Gray Matter Vulnerabilities Predict Longitudinal Development of Apathy in Huntington's Disease

Mapping Longitudinal Psychiatric Signatures in Huntington's Disease

OBJECTIVE

Although Huntington's disease is characterized by motor onset, psychiatric disturbances may present years prior and affect functioning. However, there is inter-individual variability in psychiatric expression and progression. This study therefore strives to stratify longitudinal psychiatric signatures that may inform Huntington's disease prognosis, with potential clinical applications.

METHODS

Forty-six Huntington's disease gene carriers (21 premanifest, 25 manifest; 31 female; age range 25-69) underwent short-Problem Behavior Assessment for depression, irritability, apathy, and dysexecutive behaviors for up to six longitudinal visits. The Disease Trajectories software, a machine-learning approach, was employed to perform unsupervised clustering of psychiatric trajectories. Linear fits were calculated for each cluster. Lastly, the main clusters of shared trajectories were assessed for group differences in demographic and clinical characteristics.

RESULTS

The Disease Trajectories analysis software identified two main psychiatric patterns comprising premanifest and manifest patients that explained 54% of the sample. These two clusters evinced a dissociation in the development of depression and irritability; the first cluster was defined by increasing irritability with no depression and the second by a rise-and-fall in depression with no irritability. Both clusters showed a longitudinal increase in clinically relevant apathy and dysexecutive behaviors.

CONCLUSIONS

Ultimately, through the detection of individual-level psychiatric trajectories with machine-learning, this exploratory study reveals that a dissociation of depression and irritability is apparent even in premanifest stages. These findings underscore individual differences in the severity of longitudinal multivariate clinical characteristics for real-world patient stratification, with implications for precision medicine.

Frequency of depression in Huntington's disease: A systematic review and meta-analysis

BACKGROUND

Huntington's disease (HD) is a hereditary neurodegenerative disease characterized by a combination of motor, cognitive, and mental health issues, with depression being the most common. Despite its importance, the relationship between depression and disease progression is still debatable.

OBJECTIVE

The primary objective of this study was to examine the frequency of depression across different disease stages in individuals with HD. We also explored the associations between depression and other HD-related factors.

METHODS

This systematic review comprehensively searched MEDLINE, APA PsycINFO, and Embase databases for studies on depression in individuals with HD. Pooled depression frequencies were calculated for premanifest and manifest HD. Depression was analyzed based on HD functional stages and diagnostic tools, alongside reviewing its association with various HD factors.

RESULTS

We assessed 6523 records and included 104 studies. Our meta-analyses revealed that the overall frequency of depression was higher in manifest HD compared to premanifest HD (0.38 vs. 0.23). However, the progression of depression did not follow a consistent pattern, with peaks occurring in earlier rather than later stages. Additionally, the frequency of depression was lower in studies using diagnostic criteria compared to those using clinical scales (0.25 vs. 0.42).

CONCLUSIONS

Our findings showed that the rate of depression is high in HD and varies depending on the disease stage and the criteria used. This emphasizes the necessity for tailored and unified diagnostic criteria for depression in HD.

Cognitive engagement may slow clinical progression and brain atrophy in Huntington's disease

Lifelong cognitive engagement conveys benefits in Huntington's disease (HD) and may positively affect non-cognitive domains in other populations. However, the effect of lifelong cognitive engagement on the progression of motor and psychiatric domains in HD remains unknown, as is its neurobiological basis. Forty-five HD individuals completed the Cognitive Reserve Questionnaire (CRQ) and longitudinal clinical evaluation (maximum total of six visits, mean inter-assessment duration of 13.53 ± 4.1 months). Of these, thirty-three underwent longitudinal neuroimaging (18 ± 6 months follow-up). Generalized linear mixed-effects models were executed to predict the effect of individual differences in lifelong cognitive engagement on HD clinical progression and voxel-based morphometry to explore the impact of lifelong cognitive engagement on whole-brain gray matter volume atrophy. Controlling for age, disease stage, and sex, higher CRQ scores were associated with reduced overall severity and longitudinal progression across cognitive, motor, and psychiatric domains. Those with higher CRQ scores demonstrated reduced gray matter volume loss in the middle frontal gyrus, supplementary motor area, and middle cingulate. This putative impact on HD clinical progression may be conferred by preservation of brain volume in neural hubs that integrate executive function with action initiation and behavioral regulation, providing support for early cognitive engagement, even prior to diagnosis.

Apathy and Impulsivity Co-Occur in Huntington's Disease

BACKGROUND

Apathy is a debilitating behavioral change in Huntington's disease (HD), but impulsivity in HD has not been well documented, and the co-occurrence of these behaviors in HD has not been investigated.

OBJECTIVE

Our objective was to determine whether apathy and impulsivity co-occur in people with HD and their associations with quality of life.

METHODS

Carriers of Huntington's gene expansion (premanifest to mild motor manifest disease; n = 42) along with healthy controls (n = 20) completed measures of apathy (Apathy Evaluation Scale and Apathy Motivation Index) and impulsivity (Barratt Impulsiveness Scale-11 and UPPS-P impulsivity scale), along with mood, cognition, clinical, and quality of life measures. Apathy and impulsivity measures were each reduced to a single metric per patient using principal component analysis. Correlations and multiple linear regression models determined associations between apathy and impulsivity and the potential influence of other covariates.

RESULTS

Apathy and impulsivity were significantly correlated (r = 0.6, p < 0.001, 95% CI [0.36, 0.76]) in HD, with this association remaining after controlling for depressive symptoms, motor disease severity, and cognitive function. Furthermore, apathy and depressive symptoms were associated with poorer quality of life.

CONCLUSIONS

Apathy and impulsivity co-occur in individuals with premanifest to mild manifest HD and have a significant impact on wellbeing. We add to a growing evidence body that apathy and impulsivity may be intrinsically linked.

[Psychiatric symptoms of Huntington's disease]

Huntington's disease (HD) is an autosomal dominant inherited disease, which leads to motor, cognitive and psychiatric symptoms. The diagnosis can be confirmed by genetic testing for extended CAG repeats in the Huntingtin gene. Mental and behavioral symptoms are common in HD and can appear several years before the onset of motor symptoms. The psychiatric symptoms include apathy, depression, anxiety, obsessive-compulsive symptoms and, in some cases, psychoses and aggression. These are currently restricted to symptomatic treatment as disease-modifying treatment approaches are still under investigation. The current clinical practice is based on expert opinions as well as experience with the treatment of similar symptoms in other neurological and mental health diseases. This article provides an overview of the complex psychiatric manifestations of HD, the diagnostic options and the established pharmacological and nonpharmacological treatment approaches.

Pain in Huntington's disease and its potential mechanisms

Pain is common and frequent in many neurodegenerative diseases, although it has not received much attention. In Huntington's disease (HD), pain is often ignored and under-researched because attention is more focused on motor and cognitive decline than psychiatric symptoms. In HD progression, pain symptoms are complex and involved in multiple etiologies, particularly mental issues such as apathy, anxiety and irritability. Because of psychiatric issues, HD patients rarely complain of pain, although their bodies show severe pain symptoms, ultimately resulting in insufficient awareness and lack of research. In HD, few studies have focused on pain and pain-related features. A detailed and systemic pain history is crucial to assess and explore pain pathophysiology in HD. This review provides an overview concentrating on pain-related factors in HD, including neuropathology, frequency, features, affecting factors and mechanisms. More attention and studies are still needed in this interesting field in the future.

The neural correlates of apathy in the context of aging and brain disorders: a meta-analysis of neuroimaging studies

Introduction

Apathy is a prevalent mood disturbance that occurs in a wide range of populations, including those with normal cognitive aging, mental disorders, neurodegenerative disorders and traumatic brain injuries. Recently, neuroimaging technologies have been employed to elucidate the neural substrates underlying brain disorders accompanying apathy. However, the consistent neural correlates of apathy across normal aging and brain disorders are still unclear.

Methods

This paper first provides a brief review of the neural mechanism of apathy in healthy elderly individuals, those with mental disorders, neurodegenerative disorders, and traumatic brain injuries. Further, following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, the structural and functional neuroimaging meta-analysis using activation likelihood estimation method is performed on the apathy group with brain disorders and the healthy elderly, aiming at exploring the neural correlates of apathy.

Results

The structural neuroimaging meta-analysis showed that gray matter atrophy is associated with apathy in the bilateral precentral gyrus (BA 13/6), bilateral insula (BA 47), bilateral medial frontal gyrus (BA 11), bilateral inferior frontal gyrus, left caudate (putamen) and right anterior cingulate, while the functional neuroimaging meta-analysis suggested that the functional connectivity in putamen and lateral globus pallidus is correlated with apathy.

Discussion

Through the neuroimaging meta-analysis, this study has identified the potential neural locations of apathy in terms of brain structure and function, which may offer valuable pathophysiological insights for developing more effective therapeutic interventions for affected patients.

Distinguishing apathy from depression: A review differentiating the behavioral, neuroanatomic, and treatment-related aspects of apathy from depression in neurocognitive disorders

OBJECTIVES

This narrative review describes the clinical features of apathy and depression in individuals with neurocognitive disorders (NCDs), with the goal of differentiating the two syndromes on the basis of clinical presentation, diagnostic criteria, neuropathological features, and contrasting responses to treatments.

METHODS

Literature was identified using PubMed, with search terms to capture medical conditions of interest; additional references were also included based on our collective experience and knowledge of the literature.

RESULTS

Evidence from current literature supports the distinction between the two disorders; apathy and depression occur with varying prevalence in individuals with NCDs, pose different risks of progression to dementia, and have distinct, if overlapping, neurobiological underpinnings. Although apathy is a distinct neuropsychiatric syndrome, distinguishing apathy from depression can be challenging, as both conditions may occur concurrently and share several overlapping features. Apathy is associated with unfavorable outcomes, especially those with neurodegenerative etiologies (e.g., Alzheimer's disease) and is associated with an increased burden for both patients and caregivers. Diagnosing apathy is important not only to serve as the basis for appropriate treatment, but also for the development of novel targeted interventions for this condition. Although there are currently no approved pharmacologic treatments for apathy, the research described in this review supports apathy as a distinct neuropsychiatric condition that warrants specific treatments aimed at alleviating patient disability.

CONCLUSIONS

Despite differences between these disorders, both apathy and depression pose significant challenges to patients, their families, and caregivers; better diagnostics are needed to develop more tailored treatment and support.

Frequency and Pathophysiology of Apathy in Huntington Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Apathy is a common behavioral symptom of Huntington disease (HD). This systematic review describes current evidence on the pathophysiology, assessment, and frequency of apathy in HD.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. Using a comprehensive search strategy, the investigators searched the MEDLINE, Embase, and PsycINFO databases. All studies that evaluated apathy in HD patients with a valid scale and reported apathy frequency or scores were included. Apathy scores were analyzed by mean or standardized mean differences in accordance with Cochrane guidelines.

RESULTS

A total of 1,085 records were screened and 80 studies were ultimately included. The Problem Behaviors Assessment-Short was the most frequently used apathy assessment tool. Apathy frequency generally ranged from 10%-33% in premanifest HD to 24%-76% in manifest HD. A meta-analysis of 5,311 records of patients with premanifest HD showed significantly higher apathy scores, with a standardized mean difference of 0.41 (CI=0.29-0.52; p<0.001). A comparison of 1,247 patients showed significantly higher apathy scores in manifest than premanifest HD, with a mean difference of 1.87 (CI=1.48-2.26; p<0.001). There was evidence of involvement of various cortical and subcortical brain regions in HD patients with apathy.

CONCLUSIONS

Apathy was more frequent among individuals with premanifest HD compared with those in a control group and among individuals with manifest HD compared with those with premanifest HD. Considering the complexity and unique pattern of development in neurodegenerative disease, further studies are required to explore the pathophysiology of apathy in HD.

Disordered Decision Making: A Cognitive Framework for Apathy and Impulsivity in Huntington's Disease

A caregiver's all‐too‐familiar narrative ‐ “He doesn't think through what he does, but mostly he does nothing.” Apathy and impulsivity, debilitating and poorly understood, commonly co‐occur in Huntington's disease (HD). HD is a neurodegenerative disease with manifestations bridging clinical neurology and psychiatry. In addition to movement and cognitive symptoms, neurobehavioral disturbances, particularly apathy and impulsivity, are prevalent features of HD, occurring early in the disease course, often worsening with disease progression, and substantially reducing quality of life. Treatments remain limited, in part because of limited mechanistic understanding of these behavioral disturbances. However, emerging work within the field of decision‐making neuroscience and beyond points to common neurobiological mechanisms underpinning these seemingly disparate problems. These insights bridge the gap between underlying disease pathology and clinical phenotype, offering new treatment strategies, novel behavioral and physiological biomarkers of HD, and deeper understanding of human behavior. In this review, we apply the neurobiological framework of cost‐benefit decision making to the problems of apathy and impulsivity in HD. Through this decision‐making lens, we develop a mechanistic model that elucidates the occurrence of these behavioral disturbances and points to potential treatment strategies and crucial research priorities. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson Movement Disorder Society.