Risk factors for impulse control disorders and related behaviors in Parkinson's disease: secondary analyses of the ICARUS study

Impulse control disorder: Review on clinical, pharmacologic, and genetic risk factors

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor and non-motor symptoms, among which impulse control disorders behaviors (ICD) emerge as significant non-motor manifestations. ICD in PD patients, including pathological gambling, hypersexuality, compulsive buying, among others, lead to considerable impairment and reduced quality of life. This review aims to explore the multifaceted risk factors associated with ICD in PD patients, including clinical, pharmacological, and genetic aspects, to enhance early identification, prevention, and management strategies.

METHODS

A comprehensive review of literature was conducted to identify studies investigating risk factors for ICD in PD. Data from clinical, pharmacological, and genetic studies were analyzed to elucidate the complex interplay of factors contributing to ICD development.

RESULTS

Clinical risk factors such as young age, male gender, and specific personality traits were consistently associated with a higher incidence of ICD. Environmental factors such as cultural nuances and geographic location influence ICD prevalence. Disease characteristics include early PD onset, longer disease duration, motor fluctuations, anxiety, depression, sleep disorders, and apathy. Pharmaceutical risk factors involve dopaminergic drugs, with dopamine agonists showing a dose-dependent association with ICD. Genetic risk factors highlight the involvement of dopaminergic and serotoninergic systems, with various neurotransmitter pathways implicated.

CONCLUSIONS

ICDs are common and severe in PD. Understanding the multifaceted risk factors for ICD in PD is crucial for identifying patients at high risk to develop these adverse effects and developing targeted interventions to prevent their occurrence. Given their frequency and potential consequences for the patient and their family, the current strategy is to systematically screen for ICDs throughout patient follow-up, particularly when prescribing dopamine agonists.

Behavioral disorders in Parkinson disease: current view

Patients with Parkinson disease (PD) frequently experience several behavioral symptoms, such as anxiety, apathy, irritability, agitation, impulsive control and obsessive-compulsive or REM sleep behavior disorders, which can cause severe psychosocial problems and impair quality of life. Occurring in 30-70% of PD patients, these symptoms can manifest at early stages of the disease, sometimes even before the appearance of classic motor symptoms, while others can develop later. Behavioral changes in PD show distinct patterns of brain atrophy, dopaminergic and serotonergic deterioration, altered neuronal connectivity in frontostriatal, corticolimbic, default mode and other networks due to a cascade linking molecular pathologies and deficits in multiple behavior domains. The changes suggest a multi-system neurodegenerative process in the context of a specific α-synucleinopathy inducing a variety of biochemical and functional changes, the neurobiological basis and clinical relevance of which await further elucidation. This paper is intended to review the recent literature with focus on the main behavioral disturbances in PD patients, their epidemiology, clinical features, risk factors, animal models, neuroimaging findings, pathophysiological backgrounds, and treatment options of these deleterious lesions.

Disease Stage and Motor Fluctuation Duration Predict Drug Tolerability: A Real-Life, Prospective Italian Multicenter Study on the Use of Opicapone in Parkinson's Disease

BACKGROUND

Opicapone is a third-generation catechol-O-methyl-transferase inhibitor currently used for the treatment of motor fluctuations in Parkinson's disease. Its benefit and safety have been established by clinical trials; however, data about its use in a real-life context, and particularly in an Italian population of patients with Parkinson's disease, are missing.

OBJECTIVES

We aimed to gather data about the real-life tolerability/safety of opicapone when used for the treatment of Parkinson's disease-related motor fluctuations.

METHODS

We enrolled 152 consecutive patients with Parkinson's disease and followed them for 2 years after opicapone introduction. We obtained baseline clinical and demographical information, including disease duration, stage, phenotype, as well as axial and non-motor symptoms. We collected the reasons for any treatment interruption and adverse events emerging after opicapone introduction.

RESULTS

Eighty-nine (58%) patients reported adverse events and 46 (30%) patients discontinued the treatment. Adverse events occurred less frequently in "earlier" patients accordingly to the disease course and L-Dopa treatment pathway; a motor fluctuation duration ≥12 months and Hoehn and Yahr scale score ≥2.5 were the main predictors of therapy withdrawal.

CONCLUSIONS

This study confirms the good tolerability/safety profile of opicapone in a real-life setting and provides country-specific data for Italian patients with Parkinson's disease.

Anticipating Tomorrow: Tailoring Parkinson's Symptomatic Therapy Using Predictors of Outcome

BACKGROUND

Although research into Parkinson's disease (PD) subtypes and outcome predictions has continued to advance, recommendations for using outcome prediction to guide current treatment decisions remain sparse.

OBJECTIVES

To provide expert opinion-based recommendations for individually tailored PD symptomatic treatment based on knowledge of risk prediction and subtypes.

METHODS

Using a modified Delphi approach, members of the Movement Disorders Society (MDS) Task Force on PD subtypes generated a series of general recommendations around the question: "Using what you know about genetic/biological/clinical subtypes (or any individual-level predictors of outcome), what advice would you give for selecting symptomatic treatments for an individual patient now, based on what their subtype or individual characteristics predict about their future disease course?" After four iterations and revisions, those recommendations with over 75% endorsement were adopted.

RESULTS

A total of 19 recommendations were endorsed by a group of 13 panelists. The recommendations primarily centered around two themes: (1) incorporating future risk of cognitive impairment into current treatment plans; and (2) identifying future symptom clusters that might be forestalled with a single medication.

CONCLUSIONS

These recommendations provide clinicians with a framework for integrating future outcomes into patient-specific treatment choices. They are not prescriptive guidelines, but adaptable suggestions, which should be tailored to each individual. They are to be considered as a first step of a process that will continue to evolve as additional stakeholders provide new insights and as new information becomes available. As individualized risk prediction advances, the path to better tailored treatment regimens will become clearer.

The Association of Antidepressant Use and Impulse Control Disorder in Parkinson's Disease

OBJECTIVES

To examine whether initiation of an antidepressant is associated with the development of impulse control disorder (ICD) in patients with Parkinson's disease (PD).

DESIGN

We performed a retrospective analysis utilizing data from the Parkinson's Progression Markers Initiative (PPMI). Two-sample Mann-Whitney tests were used for comparison of continuous variables and Pearson χ2 tests were used for categorical variables. Kaplan-Meier survival analysis and cox proportional hazards regression analysis was used to assess the hazard of ICD with antidepressant exposure.

SETTING

The PPMI is a multicenter observational study of early PD with 52 sites throughout North America, Europe, and Africa.

PARTICIPANTS

Participants in the current study were those in the PPMI PD cohort with a primary diagnosis of idiopathic PD.

MEASUREMENTS

The presence of ICD was captured using the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP). Antidepressant use was defined based on medication logs for each participant. Depressive symptoms were captured using the Geriatric Depression Scale (GDS).

RESULTS

A total of 1,045 individuals were included in the final analysis. There was a significant increase in the probability of ICD in those exposed to serotonergic antidepressants compared to those not exposed (Log-rank p <0.001). Serotonergic antidepressant use was associated with a hazard ratio for ICD of 1.4 (95% CI 1.0-1.8, z-value 2.1, p = 0.04) after adjusting for dopamine agonist use, depression, bupropion use, MAOI-B use, amantadine use, LEDD, disease duration, sex, and age.

CONCLUSIONS

Serotonergic antidepressant use appears to be temporally associated with ICD in patients with PD.

Management of Impulse Control and Related Disorders in Parkinson's Disease: An Expert Consensus

BACKGROUND

Impulse-control and related behavioral disorders (ICBDs) significantly impact the lives of Parkinson's disease (PD) patients and caregivers, with lasting consequences if undiagnosed and untreated. While ICBD pathophysiology and risk factors are well-studied, a standardized severity definition and treatment evidence remain elusive.

OBJECTIVE

This work aimed to establish international expert consensus on ICBD treatment strategies. To comprehensively address diverse treatment availabilities, experts from various continents were included.

METHODS

From 2021 to 2023, global movement disorders specialists engaged in a Delphi process. A core expert group initiated surveys, involving a larger panel in three iterations, leading to refined severity definitions and treatment pathways.

RESULTS

Experts achieved consensus on defining ICBD severity, emphasizing regular PD patient screenings for early detection. General treatment recommendations focused on continuous monitoring, collaboration with significant others, and seeking specialist advice for legal or financial challenges. For mild to severe ICBDs, gradual reduction in dopamine agonists was endorsed, followed by reductions in other PD medications. Second-line treatment strategies included diverse approaches like reversing the last medication change, cognitive behavior therapy, subthalamic nucleus deep brain stimulation, and specific medications like quetiapine, clozapine, and antidepressants. The panel reached consensus on distinct treatment pathways for punding and dopamine dysregulation syndrome, formulating therapy recommendations. Comprehensive discussions addressed management strategies for the exacerbation of either motor or non-motor symptoms following the proposed treatments.

CONCLUSION

The consensus offers in-depth insights into ICBD management, presenting clear severity criteria and expert consensus treatment recommendations. The study highlights the critical need for further research to enhance ICBD management. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Assessing impulse control behaviors in early Parkinson's disease: a longitudinal study

Objective

Impulse control behaviors (ICBs) frequently coexist with Parkinson's disease (PD). However, the predictors of ICBs in PD remain unclear, and there is limited data on the biological correlates of ICBs in PD. In this study, we examined clinical, imaging, and biological variables to identify factors associated with longitudinal changes in ICBs in early-stage PD.

Methods

The data for this study were obtained from the Parkinson's Progression Markers Initiative, an international prospective cohort study that evaluates markers of disease progression in PD. We examined clinical, imaging, and biological variables to determine their associations with ICBs over a period of up to 5 years. Cox regression models were employed to investigate the predictors of ICBs in early-stage, untreated PD.

Results

The study enrolled 401 individuals with PD and 185 healthy controls (HC). At baseline, 83 PD subjects (20.7%) and 36 HC (19.5%) exhibited ICBs. Over the course of 5 years, the prevalence of ICBs increased in PD (from 20.7% to 27.3%, p < 0.001), while it decreased in HC (from 19.5% to 15.2%, p < 0.001). Longitudinally, the presence of ICBs in PD was associated with depression, anxiety, autonomic dysfunction, and excessive daytime sleepiness (EDS). However, there was no significant association observed with cognitive dysfunction or motor severity. Treatment with dopamine agonists was linked to ICBs at years 3 and 4. Conversely, there was no association found between ICBs and presynaptic dopaminergic dysfunction. Additionally, biofluid markers in baseline and the first year did not show a significant association with ICBs. A predictive index for ICBs was generated, incorporating three baseline characteristics: anxiety, rapid eye movement sleep behavior disorder (RBD), and p-tau levels in cerebrospinal fluid (CSF).

Conclusion

During the early stages of PD, there is a notable increase in ICBs over time. These ICBs are associated with depression, anxiety, autonomic dysfunction, EDS, and the use of dopaminergic medications, particularly dopamine agonists. Anxiety, RBD, and p-tau levels in CSF are identified as predictors for the incident development of ICBs in early PD. Further longitudinal analyses will provide a more comprehensive understanding of the associations between ICBs and imaging findings, as well as biomarkers. These analyses will help to better characterize the relationships and implications of these factors in the context of ICBs in early PD.

White matter hyperintensities associated with impulse control disorders in Parkinson's Disease

Impulse control disorders (ICDs) in Parkinson's disease (PD) are increasingly recognized as clinically significant non-motor features that potentially impair the quality of life. White matter hyperintensities (WMHs), detected by magnetic resonance imaging, are frequently observed in PD and can be associated with both motor- and certain non-motor symptoms. Given the limited number of non-motor features studied in this context, our aim was to reveal the potential association between the severity of WMHs and ICDs in PD. Fluid-attenuated inversion recovery magnetic resonance images were retrospectively evaluated in 70 patients with PD (48 males; 59.3 ± 10.1 years). The severity of WMHs was assessed by Fazekas scores and by the volume and number of supratentorial WMHs. ICDs were evaluated using the modified Minnesota Impulsive Disorders Interview. Significant interaction between age and the severity of WMHs was present for ICDs. In our younger patients (< 60.5 years), severity of WMHs was positively associated with ICDs (p = 0.004, p = 0.021, p < 0.001 and p < 0.001, respectively for periventricular white matter and total Fazekas scores and the volume and number of WMHs). Our study supports the hypothesis that WMHs of presumed vascular origin may contribute to ICDs in PD. Future prospective studies are needed to assess the prognostic relevance of this finding.

Relationship between sleep disorders and neuropsychiatric symptoms in Parkinson's disease: A narrative review

Aim: The objective of this narrative review was to describe the versatile links between mental status and sleep in patients with Parkinson's disease. Methods: We searched randomized controlled studies, observational studies, meta-analyses, systematic reviews, and case reports written in English in PubMed during 2015 - 2021. Additionally, to ensure the completeness of the review, a second, more in-depth literature search was performed using the same electronic database with the search inquiries of increased specificity. Results: The information on pathophysiology, epidemiology, clinical features and risk factors was extracted and formed the basis for this review. Despite how widespread sleep disorders in Parkinson's disease are, there is no systematic information about their association with neuropsychiatric symptoms, such as depression, anxiety, impulse control disorders, apathy, cognitive impairment and psychosis. In this review, we described relationships between these non-motor symptoms of Parkinson's disease, their timeline occurrence, gap in knowledge and perspectives for further research. We suppose that early treatment of sleep disorders in patients with Parkinson's disease can reduce the incidence and extent of neuropsychiatric symptoms. Conclusion: We have demonstrated multiple, multidirectional relationships between sleep disorders and neuropsychiatric symptoms. However, some of them remain unexplored. The described knowledge can be applied to further study the possibility of influencing neuropsychiatric symptoms through the correction of sleep disorders in patients with different stages of Parkinson's disease.

Assessment of therapeutic strategies for management of impulse control disorder in Parkinson's disease

BACKGROUND

Impulse control disorders (ICD) occur frequently in individuals with Parkinson's disease. So far, prevention is the best treatment. Several strategies for its treatment have been suggested, but their frequency of use and benefit have scarcely been explored.

OBJECTIVE

To investigate which strategy is the most commonly used in a real-life setting and its rate of response.

METHODS

A longitudinal study was conducted. At the baseline evaluation, data on current treatment and ICD status according to QUIP-RS were collected. The treatment strategies were categorized as "no-change", dopamine agonist (DA) dose lowering, DA removal, DA switch or add-on therapy. At the six-month follow-up visit, the same tools were applied.

RESULTS

A total of 132 individuals (58.3% men) were included; 18.2% had at least one ICD at baseline. The therapeutic strategy most used in the ICD group was no-change (37.5%), followed by DA removal (16.7%), DA switch (12.5%) and DA lowering (8.3%). Unexpectedly, in 20.8% of the ICD subjects the DA dose was increased. Overall, nearly 80% of the subjects showed remission of their ICD at follow-up.

CONCLUSIONS

Regardless of the therapy used, most of the subjects presented remission of their ICD at follow-up Further research with a longer follow-up in a larger sample, with assessment of decision-making processes, is required in order to better understand the efficacy of strategies for ICD treatment.

Abnormal interhemispheric resting state functional connectivity in Parkinson's disease patients with impulse control disorders

Impulse control disorders (ICD) in Parkinson’s disease (PD) might be attributed to misestimate of rewards or the failure to curb inappropriate choices. The mechanisms underlying ICD were reported to involve the lateralization of monoamine network. Our objective was to probe the significant role of lateralization in the pathogenesis of ICD. Twenty-one PD patients with ICD (PD-ICD), thirty-three without ICD (PD-no ICD), and thirty-seven healthy controls (HCs) were recruited and performed T1-weighted, diffusion tensor imaging (DTI) scans and resting state functional magnetic resonance imaging (rs-fMRI). By applying the Voxel-mirrored Homotopic Connectivity (VMHC) and Freesurfer, we evaluated participants’ synchronicity of functional connectivity and structural changes between hemispheres. Also, tract-based spatial statistics (TBSS) was applied to compare fiber tracts differences. Relative to PD-no ICD group, PD-ICD group demonstrated reduced VMHC values in middle frontal gyrus (MFG). Compared to HCs, PD-ICD group mainly showed decreased VMHC values in MFG, middle and superior orbital frontal gyrus (OFG), inferior frontal gyrus (IFG) and caudate, which were related to reward processing and inhibitory control. The severity of impulsivity was negatively correlated with the mean VMHC values of MFG in PD-ICD group. Receiver operating characteristic (ROC) curves analyses uncovered that the mean VMHC values of MFG might be a potential marker identifying PD-ICD patients. However, we found no corresponding asymmetrical alteration in cortical thickness and no significant differences in fractional anisotropy (FA) and mean diffusivity (MD). Our results provided further evidence for asymmetry of functional connectivity in mesolimbic reward and response inhibition network in ICD.

Neuropsychiatric Disorders in Parkinson's Disease: What Do We Know About the Role of Dopaminergic and Non-dopaminergic Systems?

Besides the hallmark motor symptoms (rest tremor, hypokinesia, rigidity, and postural instability), patients with Parkinson’s disease (PD) have non-motor symptoms, namely neuropsychiatric disorders. They are frequent and may influence the other symptoms of the disease. They have also a negative impact on the quality of life of patients and their caregivers. In this article, we will describe the clinical manifestations of the main PD-related behavioral disorders (depression, anxiety disorders, apathy, psychosis, and impulse control disorders). We will also provide an overview of the clinical and preclinical literature regarding the underlying mechanisms with a focus on the role of the dopaminergic and non-dopaminergic systems.