Efficacy of cognitive behavioral therapy for insomnia comorbid to Parkinson's disease: A focus on psychological and daytime functioning with a single‐case design with multiple baselines

A Systematic Review of Psychotherapy Approaches for Anxiety in Parkinson's Disease

OBJECTIVES

Anxiety is common in Parkinson's disease (PD), negatively impacting daily functioning and quality of life in PD patients and their families. This systematic review evaluates the effectiveness of different psychotherapeutic approaches for reducing anxiety in PD and provides recommendations for clinical practise.

METHODS

Following PRISMA guidelines, 36 studies were included and risk of bias was evaluated.

RESULTS

We identified cognitive behavioral therapy (CBT), mindfulness-based therapies, acceptance and commitment therapy, and psychodrama psychotherapies. There is good evidence-base for anxiety reduction using CBT approaches, but with mixed results for mindfulness-based therapies. Other therapeutic approaches were under researched. Most randomized control trials examined anxiety as a secondary measure. There was a paucity of interventions for anxiety subtypes. Secondarily, studies revealed the consistent exclusion of PD patients with cognitive concerns, an importance of care partner involvement, and a growing interest in remote delivery of psychotherapy interventions.

CONCLUSIONS

Person-centered anxiety interventions tailored for PD patients, including those with cognitive concerns, and trials exploring modalities other than CBT, warrant future investigations.

CLINICAL IMPLICATIONS

Practitioners should consider PD-specific anxiety symptoms and cognitive concerns when treating anxiety. Key distinctions between therapeutic modalities, therapy settings and delivery methods should guide treatment planning.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

How to Evaluate a Tailor-made Social Work Intervention? Some Practice-Based Solutions with Single-Case Designs

PURPOSE

With the increased attention to the principles of evidence-based practice (EBP), social workers are challenged to adapt their daily interventions accordingly when treating clients. They usually work with individual clients, all with their own specificities. Single-Case Experimental Designs (SCEDs) can be used to inform a social worker about the effectiveness of an intervention at the individual client level. In everyday social work practice, however, it is difficult to meet methodological requirements of SCEDs to find causal explanations. A concern is that repeated measurements prior to an intervention are required in most situations. This study aims to provide researchers with alternatives to repeated measurement when using the logic of SCED to apply EBP in their everyday practice.

METHODS

In this study, we reviewed published single-case designs between January 1 and December 31, 2019, on types of SCEDs in the social domain, and how is dealt with baseline conditions.

RESULTS

SCEDs and quasi-experimental alternatives are hardly published in situations when baseline data are not available. Four underused quasi-experimental strategies that can be employed when repeated measurement during baseline is not possible are as follows: retrospective baselines, theoretical inference, multiraters, and triangulation with qualitative data.

DISCUSSION AND CONCLUSION

The suggestions to work with single-case designs with quasi-experimental elements are meant to enable social workers to evaluate their interventions in a way that enhances mere narrative evaluations of the experiences of an intervention.

Hypnotics and injuries among older adults with Parkinson's disease: a nested case-control design

BACKGROUND

Patients with Parkinson's disease often experience sleep disorders. Hypnotics increase the risk of adverse events, such as injuries due to falls. In this study, we evaluated the association between hypnotics and injuries among older adults with Parkinson's disease.

METHODS

The study used a nested case-control design. The participants were 5009 patients with Parkinson's disease aged ≥ 75 years based on claims data between April 2016 and March 2019 without prescription hypnotics 1 year before the study started. Hypnotics prescribed as oral medications included benzodiazepines, non-benzodiazepines, orexin receptor antagonists, and melatonin receptor agonists. The incidences of outcomes, including injuries, fractures, and femoral fractures, were determined. Each case had four matched controls. Conditional logistic regression analyses were performed to calculate the odds ratios and 95% confidence intervals for the number of hypnotics taken per day for each type of hypnotic.

RESULTS

The proportion of participants taking at least one type of hypnotic was 18.6%, with benzodiazepines being the most common. The incidence of injuries, fractures, and femoral fractures was 66.7%, 37.8%, and 10.2%, respectively. Benzodiazepines significantly increased the risk of injuries (odds ratio: 1.12; 95% confidence interval: 1.03-1.22), and melatonin receptor agonists significantly increased the risk of femoral fractures (odds ratio: 2.84; 95% confidence interval: 1.19-6.77).

CONCLUSIONS

Benzodiazepines and non-benzodiazepines, which are not recommended according to current guidelines, were the most prevalent among older adults with Parkinson's disease. Benzodiazepines significantly increased the risk of injuries, and melatonin receptor agonists significantly increased the risk of femoral fractures.

Clinical Evaluation of Sleep Disorders in Parkinson’s Disease

The paradigm of the framing of Parkinson’s disease (PD) has undergone significant revision in recent years, making this neurodegenerative disease a multi-behavioral disorder rather than a purely motor disease. PD affects not only the “classic” substantia nigra at the subthalamic nuclei level but also the nerve nuclei, which are responsible for sleep regulation. Sleep disturbances are the clinical manifestations of Parkinson’s disease that most negatively affect the quality of life of patients and their caregivers. First-choice treatments for Parkinson’s disease determine amazing effects on improving motor functions. However, it is still little known whether they can affect the quantity and quality of sleep in these patients. In this perspective article, we will analyze the treatments available for this specific clinical setting, hypothesizing a therapeutic approach in relation to neurodegenerative disease state.

Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand?

PURPOSE

To explore the heterogeneity of the literature on psychological interventions for psychological difficulties in people with Parkinson's disease (PD).

METHODS

A scoping review was performed across five major databases (MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library) up to June 2020.

RESULTS

From an initial return of 4911 citations, 56 studies were included, of which 21 were RCTs. A relatively wide range of therapeutic models have been adopted with people with PD, from common therapies such as cognitive behavioural therapy (CBT) and mindfulness, to less frequent approaches, for example, acceptance and commitment therapy (ACT) and psychodrama. The clinical implications of the findings are discussed, and suggestions are provided for future research on intervention studies and key psychological outcomes.

CONCLUSIONS

CBT appears to be effective in treating depression and sleep disorders in people with PD, while psychoeducation programmes alone should be avoided. The use of CBT to improve anxiety, quality of life, and impulse control, as well mindfulness-based interventions, should be undertaken with some caution because of insufficient research and inconsistent results. As we enter the new decade, more high-quality evidence is required for psychological interventions in people with PD in general and to corroborate preliminary positive findings on the adoption of less frequent approaches such as ACT.

PRACTITIONER POINTS

Parkinson's disease is a progressive neurodegenerative condition associated with several psychological difficulties which be targeted by psychological interventions. Currently, cognitive behavioural therapy (CBT) can be recommended to treat depression and sleep disorders in people with Parkinson's, while psychoeducation alone should be avoided. Caution is advised regarding the use of CBT and mindfulness-based interventions to improve anxiety, quality of life, and impulse control. Further evidence is required for less common approaches, such as acceptance and commitment therapy, psychodrama, and EMDR.

The Growing Role of Cognitive Behavior Therapy in the Treatment of Parkinson's Disease

Neuropsychiatric symptoms occur frequently in Parkinson's disease (PD) patients. Pharmacological treatment of the psychiatric symptoms has been found to be inadequate. Cognitive behavior therapy (CBT) is an evidence based form of psychotherapy that is effective in treating a number of psychiatric disorders. In this article we examine the evidence of CBT in treating common psychiatric symptoms seen in PD patients, namely depression, anxiety, insomnia and impulse control behaviors. Most of the studies adapted CBT to address PD related concerns. Caregivers were frequently part of the CBT programs. Among the studies reviewed, randomized controlled trials showed significant effects in treating depression with CBT in PD patients. Studies have also provided preliminary data for effects of CBT on anxiety, impulse-control behaviors and insomnia. There is a need for more well designed studies with sufficient power for CBT to be established as a useful non-pharmacological treatment for psychiatric symptoms in PD.

Sleep Disorders in Parkinson Disease

Sleep disorders in Parkinson disease have attracted the attention of clinicians and researchers for decades. Recently, major advances in their clinical characterization, polysomnographic description, pathophysiologic understanding, and treatment took place. Parkinson disease encompasses the whole spectrum of sleep medicine: every category of sleep disorder can be observed in these patients. Video polysomnography frequently is indicated, sometimes followed by multiple sleep latency/maintenance of wakefulness tests. Additional studies may include actigraphy, cardiorespiratory polygraphy, and dim light melatonin assessment. Treatment needs to be specific to the underlying sleep disorder and can include medications and nondrug treatments, for example, behavioral therapy and light therapy.

The effects of bright light therapy on depression and sleep disturbances in patients with Parkinson's disease: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Depression and sleep disturbance are well-recognized non-motor features in patients with Parkinson's disease (PD). This meta-analysis aimed to explore the potential role of bright light therapy (BLT) in depression and sleep disturbances in Parkinson's Disease (PD).

METHODS

Four databases were independently searched by two reviewers: PubMed, Cochrane, Web of Science and Embase until February 2021. We evaluated the following depression related scales: Beck's Depression Inventory (BDI); the Geriatric Depression Rating Scale, 30-item (GDS-30); the Hamilton Depression Rating Scale (HDRS); the Hospital Anxiety and Depression Scale (HADS); the Epworth sleepiness scale (ESS); the Fatigue Severity Scale (FSS); the Pittsburgh sleep quality index (PSQI); the Parkinson's disease sleep scale (PDSS); Scales for Outcomes in Parkinson's disease Sleep Scale (SCOPA) and the Insomnia severity index (ISI) to access the effects of bright light therapy on depression and sleep disturbances in patients with PD. Effect size (standardized mean deviation [SMD] and 95% confidence interval [CI]) were used to analyze the continuous results data of intervention group and control light group. Data from five randomized, controlled trials totaling 173 patients with PD was included.

RESULTS

BLT significantly improved depression symptoms (BDI, GDS-30, HDRS and HADS) of PD patients (0.34, 95% CI = 0.06-0.61). Insomnia symptoms (SCOPA and ISI) for patients with PD were significantly improved by BLT as well (1.15, 95% CI = 0.71-1.60). Whereas, no difference was observed in the control light group in improving the depression or insomnia symptoms of PD patients.

CONCLUSION

BLT is an effective intervention for improving depressive symptoms and sleep disturbances in patients with PD.

Understanding the influence of pain and fatigue on physical performance, fear of falling and falls in people with Parkinson's disease: a pilot study

Objective: Pain and fatigue are highly prevalent debilitating symptoms in Parkinson's disease (PD), however, their relationship with physical performance, fear of falling (FOF) and falls is not clear. We aim in this pilot study to investigate the relationship of pain and fatigue with physical performance, FOF and falls in people with Parkinson's disease (PwPD). Materials & methods: 53 PD patients were assessed for fall history, physical performance, FOF, pain and fatigue. Results: Pain and fatigue are significantly associated with physical performance and FOF (p ≤ 0.002). Pain and fatigue were different between fallers and non-fallers (p < 0.5), but only fatigue could distinguish fallers from non-fallers (area under the receiver operating characteristics curve = 0.81; p < 0.0001). Conclusion: This pilot study indicated that FOF in PwPD is significantly associated with pain and fatigue. Furthermore, fatigue level is related to fall history. By addressing pain and fatigue, we may ameliorate the deterioration of FOF and falls in PwPD.

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.

Sleep Issues in Parkinson's Disease and Their Management

Parkinson's disease (PD) is an alpha-synucleinopathy that leads to prominent motor symptoms including tremor, bradykinesia, and postural instability. Nonmotor symptoms including autonomic, neurocognitive, psychiatric symptoms, and sleep disturbances are also seen frequently in PD. The impact of PD on sleep is related to motor and nonmotor symptoms, in addition to the disruption of the pathways regulating sleep by central nervous system pathology. Rapid eye movement sleep behavior disorder is a parasomnia that can lead to self-injury and/or injury to partners at night. Restless legs syndrome is a subjective sensation of discomfort and urge to move the legs prior to falling asleep and can lead to insomnia and reduced sleep quality. Excessive daytime sleepiness is common in PD and exerts a negative impact on quality of life in addition to increasing the risk of falls. Obstructive sleep apnea is a breathing disorder during sleep that can cause frequent awakenings and excessive daytime sleepiness. Circadian rhythm dysfunction can lead to an advanced or delayed onset of sleep in patients and create disruption of normal sleep and wake times. All of these disorders are common in PD and can significantly reduce sleep quantity, sleep quality, or quality of life for patients and caretakers. Treatment approaches for each of these disorders are distinct and should be individualized to the patient. We review the literature regarding these common sleep issues encountered in PD and their treatment options.

Clinical practice guidelines based on evidence for cognitive-behavioural therapy in Parkinson's disease comorbidities: A literature review

The purpose of this review is to provide psychologists and other health care professional enough knowledge about available cognitive-behavioural interventions for comorbidities in Parkinson's disease that include depression, anxiety, impulsive disorder, pain, and sleep disturbances. This review has clear clinical practical suggestions how to adapt psychological interventions and techniques to the motor and/or cognitive impairments of patients with Parkinson's disease, based on earlier available research results. Every available research that could be found with the help of search engines from Medline, Springer, PsychINFO, and Google Scholar, which used cognitive-behavioural therapy to treat Parkinson's comorbidities, was cited and explained. Cognitive-behavioural interventions and techniques are presented based on available research results for Parkinson's comorbidities. It is recommended to use treatment plans and interventions that are earlier suggested as efficient in patients with Parkinson's disease. Strongest available research based recommendations are available for depression and anxiety. There are only few available research studies that used cognitive and/or behavioural interventions for pain, impulsive disorder, or sleeping disturbances, except insomnia in Parkinson's disease. Cognitive-behavioural therapy is safe to use and should be adapted to the specific needs of patients and with the scientific approved treatment interventions and techniques. Psychologists should be careful on how they adapt their treatment plan for patients.