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Maher S, Donlon E, Mullane G, Walsh R, Lynch T, Fearon C. Treatment of Apathy in Parkinson's Disease and Implications for Underlying Pathophysiology. J Clin Med 2024; 13:2216. [PMID: 38673489 PMCID: PMC11051068 DOI: 10.3390/jcm13082216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/28/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
Apathy is a prevalent and highly debilitating non-motor symptom of Parkinson's disease (PD) that is often overlooked in clinical practice due to its subtle nature. This review aims to provide a comprehensive overview of the current evidence for the treatment of apathy in PD, highlighting recent advancements and emerging therapeutic avenues. In this review, we analyse a diverse array of treatment strategies for apathy in PD, including pharmacological interventions, non-pharmacological approaches, and emerging neuromodulation techniques. We evaluate the efficacy, safety, and limitations of established pharmacotherapies, such as dopaminergic agents, antidepressants, and cognitive enhancers. Additionally, we examine the promising role of non-pharmacological interventions, encompassing psychotherapies and behavioural interventions, in ameliorating apathetic symptoms. Furthermore, this review explores the effects of neuromodulation techniques on apathy, including the modulation of apathy via deep brain stimulation and emerging data on the potential influence of transcranial magnetic stimulation (TMS) on apathy in PD. Ultimately, a deeper understanding of effective treatment strategies for apathy has the potential to significantly improve the quality of life and overall well-being of individuals living with PD.
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Affiliation(s)
- Senan Maher
- Dublin Neurological Institute, Mater Misericordiae Hospital, D07 W7XF Dublin, Ireland
| | - Eoghan Donlon
- Dublin Neurological Institute, Mater Misericordiae Hospital, D07 W7XF Dublin, Ireland
| | - Gerard Mullane
- Dublin Neurological Institute, Mater Misericordiae Hospital, D07 W7XF Dublin, Ireland
| | - Richard Walsh
- Dublin Neurological Institute, Mater Misericordiae Hospital, D07 W7XF Dublin, Ireland
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Tim Lynch
- Dublin Neurological Institute, Mater Misericordiae Hospital, D07 W7XF Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Conor Fearon
- Dublin Neurological Institute, Mater Misericordiae Hospital, D07 W7XF Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
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Espiritu AI, Hara T, Tolledo JK, Blair M, Burhan AM. Repetitive transcranial magnetic stimulation for apathy in patients with neurodegenerative conditions, cognitive impairment, stroke, and traumatic brain injury: a systematic review. Front Psychiatry 2023; 14:1259481. [PMID: 38034914 PMCID: PMC10684725 DOI: 10.3389/fpsyt.2023.1259481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Background We aimed to determine the effects and tolerability of repetitive transcranial magnetic stimulation (rTMS) on apathy in patients with neurodegenerative conditions, mild cognitive impairment (MCI), stroke, and traumatic brain injury (TBI) via systematic review. Methods We conducted a systematic search in major electronic health databases, including PubMed, Scopus, and PsycINFO, covering the period from inception to June 2023. Comparative clinical trials and cohort studies, and studies with before-after designs were considered for inclusion. We used the Cochrane Risk of Bias and the National Institutes of Health (NIH) tools to assess methodological quality. Results Out of 258 records identified, 14 studies met our eligibility criteria (11 randomized controlled trials (RCT) and 3 studies utilized before-and-after designs) with a total of 418 patients (overall female-to-male ratio 1:1.17) included in the review. The overall methodological quality of the included studies was assessed to be fair to good. The stimulation parameters used varied considerably across the studies. The summary findings of our review indicate the following observations on the effects of rTMS on apathy: (1) the results of all included studies in Alzheimer's disease investigating the effects of rTMS on apathy have consistently shown a positive impact on apathy; (2) the majority of studies conducted in Parkinson's disease have not found statistically significant results; (3) a single study (RCT) on patients with primary progressive aphasia demonstrated significant beneficial effects of rTMS on apathy; (4) the trials conducted on individuals with MCI yielded varying conclusions; (5) one study (RCT) in chronic stroke suggested that rTMS might have the potential to improve apathy; (6) one study conducted on individuals with mild TBI did not find a significant favorable association on apathy; and (7) the use of different rTMS protocols on the populations described is generally safe. Conclusion The feasibility of utilizing rTMS as a treatment for apathy has been suggested in this review. Overall, limited evidence suggests that rTMS intervention may have the potential to modify apathy among patients with AD, PPA, MCI and chronic stroke, but less so in PD and mild TBI. These findings require confirmation by larger, well-designed clinical trials.
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Affiliation(s)
- Adrian I. Espiritu
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
- Department of Psychiatry and Department of Medicine, Division of Neurology, University of Toronto, Toronto, ON, Canada
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Takatoshi Hara
- Department of Rehabilitation Medicine, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Mervin Blair
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
- Lawson Research Institute, London, ON, Canada
| | - Amer M. Burhan
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Béreau M, Van Waes V, Servant M, Magnin E, Tatu L, Anheim M. Apathy in Parkinson's Disease: Clinical Patterns and Neurobiological Basis. Cells 2023; 12:1599. [PMID: 37371068 DOI: 10.3390/cells12121599] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Apathy is commonly defined as a loss of motivation leading to a reduction in goal-directed behaviors. This multidimensional syndrome, which includes cognitive, emotional and behavioral components, is one of the most prevalent neuropsychiatric features of Parkinson's disease (PD). It has been established that the prevalence of apathy increases as PD progresses. However, the pathophysiology and anatomic substrate of this syndrome remain unclear. Apathy seems to be underpinned by impaired anatomical structures that link the prefrontal cortex with the limbic system. It can be encountered in the prodromal stage of the disease and in fluctuating PD patients receiving bilateral chronic subthalamic nucleus stimulation. In these stages, apathy may be considered as a disorder of motivation that embodies amotivational behavioral syndrome, is underpinned by combined dopaminergic and serotonergic denervation and is dopa-responsive. In contrast, in advanced PD patients, apathy may be considered as cognitive apathy that announces cognitive decline and PD dementia, is underpinned by diffuse neurotransmitter system dysfunction and Lewy pathology spreading and is no longer dopa-responsive. In this review, we discuss the clinical patterns of apathy and their treatment, the neurobiological basis of apathy, the potential role of the anatomical structures involved and the pathways in motivational and cognitive apathy.
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Affiliation(s)
- Matthieu Béreau
- Département de Neurologie, CHU de Besançon, 25000 Besançon, France
- Université de Franche-Comté, LINC Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive, 25000 Besançon, France
| | - Vincent Van Waes
- Université de Franche-Comté, LINC Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive, 25000 Besançon, France
| | - Mathieu Servant
- Université de Franche-Comté, LINC Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive, 25000 Besançon, France
| | - Eloi Magnin
- Département de Neurologie, CHU de Besançon, 25000 Besançon, France
- Université de Franche-Comté, LINC Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive, 25000 Besançon, France
| | - Laurent Tatu
- Département de Neurologie, CHU de Besançon, 25000 Besançon, France
- Université de Franche-Comté, LINC Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive, 25000 Besançon, France
- Laboratoire d'Anatomie, Université de Franche-Comté, 25000 Besançon, France
| | - Mathieu Anheim
- Département de Neurologie, CHU de Strasbourg, 67200 Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, 67000 Strasbourg, France
- Institut de génétique Et de Biologie Moléculaire Et Cellulaire (IGBMC), INSERM-U964, CNRS-UMR7104, Université de Strasbourg, 67400 Illkirch-Graffenstaden, France
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Mantovani E, Zucchella C, Argyriou AA, Tamburin S. Treatment for cognitive and neuropsychiatric non-motor symptoms in Parkinson's disease: current evidence and future perspectives. Expert Rev Neurother 2023; 23:25-43. [PMID: 36701529 DOI: 10.1080/14737175.2023.2173576] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Non-motor symptoms (NMS) affect patients with Parkinson's disease (PD) from the prodromal to the advanced stages. NMS phenotypes greatly vary and have a huge impact on patients' and caregivers' quality of life (QoL). The management of cognitive and neuropsychiatric NMS remains an unmet need. AREAS COVERED The authors, herein, review the dopaminergic and non-dopaminergic pathogenesis, clinical features, assessment, and pharmacological and non-pharmacological treatments of cognitive and neuropsychiatric NMS in PD. They discuss the current evidence and report the findings of an overview of ongoing trials on pharmacological and selected non-pharmacological strategies. EXPERT OPINION The treatment of cognitive and neuropsychiatric NMS in PD is poorly explored, and therapeutic options are unsatisfactory. Pharmacological treatment of cognitive NMS is based on symptomatic active principles used in Alzheimer's disease. Dopamine agonists, selective serotonin, and serotonin-norepinephrine reuptake inhibitors have some evidence on PD-related depression. Clozapine, quetiapine, and pimavanserin may be considered for psychosis in PD. Evidence on the treatment of other neuropsychiatric NMS is limited or lacking. Addressing pathophysiological and clinical issues, which hamper solid evidence on the treatment of cognitive and neuropsychiatric NMS, may reduce the impact on QoL for PD patients and their caregivers.
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Affiliation(s)
- Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Chiara Zucchella
- Section of Neurology, Department of Neurosciences, Verona University Hospital, Verona, Italy
| | - Andreas A Argyriou
- Department of Neurology, "Agios Andreas" State General Hospital of Patras, Patras, Greece
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Apathy in Parkinson’s Disease: Defining the Park Apathy Subtype. Brain Sci 2022; 12:brainsci12070923. [PMID: 35884730 PMCID: PMC9313138 DOI: 10.3390/brainsci12070923] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023] Open
Abstract
Apathy is a neurobehavioural symptom affecting Parkinson’s disease patients of all disease stages. Apathy seems to be associated with a specific underlying non-motor disease subtype and reflects dysfunction of separate neural networks with distinct neurotransmitter systems. Due to the complicated neuropsychiatric aetiology of apathy, clinical assessment of this invalidating non-motor symptom remains challenging. We aim to summarize the current findings on apathy in Parkinson’s disease and highlight knowledge gaps. We will discuss the prevalence rates across the different disease stages and suggest screening tools for clinically relevant apathetic symptoms. We will approach the fundamental knowledge on the neural networks implicated in apathy in a practical manner and formulate recommendations on patient-tailored treatment. We will discuss the Park apathy phenotype in detail, shedding light on different clinical manifestations and implications for prognosis. With this review, we strive to distil the vast available theoretical knowledge into a clinical and patient-oriented perspective.
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Neuromodulation of facial emotion recognition in health and disease: A systematic review. Neurophysiol Clin 2022; 52:183-201. [DOI: 10.1016/j.neucli.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/20/2022] Open
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Implications of Transcranial Magnetic Stimulation as a Treatment Modality for Tinnitus. J Clin Med 2021; 10:jcm10225422. [PMID: 34830704 PMCID: PMC8622674 DOI: 10.3390/jcm10225422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 12/24/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive, neuromodulating technique for brain hyperexcitability disorders. The objective of this paper is to discuss the mechanism of action of rTMS as well as to investigate the literature involving the application of rTMS in the treatment of tinnitus. The reviewed aspects of the protocols included baseline evaluation, the total number of sessions, frequency and the total number of stimuli, the location of treatment, and the outcome measures. Even with heterogeneous protocols, most studies utilized validated tinnitus questionnaires as baseline and outcome measures. Low frequency (1 Hz) stimulation throughout 10 consecutive sessions was the most widely used frequency and treatment duration; however, there was no consensus on the total number of stimuli necessary to achieve significant results. The auditory cortex (AC) was the most targeted location, with most studies supporting changes in neural activity with multi-site stimulation to areas in the frontal cortex (FC), particularly the dorsolateral prefrontal cortex (DLPFC). The overall efficacy across most of the reviewed trials reveals positive statistically significant results. Though rTMS has proven to impact neuroplasticity at the microscopic and clinical level, further studies are warranted to demonstrate and support the clinical use of rTMS in tinnitus treatment with a standardized protocol.
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