0.03, p > 0.05), as indicated by the absence of significant correlations. However, there was a significant correlation between the PAS-BV and part I of the UPDRS (r_s = 0.67, p < 0.05).

Conclusion

The PAS-BV presents substantial reliability and validity for patients with PD without dementia.

Lewy Body Degenerations as Neuropsychiatric Disorders

Parkinson disease has historically been conceptualized as a movement disorder. In recent decades, nonmotor and neuropsychiatric symptoms have become increasingly recognized as being of paramount importance for patients with Parkinson disease. Neuropsychiatric phenomena dominate the course of the other major Lewy body disease, dementia with Lewy bodies. In this review, we survey the clinical relevance of nonmotor and neuropsychiatric symptoms to the heterogeneous presentations of Lewy body disease and their significance to ongoing research in this area. We consider how the nature of Lewy body neuropathology may help explicate the basis of nonmotor and neuropsychiatric symptoms in these two disorders.

The prevalence of freezing of gait in Parkinson's disease and in patients with different disease durations and severities

Background

The prevalence rates of freezing of gait (FOG) in Parkinson’s disease (PD) vary widely, ranging from 14.0 to 55.1%. Our aim is to calculate the overall prevalence of FOG in all PD patients with different disease durations and severities.

Methods

Using Medline/PubMed/Embase, we carried out a systematic literature search for studies reporting the PD and clinically relevant FOG.

Results

After primary screening, a total of 35 studies were identified and further analyzed for inclusion into the analysis, and 29 studies fulfilled the quality criteria and included in this meta-analysis. The overall prevalence of FOG in PD was 39.9% (95% CI 35.3-44.5%). The FOG identified by the freezing of gait questionnaire item 3 may be more prevalent (43.8%, 95% CI 38.5-49.1%) than the FOG identified by the Unified Parkinson’s Disease Rating Scale item 14 (36.0%, 95% CI 29.0-43.1%). Disease duration and severity are both the clinical features associated with the FOG. The highest FOG prevalence rate in PD patients was seen in patients with disease durations ≥ 10 years, at 70.8%, followed that of PD patients with disease durations ≥ 5 years (53.3%), and PD patients with disease durations < 5 years (22.4%). FOG presented in 28.4% of PD patients with Hoehn and Yahr staging (H&Y) score ≤ 2.5, and in 68.4% of PD patients with H&Y score ≥ 2.5.

Conclusion

This meta-analysis confirms that the prevalence of FOG in PD is considerable, and highlights the need for accurate identification of FOG in PD.

Melatonin supplementation and the effects on clinical and metabolic status in Parkinson's disease: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

This study was performed to evaluate the impact of melatonin supplementation on clinical and metabolic profiles in people with Parkinson's disease (PD).

METHODS

This randomized, double-blind, placebo-controlled clinical trial was conducted among 60 patients with PD. Participants were randomly divided into two groups to intake either 10 mg melatonin (two melatonin capsules, 5 mg each) (n = 30) or placebo (n = 30) once a day, 1 h before bedtime for 12 weeks.

RESULTS

Melatonin supplementation significantly reduced the Unified Parkinson's Disease Rating Scale (UPDRS) part I score (β -2.33; 95% CI, -3.57, -1.09; P < 0.001), Pittsburgh Sleep Quality Index (PSQI) (β -1.82; 95% CI, -3.36, -0.27; P = 0.02), Beck Depression Inventory (BDI) (β -3.32; 95% CI, -5.23, -1.41; P = 0.001) and Beck Anxiety Inventory (BAI) (β -2.22; 95% CI, -3.84, -0.60; P = 0.008) compared with the placebo treatment. Compared with the placebo, melatonin supplementation resulted in a significant reduction in serum high sensitivity C-reactive protein (hs-CRP) (β -0.94 mg/L; 95% CI, -1.55, -0.32; P = 0.003) and a significant elevation in plasma total antioxidant capacity (TAC) (β 108.09 mmol/L; 95% CI, 78.21, 137.97; P < 0.001) and total glutathione (GSH) levels (β 77.08 μmol/L; 95% CI, 44.29, 109.86; P < 0.001). Additionally, consuming melatonin significantly decreased serum insulin levels (β -1.79 μIU/mL; 95% CI, -3.12, -0.46; P = 0.009), homeostasis model of assessment-insulin resistance (HOMA-IR) (β -0.47; 95% CI, -0.80, -0.13; P = 0.007), total- (β -13.16 mg/dL; 95% CI, -25.14, -1.17; P = 0.03) and LDL- (β -10.44 mg/dL; 95% CI, -20.55, -0.34; P = 0.04) compared with the placebo.

CONCLUSIONS

Overall, melatonin supplementation for 12 weeks to patients with PD had favorable effects on the UPDRS part I score, PSQI, BDI, BAI, hs-CRP, TAC, GSH, insulin levels, HOMA-IR, total-, LDL-cholesterol, and gene expression of TNF-α, PPAR-γ and LDLR, but did not affect other metabolic profiles.

Neuropsychiatric aspects of Parkinson disease psychopharmacology: Insights from circuit dynamics

Parkinson disease (PD) is a neurodegenerative disorder with a complex pathophysiology characterized by the progressive loss of dopaminergic neurons within the substantia nigra. Persons with PD experience several motoric and neuropsychiatric symptoms. Neuropsychiatric features of PD include depression, anxiety, psychosis, impulse control disorders, and apathy. In this chapter, we will utilize the National Institutes of Mental Health Research Domain Criteria (RDoC) to frame and integrate observations from two prevailing disease constructions: neurotransmitter anomalies and circuit physiology. When there is available evidence, we posit how unified translational observations may have clinical relevance and postulate importance outside of PD. Finally, we review the limited evidence available for pharmacologic management of these symptoms.

The role of the motor subtypes on the relationship between anxiety and cognitive dysfunctions in Parkinson's disease

Anxiety is a common neuropsychiatric symptom in Parkinson's disease (PD). Until now, anxiety has been consistently related to cognitive deficits and severity of motor symptoms, whereas the association between anxiety and motor subtypes (TD-PD, tremor dominant and PIGD-PD, postural instability/gait disturbances dominant) revealed contrasting results. The present study aims to investigate the relationship between PD motor subtypes and anxiety and to explore whether the relationship between anxiety and cognitive deficits occurs in a specific PD motor subtype. Consecutive PD outpatients were recruited and divided into TD-PD and PIGD-PD groups according to Jankovic et al.'s criteria. All participants underwent a neuropsychological battery to evaluate anxiety, apathy, the global cognitive functioning, memory abilities, executive and visuo-constructional functions. Thirty-six patients with TD-PD and 35 patients with PIGD-PD were enrolled. The two groups did not differ on demographical and clinical variables. As for the severity of anxiety, no significant difference between the two groups was found. Regression analysis revealed that higher anxiety score was associated with poorer performance on constructional visuospatial test in both TD-PD and PIGD-PD. Clinical variables were not associated with anxiety in the two groups. Our findings indicated that the severity of anxiety was not associated with any PD motor subtypes. Moreover, regression analysis revealed that impaired visuo-constructional abilities are related to anxiety independently of PD motor subtypes. Since altered fronto-parietal network might be one of the pathogenetic mechanisms underpinning anxiety and constructional visuospatial deficits, the treatment of cognitive dysfunctions might reduce anxious symptoms.

Exploring the Etiological Links behind Neurodegenerative Diseases: Inflammatory Cytokines and Bioactive Kynurenines

Alzheimer's disease (AD) and Parkinson's disease (PD) are the most common neurodegenerative diseases (NDs), presenting a broad range of symptoms from motor dysfunctions to psychobehavioral manifestations. A common clinical course is the proteinopathy-induced neural dysfunction leading to anatomically corresponding neuropathies. However, current diagnostic criteria based on pathology and symptomatology are of little value for the sake of disease prevention and drug development. Overviewing the pathomechanism of NDs, this review incorporates systematic reviews on inflammatory cytokines and tryptophan metabolites kynurenines (KYNs) of human samples, to present an inferential method to explore potential links behind NDs. The results revealed increases of pro-inflammatory cytokines and neurotoxic KYNs in NDs, increases of anti-inflammatory cytokines in AD, PD, Huntington's disease (HD), Creutzfeldt-Jakob disease, and human immunodeficiency virus (HIV)-associated neurocognitive disorders, and decreases of neuromodulatory KYNs in AD, PD, and HD. The results reinforced a strong link between inflammation and neurotoxic KYNs, confirmed activation of adaptive immune response, and suggested a possible role in the decrease of neuromodulatory KYNs, all of which may contribute to the development of chronic low grade inflammation. Commonalities of multifactorial NDs were discussed to present a current limit of diagnostic criteria, a need for preclinical biomarkers, and an approach to search the initiation factors of NDs.

The association of physical activity and sleep duration with incident anxiety symptoms: A cohort study of 134,957 Korean adults

BACKGROUND

Maintaining adequate levels of sleep and physical activity (PA) as self-help for the prevention of new-onset anxiety symptoms is becoming more important.

METHODS

A cohort study was performed with 134,957 adults, free of anxiety symptoms at baseline who underwent at least two comprehensive health screening examinations between 2012 and 2017. At baseline, the amount of PA was measured using the International Physical Activity Questionnaire-Short Form and sleep duration per day was assessed using a self-report questionnaire. The study's end point was new-onset anxiety symptoms, defined as a Beck Anxiety Inventory score of ≥19.

RESULTS

During 361,969 person-years of follow-up, 5086 participants developed case-level anxiety. Compared with a reference (0-600 METs-min/wk), a U-shaped relationship was observed between PA and case-level anxiety. The most beneficial levels of PA for reducing incident anxiety symptoms were higher in men than women (men: 1800-3000 METs-min/wk HR, 0.88 [95% CI, 0.78-0.81], 3000-6000 METs-min/wk HR, 0.81 [95% CI, 0.70-0.93]; women: 600-1,200 METs-min/wk HR, 0.86 [95% CI, 0.76-0.98]). In comparison with a reference (<6 h), the relationship between sleep duration and case-level anxiety also had a U-shaped pattern. The optimal sleep duration for decreasing the onset of case-level anxiety was 7-8 h, regardless of sex (men: HR, 0.75 [95% CI, 0.63-0.90]; women; HR, 0.61 [95% CI, 0.54-0.70]).

LIMITATIONS

PA, sleep duration, and anxiety symptoms were measured using self-report questionnaires.

CONCLUSIONS

The results of this study revealed the appropriate levels of PA and total sleep time for reducing incident anxiety symptoms.

Ages at Onset of Anxiety and Depressive Disorders in Parkinson's Disease

OBJECTIVE

Parkinson's disease (PD) is a quintessential neuropsychiatric condition in which anxiety and depressive symptoms are common and may precede motor manifestations. The authors explored the ages at onset of anxiety and depressive disorders among patients with PD evaluated by psychiatrists at a deep brain stimulation center.

METHODS

Psychiatric diagnoses and ages at onset were collected via clinical interviews. The ages at PD diagnosis were ascertained by chart review. Onset ages for anxiety and depressive disorders (overall and for specific disorders) were compared with patients' ages at PD diagnosis by using t tests. Onset ages for major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder were compared with typical onset ages in the general population by using the sign test. A total of 108 patients (66.7% men; age 63.7 years [SD=8.9]) were included in the analysis.

RESULTS

Anxiety and depressive disorders occurred significantly earlier than PD diagnoses. Among patients whose anxiety and depression predated motor symptoms, the mean age at onset of anxiety disorders was 25.6 years earlier, and the mean age at onset of depressive disorders was 17.6 years earlier compared with the mean age at PD diagnosis (both p values <0.0001). Median onset ages for MDD (p<0.0001), GAD (p=0.0002), and panic disorder (p=0.0005) were significantly higher than typical median onset ages in the general population.

CONCLUSIONS

These results may indicate that neurodegenerative changes are present in parts of the brainstem reticular core and limbic system before motor circuits are affected to a degree that causes motor symptoms. Psychiatrists should be mindful that onset of MDD, GAD, and panic disorder after age 45 might signal a neurodegenerative movement disorder such as PD.

Neuropsychiatric symptoms in Parkinson's disease: aetiology, diagnosis and treatment

Historically, Parkinson's disease was viewed as a motor disorder and it is only in recent years that the spectrum of non-motor disorders associated with the condition has been fully recognised. There is a broad scope of neuropsychiatric manifestations, including depression, anxiety, apathy, psychosis and cognitive impairment. Patients are more predisposed to delirium, and Parkinson's disease treatments give rise to specific syndromes, including impulse control disorders, dopamine agonist withdrawal syndrome and dopamine dysregulation syndrome. This article gives a broad overview of the spectrum of these conditions, describes the association with severity of Parkinson's disease and the degree to which dopaminergic degeneration and/or treatment influence symptoms. We highlight useful assessment scales that inform diagnosis and current treatment strategies to ameliorate these troublesome symptoms, which frequently negatively affect quality of life.

Unilateral accumbal dopamine depletion affects decision-making in a side-specific manner

Mechanisms underlying affective and cognitive deficits in Parkinson's disease (PD) remain less studied than motor symptoms. Nucleus accumbens (NAc) is affected in PD and due to its well-known involvement in motivation is an interesting target in this context. Furthermore, PD is frequently asymmetrical, with side-specific deficits aligning with evidences of accumbal laterality. We therefore used a 6-hydroxydopamine (6-OHDA) model to study the role of left and right NAc dopamine depletion in a battery of behavioral tasks. 2 months old male rats were used in all experiments. Habitual-based and goal-directed decision-making, impulsivity, anxiety- and depressive-like behavior and motor performance were tested 3 weeks after left (6-OHDA L) or right (6-OHDA R) NAc lesion was induced. Upon contingency degradation, 6-OHDA R decrease their lever press rate less than Sham and 6-OHDA L, indicating an impairment in the shift from habit-based to goal-directed strategies. On the other hand, 6-OHDA L lesions lead to increased rates of premature responding when delays where increased in the variable delay-to-signal test. Importantly, in both paradigms task acquisition was similar between groups. In the same line we found no differences in the amount of sugared pellets eaten when freely available as well as in both general and fine motor behaviors. In conclusion, left and right NAc play distinct roles in the contingency degradation and impulsivity. More studies are needed to understand the mechanisms behind this functional lateralization and its implications for PD patients.

Effects of acute cannabidiol administration on anxiety and tremors induced by a Simulated Public Speaking Test in patients with Parkinson's disease

BACKGROUND

Cannabidiol (CBD) is one of the main components of Cannabis sativa and has anxiolytic properties, but no study has been conducted to evaluate the effects of CBD on anxiety signs and symptoms in patients with Parkinson's disease (PD). This study aimed to evaluate the impacts of acute CBD administration at a dose of 300 mg on anxiety measures and tremors induced by a Simulated Public Speaking Test (SPST) in individuals with PD.

METHODS

A randomised, double-blinded, placebo-controlled, crossover clinical trial was conducted. A total of 24 individuals with PD were included and underwent two experimental sessions within a 15-day interval. After taking CBD or a placebo, participants underwent the SPST. During the test, the following data were collected: heart rate, systemic blood pressure and tremor frequency and amplitude. In addition, the Visual Analog Mood Scales (VAMS) and Self-Statements during Public Speaking Scale were applied. Statistical analysis was performed by repeated-measures analysis of variance (ANOVA) while considering the drug, SPST phase and interactions between these variables.

RESULTS

There were statistically significant differences in the VAMS anxiety factor for the drug; CBD attenuated the anxiety experimentally induced by the SPST. Repeated-measures ANOVA showed significant differences in the drug for the variable related to tremor amplitude as recorded by the accelerometer.

CONCLUSION

Acute CBD administration at a dose of 300 mg decreased anxiety in patients with PD, and there was also decreased tremor amplitude in an anxiogenic situation.

Neuropsychiatric Disorders in Parkinson's Disease: What Do We Know About the Role of Dopaminergic and Non-dopaminergic Systems?

Besides the hallmark motor symptoms (rest tremor, hypokinesia, rigidity, and postural instability), patients with Parkinson’s disease (PD) have non-motor symptoms, namely neuropsychiatric disorders. They are frequent and may influence the other symptoms of the disease. They have also a negative impact on the quality of life of patients and their caregivers. In this article, we will describe the clinical manifestations of the main PD-related behavioral disorders (depression, anxiety disorders, apathy, psychosis, and impulse control disorders). We will also provide an overview of the clinical and preclinical literature regarding the underlying mechanisms with a focus on the role of the dopaminergic and non-dopaminergic systems.

Influence of aversive stimulation on haloperidol-induced catalepsy in rats

Catalepsy - an immobile state in which individuals fail to change imposed postures - can be induced by haloperidol. In rats, the pattern of haloperidol-induced catalepsy is very similar to that observed in Parkinson's disease (PD). As some PD symptoms seem to depend on the patient's emotional state, and as anxiety disorders are common in PD, it is possible that the central mechanisms regulating emotional and cataleptic states interplay. Previously, we showed that haloperidol impaired contextual-induced alarm calls in rats, without affecting footshock-evoked calls. Here, we evaluated the influence of distinct aversive stimulations on the haloperidol-induced catalepsy. First, male Wistar rats were subjected to catalepsy tests to establish a baseline state after haloperidol or saline administration. Next, distinct cohorts were exposed to open-field; elevated plus-maze; open-arm confinement; inescapable footshocks; contextual conditioned fear; or corticosterone administration. Subsequently, catalepsy tests were performed again. Haloperidol-induced catalepsy was verified in all drug-treated animals. Exposure to open-field, elevated plus-maze, open-arm confinement, footshocks, or administration of corticosterone had no significant effect on haloperidol-induced catalepsy. Contextual conditioned fear, which is supposed to promote a more intense fear, increased catalepsy over time. Our findings suggest that only specific defensive circuitries modulate the nigrostriatal system mediating the haloperidol-induced cataleptic state.

The Effect of the COVID-19 Pandemic on People with Parkinson's Disease

BACKGROUND

The effect of the COVID-19 pandemic on people with Parkinson's disease (PD) is poorly understood.

OBJECTIVE

To rapidly identify areas of need and improve care in people with PD during the COVID-19 pandemic, we deployed a survey to assess COVID-19 symptoms and the pandemic's effect among those with and without COVID-19.

METHODS

People with and without PD participating in the online study Fox Insight (FI) were invited to complete a survey between April 23 and May 23, 2020. Among people reporting COVID-19 diagnoses, we compared symptoms and outcomes in people with and without PD. Among people not reporting COVID-19, we assessed access to healthcare and services and PD symptoms.

RESULTS

7,209/9,762 active FI users responded (approximately 74% response rate), 5,429 people with PD and 1,452 without PD. COVID-19 diagnoses were reported by 51 people with and 26 without PD. Complications were more frequent in people with longer PD duration. People with PD and COVID-19 experienced new or worsening motor (63%) and nonmotor (75%) symptoms. People with PD not diagnosed with COVID-19 reported disrupted medical care (64%), exercise (21%), and social activities (57%), and worsened motor (43%) and non-motor (52%) symptoms. Disruptions were more common for those living alone, with lower income and non-White race.

CONCLUSIONS

The COVID-19 pandemic is associated with wide-ranging effects on people with PD, and certain groups may be at particular risk. FI provides a rapid, patient-centered means to assess these effects and identify needs that can be used to improve the health of people with PD.

Report from a multidisciplinary meeting on anxiety as a non-motor manifestation of Parkinson's disease

Anxiety is a severe problem for at least one-third of people living with Parkinson's disease (PD). Anxiety appears to have a greater adverse impact on quality of life than motor impairment. Despite its high prevalence and impact on daily life, anxiety is often undiagnosed and untreated. To better address anxiety in PD, future research must improve knowledge about the mechanism of anxiety in PD and address the lack of empirical evidence from clinical trials. In response to these challenges, the Parkinson's Foundation sponsored an expert meeting on anxiety on June 13th and 14th 2018. This paper summarizes the findings from that meeting informed by a review of the existing literature and discussions among patients, caregivers, and an international, clinician-scientist, expert panel working group. The goal is to provide recommendations to improve our understanding and treatment of anxiety in PD.

Measuring Anxiety in Older Adults: Development, Diagnostic Accuracy, and Preliminary Validation of a Short-Form of the German Geriatric Anxiety Scale (GAS-G-SF)

Anxiety symptoms and anxiety disorders are highly prevalent among older adults, and are associated with considerable distress, functional impairment, and burden. Also, there is growing need for brief instruments to measure anxiety symptoms in primary care and geriatric medical settings. Therefore, the current study focuses on the development and psychometric evaluation of a short-form of the Geriatric Anxiety Scale (GAS-G), a well-established anxiety instrument for use with older adults. Study 1 draws on the original data from the GAS-G validation study (N = 242) to develop the short-form (GAS-G-SF) and determines whether the results replicate with the short-form. Study 2 extends the validation of the GAS-G-SF to a clinical sample (N = 156; 62 patients with heart disease, 94 patients with Parkinson's disease). Overall, the GAS-G-SF showed promising psychometric properties in terms of internal consistency and validity. Also, the GAS-G-SF showed good discriminatory power based on receiver operating characteristic curve analysis in both studies. These results support the utility of the GAS-G-SF as a brief assessment measure for anxiety.

Effects of Cognitive Performance and Affective Status on Fatigue in Parkinson's Disease

Background

Fatigue is a common non-motor symptom in Parkinson's disease (PD) and is typically assessed via self-reported questionnaires such as the Parkinson's Fatigue Scale (PFS). The PFS captures the presence of subjective experience of physical fatigue as well as its impact on daily functioning.

Objectives

We aimed to investigate whether different variables (cognition, neuropsychiatric symptoms, disease-related measures) are associated with the experience of physical fatigue in comparison to fatigue affecting daily functioning.

Method

Sixty-two non-demented PD patients were evaluated through questionnaires assessing fatigue, daytime sleepiness, apathy, depression, anxiety, and cognition. Items of fatigue were classified and summarized into two index variables measuring either the subjective experience of physical fatigue or the impact of fatigue on daily functioning. Linear regression with a stepwise elimination procedure was conducted to select the significant predictors for each index variable separately.

Results

Subjective experience of physical fatigue (Model 1; r² = 0.46; p <0.01) was significantly associated with higher levels of depression (b =0.07; p <0.01), anxiety (b =0.03; p <0.05), and lower performances in verbal episodic memory (b =-0.16; p <0.05). Fatigue affecting daily functioning (Model 2; r² = 0.44; p <0.05) was significantly related to higher levels of depression (b = 0.07; p < 0.01), anxiety (b = 0.03; p > 0.05), and lower motor functioning (b = 0.01; p = 0.05).

Conclusions

In conclusion, our work supports associations between fatigue and other neuropsychiatric symptoms in PD and extends prior work suggesting that motor disturbances are specifically linked to fatigue-related impairment of daily functioning, but not to the subjective experience of physical fatigue.

Depression and Anxiety in Parkinson Disease

Depression and anxiety are common neuropsychiatric manifestations of Parkinson disease. However, they are often under-recognized because the somatic symptoms of depression often overlap with the motor symptoms of Parkinson disease and there is low self-reporting. Clinicians need to be vigilant about early detection and treatment of anxiety and depression in the patient with Parkinson disease. The development of new therapeutic strategies, including diet, exercise, and counseling along with antidepressants provide a holistic approach to management.

Design and validation of a new instrument to assess fear of falling in Parkinson's disease

BACKGROUND

Fear of falling may be significantly associated with falls in Parkinson's disease (PD) and may have a negative impact on quality of life. Nevertheless, there are no valid and reliable tools to examine this condition in PD. The objective of this study was to design and determine the psychometric attributes of an instrument to assess fear of falling in PD.

METHODS

A prospective 1-year, 2-phase study was conducted to validate the Fear of Falling Scale, a self-assessed instrument for assessing fear of falling in PD. During phase 1, we designed a scale to measure the severity of fear of falling and determine its baseline psychometric characteristics, whereas phase 2 was a 1-year follow-up study to assess the frequency of falls and other clinical factors linked to fear of falling. Convergent and discriminant validity were assessed against the Fear of Falling Measure and the Starkstein Apathy Scale, respectively.

RESULTS

The Fear of Falling Scale showed high internal consistency, test-retest reliability, and strong convergent and discriminant validity. There was a significant association between fear of falling score and the presence of both generalized anxiety disorder and major depression, poor balance-related motor ability, increased nonmotor symptoms of PD, more severe impairments in activities of daily living, and increased motor fluctuations. Finally, generalized anxiety disorder was a significant predictor of number of falls during a 12-month follow-up period.

CONCLUSIONS

The Fear of Falling Scale is a valid and reliable instrument to assess fear of falling in PD. Fear of falling in PD is associated with specific psychiatric and motor disorders and is significantly related to the performance of balance-related motor functions. © 2019 International Parkinson and Movement Disorder Society.

Imaging behavioural complications of Parkinson's disease

In addition to motor symptoms, behavioural complications are commonly found in patients with Parkinson's disease (PD). Behavioural complications, including depression, anxiety, apathy, impulse control disorder and psychosis, together have a large impact on PD patient's quality of life. Many neuroimaging studies using PET, SPECT and MRI techniques have been conducted to study the underlying neural mechanisms of PD pathogenesis and pathophysiology in relation to its behavioural complications. This review will survey these PET, SPECT and MRI studies to describe the current understanding of the neuro-chemical, functional and structural changes associated with behavioural complications in PD patients.