Task switching deficits associated with Parkinson's disease reflect depleted attentional resources

Benefits of subthalamic nucleus deep brain stimulation on visually-guided saccades depend on stimulation side and classic paradigm in Parkinson's disease

OBJECTIVE

We aimed to gain further insight into previously reported beneficial effects of subthalamic nucleus deep brain stimulation (STN-DBS) on visually-guided saccades by examining the effects of unilateral compared to bilateral stimulation, paradigm, and target eccentricity on saccades in individuals with Parkinson's disease (PD).

METHODS

Eleven participants with PD and STN-DBS completed the visually-guided saccade paradigms with OFF, RIGHT, LEFT, and BOTH stimulation. Rightward saccade performance was evaluated for three paradigms and two target eccentricities.

RESULTS

First, we found that BOTH and LEFT increased gain, peak velocity, and duration compared to OFF stimulation. Second, we found that BOTH and LEFT stimulation decreased latency during the gap and step paradigms but had no effect on latency during the overlap paradigm. Third, we found that RIGHT was not different compared to OFF at benefiting rightward saccade performance.

CONCLUSIONS

Left unilateral and bilateral stimulation both improve the motor outcomes of rightward visually-guided saccades. Additionally, both improve latency, a cognitive-motor outcome, but only in paradigms when attention does not require disengagement from a present stimulus.

SIGNIFICANCE

STN-DBS primarily benefits motor and cognitive-motor aspects of visually-guided saccades related to reflexive attentional shifting, with the latter only evident when the fixation-related attentional system is not engaged.

Medication adversely impacts visually-guided eye movements in Parkinson's disease

OBJECTIVE

We examined whether previous inconsistent findings about the effect of anti-Parkinsonian medication on visually-guided saccades (VGS) were due to the use of different paradigms, which change the timing of fixation offset and target onset, or different target eccentricities.

METHODS

Thirty-three participants with Parkinson's disease (PD) completed the VGS tasks OFF and ON medication, along with 13 healthy controls. Performance on 3 paradigms (gap, step, and overlap) and 2 target eccentricities was recorded. We used mixed models to determine the effect of medication, paradigm, and target eccentricity on saccade latency, gain, and peak velocity.

RESULTS

First, we confirmed known paradigm effects on latency, and target eccentricity effects on gain and peak velocity in participants with PD. Second, latency was positively associated with OFF medication Movement Disorders Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score in PD. Third, medication prolonged latency for the larger target eccentricity across the 3 paradigms, while decreasing gain and peak velocity in the step paradigm across target eccentricities.

CONCLUSIONS

Medication adversely affected and was not therapeutically beneficial for VGS. Previous inconsistencies may have resulted from chosen target eccentricity.

SIGNIFICANCE

The negative medication effect on VGS may be clinically significant, as many activities in daily life require oculomotor control, inhibitory control, and visually-guided shifts of attention.

Role of dopamine and clinical heterogeneity in cognitive dysfunction in Parkinson's disease

Parkinson's disease (PD) is commonly treated with dopaminergic medication, which enhances some, while impairing other cognitive functions. It can even contribute to impulse control disorder and addiction. We describe the history of research supporting the dopamine overdose hypothesis, which accounts for the large within-patient variability in dopaminergic medication effects across different tasks by referring to the spatially non-uniform pattern of dopamine depletion in dorsal versus ventral striatum. However, there is tremendous variability in dopaminergic medication effects not just within patients across distinct tasks, but also across different patients. In the second part of this chapter we review recent studies addressing the large individual variability in the negative side effects of dopaminergic medication on functions that implicate dopamine, such as value-based learning and choice. These studies begin to unravel the mechanisms of dopamine overdosing, thus revising the strict version of the overdose hypothesis. For example, the work shows that the canonical boosting of reward-versus punishment-based choice by medication is greater in patients with depression and a non-tremor phenotype, which both implicate, among other pathology, more rather than less severe dysregulation of the mesolimbic dopamine system. Future longitudinal cohort studies are needed to identify how to optimally combine different clinical, personality, cognitive, neural, genetic and molecular predictors of detrimental medication effects in order to account for as much of the relevant variability as possible. This will provide a useful tool for precision neurology, allowing individual and contextual tailoring of (the dose of) dopaminergic medication in order to maximize its cognitive benefits, yet minimize its side effects.

The Attention Network Test in Parkinson and Lewy Body Disease: A Systematic Review

BACKGROUND

The Attention Network Test (ANT) is a well-established measure of efficiency for the alerting, orienting, and executive attentional networks. However, its novel application in Parkinson disease (PD) and Lewy body dementia (LBD) research more broadly has yet to be evaluated systematically.

OBJECTIVE

To compare and consolidate the outcomes of studies reporting use of the ANT in PD and LBD groups and to identify the methodological considerations for the conduct of such studies.

METHOD

We performed a systematic literature search for articles exploring attention in PD and LBD groups using the ANT. We excluded articles on the basis of irrelevant scope, non-English, and groups other than PD and LBD. Once the full text articles were identified, we extracted the data and assessed the studies' quality.

RESULTS

The final sample included 16 articles ranging from low to moderate quality. Behavioral findings suggested a general slowing of responses yet preserved accuracy from the PD group compared with controls. Overall, the evidence was inconclusive regarding the state of the alerting network in the PD and LBD groups, mostly supportive of an intact orienting network, and strongly suggestive of an impaired executive network. Differences in sample stratification, patient symptomatology, and dopaminergic medication levels were identified as influential factors in the attentional results across studies.

CONCLUSION

Although sparse, the existing evidence indicates that the ANT is a viable option for measuring attention in PD; it can also be harnessed to explore the impact of symptoms and medications on attentional networks in PD and LBD groups.

Electrophysiological correlates of the reverse Stroop effect: Results from a simulated handgun task

The color-word reverse Stroop (RS) effect still represents an interesting puzzle for cognitive researchers as an interference between incongruent ink colors and the meaning of the words is not always found. Here, we examined whether an unfamiliar and complex visuomotor task would produce a RS effect. Forty inexperienced shooters carried out a simulated shooting task. To test if the RS effect is related to the stimuli processing or to a late processing of the color (early and late time-windows), electroencephalographic global field power (GFP) variations were recorded with a high-impedance system (32 channels configuration in a standard monopolar montage, referenced to FCz and grounded to FPz). The color-word RS effect was reflected in the performance of 32 participants, suggesting that the strength of the association between the target and the specific response requested might be central to the RS interference. This behavioral result was paralleled by GFP modulations in 20 participants. A significant increase of the GFP for the congruent trials (e.g., the word "red" written in red ink) was recorded after stimulus presentation (conflict detection), followed by an increase for the incongruent trials (e.g., the word "red" written in green ink) just before the shooting (conflict resolution). Despite the limitations of the study, such as the inclusion of a low number of channels in the GFP analyses, the results suggest that the RS interference is easily elicited in tasks requiring an unfamiliar response, which supports the strength of association hypothesis. Moreover, as implied by the GFP modulations, the interference might occur early in time, but also in a later stage, closer to the response.

The role of dopamine in action control: Insights from medication effects in Parkinson's disease

Parkinson's disease (PD) is a neurological disorder associated primarily with overt motor symptoms. Several studies show that PD is additionally accompanied by impairments in covert cognitive processes underlying goal-directed motor functioning (e.g., action planning, conflict adaptation, inhibition), and that dopaminergic medication may modulate these action control components. In this review we aim to leverage findings from studies in this domain to elucidate the role of dopamine (DA) in action control. A qualitative review of studies that investigated the effects of medication status (on vs. off) on action control in PD suggests a component-specific role for DA in action control, although the expression of medication effects depends on characteristics of both the patients and experimental tasks used to measure action control. We discuss these results in the light of findings from other research lines examining the role of DA in action control (e.g., animal research, pharmacology), and recommend that future studies use multi-method, within-subject approaches to model DA effects on action control across different components as well as underlying striatal pathways (ventral vs. dorsal).

The continuous impact of cognitive flexibility on the development of emotion understanding in children aged 4 and 5 years: A longitudinal study

The current study investigated the impact of cognitive flexibility on the development of emotion understanding using a longitudinal tracking study. A total of 98 children aged 4 and 5 years were tested for cognitive flexibility, emotion understanding, and verbal ability across three time points within a year. The cross-lagged analyses indicated that early cognitive flexibility played a predictive role in the development of emotion understanding. More precisely, cognitive flexibility at Time 1 predicted emotion understanding at Time 2 and Time 3, and cognitive flexibility at Time 2 predicted emotion understanding at Time 3. Furthermore, mediation analysis showed that verbal ability mediated the impact of cognitive flexibility on emotion understanding. Early cognitive flexibility contributed to later emotion understanding by improving children's verbal ability. These findings suggest that there is a verbal ability-mediated pathway from cognitive flexibility to emotion understanding that provides a new perspective for the development mechanism of children's emotion understanding.

Acute effects of adaptive Deep Brain Stimulation in Parkinson's disease

Background

Beta-based adaptive Deep Brain Stimulation (aDBS) is effective in Parkinson’s disease (PD), when assessed in the immediate post-implantation phase. However, the potential benefits of aDBS in patients with electrodes chronically implanted, in whom changes due to the microlesion effect have disappeared, are yet to be assessed.

Methods

To determine the acute effectiveness and side-effect profile of aDBS in PD compared to conventional continuous DBS (cDBS) and no stimulation (NoStim), years after DBS implantation, 13 PD patients undergoing battery replacement were pseudo-randomised in a crossover fashion, into three conditions (NoStim, aDBS or cDBS), with a 2-min interval between them. Patient videos were blindly evaluated using a short version of the Unified Parkinson’s Disease Rating Scale (subUPDRS), and the Speech Intelligibility Test (SIT).

Results

Mean disease duration was 16 years, and the mean time since DBS-implantation was 6.9 years. subUPDRS scores (11 patients tested) were significantly lower both in aDBS (p = <.001), and cDBS (p = .001), when compared to NoStim. Bradykinesia subscores were significantly lower in aDBS (p = .002), and did not achieve significance during cDBS (p = .08), when compared to NoStim. Two patients demonstrated re-emerging tremor during aDBS. SIT scores of patients who presented stimulation-induced dysarthria significantly worsened in cDBS (p = .009), but not in aDBS (p = .407), when compared to NoStim. Overall, stimulation was applied 48.8% of the time during aDBS.

Conclusion

Beta-based aDBS is effective in PD patients with bradykinetic phenotypes, delivers less stimulation than cDBS, and potentially has a more favourable speech side-effect profile. Patients with prominent tremor may require a modified adaptive strategy.

Implicit task switching in Parkinson's disease is preserved when on medication

People with Parkinson's disease have been shown to have difficulty switching between movement plans. In the great majority of studies, the need to switch between tasks was made explicitly. Here, we tested whether people with Parkinson's disease, taking their normal medication, have difficulty switching between implicitly specified tasks. We further examined whether this switch is performed predictively or reactively. Twenty five people with Parkinson's disease continuously increased or decreased the frequency of their arm movements, inducing an abrupt-but unaware-switch between rhythmic movements (at high frequencies) and discrete movements (at low frequencies). We tested whether that precipitous change was performed reactively or predictively. We found that 56% of participants predictively switched between the two movement types. The ability of people with Parkinson's disease, taking their regular medication, to predictively control their movements on implicit tasks is thus preserved.

The Suppression of Irrelevant Semantic Representations in Parkinson's Disease

The impairment of lexical-semantic inhibition mechanisms in Parkinson's disease (PD) remains a source of contention. In order to observe whether people with PD are able to suppress irrelevant semantic information during picture naming, the present study employed an object-based negative priming paradigm with 16 participants with PD and 13 healthy controls. The task required participants to name a red target image while ignoring a superimposed, green distractor image. The semantic relationship between the distractor image and the target image of the subsequent trial was manipulated, such that the distractor image was identical, semantically related, or semantically unrelated to said target image. The PD group and the control group were slower in naming a target image that had previously served as a distractor image, relative to naming a target image that was unrelated to the previous distractor image. Thus, a negative priming effect was present in both groups. Furthermore, no significant difference in the magnitude of this effect was observed between the control and PD groups. When considered in the context of existing literature surrounding negative priming in PD, these results suggest that inhibition is subserved by multiple, domain-specific mechanisms and that the inhibitory processing of visual-semantic stimuli is intact in PD.

Probing links between action perception and action production in Parkinson's disease using Fitts' law

Information on how the subcortical brain encodes information required to execute actions or to evaluate others' actions remains scanty. To clarify this link, Fitts'-law tasks for perception and execution were tested in patients with Parkinson's disease (PD). For the perception task, participants were shown apparent motion displays of a person moving their arm between two identical targets and reported whether they judged that the person could realistically move at the perceived speed without missing the targets. For the motor task, participants were required to touch the two targets as quickly and accurately as possible, similarly to the person observed in the perception task. In both tasks, the PD group exhibited, or imputed to others, significantly slower performances than those of the control group. However, in both groups, the relationships of perception and execution with task difficulty were exactly those predicted by Fitts' law. This suggests that despite dysfunction of the subcortical region, motor simulation abilities reflected mechanisms of compensation in the PD group. Moreover, we found that patients with PD had difficulty in switching their strategy for estimating others' actions when asked to do so.

Sensorimotor adaptation of voice fundamental frequency in Parkinson's disease

OBJECTIVE

This study examined adaptive responses to auditory perturbation of fundamental frequency (fo) in speakers with Parkinson's disease (PD) and control speakers.

METHOD

Sixteen speakers with PD and nineteen control speakers produced sustained vowels while they received perturbed auditory feedback (i.e., fo shifted upward or downward). Speakers' pitch acuity was quantified using a just-noticeable-difference (JND) paradigm. Twelve listeners provided estimates of the speech intelligibility for speakers with PD.

RESULTS

Fifteen responses from each speaker group for each shift direction were included in analyses. While control speakers generally showed consistent adaptive responses opposing the perturbation, speakers with PD showed no compensation on average, with individual PD speakers showing highly variable responses. In the PD group, the degree of compensation was not significantly correlated with age, disease progression, pitch acuity, or intelligibility.

CONCLUSIONS

These findings indicate reduced adaptation to sustained fo perturbation and higher variability in PD compared to control participants. No significant differences were seen in pitch acuity between groups, suggesting that the fo adaptation deficit in PD is not the result of purely perceptual mechanisms.

SIGNIFICANCE

These results suggest there is an impairment in vocal motor control in PD. Building on these results, contributions can be made to developing targeted voice treatments for PD.

Positive Emotion Facilitates Cognitive Flexibility: An fMRI Study

Cognitive flexibility is the ability to switch rapidly between multiple goals. By using a task-switching paradigm, the present study investigated how positive emotion affected cognitive flexibility and the underlying neural mechanisms. After viewing pictures of different emotional valence (positive, negative, or neutral), participants discriminated whether a target digit in a specific color was odd or even. After a series of trials, the color of target stimuli was changed, i.e., the switch condition. Switch costs were measured by the increase of reaction times (RTs) in the switch trials compared to those in the repeat trials. Behavior results indicated that switch costs significantly decreased in the positive emotional condition, and increased in the negative emotional condition, compared with those in the neutral condition. Imaging data revealed enhanced activation in the dorsal anterior cingulate cortex (dACC) in switch trials than those in repeat trials. Moreover, the interaction between emotion (positive, negative, neutral) and trial type (repeat vs. switch) was significant. For switch trials, the activation of dACC decreased significantly in the positive condition, while increased significantly in the negative condition compared to neutral condition. By contrast, for repeat trials, no significant difference was observed for the activation of dACC among three emotional conditions. Our results showed that positive emotions could increase the cognitive flexibility and reduce the conflict by decreasing the activation of dACC.

Response inhibition in Parkinson's disease: a meta-analysis of dopaminergic medication and disease duration effects

Parkinson's disease is a neurodegenerative disorder involving the basal ganglia that results in a host of motor and cognitive deficits. Dopamine-replacement therapy ameliorates some of the hallmark motor symptoms of Parkinson's disease, but whether these medications improve deficits in response inhibition, a critical executive function for behavioral control, has been questioned. Several studies of Parkinson's disease patients "on" and "off" (12-h withdrawal) dopaminergic medications suggested that dopamine-replacement therapy did not provide significant response inhibition benefits. However, these studies tended to include patients with moderate-to-advanced Parkinson's disease, when the efficacy of dopaminergic drugs is reduced compared to early-stage Parkinson's disease. In contrast, a few recent studies in early-stage Parkinson's disease report that dopaminergic drugs do improve response inhibition deficits. Based on these findings, we hypothesized that Parkinson's disease duration interacts with medication status to produce changes in cognitive function. To investigate this issue, we conducted a meta-analysis of studies comparing patients with Parkinson's disease and healthy controls on tests of response inhibition (50 comparisons from 42 studies). The findings supported the hypothesis; medication benefited response inhibition in patients with shorter disease duration, whereas "off" medication, moderate deficits were present that were relatively unaffected by disease duration. These findings support the role of dopamine in response inhibition and suggest the need to consider disease duration in research of the efficacy of dopamine-replacement therapy on cognitive function in Parkinson's disease.

Frontal-subcortical defects correlate with task switching deficits in Parkinson`s disease

Objectives:

To examine correlation between frontal-subcortical/ parietal-cortical functioning and task switching.

Methods:

An experimental study was designed to examine objectives with 80 participants (40 patients with idiopathic Parkinson’s disease (PD) and 40 healthy controls). Patients were recruited from February until September 2016 at Recep Tayyip Erdogan Hospital Pakistan, Muzaffargarh, Pakistan and healthy controls participated from community. Participants were administered Parkinson’s disease cognitive rating scale and Word-Digit categorization task switching experiment.

Results:

In contrast to healthy controls, (i) PD patients showed impaired cognitive performance on frontal-subcortical and posterior-cortical functions as assessed through PD cognitive rating scale (ii) PD patients showed task switching deficits. Frontal-subcortical defects correlated with task switching deficits. Lesser the scores on frontal-subcortical functions, larger switch costs will appear. Frontal-subcortical defects significantly predicted task switch costs.

Conclusion:

Frontal-subcortical not the posterior-cortical dysfunctions are significant marker of task switching deficits.

The cerebellum in dual-task performance in Parkinson's disease

Parkinson’s disease (PD) patients have difficulty in performing a dual-task. It has been suggested that the cerebellum is important in dual-tasking. We used functional MRI to investigate the role of the cerebellum in performing a dual motor and cognitive task in PD patients. We have examined whether there are any areas additionally activated for dual-task performance, and compared the neural activity and functional connectivity pattern in the cerebellum between PD patients and healthy controls. We found that the right cerebellar vermis and left lobule V of cerebellar anterior lobe were additionally activated for dual-task performance in healthy controls and for motor task in PD patients. We didn’t find any cerebellar regions additionally activated while performing dual-task in PD patients. In addition, the right cerebellar vermis had enhanced connectivity with motor and cognitive associated networks in PD patients. PD patients have limited cerebellar resources that are already utilized for single tasks and, for dual tasks, cannot augment as necessary in order to integrate motor and cognitive networks.

Presynaptic dopaminergic terminal imaging and non-motor symptoms assessment of Parkinson's disease: evidence for dopaminergic basis?

Parkinson's disease (PD) is now considered to be a multisystemic disorder consequent on multineuropeptide dysfunction including dopaminergic, serotonergic, cholinergic, and noradrenergic systems. This multipeptide dysfunction leads to expression of a range of non-motor symptoms now known to be integral to the concept of PD and preceding the diagnosis of motor PD. Some non-motor symptoms in PD may have a dopaminergic basis and in this review, we investigate the evidence for this based on imaging techniques using dopamine-based radioligands. To discuss non-motor symptoms we follow the classification as outlined by the validated PD non-motor symptoms scale.

A Neurocomputational Model of the Effect of Cognitive Load on Freezing of Gait in Parkinson's Disease

Experimental data show that perceptual cues can either exacerbate or ameliorate freezing of gait (FOG) in Parkinson's Disease (PD). For example, simple visual stimuli like stripes on the floor can alleviate freezing whereas complex stimuli like narrow doorways can trigger it. We present a computational model of the cognitive and motor cortico-basal ganglia loops that explains the effects of sensory and cognitive processes on FOG. The model simulates strong causative factors of FOG including decision conflict (a disagreement of various sensory stimuli in their association with a response) and cognitive load (complexity of coupling a stimulus with downstream mechanisms that control gait execution). Specifically, the model simulates gait of PD patients (freezers and non-freezers) as they navigate a series of doorways while simultaneously responding to several Stroop word cues in a virtual reality setup. The model is based on an actor-critic architecture of Reinforcement Learning involving Utility-based decision making, where Utility is a weighted sum of Value and Risk functions. The model accounts for the following experimental data: (a) the increased foot-step latency seen in relation to high conflict cues, (b) the high number of motor arrests seen in PD freezers when faced with a complex cue compared to the simple cue, and (c) the effect of dopamine medication on these motor arrests. The freezing behavior arises as a result of addition of task parameters (doorways and cues) and not due to inherent differences in the subject group. The model predicts a differential role of risk sensitivity in PD freezers and non-freezers in the cognitive and motor loops. Additionally this first-of-its-kind model provides a plausible framework for understanding the influence of cognition on automatic motor actions in controls and Parkinson's Disease.

Effects of Regular Switching between Languages during Random Number Generation

Random number generation is a task that engages working memory and executive processes within the domain of number representation. In the present study we address the role of language in number processing by switching languages during random number generation (numbers 1–9), using German (L1) and English (L2), and alternating L1/L2. Results indicate large correspondence between performance in L1 and L2. In contrast to nonswitching performance, randomization with alternating languages showed a significant increase of omitted responses, whereas the random sequences were less stereotyped, showing significantly less repetition avoidance and cycling behavior. During an intentional switch between languages, errors in language sequence appeared in 23% of responses on the average, independently of the quality of randomization but associated with a clear persistence of L2. These results indicate that random number generation is more closely linked to auditory-phonological representation of numerals than to visual arabic notation.

Parkinson's disease and the Stroop color word test: processing speed and interference algorithms

OBJECTIVE

Processing speed alters the traditional Stroop calculations of interference. Consequently, alternative algorithms for calculating Stroop interference have been introduced to control for processing speed, and have done so in a multiple sclerosis sample. This study examined how these processing speed correction algorithms change interference scores for individuals with idiopathic Parkinson's disease (PD, n = 58) and non-PD peers (n = 68).

METHOD

Linear regressions controlling for demographics predicted group (PD vs. non-PD) differences for Jensen's, Golden's, relative, ratio, and residualized interference scores. To examine convergent and divergent validity, interference scores were correlated with standardized measures of processing speed and executive function.

RESULTS

PD-non-PD differences were found for Jensen's interference score, but not Golden's score, or the relative, ratio, and residualized interference scores. Jensen's score correlated significantly with standardized processing speed but not executive function measures. Relative, ratio, and residualized scores correlated with executive function but not processing speed measures. Golden's score did not correlate with any other standardized measures.

CONCLUSIONS

The relative, ratio, and residualized scores were comparable for measuring Stroop interference in processing speed-impaired populations. Overall, the ratio interference score may be the most useful calculation method to control for processing speed in this population.

Dysfunctional action control as a specific feature of Parkinson's disease

Parkinson's disease (PD) is characterised by motor deficits as well as cognitive alterations, particularly concerning frontal lobe control. Here, we were interested in whether executive function is abnormal already early in PD, as well as whether this dysfunction worsens as a part of the dementia in PD. The following groups engaged in tasks addressing action control: PD patients with mild and advanced motor symptoms (aPD) without dementia, PD patients with dementia (PDD), patients with Alzheimer's disease (AD) and healthy subjects (CON). Subjects either had to perform or inhibit button presses upon go and no-go cues, respectively. These cues were preceded by pre-cues, either randomly instructive of right or left hand preparation (switch condition), or repetitively instructive for one side only (non-switch condition). PDD and aPD omitted more go responses than CON. Furthermore, PDD disproportionally committed failures upon no-go cues compared to CON. In the non-switch condition, PDD performed worse than AD, whose deficits increased to the level of PDD in the switch condition. Over all PD patients, task performance correlated with disease severity. Under the switch condition, task performance was low in both PDD and AD. In the non-switch condition, this also held true for advanced PD patients (with and without dementia), but not for AD. Thus, the deficits evident in PDD appear to develop from imbalanced inhibitory-to-excitatory action control generally inherent to PD. These results specify the concept of dysexecution in PD and differentiate the cognitive profile of PDD from that of AD patients.

Revisiting the effects of Parkinson's disease and frontal lobe lesions on task switching: the role of rule reconfiguration

This study investigated the hypothesis that rule reconfiguration in task switching can isolate aspects of intact and impaired control at different stages of Parkinson's disease (PD) by comparing switches between concrete naming rules pertaining to stimulus selection, to switches between abstract rules which allocate categorization responses to these stimuli. Based on previous findings, it was hypothesized that attentional switches, where task set competition emerges at the stimulus but not response set level, highlights striatal dopaminergic function. Conversely, increasing the degree of task set competition to encompass reconfiguration of response set when switching between abstract rules, represents a condition which engages the prefrontal cortex (PFC) and renders this manipulation sensitive to frontal damage. To this end, we investigated task switching with concrete and abstract rules in unilaterally (Hoehn & Yahr stage I) and bilaterally (Hoehn & Yahr stage II) affected PD patients, as well as striatally intact frontal lesion patients. As predicted, frontal lesion patients demonstrated switching deficits only with abstract categorization rules, where switching engendered complete task set reconfiguration and a new response, as did stage II PD patients with presumed frontal cortical pathology. Replicating previous findings, stage I PD patients with relatively circumscribed striatal pathology demonstrated no such impairment. Disease severity also impacted on attentional switching indexed by naming rules, since medicated stage II but not stage I patients demonstrated switching deficits emerging from stimulus set reconfiguration, suggesting that the ameliorative efficacy of dopaminergic medication is inversely related to the severity of the striatal deficit. These findings illustrate that the nature of the rules that are switched, and its implication in terms of reconfiguring different task set elements, highlights different neural characters of cognitive flexibility. These manipulations may help decipher the differential effects of progressive neurodegeneration on parkinsonian cognition, and provide a framework in which to conceptualize the contributions of cortical and subcortical regions to cognitive control.

The pattern of attentional deficits in Parkinson's disease

BACKGROUND

Cognitive impairment without dementia is frequent in Parkinson's disease. It often presents as a dysexecutive syndrome with deficient attentional resource allocation. The nature of attention deficits in Parkinson's disease has rarely been investigated with robust, theory-based tasks. The main objective of the present study was to investigate attention disorders in Parkinson's disease patients by applying a paradigm based on a model of attention. We also sought to identify the main demographic and clinical characteristics associated with attention deficits in Parkinson's disease.

METHODS

Eighty non-demented Parkinson's disease patients and 60 healthy controls participated in the study. Attention was assessed in a computer-controlled reaction time paradigm. The test session comprised a simple reaction time task and four choice reaction time tasks: a go/no-go task, a one-dimension, focused-attention task, a two-dimension, divided-attention task and an alternating task. Performance was assessed by composite measures: (i) cognitive reaction time, corresponding to the difference between the simple reaction time and the choice reaction time in the given condition, and (ii) reaction time variability, corresponding to the sum of the coefficients of variance of the reaction times. Accuracy was also considered.

RESULTS

Apart from an overall slowing and greater reaction time variability, Parkinson's disease patients were only significantly impaired in the alternating condition. This set-shifting impairment was associated with their performance in the go/no-go and divided-attention conditions.

CONCLUSION

Our systematic assessment of the different attentional subcomponents revealed that mental flexibility is particularly impaired in non-demented Parkinson's disease patients.

Symptoms of rapid eye movement sleep behavior disorder are associated with cholinergic denervation in Parkinson disease

OBJECTIVE

Rapid eye movement sleep behavior disorder (RBD) is common in Parkinson disease (PD), but its relationship to the varied neurotransmitter deficits of PD and prognostic significance remain incompletely understood. RBD and cholinergic system degeneration are identified independently as risk factors for cognitive impairment in PD. We aimed to assess the association between cholinergic denervation and symptoms of RBD in PD patients without dementia.

METHODS

Eighty subjects with PD without dementia (age, 64.6 ± 7.0 years; range, 50-82 years; 60 males, 20 females; mean Montreal Cognitive Assessment Test [MoCA] score, 26.2 ± 2.1; range 21-30) underwent clinical assessment, neuropsychological testing, and [(11)C]methylpiperidyl propionate acetylcholinesterase and [(11)C]dihydrotetrabenazine (DTBZ) vesicular monoamine transporter type 2 positron emission tomography (PET) imaging. (11)C3-Amino-4-(2-dimethylaminomethyl-phenylsulfaryl)-benzonitrile (DASB) serotonin transporter PET imaging was performed in a subset of 35 subjects. The presence of RBD symptoms was determined using the Mayo Sleep Questionnaire.

RESULTS

Twenty-seven of 80 subjects (33.8%) indicated a history of RBD symptoms. Subjects with and without RBD symptoms showed no significant differences in age, motor disease duration, MoCA, Unified Parkinson Disease Rating Scale motor scores, or striatal DTBZ binding. Subjects with RBD symptoms, in comparison to those without, exhibited decreased neocortical, limbic cortical, and thalamic cholinergic innervation (0.0213 ± 0.0018 vs 0.0236 ± 0.0022, t = 4.55, p < 0.0001; 0.0388 ± 0.0029 vs 0.0423 ± 0.0058, t = 2.85, p = 0.0056; 0.0388 ± 0.0025 vs 0.0427 ± 0.0042, t = 4.49, p < 0.0001, respectively). Brainstem and striatal DASB binding showed no significant differences between groups.

INTERPRETATION

The presence of RBD symptoms in PD is associated with relative neocortical, limbic cortical, and thalamic cholinergic denervation although not with differential serotoninergic or nigrostriatal dopaminergic denervation. The presence of RBD symptoms may signal cholinergic system degeneration.

Striatal dopamine influences the default mode network to affect shifting between object features

Cognitive flexibility or the ability to change behavior in response to external cues is conceptualized as two processes: one for shifting between perceptual features of objects and another for shifting between the abstract rules governing the selection of these objects. Object and rule shifts are believed to engage distinct anatomical structures and functional processes. Dopamine activity has been associated with cognitive flexibility, but patients with dopaminergic deficits are not impaired on all tasks assessing cognitive flexibility, suggesting that dopamine may have different roles in the shifting of objects and rules. The goals of this study were to identify brain regions supporting object and rule shifts and to examine the role of dopamine in modulating these two forms of cognitive flexibility. Sixteen young, healthy volunteers underwent fMRI while performing a set-shift task designed to differentiate shifting between object features from shifting between abstract task rules. Participants also underwent PET with 6-[¹⁸F]-fluoro-l-m-tyrosine (FMT), a radiotracer measuring dopamine synthesis capacity. Shifts of abstract rules were not associated with activation in any brain region, and FMT uptake did not correlate with rule shift performance. Shifting between object features deactivated the medial PFC and the posterior cingulate and activated the lateral PFC, posterior parietal areas, and the striatum. FMT signal in the striatum correlated negatively with object shift performance and deactivation in the medial PFC, a component of the default mode network, suggesting that dopamine influences object shifts via modulation of activity in the default mode network.

Cognitive Impairment in Parkinson's Disease: Is It a Unified Phenomenon?

Parkinson's disease (PD) has long been associated with dementia. This has been found to correlate with participant age, age at onset of PD and severity of PD. In addition, a large corpus of research points to the fact that participants with, as well as without, dementia can be impaired in a variety of cognitive tasks. Among these, set-shifting and dual-tasking skills have received particular focus. Most studies report that a reduction in attentional resources can lead to problems with these tasks. However, none have been able to determine exactly which systems are involved in these skills and which neurological impairments underlie the observed cognitive deficits. The current study set out to investigate how performance on tasks requiring set-shifting and dual tasking related to each other, as well as overall measures of cognition gained across a variety of tasks. Fifteen participants with PD and 12 control participants underwent screening tests for dementia, as well as specific tests to assess attention, set-shifting and dual tasking. The results indicate that set-shifting ability correlated well with other measures of cognitive performance, whereas dualtasking skills did not. This could suggest that set-shifting and dual tasking are not necessarily controlled by the same process, or that a particular process is involved to different degrees. In addition, many participants showed individual performance variations and dissociations between tasks that were not necessarily evident from the statistical analysis. This indicates that it can be difficult to make assumptions on overall cognitive performance from specific tasks and vice versa. This observation has implications for clinical practice as well as research methodology.

The impact of sleep quality on cognitive functioning in Parkinson's disease

In healthy individuals and those with insomnia, poor sleep quality is associated with decrements in performance on tests of cognition, especially executive function. Sleep disturbances and cognitive deficits are both prevalent in Parkinson's disease (PD). Sleep problems occur in over 75% of patients, with sleep fragmentation and decreased sleep efficiency being the most common sleep complaints, but their relation to cognition is unknown. We examined the association between sleep quality and cognition in PD. In 35 non-demented individuals with PD and 18 normal control adults (NC), sleep was measured using 24-hr wrist actigraphy over 7 days. Cognitive domains tested included attention and executive function, memory and psychomotor function. In both groups, poor sleep was associated with worse performance on tests of attention/executive function but not memory or psychomotor function. In the PD group, attention/executive function was predicted by sleep efficiency, whereas memory and psychomotor function were not predicted by sleep quality. Psychomotor and memory function were predicted by motor symptom severity. This study is the first to demonstrate that sleep quality in PD is significantly correlated with cognition and that it differentially impacts attention and executive function, thereby furthering our understanding of the link between sleep and cognition.

Decomposition of warning effects in Parkinson's disease

Neutral warning signals speed voluntary reactions by reducing temporal uncertainty and by triggering a brief burst of arousal. We attempted to isolate the phasic arousal mechanism in people with Parkinson's disease (PD) using a clock display to minimize temporal uncertainty. In this condition, the speeding of responses in a color-discrimination task by an accessory stimulus was the fully equivalent to the effect in age-matched control subjects. This indicates preserved phasic arousal in PD. Temporal preparation based on warning cues also appeared to be normal. By contrast, in a condition with high temporal uncertainty, the accessory stimulus (an air puff to the foot) impaired accuracy for the patients but not the neurologically normal subjects. The data are consistent with the view that PD disrupts internal but not external control of alertness.

The utility of Stroop task switching as a marker for early-stage Alzheimer's disease

Past studies have suggested attentional control tasks such as the Stroop task and the task-switching paradigm may be sensitive for the early detection of dementia of the Alzheimer's type (DAT). The authors of the current study combined these tasks to create a Stroop switching task. Performance was compared across young adults, older adults, and individuals diagnosed with very mild dementia. Results indicated that this task strongly discriminated individuals with healthy aging from those with early-stage DAT. In a logistic regression analysis, incongruent error rates from the Stroop switching task discriminated healthy aging from DAT better than any of the other 18 cognitive tasks given in a psychometric battery.

Motor sequence learning performance in Parkinson's disease patients depends on the stage of disease

It is still unclear, whether patients with Parkinson's disease (PD) are impaired in the incidental learning of different motor sequences in short succession, although such a deficit might greatly impact their daily life. The aim of this study was thus to clarify the relation between disease parameters of PD and incidental motor learning of two different sequences in short succession. Results revealed that the PD patients were able to acquire two sequences in short succession but needed more time than healthy subjects. However, both the severity of axial manifestations, as assessed on a subsection of the Unified Parkinson's Disease Rating Scale III (UPDRS III) and the Hoehn and Yahr score, and the levodopa-equivalent dose (LED) were negatively correlated with the sequence learning performance. These findings indicate that, although PD patients are able to learn two sequences in short succession, they need more time and their overall sequence learning performance is strongly correlated with the stage of disease.

Remedial effects of motivational incentive on declining cognitive control in healthy aging and Parkinson's disease

The prospect of reward may provide a motivational incentive for optimizing goal-directed behavior. Animal work demonstrates that reward-processing networks and oculomotor-control networks in the brain are connected through the dorsal striatum, and that reward anticipation can improve oculomotor control via this nexus. Due perhaps to deterioration in dopaminergic striatal circuitry, goal-directed oculomotor control is subject to decline in healthy seniors, and even more in individuals with Parkinson's disease (PD). Here we examine whether healthy seniors and PD patients are able to utilize reward prospects to improve their impaired antisaccade performance. Results confirmed that oculomotor control declined in PD patients compared to healthy seniors, and in healthy seniors compared to young adults. However, the motivational incentive of reward expectation resulted in benefits in antisaccade performance in all groups alike. These findings speak against structural and non-modifiable decline in cognitive control functions, and emphasize the remedial potential of motivational incentive mechanisms in healthy as well as pathological aging.

Effects of a central cholinesterase inhibitor on reducing falls in Parkinson disease

OBJECTIVE

To investigate if a central cholinesterase inhibitor will reduce falling frequency in subjects with Parkinson disease (PD) with advanced postural instability.

BACKGROUND

Falling due to postural instability is a significant problem in advancing PD, and is minimally impacted by dopaminergic therapy. Anticholinergic medications increase falling in the elderly. Further, CNS cholinergic neuron loss occurs in PD. We hypothesized that acetylcholine augmentation may reduce frequent falling in subjects with PD.

METHODS

We enrolled 23 subjects with PD who reported falling or nearly falling more than 2 times per week. In a randomized, placebo-controlled, crossover design, subjects were given 6 weeks of donepezil or placebo with a 3-week washout between phases. The primary outcomes were daily falls and near falls reported on postcards. Secondary outcomes included scores on the Activities of Balance Confidence Scale, Berg Balance Scale, Clinical Global Impression of Change, Folstein Mini-Mental State Examination, and the motor section of the Unified Parkinson's Disease Rating Scale.

RESULTS

Fall frequency per day on placebo was 0.25 ± 0.08 (SEM) compared with 0.13 ± 0.03 on donepezil (p < 0.05). The frequency of near falls was not significantly different between phases. The secondary outcomes did not differ; however, there was a trend to improvement on the subject-completed Global Impression of Change scale.

CONCLUSIONS

Subjects with PD fell approximately half as often during the 6 weeks on donepezil than on placebo. Larger trials of cholinergic augmentation are warranted in subjects with PD with frequent falls.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that donepezil (maximum 10 mg per day) significantly reduced the number of falls in patients with PD (0.13 falls/day, SEM = 0.03) than when taking placebo (0.25 falls/day, SEM = 0.08, p = 0.049).

Gray matter correlates of set-shifting among neurodegenerative disease, mild cognitive impairment, and healthy older adults

There is increasing recognition that set-shifting, a form of cognitive control, is mediated by different neural structures. However, these regions have not yet been carefully identified as many studies do not account for the influence of component processes (e.g., motor speed). We investigated gray matter correlates of set-shifting while controlling for component processes. Using the Design Fluency (DF), Trail Making Test (TMT), and Color Word Interference (CWI) subtests from the Delis-Kaplan Executive Function System (D-KEFS), we investigated the correlation between set-shifting performance and gray matter volume in 160 subjects with neurodegenerative disease, mild cognitive impairment, and healthy older adults using voxel-based morphometry. All three set-shifting tasks correlated with multiple, widespread gray matter regions. After controlling for the component processes, set-shifting performance correlated with focal regions in prefrontal and posterior parietal cortices. We also identified bilateral prefrontal cortex and the right posterior parietal lobe as common sites for set-shifting across the three tasks. There was a high degree of multicollinearity between the set-shifting conditions and the component processes of TMT and CWI, suggesting DF may better isolate set-shifting regions. Overall, these findings highlight the neuroanatomical correlates of set-shifting and the importance of controlling for component processes when investigating complex cognitive tasks.

Road safety in drivers with Parkinson disease

OBJECTIVE

To assess road safety and its predictors in drivers with Parkinson disease (PD).

METHODS

Licensed, active drivers with PD (n = 84; age = 67.3 +/- 7.8, median Hoehn & Yahr stage II) and controls (n = 182; age = 67.6 +/- 7.5) underwent cognitive, visual, and motor tests, and drove a standardized route in urban and rural settings in an instrumented vehicle. Safety errors were judged and documented by a driving expert based on video data review.

RESULTS

Drivers with PD committed more total safety errors compared to controls (41.6 +/- 14.6 vs 32.9 +/- 12.3, p < 0.0001); 77.4% of drivers with PD committed more errors than the median total error count of the controls (medians: PD = 39.5, controls = 31.0). Lane violations were the most common error category in both groups. Group differences in some error categories became insignificant after results were adjusted for demographics and familiarity with the local driving environment. The PD group performed worse on tests of motor, cognitive, and visual abilities. Within the PD group, older age and worse performances on tests of visual acuity, contrast sensitivity, attention, visuospatial abilities, visual memory, and general cognition predicted error counts. Measures of visual processing speed and attention and far visual acuity were jointly predictive of error counts in a multivariate model.

CONCLUSIONS

Overall, drivers with Parkinson disease (PD) had poorer road safety compared to controls, but there was considerable variability among the drivers with PD, and some performed normally. Familiarity with the driving environment was a mitigating factor against unsafe driving in PD. Impairments in visual perception and cognition were associated with road safety errors in drivers with PD.

Assessing cognition in Parkinson disease: use of the cognitive linguistic quick test

OBJECTIVE

To evaluate the Cognitive Linguistic Quick Test (CLQT) as a cognitive screening tool in Parkinson disease (PD).

METHODS

A total of 93 patients with PD were evaluated with the Mini-Mental State Examination (MMSE) and the CLQT. The CLQT provides separate ratings for 5 cognitive domains. Descriptive statistics, correlations between the tests, and diagnostic value for dementia were analyzed.

RESULTS

Cognitive Linguistic Quick Test correlated well with MMSE. Diagnostic values for dementia were similar for the 2 instruments. Unlike the MMSE, the CLQT also provided domain-specific information on cognitive deficits. Cognitive domains were differentially affected between and within the demented and nondemented patient groups with PD: memory was the weakest domain in the demented group and attention in the nondemented.

CONCLUSIONS

The CLQT is a valuable instrument in assessing cognitive dysfunction in PD. The CLQT is superior to the MMSE as it also provides cognitive domain-specific information.

Response priming patterns differ with interstimulus interval duration

Priming paradigms make it possible to study the nature of response preparation before the onset of movement. One way to examine this process is through manipulation of the interstimulus interval (ISI). The timing of the prime and target presentation has been shown to have distinct effects on reaction time patterns, in both healthy and neurologically impaired individuals, during cognitive task switching paradigms and semantic priming studies. What is unclear, however, are the effects of ISI durations on response priming paradigms. In the present study, ISIs of five durations were manipulated within a speech response priming paradigm to investigate reaction time patterns in 25 healthy adults. Results suggested that ISIs have a significant influence on the magnitude of the priming effect. Brief ISIs, with a putatively high sensitivity to reprogramming, resulted in robust priming effects. Long ISIs, thought to be influenced by attentional factors, resulted in priming effects of lesser magnitude.

Basal Ganglia Play a Unique Role in Task Switching within the Frontal-Subcortical Circuits: Evidence from Patients with Focal Lesions

The performance of patients with lesions involving the basal ganglia (BG) was compared to that of patients with prefrontal (PFC) lesions, thalamic (TH) lesions, and age-matched controls in order to examine the specific role of the BG within the frontal-subcortical circuits (FSCC) in task switching. All the BG patients and none of the other participants showed a marked increase in error rate in incongruent trials where correct responses depended upon the choice of the correct task rule. Some BG patients erred in failing to switch tasks and others failed despite their attempt to switch tasks. Additionally, reaction time results indicate abnormal response repetition effects among the BG patients; failure in benefiting from advance task information among all the patients; and increased task mixing costs following PFC lesions. The authors conclude that although the frontal-subcortical circuits jointly determine some behaviors (such as benefiting from preparation), the BG play a unique role within the FSCC in action selection and/or the inhibition of irrelevant information.

Planning and task management in Parkinson's disease: differential emphasis in dual-task performance

Seventeen patients diagnosed with Parkinson's disease completed a complex computer-based task that involved planning and management while also performing an attention-demanding secondary task. The tasks were performed concurrently, but it was necessary to switch from one to the other. Performance was compared to a group of healthy age-matched control participants and a group of young participants. Parkinson's patients performed better than the age-matched controls on almost all measures and as well as the young controls in many cases. However, the Parkinson's patients achieved this by paying relatively less attention to the secondary task and focusing attention more on the primary task. Thus, Parkinson's patients can apparently improve their performance on some aspects of a multidimensional task by simplifying task demands. This benefit may occur as a consequence of their inflexible exaggerated attention to some aspects of a complex task to the relative neglect of other aspects.

The effects of visual, auditory, and mixed cues on choice reaction in Parkinson's disease

We investigated the effects of visual, auditory, and mixed cues on complex choice reaction in people with Parkinson's disease (PD). The paradigm using a computerized task was based on a game, "paper-rock-scissors." Four types of sensory cues were employed: simple visual cues, auditory cues, visual cues with auditory distracters, and auditory cues with visual distracters. Subjects were instructed to win, draw, or even lose the games and were required to respond as soon as possible after the sensory cues. When bradykinesia was taken into account, the PD patients had slower motor reactions. Further, when asked to lose in response to auditory cues, they displayed a significant delay in cognitive processing as compared to the healthy controls (HC), with a greater delay in the presence of a visual distracter. The error rates in the PD group were significantly higher than those in the HC group. These results suggest that PD patients are more influenced in choice reaction than the HC and by visual rather than auditory cues, especially under conditions with stimulus-response incompatibility that requires overriding habitual behavior. These data may be helpful in designing effective rehabilitation programs for PD to avoid inhibition of overlearned and contextually compatible reactions with visual distracters.