Management of impulse control disorders in Parkinson's disease

Designing Virtual Reality Assisted Psychotherapy for Anxiety in Older Adults Living with Parkinson's Disease: Integrating Literature for Scoping

Objective: This review integrates literature to discuss the potential use of virtual reality (VR) in treatment of anxiety in Parkinson's disease (PD) and inform next steps.Methods: A systematic search was performed to identify studies of VR use in PD, using four databases. Data were reported in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR).Results: Thirty-two studies met the inclusion criteria with four VR studies from the same study group directly assessing the effects of anxiety on motor symptoms in PD. Primary studies implementing a VR protocol in PD identified focus areas of understanding and alleviating freezing of gait (FOG), balance training, and cognitive and motor rehabilitation, and informed design considerations.Conclusion: VR in PD studies suggested established feasibility. With appropriate design considerations, a VR based protocol could improve anxiety outcomes in PD.Clinical implications: VR in PD provides control of a patient's field of view, which can be exploited to induce specific responses, provide visual feedback, analysis of patient actions, and introduce safe challenges in the context of training. VR assisted Cognitive Behavioral Therapy (CBT) tailored to suit subtypes of anxiety disorders in PD have the potential to improve the efficacy and effectiveness of psychotherapy in PD.

Exploring Nonmotor Neuropsychiatric Manifestations of Parkinson Disease in a Comprehensive Care Setting

Parkinson disease (PD) is a debilitating neurological condition that includes both motor symptoms and nonmotor symptoms (NMS). Psychiatric complaints comprise NMS and are collectively referred to as neuropsychiatric manifestations. Common findings include atypical depressive symptoms, anxiety, psychosis, impulse control disorder, deterioration of cognition, and sleep disturbances. Quality of life (QoL) of patients suffering from NMS is greatly impacted and many times can be more debilitating than motor symptoms of PD. We expand on knowledge gained from treatment models within a comprehensive care model that incorporates multidisciplinary specialists working alongside psychiatrists to treat PD. Insight into background, clinical presentations, and treatment options for patients suffering from neuropsychiatric manifestations of PD are discussed. Identifying symptoms early can help improve QoL, provide early symptom relief, and can assist tailoring treatment plans that limit neuropsychiatric manifestations.

Evolution of impulsive-compulsive behaviors and cognition in Parkinson's disease

The longitudinal course of ICBs in patients with Parkinson's disease (PwP) relative to controls has not been explored as of yet. The aim of this study is to determine the frequency, evolution and associated cognitive and clinical features of impulsive and compulsive behaviors (ICBs) over 4 years of prospective follow-up in a population-based cohort with early Parkinson's disease (PD). We recruited 124 cognitively intact participants with early PD and 156 matched controls from the Norwegian ParkWest study. ICBs were assessed using the self-report short form version of the Questionnaire for Impulsive-Compulsive Disorders in PD. Cognitive changes were examined in PwP with and without ICBs who completed the 4-year follow-up. Generalized linear mixed modelling and mixed linear regression were used to analyze clinical factors and cognitive changes associated with ICBs in PwP over time. ICBs were more common in PwP than controls at all visits, with an age-adjusted odds ratio (OR) varying between 2.5 (95% CI 1.1-5.6; p = 0.022) and 5.1 (95% CI 2.4-11.0; p < 0.001). The 4-year cumulative frequency of ICBs in PwP was 46.8% and 23.3% developed incident ICBs during the study period, but the presence of ICBs was non-persistent in nearly 30%. ICBs were independently associated with younger age (OR 0.95, 95% CI 0.91-0.99: p = 0.008) and use of dopamine agonist (OR 4.1, 95% CI 1.56-10.69). Cognitive changes over time did not differ between patients with and without ICBs. In conclusion, ICBs are common in PwP, but are often non-persistent and not associated with greater cognitive impairment over time.

Iowa Gambling Task Performance in Parkinson Disease Patients with Impulse Control Disorders

OBJECTIVE

A subgroup of patients with Parkinson disease (PD) develops impulse control disorders (ICD) associated with their dopamine replacement therapy. Patients and their families may be reluctant to report ICD symptoms or unaware these symptoms are related to PD medication, which can make detecting an ICD difficult for clinicians. Ideally, a behavioral measure that is sensitive to ICD could be employed to ensure that patients with these behaviors are identified and treated. The Iowa Gambling Task (IGT), a standardized decision-making task, has proven sensitive in other populations with impulse control problems. We hypothesized that the IGT would differentiate between PD patients with and without ICD.

METHODS

We compared IGT performance and disease variables in 24 PD patients with ICD and 24 PD patients without ICD. Patient groups were matched in terms of age, sex, and duration of PD.

RESULTS

There were no significant differences in IGT scores between PD groups. IGT performance declined with increasing age, but the majority of patients performed within normal limits based on published age- and education-corrected normative data.

CONCLUSIONS

The IGT did not distinguish between PD patients with and without ICD. Increasing age negatively impacted performance in both groups. Other studies have found that IGT performance may decline in normal aging. Our results suggest that the IGT lacks the sensitivity and specificity needed to differentiate between age-related deficits and disruption in frontal-subcortical circuits underlying ICD associated with PD medications. Therefore, the IGT is not an appropriate behavioral measure for ICD in PD patients.

Unmasking neurobiological commonalities between addictive disorders and impulse control disorders in Parkinson’s disease

Changes in reward circuitry have been studied extensively in substance and behavioural addictions. However, comparatively little is known about the neurobiology underlying impulse control disorders (ICDs) in Parkinson's disease, which show roughly similar risk factors and behavioural presentations to both stimulant and behavioural addictions. ICDs occur in a subset of susceptible patients with Parkinson's disease (PD) following intake of dopamine replacement therapy (DRT). These behavioural disorders often have debilitating effects on a patient's quality of life and increase caregiver burden. This comprehensive review examined findings of 40 neuroimaging studies of ICDs in PD to determine (a) whether there are putative neurobiological commonalities between traditional substance and behavioural addictions and DRT-induced ICD in PD and (b) opportunities for future studies to advance current neurobiological understanding of the phenomenon. Results revealed that strikingly similar (a) deficits in dopaminergic receptor expression, (b) connectivity changes in corticostriatal circuitry and (c) neural responses to cue exposure are observed in both ICDs in PD and addictive disorders. These findings point to the value of adopting a transdiagnostic approach when studying addicted populations and pave the way for demystifying this peculiar, often-devastating phenomenon in PD that has so far proven extremely difficult to treat and predict with any precision.

Impulse Control Disorders and Dopamine-Related Creativity: Pathogenesis and Mechanism, Short Review, and Hypothesis

Impulse control disorder (ICD), including pathological gambling, hypersexuality, and compulsive shopping has been linked to antiparkinsonian medication, especially dopamine agonists. The mechanism of ICD is not completely clear, but it seems that ICD is the result of an activation of dopamine receptors, mostly D3 in the ventral striatum. Patients treated with dopamine agonists that have preferential affinity for D3 (including ropinirole and pramipexole) are much more prone to develop ICD. In addition, a genetic component is probably present, especially in young patients. Finally, environment and lifestyle may also play a role: those patients engaged in physical, social, and artistic activities are probably less likely to develop ICD compared to those patients with poor physical activity living in isolated environments.

Remote delivery of psychological interventions for Parkinson's disease

ABSTRACTObjective:Over two-thirds of Parkinson's disease (PD) patients experience comorbid neuropsychiatric symptoms, which adversely impact their quality of life and often require intervention. There is a preference for non-pharmacological, psychological approaches in addressing these symptoms. Given mobility limitations, travel burden, and cost, accessibility to psychological treatment can be problematic in this population. There has been a recent shift toward delivering care via telehealth in PD. Accordingly, this review aimed to examine remotely delivered psychological interventions for PD patients.Results:Most of the telehealth studies for PD involved Cognitive Behavioral Therapy (CBT) based anxiety and depression telephone interventions with relatively short (one month) follow-up periods.Conclusion:Although a preliminary work indicates efficacy, future studies should demonstrate the non-inferiority of these telehealth programs compared to face-to-face delivery, and examine the long-term outcomes of remotely delivered therapy. Video-conferencing (VC) appears to be a promising modality to overcome noted limitations of telephone delivery, and has demonstrated efficacy for PD speech programs. Further research should be conducted evaluating telehealth VC modalities for delivery of psychotherapy including CBT, as well as mindfulness-based therapy and acceptance and commitment therapy for remote treatment of depression and anxiety in PD.

Neurocognitive correlates of medication-induced addictive behaviours in Parkinson's disease: A systematic review

Dopaminergic medication can induce severe addictive behaviours (e.g., pathological gambling) in susceptible Parkinson's disease (PD) patients. It is still unknown which particular neurocognitive processes become exacerbated or dysfunctional in PD patients with addictive behaviours. We sought to systematically review the relevant literature to identity potential neurocognitive correlates of medication-induced addictive behaviours in PD. We framed our review around neurocognitive processes central to four dominant accounts of substance addiction: 'aberrant learning', 'incentive sensitization', 'impulsivity to compulsivity' and 'impaired response inhibition and salience attribution'. Searches of the PubMed and Scopus databases were completed on June 23, 2017. To be included, studies were required to involve: (a) medicated PD patients, without a history of deep brain stimulation, with and without addictive behaviours; (b) a reward-related or decision-making task; and (c) statistical comparison of addictive and non-addictive groups' 'on' medication performance on the task(s). Studies were summarised qualitatively with statistically significant (p<.05) group differences and effect sizes (Cohen's d) highlighted. 35 studies were included. Findings showed that the extant literature is highly heterogeneous. The domains of reward and punishment learning, reflection impulsivity and disadvantageous decision-making exemplify this. More homogeneity exists in domains in which (a) neurocognitive dysfunction is not apparent (motor control, cognitive/attentional flexibility and cognitive control) or (b) typical neurocognitive processes appear exacerbated by medication (reward motivation and choice impulsivity). Future large-scale neurocognitive studies are still required to develop our scientific understanding of addictive behaviours in PD and aid their clinical treatment and prediction.

Parkinson's Disease: Impulsivity Does Not Cause Impulse Control Disorders but Boosts Their Severity

Introduction: Impulse control disorders (ICDs) are a common complication of Parkinson's disease (PD) receiving dopamine agonist (DAA) Impulsivity is considered an underlying mechanism but evidence of this relationship is scarce. To explore the relationship between impulsivity and the presence and severity of ICD in PD. Methods: Prospective cross-sectional study of consecutive PD outpatients. Patients with dementia or previously known ICDs were excluded. Two measures of impulsivity were assessed: Barratt Impulsiveness Scale (BIS-11) for impulsiveness trait (main exposure) and commission errors in the Continuous Performance Test (CE) for motor inhibition. Main outcomes were diagnosis of ICD based on a comprehensive clinical interview and severity of ICD based on the Questionnaire for Impulsive-Compulsive Disorders. Results: Of 100 patients (mean [SD] age, 67.2 [8.8], 54 male), 31 had ICD. Patients with ICDs were 5.3 years younger (p = 0.01), used more frequently dopamine agonist (p = 0.02), alcohol (p = 0.009) and tobacco (p = 0.02). They were not more impulsive on BIS-11 (56 vs. 58, p = 0.23, adjusted p = 0.46) and CE (p = 0.96). No relationship was found between dopaminergic medications and impulsivity or ICD severity. Among patients with ICD, impulsivity was correlated with ICD severity (BIS-11 r = 0.33, p = 0.001, adjusted p = 0.002, CE r = 0.53, p = 0.006). Multivariate regression analysis confirmed the independent predictive role of both measures. Conclusions: Impulsivity is not associated with increased prevalence of ICD in PD but it is strongly linked to ICD severity. When considering dopamine replacement therapy, assessment of impulsivity may be a useful approach to detect those patients at risk of severe forms of ICD.

Caregiver Burden in Parkinson Disease: A Critical Review of Recent Literature

Burden is a negative psychological state induced in caregivers by the demands of providing care to a person with an illness or a disability. Managing caregiver burden in Parkinson disease (PD) is significant because informal caregivers make a substantial contribution to the well-being of persons with PD, incurring financial, social, and personal losses. Failure to recognize and manage caregiver burden may lead to burnout and premature institutionalization of the person with PD. We conducted a comprehensive literature review to identify and summarize factors that may amplify burden, including motor and nonmotor symptoms of PD, caregiver psychiatric symptoms, and caregiver coping style. We review instruments designed to sample the construct of burden among caregivers and evaluate interventions that may reduce burden, either by directly targeting caregivers or by treating PD symptoms associated with burden. We aim to provide a concise synopsis of these issues for the clinician or researcher working with this population in order to facilitate recognition of caregiver burden, provide accurate assessment, administer appropriate interventions, and stimulate further research in this area.