Psychiatric aspects of Parkinson's disease

Impact of the Parkinson's disease medication protocol program on nurses' knowledge and management of Parkinson's disease medicines in acute and aged care settings

AIMS

To determine the impact of a Parkinson's medicine education program on nurses' knowledge and practices in two settings where people with Parkinson's disease are cared for: hospitals and residential aged care facilities. The Parkinson's Disease Medication Protocol Program aimed to increase nurse knowledge of Parkinson's medication administration and safety in care management in order to improve health outcomes, function and well-being for the person with Parkinson's.

BACKGROUND

The ageing demographic of the developed world is concomitant with an increase in chronic disease, with Parkinson's disease being one of the most debilitating and costly. Individually complex medication regimens and unique spectrums of symptoms require disease-specific knowledge in nurses. People with Parkinson's disease admitted to hospitals and/or living in residential aged care facilities often have multiple co-morbidities, rendering care more complex still. Nurse ignorance of Parkinson's disease medicines, their uses, side effects and administration regimens, and safe care practices, can cause unnecessary distress and dysfunction for the person.

METHOD

The two pilot studies employed an eighteen month pre/post-test/follow up design at different time frames, using a questionnaire developed by the study team and an expert panel to evaluate nurses' self-assessed 'perceived' knowledge and actual knowledge of Parkinson's disease, Parkinson's medicines and safe care practices, and satisfaction with the targeted Parkinson's education program.

RESULTS/FINDINGS

Nurses in the hospital pilot (2006/8) revealed deficits in pre-test perceived and actual knowledge levels, which increased significantly at post-test and follow-up. In contrast, in the residential aged care pilot (2008/10) the nurses had higher perceived and actual (correct) knowledge relevant to experience at pre-test and these levels increased at follow-up. Both pilot study cohorts were very satisfied with the PDMPP as an education and support vehicle in Parkinson's management.

CONCLUSION

These study results concur with the international literature which identifies that without targeted clinical education nurses do not necessarily have sufficient knowledge to effectively manage Parkinson's medicines and avoid unnecessary negative outcomes arising from delays, errors and omissions, nor do they know how to provide safe and effective care for persons with Parkinson's. A well-developed and resourced Parkinson's medicine education program, such as the PDMPP, has the potential to improve deficits in clinical practice.

Striatal mechanisms underlying movement, reinforcement, and punishment

Direct and indirect pathway striatal neurons are known to exert opposing control over motor output. In this review, we discuss a hypothetical extension of this framework, in which direct pathway striatal neurons also mediate reinforcement and reward, and indirect pathway neurons mediate punishment and aversion.

Feasibility and acceptance of a nonpharmacological cognitive remediation intervention for patients with Parkinson disease

Many patients with idiopathic Parkinson disease (PD) experience deficits in executive skills (ES; eg, attentional control, self-monitoring), which are associated with a range of impairing symptoms such as visual hallucinations, decreased motor control, and increased apathy. Pharmacological methods for improving ES in PD have shown to be somewhat unreliable. The goal of this study was to evaluate the feasibility and patient acceptance of a nonpharmacological cognitive remediation program that aimed to improve sustained, selective, alternating, and divided attentional abilities in a sample of 16 nondemented PD patients. Based on ratings of 4 feasibility dimensions (fatigue, effort, progress, enjoyment), patients with PD demonstrated a high degree of acceptance and successfully engaged in the program. As predicted, ratings of progress differed significantly across tasks according to difficulty level and were positively related to posttraining improvement in ES. Fatigue ratings showed negative associations with other indices across task types, suggesting that monitoring fatigue during cognitive remediation is essential. Patients' ratings of enjoyment did not correspond to task difficulty, indicating that tasks could be simultaneously challenging and rewarding. Males reported exerting greater effort during the training than females. It was concluded that the intervention is appropriate for testing in a randomized controlled trial.

New developments in depression, anxiety, compulsiveness, and hallucinations in Parkinson's disease

Increasing research efforts are focused on nonmotor aspects of Parkinson's disease (PD). Depression, anxiety, compulsivity (dopamine dysregulation symptoms), and hallucinations/psychosis are among these disorders, and all complicate the management of PD with negative influences on quality of life. There is a strong overlap between depression and apathy and likewise, depression and anxiety can coexist and require careful pharmacologic management. Dopamine dysregulation syndrome is linked to medication use and most clearly associated with dopamine agonists. In contrast, although hallucinations and psychosis do not occur unless patients with PD are treated with dopaminergic drugs, medication doses do not directly relate to this problem. Functional neuroimaging provides an excellent resource for investigating these behaviors as well as their anatomical and neurochemical bases. New treatments are being developed, but there have been very few large-scale randomized clinical trials to test the relative roles of new or available agents for abating these problematic behaviors.

A Novel Approach to Treating Anxiety and Enhancing Executive Skills in an Older Adult with Parkinson's Disease

Scientific interest in the nonmotoric symptoms of Parkinson's disease (PD) has increased dramatically, and psychiatric symptoms (e.g., cognitive impairment, anxiety and mood disorders) are now considered prime targets for treatment optimization. Psychiatric complications in PD are quite common, affecting as many as 60 to 80% of patients. This study describes the case of a 74 year-old male with PD who presented with complaints of anxiety and trouble with memory and attention. A combined cognitive behavior therapy and cognitive enhancement intervention was delivered in ten 90-to-120 minute sessions. The patient showed a reduction in anxiety symptoms that was of sufficient magnitude to meet criteria for 'responder' status. His cognitive skills were mostly unchanged, despite the rigorous rehabilitation practice. Implications for treatment and strategies for enhancing therapeutic benefits are discussed.

Clinical correlates of Parkinsonian signs in community- dwelling Chinese older persons: a population based study

BACKGROUND AND OBJECTIVE

This study examined the clinical correlates of parkinsonian signs including neuropsychiatric symptoms, cognitive impairment and medical illness burden in the community-dwelling non-demented Chinese elderly.

METHODS

A random sample of 765 Chinese elderly subjects from a thematic household survey was recruited. There were 389 normal elderly controls (Clinical Dementia Rating [CDR] 0) (NC) and 376 subjects with questionable dementia (CDR 0.5). The subjects with questionable dementia (CDR 0.5) were categorized into two groups: a MCI group (n = 291) and a very mild dementia (VMD) group (n = 85). Parkinsonian signs were measured by Unified Parkinson Disease Rating Scale- motor scale (UPDRS). The clinical correlates were investigated in each group.

RESULTS

UPDRS motor score was associated with age, cumulative medical illness burden and cerebrovascular accidents in the normal control and MCI groups. It correlated negatively with MMSE scores in the NC group. It was associated with presence of soft signs in the NC and MCI groups; and apathy in the VMD group.

CONCLUSION

Neuropsychiatric symptoms, cognitive impairment and vascular risk factors had different patterns of associations with parkinsonian signs in the older persons with different degree of cognitive impairment.

Clinicopathological findings of suicide in the elderly: three cases

The neuropathological correlates of suicide in older persons have received little research attention. Our recent study of elderly suicide victims from an Australian forensic medicine department (n = 143), unlike a previous case-control study, did not find an increased prevalence of Alzheimer's disease (AD) in older persons who committed suicide despite a history of dementia in 6.3%. Both studies were limited to the examination of AD-related pathology by the availability of tissue. We present clinicopathological data on three cases from our study for whom autopsy findings were available. These cases included: a community-dwelling male in his early eighties with dementia who was found to have multiple cortical and striatal lacunes and glial scars, small vessel cerebrovascular disease (SVD) and AD-related pathology; a community-dwelling male in his mid-seventies with depression and loss of concentration, with brainstem predominant Lewy body disease (LBD) and AD-related pathology; and a female nursing home resident in her nineties with a history of stroke and prior suicide attempts who was found to have infarcts and SVD in frontal regions. Neuropathological findings in elderly suicide victims may include multiple neurodegenerative pathologies. The burden and distribution of neurodegenerative diseases apart from AD, including SVD and LBD, should be assessed as possible pathophysiological factors contributing to late life suicide.