Long-term effects of cognitive rehabilitation on brain, functional outcome and cognition in Parkinson's disease

The use of combined cognitive training and non-invasive brain stimulation to modulate impulsivity in adult populations: a systematic review and meta-analysis of existing studies

Introduction

Impulsivity, a tendency to act rashly and without forethought, is a core feature of many mental disorders that has been implicated in suicidality and offending behaviours. While research supports the use of non-invasive brain stimulation (NIBS) techniques, such as transcranial direct current stimulation (tDCS), to modulate brain functions, no studies specifically reviewed the use of combined cognitive training and NIBS to modulate impulsivity.

Methods

We aimed to conduct a systematic review and meta-analysis to synthesise the literature on the use of combined cognitive training and NIBS to modulate impulsivity and its subdomains (motor, delay discounting, reflection). We searched Scopus, PsychInfo, Medline, and Cinahl electronic databases, dissertations database, and Google scholar up to September 2024.

Results

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, four randomised controlled studies involving the use of combined cognitive training and tDCS in 127 subjects were included in the study. These studies included subjects with substance use disorders, obesity, and Parkinson's disease. Meta-analysis showed that combined cognitive training and tDCS had no statistically significant effects on motor impulsivity as measured using reaction times on the Stop Signal Task and Go/No Go tasks. One study that measured impulsiveness scores on a delay discounting task also showed no significant results. No studies measured reflection or cognitive impulsivity.

Discussion

There is a dearth of literature on the use of combined cognitive training and NIBS for impulsivity. This in conjunction of clinical heterogeneity across studies makes it difficult to draw definitive conclusions about the neuromodulation of impulsivity and its subdomains using combined cognitive training and NIBS. The findings of this study highlight the need to conduct more studies in the field.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD 42024511576.

Towards a Non-pharmacological Intervention on Apathy in Korsakoff's Syndrome: A Systematic Narrative Review Across Different Clinical Conditions

Abstract

Apathy is a quantitative reduction of goal-directed activity, which can be observed in relation to behavior, cognition, emotions and social interaction. It is an invalidating behavioral symptom that is frequently present across different psychiatric conditions and neurocognitive disorders including Korsakoff's Syndrome (KS). In fact, apathy is one of the most severe behavioral symptoms of KS and has a major impact on the lives of patients and their relatives and other informal caregivers. However, guidelines for the treatment of apathy in KS are currently not available. This systematic narrative review provides a transdiagnostic overview of the effectiveness of different types of non-pharmacological interventions on apathy across different study populations that at symptom-level share characteristics with KS. This evidence may inform the development of an intervention targeting apathy in KS. The included study populations are dementia (due to Alzheimer's disease, or vascular dementia), Parkinson's disease, schizophrenia and traumatic brain injury. Through a stepped selection approach and with regard to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 22 systematic reviews and 32 empirical articles on the non-pharmacological treatment of apathy were identified. The results show a variety of effective non-pharmacological interventions on apathy. In conditions with severe cognitive impairments, successful interventions did not rely on intrinsic motivation, self-monitoring, or illness insight of the patients, but depend on external stimulation and behavioral activation. Since apathy is a multidimensional construct, identification of the extent and type of apathetic behavior before starting an intervention is highly recommended. Furthermore, it is important to adjust the treatment to the patients' personal interests and needs and embedded in daily care.

Trial registration

CRD42022298464 (PROSPERO).

I didn't know I had executive dysfunction, now I can do something about it: perspectives about CO-OP from people with Parkinson's disease

PURPOSES

People with Parkinson's disease (PD) experience increasing disability across their lifespan. Holistic rehabilitation approaches are needed to maximize their daily functioning and quality of life (QoL). The Cognitive Orientation to daily Occupational Performance (CO-OP) approach targets daily functioning, with established efficacy in other neurological populations. This study is part of a larger trial of CO-OP with people with PD, describing the perspectives of people with PD who received CO-OP about its effect on their lives.

METHODS

People with PD participating in a randomized controlled trial (RCT) were interviewed following the CO-OP programme. Views about the feasibility, acceptability, and experiences of CO-OP were explored. Inductive thematic analysis was used to interpret the findings.

RESULTS

Analysis of interviews (n = 20) identified that CO-OP drove positive change in participants' daily lives. Participants reported transfer and generalization of learned strategies, suggesting effective use of skills learned in CO-OP.

CONCLUSIONS

Addressing a critical gap in PD management, findings suggest that CO-OP was perceived as effective in addressing a broad scope of PD-related issues. Findings hold particular significance for individuals experiencing long-term PD consequences, potentially offering a viable option to enhance participation and QoL. Findings support CO-OP as an implementable, acceptable, and potentially beneficial intervention in PD. Further research is warranted to establish efficacy.

Long-term effects of cognitive training in Parkinson's disease: A randomized, controlled trial

Background

Computerized cognitive training may be promising to improve cognitive impairment in Parkinson's disease and has even been suggested to delay cognitive decline. However, evidence to date is limited. The aim of this study was to assess the durability of eight-week cognitive training effects at up to two years follow-up.

Methods

One hundred and thirty-six (1 3 6) individuals with Parkinson's disease, subjective cognitive complaints but without severe cognitive impairment (Montreal Cognitive Assessment ≥ 22) participated in this double-blind RCT. Participants underwent an eight-week home-based intervention of either adaptive, computerized cognitive training with BrainGymmer (n = 68) or an active control (n = 68). They underwent extensive neuropsychological assessment, psychiatric questionnaires and motor symptom assessment at baseline and one and two years after the intervention. We used mixed-model analyses to assess changes in cognitive function at follow-up and performed Fisher's exact tests to assess conversion of cognitive status.

Results

There were no group differences on any neuropsychological assessment outcome at one- and two-year follow-up. Groups were equally likely to show conversion of cognitive status at follow-up. A considerable amount of assessments was missed (1y: n = 27; 2y: n = 33), most notably due to COVID-19 regulations.

Conclusions

Eight-week cognitive training did not affect long-term cognitive function in Parkinson's disease. Future studies may focus on one cognitive subgroup to enhance reliability of study results. Intervention improvements are needed to work towards effective, lasting treatment options.

Efficacy and Feasibility of Remote Cognitive Remediation Therapy in Parkinson's Disease: A Randomized Controlled Trial

Background

Non-motor symptoms of Parkinson's disease (PD) such as cognitive impairment are common and decrease patient quality of life and daily functioning. While no pharmacological treatments have effectively alleviated these symptoms to date, non-pharmacological approaches such as cognitive remediation therapy (CRT) and physical exercise have both been shown to improve cognitive function and quality of life in people with PD.

Objective

This study aims to determine the feasibility and impact of remote CRT on cognitive function and quality of life in patients with PD participating in an organized group exercise program.

Methods

Twenty-four subjects with PD recruited from Rock Steady Boxing (RSB), a non-contact group exercise program, were evaluated using standard neuropsychological and quality of life measures and randomized to the control or intervention group. The intervention group attended online CRT sessions for one hour, twice a week for 10 weeks, engaging in multi-domain cognitive exercises and group discussion.

Results

Twenty-one subjects completed the study and were reevaluated. Comparing groups over time, the control group (n = 10) saw a decline in overall cognitive performance that trended towards significance (p = 0.05) and a statistically significant decrease in delayed memory (p = 0.010) and self-reported cognition (p = 0.011). Neither of these findings were seen in the intervention group (n = 11), which overwhelmingly enjoyed the CRT sessions and attested to subjective improvements in their daily lives.

Conclusions

This randomized controlled pilot study suggests that remote CRT for PD patients is feasible, enjoyable, and may help slow the progression of cognitive decline. Further trials are warranted to determine the longitudinal effects of such a program.

Sex Differences in Brain Structure in de novo Parkinson's Disease: A Cross-Sectional and Longitudinal Neuroimaging Study

BACKGROUND

Parkinson's disease (PD) varies in occurrence, presentation, and severity between males and females. However, the sex effects on the patterns of brain structure, cross-sectionally and longitudinally, are still unclear.

OBJECTIVE

We aimed to compare sex differences in brain features cross-sectionally and longitudinally using grey matter volume (GMV) and cortical thickness in a large sample of newly diagnosed drug-naive PD patients.

METHODS

Cognitive assessments and structural MR images of 262 PD patients (171 males) and 113 healthy controls (68 males) were selected from the Parkinson's Progression Markers Initiative. Of these, 97 PD patients (66 males) completed 12- and 24-month follow-up examinations. After regressing out the expected effects of age and sex, brain maps of GMV and cortical thickness were compared using two-sample t tests cross-sectionally and were compared using repeated measurement analyses of variance longitudinally.

RESULTS

At baseline, male PD patients exhibited a greater extent of brain atrophy and cortical thickness reduction than females, which mainly occurred in the cerebellum, frontal lobe, parietal lobe, and temporal lobe. At follow-up, female and male PD patients showed similar dynamics of disease progression, as both groups declined over time while the females maintained the advantage. The cortical thickness of the right precentral gyrus at baseline was negatively associated with the longitudinal changes of motor function in male PD patients.

CONCLUSION

The current findings might demonstrate sex effect in neuroanatomy during the course of PD, provide new insights into the neurodegenerative process, and facilitate the development of more effective sex-specific therapeutic strategies.

Factors associated with frailty syndrome in elderly people with Parkinson's disease

OBJECTIVES

to analyze the sociodemographic and clinical factors associated with frailty in the elderly with Parkinson's disease in the context of a Specialized Health Care Service for the Elderly.

METHODS

documentary, analytical, correlational, cross-sectional study carried out with 230 elderly people with Parkinson's. The medical records of the patients were evaluated with a focus on two instruments: Clinical-Functional Vulnerability Index - 20; and the Multidimensional Assessment Care Plan.

RESULTS

predominance of elderly people between 80 and 89 years old; women; with low education; classified as fragile. There was a correlation between frailty and the variables: sex; age; age group; schooling; motor manifestations; non-motor manifestations; Hoehn and Yahr staging and time to diagnosis.

CONCLUSIONS

high simultaneity of frailty conditions and Parkinson's disease was observed. It is believed that the results will be able to help the structuring of protocols for nursing performance in a systematic way in the promotion of self-care of these individuals.

Apathy in Parkinson's Disease: Defining the Park Apathy Subtype

Apathy is a neurobehavioural symptom affecting Parkinson's disease patients of all disease stages. Apathy seems to be associated with a specific underlying non-motor disease subtype and reflects dysfunction of separate neural networks with distinct neurotransmitter systems. Due to the complicated neuropsychiatric aetiology of apathy, clinical assessment of this invalidating non-motor symptom remains challenging. We aim to summarize the current findings on apathy in Parkinson's disease and highlight knowledge gaps. We will discuss the prevalence rates across the different disease stages and suggest screening tools for clinically relevant apathetic symptoms. We will approach the fundamental knowledge on the neural networks implicated in apathy in a practical manner and formulate recommendations on patient-tailored treatment. We will discuss the Park apathy phenotype in detail, shedding light on different clinical manifestations and implications for prognosis. With this review, we strive to distil the vast available theoretical knowledge into a clinical and patient-oriented perspective.

Effect of eight-week online cognitive training in Parkinson's disease: A double-blind, randomized, controlled trial

INTRODUCTION

Cognitive training (CT) has been proposed as a treatment option for cognitive impairment in Parkinson's disease (PD). We aimed to assess the efficacy of adaptive, computerized CT on cognitive function in PD.

METHODS

In this double-blind, randomized controlled trial we enrolled PD patients that experienced substantial subjective cognitive complaints. Over a period of eight weeks, participants underwent 24 sessions of computerized multi-domain CT or an active control intervention for 45 min each (randomized 1:1). The primary outcome was the accuracy on the Tower of London task; secondary outcomes included effects on other neuropsychological outcomes and subjective cognitive complaints. Outcomes were assessed before and after training and at six-months follow-up, and analyzed with multivariate mixed-model analyses.

RESULTS

The intention-to-treat population consisted of 136 participants (n = 68 vs. n = 68, age M: 62.9y, female: 39.7%). Multivariate mixed-model analyses showed no group difference on the Tower of London accuracy corrected for baseline performance (n = 130): B: -0.06, 95% CI: -0.27 to 0.15, p = 0.562. Participants in the CT group were on average 0.30 SD (i.e., 1.5 s) faster on difficulty load 4 of this task (secondary outcome): 95% CI: -0.55 to -0.06, p = 0.015. CT did not reduce subjective cognitive complaints. At follow-up, no group differences were found.

CONCLUSIONS

This study shows no beneficial effect of eight-week computerized CT on the primary outcome (i.e., planning accuracy) and only minor improvements on secondary outcomes (i.e., processing speed) with limited clinical impact. Personalized or ecologically valid multi-modal intervention methods could be considered to achieve clinically meaningful and lasting effects.

Fatores associados à síndrome de fragilidade em idosos com doença de Parkinson

RESUMO Objetivos: analisar os fatores sociodemográficos e clínicos associados à fragilidade em idosos com doença de Parkinson no contexto de um Serviço de Atenção Especializada em Saúde do Idoso. Métodos: estudo documental, analítico, correlacional, de corte transversal, realizado com 230 idosos com Parkinson. Foram avaliados os prontuários dos pacientes com enfoque em dois instrumentos: Índice de Vulnerabilidade Clínico-Funcional - 20; e o Plano de Cuidados da avaliação multidimensional. Resultados: predomínio de idosos entre 80 e 89 anos; sexo feminino; com baixa escolaridade; classificados como frágeis. Houve correlação entre a fragilidade e as variáveis: sexo; idade; faixa etária; escolaridade; manifestações motoras; manifestações não motoras; estadiamento de Hoehn e Yahr e tempo de diagnóstico. Conclusões: constatou-se alta simultaneidade das condições de fragilidade e doença de Parkinson. Acredita-se que os resultados poderão auxiliar a estruturação de protocolos para atuação da enfermagem de forma sistematizada na promoção do autocuidado desses indivíduos.

Optimizing Cognitive Training for the Treatment of Cognitive Dysfunction in Parkinson's Disease: Current Limitations and Future Directions

Cognitive dysfunction, primarily involving impairments in executive function, visuospatial function and memory, is one of the most common non-motor symptoms of Parkinson’s disease (PD). Currently, the only pharmacological treatments available for the treatment of cognitive dysfunction in PD provide variable benefit, making the search for potential non-pharmacological therapies to improve cognitive function of significant interest. One such therapeutic strategy may be cognitive training (CT), which involves the repetition of standardized tasks with the aim of improving specific aspects of cognition. Several studies have examined the effects of CT in individuals with PD and have shown benefits in a variety of cognitive domains, but the widespread use of CT in these individuals may be limited by motor impairments and other concerns in study design. Here, we discuss the current state of the literature on the use of CT for PD and propose recommendations for future implementation. We also explore the potential use of more recent integrative, adaptive and assistive technologies, such as virtual reality, which may optimize the delivery of CT in PD.

Cognitive Training in Parkinson's Disease Induces Local, Not Global, Changes in White Matter Microstructure

Previous studies showed that cognitive training can improve cognitive performance in various neurodegenerative diseases but little is known about the effects of cognitive training on the brain. Here, we investigated the effects of our cognitive training paradigm, COGTIPS, on regional white matter microstructure and structural network topology. We previously showed that COGTIPS has small, positive effects on processing speed. A subsample of 79 PD patients (N = 40 cognitive training group, N = 39 active control group) underwent multi-shell diffusion-weighted imaging pre- and post-intervention. Our pre-registered analysis plan (osf.io/cht6g) entailed investigating white matter microstructural integrity (e.g., fractional anisotropy) in five tracts of interest, including the anterior thalamic radiation (ATR), whole-brain tract-based spatial statistics (TBSS), and the topology of the structural network. Relative to the active control condition, cognitive training had no effect on topology of the structural network or whole-brain TBSS. Cognitive training did lead to a reduction in fractional anisotropy in the ATR (B [SE]: - 0.32 [0.12], P = 0.01). This reduction was associated with faster responses on the Tower of London task (r = 0.42, P = 0.007), but this just fell short of our statistical threshold (P < 0.006). Post hoc "fixel-based" analyses showed that this was not due to changes in fiber density and cross section. This suggests that the observed effect in the ATR is due to training-induced alterations in neighboring fibers running through the same voxels, such as intra-striatal and thalamo-striatal fibers. These results indicate that 8 weeks of cognitive training does not alter network topology, but has subtle local effects on structural connectivity.

Exercise Management Using a Mobile App in Patients With Parkinsonism: Prospective, Open-Label, Single-Arm Pilot Study

Background

Patients with parkinsonism have higher inactivity levels than the general population, and this results in increased comorbidities. Although exercise has benefits for motor function and quality of life (QOL) in patients with parkinsonism, these patients face many barriers to exercise participation, such as lack of motivation, fatigue, depression, and time constraints. Recently, the use of mobile apps has been highlighted as a remote exercise management strategy for patients with chronic diseases.

Objective

This study aimed to evaluate the effects of home-based exercise management with a customized mobile app on the exercise amount, physical activity, and QOL of patients with parkinsonism.

Methods

This was a prospective, open-label, single-arm pilot study. The therapist installed the app in the smartphones of the participants and educated them on how to use the app. The therapist developed an individualized multimodal exercise program that consisted of stretching, strengthening, aerobic, balance and coordination, and oral-motor and vocal exercises. Participants were encouraged to engage in an 8-week home-based exercise program delivered through a customized app. The alarm notifications of the app provided reminders to exercise regularly at home. The primary outcome was the exercise amount. The secondary outcomes were assessed using the International Physical Activity Questionnaire (IPAQ), Parkinson’s Disease Questionnaire-39 (PDQ-39), and Geriatric Depression Scale (GDS). The usability of the customized app was assessed using a self-report questionnaire.

Results

A total of 21 participants with parkinsonism completed the intervention and assessment between September and December 2020 (mean age: 72 years; women: 17/21, 81%; men: 4/21, 19%). The participants reported a significant increase in the total amount of exercise (baseline: mean 343.33, SD 206.70 min/week; 8-week follow-up: mean 693.10, SD 373.45 min/week; P<.001) and in the amount of each exercise component, including stretching, strengthening, balance and coordination, and oral-motor and vocal exercise after 8 weeks. Analysis of the secondary outcomes revealed significant improvements in the IPAQ (P=.006), PDQ-39 (P=.02), and GDS (P=.04) scores. The usability of the program with the mobile app was verified based on the positive responses such as “intention to use” and “role expectation for rehabilitation.”

Conclusions

Exercise management with a customized mobile app may be beneficial for improving exercise adherence, physical activity levels, depression management, and QOL in patients with parkinsonism. This remotely supervised technology-based, reinforcing, and multimodal exercise management strategy is recommended for use in patients with parkinsonism. In addition, this program proved useful as an alternative exercise management strategy during the COVID-19 pandemic when patients with Parkinson disease were less physically active than before and showed aggravation of symptoms. However, additional clinical trials are needed to evaluate the efficacy of this exercise program in a large population and to confirm its disease-modifying effects.

Early implementation of intended exercise improves quality of life in Parkinson's disease patients

OBJECTIVE

Recent data have shown that regular exercise may ameliorate motor symptoms in Parkinson's disease (PD). This study aims to investigate how intended exercise impacts motor and non-movement symptoms of PD.

METHODS

Eighty-eight patients were randomly assigned to an early exercise group (E-EG), late exercise group (L-EG), or a control group (CG) using a randomized delayed-start design. The E-EG carried out a rigorous, formal exercise program for 1 h, twice per week, for 18 months (May 2018-November 2019). The L-EG took part in the exercise program in the final 6-12 months of the study. We assessed outcomes using the Unified Parkinson's Disease Rating Scale (UPDRS), PDQ-39 Questionnaire, Line A test, Line B test, Nine-hole column test, 30 s squat and stand-up test (30 s SST), 10-m walk test (10mW), Balance Evaluation Systems Mini Test (MiniBESTest), FAB, and Time Up and Go Test (TUG).

RESULTS

The patients with PD in the E-EG had lower performance in the UPDRS and Line B test compared to those in the L-EG at post-exercise (p < 0.05). Moreover, the patients with PD in the E-EG had much lower performance in the PDQ-39 and 9-Hole Peg test compared to those in the L-EG at post-exercise (p < 0.01).

CONCLUSION

Implementation of an exercise regimen improved the movement abilities and quality of life in PD patients, especially in the E-EG. This data supports the idea that intended exercise should be implemented as part of the treatment strategy for PD patients as early as possible.

A Scoping Review of Cognitive Training in Neurodegenerative Diseases via Computerized and Virtual Reality Tools: What We Know So Far

Most prevalent neurodegenerative diseases such as Alzheimer's disease, frontotemporal dementia, Parkinson's disease and multiple sclerosis are heterogeneous in their clinical profiles and underlying pathophysiology, although they typically share the presence of cognitive impairment that worsens significantly during the course of the disease. Viable pharmacological options for cognitive symptoms in these clinical conditions are currently lacking. In recent years, several studies have started to apply Computerized Cognitive Training (CCT) and Virtual Reality (VR) tools to try and contrast patients' cognitive decay over time. However, no in-depth literature review of the contribution of these promising therapeutic options across main neurodegenerative diseases has been conducted yet. The present paper reports the state-of-the-art of CCT and VR studies targeting cognitive impairment in most common neurodegenerative conditions. Our twofold aim is to point out the scientific evidence available so far and to support health professionals to consider these promising therapeutic tools when planning rehabilitative interventions, especially when the access to regular and frequent hospital consultations is not easy to be provided.

Functional and Cognitive Improvement After an Intensive Inpatient Multidisciplinary Rehabilitation Program in Mild to Severe Parkinson's Disease: A Retrospective and Observational Study

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor (resting tremor, rigidity, bradykinesia, postural instability, and gait disturbances) and nonmotor symptoms (cognitive, neuropsychiatric, and autonomic problems). In recent years, several studies demonstrated that neurorehabilitation therapy is an effective treatment in addition to pharmacological personalized interventions in persons with PD (PwPD). The main aim of this study was to explore the short-term changes in functional, cognitive, and geriatric domains after a multidimensional rehabilitation program in PwPD (as primary condition) in mild-moderate (M-Ms) to severe (Ss) stages. Our second aim was to compare the effects of multidimensional rehabilitation in M-Ms versus Ss of PD. Twenty-four PwPD in M-Ms to Ss [age (mean ± SD) = 76.25 ± 9.42 years; male/female = 10/14; Hoehn and Yahr (median; IQR) = 4.00; 1.75] were included in a retrospective, observational study. Motor, cognitive, functional, and neuropsychiatric aspects were collected in admission (T0) and in discharge (T1). PwPD were involved in a person-tailored (to individual's needs), inpatient, intensive (5-7 days per week), multidisciplinary (combining cognitive, physical, occupational, and speech therapies), comprehensive, and rehabilitative program. According to Movement Disorders Society Unified Parkinson's Disease Rating Scale III cutoff, PwPD were classified in M-Ms or Ss (M-Ms ≤59; Ss >59); 87.50% of our sample reported significant reduction of functional disability at Barthel Index (p < 0.001). A significant improvement in Token test (p = 0.021), semantic fluency (p = 0.036), Rey's Figure-Copy (p < 0.001), and Raven's Colored Progressive Matrices (p = 0.004) was observed. The pain intensity perception (p < 0.001) and the risk of developing pressure ulcers (p < 0.001) as assessed, respectively, by the Numeric Rating Scale and by the Norton Scale were improved. With regard to the second aim, in M-Ms group, we found a positive correlation between the number of neuromotor sessions and the change in functional disability and language comprehension; in the Ss group, on the other hand, despite a higher number of hospitalization days, the total number of completed sessions was positively associated with the change in visuoconstructional abilities. Our findings suggest that an intensive, inpatient, and multidisciplinary rehabilitation program may improve functional abilities, some strategic cognitive functions, and geriatric aspects in PwPD with mild-moderate motor impairment.

Resting-State Functional Magnetic Resonance Imaging Networks as a Quantitative Metric for Impact of Neurosurgical Interventions

Objective: Resting-state functional MRI (rs-fMRI) has been used to evaluate brain network connectivity as a result of intracranial surgery but has not been used to compare different neurosurgical procedures. Laser interstitial thermal therapy (LITT) is an alternative to conventional craniotomy for the treatment of brain lesions such as tumors and epileptogenic foci. While LITT is thought of as minimally invasive, its effect on the functional organization of the brain is still under active investigation and its impact on network changes compared to conventional craniotomy has not yet been explored. We describe a novel computational method for quantifying and comparing the impact of two neurosurgical procedures on brain functional connectivity. Methods: We used a previously described seed-based correlation analysis to generate resting-state network (RSN) correlation matrices, and compared changes in correlation patterns within and across RSNs between LITT and conventional craniotomy for treatment of 24 patients with singular intracranial tumors at our institution between 2014 and 2017. Specifically, we analyzed the differences in patient-specific changes in the within-hemisphere correlation patterns of the contralesional hemisphere. Results: In a post-operative follow-up period up to 2 years within-hemisphere connectivity of the contralesional hemisphere after surgery was more highly correlated to the pre-operative state in LITT patients when compared to craniotomy patients (P = 0.0287). Moreover, 4 out of 11 individual RSNs demonstrated significantly higher degrees of correlation between pre-operative and post-operative network connectivity in patients who underwent LITT (all P < 0.05). Conclusion: Rs-fMRI may be used as a quantitative metric to determine the impact of different neurosurgical procedures on brain functional connectivity. Global and individual network connectivity in the contralesional hemisphere may be more highly preserved after LITT when compared to craniotomy for the treatment of brain tumors.

Rationale and Design of the PAIRED Trial: Partnered Dance Aerobic Exercise as a Neuroprotective, Motor, and Cognitive Intervention in Parkinson's Disease

Parkinson's disease (PD), an intractable condition impairing motor and cognitive function, is imperfectly treated by drugs and surgery. Two priority issues for many people with PD are OFF-time and cognitive impairment. Even under best medical management, three-fourths of people with PD experience “OFF-time” related to medication-related motor fluctuations, which severely impacts both quality of life and cognition. Cognitive deficits are found even in newly diagnosed people with PD and are often intractable. Our data suggest that partnered dance aerobic exercise (PDAE) reduces OFF-time on the Movement Disorders Society Unified Parkinson Disease Rating Scale-IV (MDS-UPDRS-IV) and ameliorates other disease features, which motivate the PAIRED trial. PDAE provides AE during an improvisational, cognitively engaging rehabilitative physical activity. Although exercise benefits motor and cognitive symptoms and may be neuroprotective for PD, studies using robust biomarkers of neuroprotection in humans are rare. We propose to perform a randomized, controlled trial in individuals with diagnosed mild–moderate PD to compare the efficacy of PDAE vs. walking aerobic exercise (WALK) for OFF-time, cognition, and neuroprotection. We will assess neuroprotection with neuromelanin-sensitive MRI (NM-MRI) and iron-sensitive (R2^*) MRI sequences to quantify neuromelanin loss and iron accumulation in substantia nigra pars compacta (SNc). We will use these biomarkers, neuromelanin loss, and iron accumulation, as tools to chart the course of neurodegeneration in patients with PD who have undergone long-term (16 months) intervention. We will randomly assign 102 individuals with mild–moderate PD to 16 months of PDAE or WALK. The 16-month intervention period will consist of Training (3 months of biweekly sessions) and Maintenance (13 months of weekly sessions) phases. We will assess participants at baseline, 3 months (immediately post-Training), and 16 months (immediately post-Maintenance) for OFF-time and behaviorally and physiologically measured cognition. We will acquire NM-MRI and R2^* imaging data at baseline and 16 months to assess neuroprotection. We will (1) examine effects of Training and Maintenance phases of PDAE vs. WALK on OFF-time, (2) compare PDAE vs. WALK at 3 and 16 months on behavioral and functional MRI (fMRI) measures of spatial cognition, and (3) compare PDAE vs. WALK for effects on rates of neurodegeneration.

Cognitive training interventions for dementia and mild cognitive impairment in Parkinson's disease

BACKGROUND

Approximately 60% to 80% of people with Parkinson's disease (PD) experience cognitive impairment that impacts on their quality of life. Cognitive decline is a core feature of the disease and can often present before the onset of motor symptoms. Cognitive training may be a useful non-pharmacological intervention that could help to maintain or improve cognition and quality of life for people with PD dementia (PDD) or PD-related mild cognitive impairment (PD-MCI).

OBJECTIVES

To determine whether cognitive training (targeting single or multiple domains) improves cognition in people with PDD and PD-MCI or other clearly defined forms of cognitive impairment in people with PD.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group Trials Register (8 August 2019), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO. We searched reference lists and trial registers, searched relevant reviews in the area and conference proceedings. We also contacted experts for clarifications on data and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials where the participants had PDD or PD-MCI, and where the intervention was intended to train general or specific areas of cognitive function, targeting either a single domain or multiple domains of cognition, and was compared to a control condition. Multicomponent interventions that also included motor or other elements were considered eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and full-text articles for inclusion in the review. Two review authors also independently undertook extraction of data and assessment of methodological quality. We used GRADE methods to assess the overall quality of the evidence.

MAIN RESULTS

Seven studies with a total of 225 participants met the inclusion criteria for this review. All seven studies compared the effects of a cognitive training intervention to a control intervention at the end of treatment periods lasting four to eight weeks. Six studies included people with PD living in the community. These six studies recruited people with single-domain (executive) or multiple-domain mild cognitive impairment in PD. Four of these studies identified participants with MCI using established diagnostic criteria, and two included both people with PD-MCI and people with PD who were not cognitively impaired. One study recruited people with a diagnosis of PD dementia who were living in long-term care settings. The cognitive training intervention in three studies targeted a single cognitive domain, whilst in four studies multiple domains of cognitive function were targeted. The comparison groups either received no intervention or took part in recreational activities (sports, music, arts), speech or language exercises, computerised motor therapy, or motor rehabilitation combined with recreational activity. We found no clear evidence that cognitive training improved global cognition. Although cognitive training was associated with higher scores on global cognition at the end of treatment, the result was imprecise and not statistically significant (6 trials, 178 participants, standardised mean difference (SMD) 0.28, 95% confidence interval (CI) -0.03 to 0.59; low-certainty evidence). There was no evidence of a difference at the end of treatment between cognitive training and control interventions on executive function (5 trials, 112 participants; SMD 0.10, 95% CI -0.28 to 0.48; low-certainty evidence) or visual processing (3 trials, 64 participants; SMD 0.30, 95% CI -0.21 to 0.81; low-certainty evidence). The evidence favoured the cognitive training group on attention (5 trials, 160 participants; SMD 0.36, 95% CI 0.03 to 0.68; low-certainty evidence) and verbal memory (5 trials, 160 participants; SMD 0.37, 95% CI 0.04 to 0.69; low-certainty evidence), but these effects were less certain in sensitivity analyses that excluded a study in which only a minority of the sample were cognitively impaired. There was no evidence of differences between treatment and control groups in activities of daily living (3 trials, 67 participants; SMD 0.03, 95% CI -0.47 to 0.53; low-certainty evidence) or quality of life (5 trials, 147 participants; SMD -0.01, 95% CI -0.35 to 0.33; low-certainty evidence). There was very little information on adverse events. We considered the certainty of the evidence for all outcomes to be low due to risk of bias in the included studies and imprecision of the results. We identified six ongoing trials recruiting participants with PD-MCI, but no ongoing trials of cognitive training for people with PDD.

AUTHORS' CONCLUSIONS

This review found no evidence that people with PD-MCI or PDD who receive cognitive training for four to eight weeks experience any important cognitive improvements at the end of training. However, this conclusion was based on a small number of studies with few participants, limitations of study design and execution, and imprecise results. There is a need for more robust, adequately powered studies of cognitive training before conclusions can be drawn about the effectiveness of cognitive training for people with PDD and PD-MCI. Studies should use formal criteria to diagnose cognitive impairments, and there is a particular need for more studies testing the efficacy of cognitive training in people with PDD.

Effect of Cognitive Disability and Ambulation Status on Functioning in Moderate-to-Advanced Parkinson Disease

Background: As the disease progresses to moderate to advanced stages, people with Parkinson's disease (PwP) are likely to have various degrees of disability due to the motor and non-motor symptoms, such as ambulatory difficulty and cognitive impairment. The objective of this study was to investigate the impact of cognition and ambulation status on the functioning and disability of PwP using the World Health Orgnaization Disability Assessment Schedule 2.0 (WHODAS 2.0).

Materials and Methods: A group of 10,581 PwP with Hoehn and Yahr Staging 3 and above were collected from a database of disability evaluation and functional assessment using the Taiwan Data Bank of Persons with Disability between July 2012 and October 2018. WHODAS 2.0 was administered and all PwP were grouped based on their ambulatory status, which was assessed by 3-m back and forth walk and cognitive ability, assessed by WHODAS 2.0 first domain with cut-off level at 58.

Results: Non-ambulation and cognitive disability contributed independently to disability in all aspects of WHODAS 2.0 survey, including self-care, getting along with others, performing life activities and participation in society. Compared to ambulation status, cognitive disability had a greater negative impact on functioning in all aspects.

Conclusion: Cognitive disability was associated with greater disability in moderate to advanced PwP than non-ambulatory status. The results of this study may indicate that cognition preservation is essential to ameliorate functional impairment and disability in moderate to advanced PwP.

A Neuropsychological Rehabilitation Program for Cognitive Impairment in Psychiatric and Neurological Conditions: A Review That Supports Its Efficacy

Neuropsychological rehabilitation has been the focus of much scientific research over the past decades due to its efficacy in different pathologies. Advances in the neuropsychology field have led to improvements and changes in neuropsychological interventions, which in turn have given rise to different approaches and rehabilitation programs. REHACOP is an integrative neuropsychological rehabilitation program designed by specialist neuropsychologists. With an integrated bottom-up and top-down approach, REHACOP includes neurocognition, social cognition, and daily living tasks hierarchically organized on an increasing level of difficulty. Task arrangement is addressed to maximize improvements and transfer effects into participant's daily living. To date, REHACOP has been implemented on different clinical samples such as patients with schizophrenia, multiple sclerosis (MS), and Parkinson's disease (PD). This manuscript presents the efficacy data of REHACOP across these three populations and discusses it in the context of the available literature. Overall, the magnitude of improvements obtained by means of REHACOP ranged from medium to high across samples. These changes were not restricted to specific neurocognitive domains since participants attending the REHACOP program also showed changes in social cognition and daily functioning variables by means of both direct and transfer effects. Results regarding REHACOP's efficacy in psychiatric and neurological conditions have contributed to expanding the existing evidence about the use of structured neuropsychological rehabilitation. In addition, the results obtained after its implementation highlighted the need and importance of designing and implementing integrative neuropsychological rehabilitation programs that are focused not only on cognition per se but also on participants' performance in daily living.

Cognitive Interventions in Parkinson's Disease: Where We Want to Go within 20 Years

 Today, meta-analyses demonstrate that cognitive training is safe and effective to enhance vulnerable cognitive functions in patients with Parkinson’s disease (PD), so that cognitive interventions can be regarded as a promising approach to treat or even prevent cognitive dysfunction in PD. However, many research gaps exist. Thus, this article aims to identify relevant research topics with regard to cognitive interventions in PD patients for the next 20 years. The most important to do's include the development of (non-digital and digital, maybe also artificial intelligence based) standardized cognitive interventions for PD patients in different cognitive stages and the conduct of large randomized controlled trials (RCTs) in these groups, also considering different patient profiles (e.g., motor subtypes) and the living setting (inpatient versus outpatient). The impact of cognitive and combined interventions in individuals with prodromal PD is of high relevance. Studies should elucidate underlying mechanisms of cognitive and neural plasticity induced by cognitive interventions and propose prediction models on which patients profit from which intervention. Health-economic analyses are also urgently needed. More generally, increasing the awareness of the concept of cognitive reserve and possibilities for the prevention of cognitive dysfunction is an important goal.

Long-term effects of executive function training among veterans with chronic TBI

Objective: To investigate long-term effects of GOALS executive function training in Veterans with chronic TBI. In a recently completed study Veterans with chronic TBI showed improvement immediately post-GOALS but not control training on measures of executive function, functional task performance, and emotion regulation. We now examine the long-term maintenance of post-GOALS training changes in the same sample. Setting: San Francisco VA Health Care System (SFVAHCS), and VA Northern California Health-Care System (VANCHS) in Martinez. Participants and Design: 24 Veterans with chronic TBI were assessed at baseline, post-GOALS training, and long-term follow-up 6+ months following completion of training with a structured telephone interview, neuropsychological and complex functional performance measures, and self-report measures of daily and emotional functioning. Results: Participants reported an increased likelihood of involvement in competitive employment/volunteering at follow-up (61%) compared to baseline (26%; χ2 = 5.66, p < .01, ѱ = .35). Repeated measures MANOVAS indicated improvement on attention/executive function (F = 13.85, p < .01, partial η2 = .42), complex functional task performance (GPS Total: F = 9.12, p < .01, partial η2 = .38) and daily functioning (MPAI Total: F = 3.23, p < .05, partial η2 = .21), and reduction in overall mood disturbance (POMS Total: F = 3.42, p < .05, partial η2 = .22) at follow-up relative to baseline. Discussion: Training in attention regulation applied to participant-defined goals is associated with meaningful long-term improvement in cognitive skills, emotion regulation, and daily functioning in Veterans with chronic TBI.

Parkinson's-adapted cognitive stimulation therapy: a pilot randomized controlled clinical trial

Cognitive stimulation therapy (CST) is widely used with people with dementia, but there is no evidence of its efficacy in mild cognitive impairment or dementia in Parkinson's disease (PD-MCI; PDD) or dementia with Lewy bodies (DLB). We aimed to explore the impact of 'CST-PD', which is home-based, individualized CST adapted for this population. In a single-blind, randomized controlled exploratory pilot trial (RCT), we randomized 76 participant-dyads [PD-MCI (n = 15), PDD (n = 40), DLB (n = 21) and their care partners] to CST-PD or treatment as usual (TAU). CST-PD involves home-based cognitively stimulating and engaging activities delivered by a trained care partner. Exploratory outcomes at 12 weeks included cognition (Addenbrooke's Cognitive Evaluation; ACE-III), neuropsychiatric symptoms and function. In care partners, we assessed burden, stress and general health status. Relationship quality and quality of life were assessed in both dyad members. At 12 weeks, the ACE-III showed a nonstatistically significant improvement in the CST-PD group compared with the TAU group, although neuropsychiatric symptoms increased significantly in the former. In contrast, care partners' quality of life (d = 0.16) and relationship quality ('satisfaction', d = 0.01; 'positive interaction', d = 0.55) improved significantly in the CST-PD group, and care burden (d = 0.16) and stress (d = 0.05) were significantly lower. Qualitative findings in the CST-PD recipients revealed positive 'in the moment' responses to the intervention, supporting the quantitative results. In conclusion, care-partner-delivered CST-PD may improve a range of care-partner outcomes that are important in supporting home-based care. A full-scale follow-up RCT to evaluate clinical and cost effectiveness is warranted.

Resting-state Functional MRI in Parkinsonian Syndromes

Background

Functional MRI (fMRI) has been widely used to study abnormal patterns of functional connectivity at rest in patients with movement disorders such as idiopathic Parkinson's disease (PD) and atypical parkinsonisms.

Methods

This manuscript provides an educational review of the current use of resting-state fMRI in the field of parkinsonian syndromes.

Results

Resting-state fMRI studies have improved the current knowledge about the mechanisms underlying motor and non-motor symptom development and progression in movement disorders. Even if its inclusion in clinical practice is still far away, resting-state fMRI has the potential to be a promising biomarker for early disease detection and prediction. It may also aid in differential diagnosis and monitoring brain responses to therapeutic agents and neurorehabilitation strategies in different movement disorders.

Conclusions

There is urgent need to identify and validate prodromal biomarkers in PD patients, to perform further studies assessing both overlapping and disease-specific fMRI abnormalities among parkinsonian syndromes, and to continue technical advances to fully realize the potential of fMRI as a tool to monitor the efficacy of chronic therapies.

Longitudinal Progression Markers of Parkinson's Disease: Current View on Structural Imaging

PURPOSE OF REVIEW

Advances in neuroimaging techniques pave a rich avenue for in vivo progression biomarkers, which can objectively and noninvasively assess the long-term dynamic alterations in the brain of Parkinson's disease (PD) patients. This article reviews recent progress in structural magnetic resonance imaging (MRI) tools to track disease progression in PD, and discusses specific criteria a neuroimaging tool needs to meet to be a progression biomarker of PD and the potential applications of these techniques in PD based on current evidence.

RECENT FINDINGS

Recent longitudinal studies showed that quantitative structural MRI markers derived from T1-weighted, diffusion-weighted, neuromelanin-sensitive, and iron-sensitive imaging have the potential to track disease progression in PD. However, validation of these progression biomarkers is only beginning, and more work is required for multisite validation, the sample size for use in a clinical trial, and drug-responsiveness of most of these biomarkers. At present, the most clinical trial-ready biomarker is free-water diffusion imaging of the substantia nigra and seems well established to be used in disease-modifying studies in PD. A variety of structural imaging biomarkers are promising candidates to be progression biomarkers in PD. Further studies are needed to elucidate the sensitivity, reliability, sample size, and effect of confounding factors of these progression biomarkers.

Functional MRI in Idiopathic Parkinson's Disease

Functional MRI (fMRI) has been widely used to study abnormal patterns of brain connectivity at rest and activation during a variety of tasks in patients with idiopathic Parkinson's disease (PD). fMRI studies in PD have led to a better understanding of many aspects of the disease including both motor and non-motor symptoms. Although its translation into clinical practice is still at an early stage, fMRI measures hold promise for multiple clinical applications in PD, including the early detection, predicting future change in clinical status, and as a marker of alterations in brain physiology related to neurotherapeutic agents and neurorehabilitative strategies.

Neurorehabilitation in Parkinson's Disease: A Critical Review of Cognitive Rehabilitation Effects on Cognition and Brain

Background

Parkinson's disease (PD) patients experience cognitive impairment which has been related to reduced quality of life and functional disability. These symptoms usually progress until dementia occurs. Some studies have been published assessing the efficacy of cognitive treatments on improving cognition, functional outcome, and producing changes in brain activity.

Objective

A critical review was performed to present up-to-date neurorehabilitation effects of cognitive rehabilitation in PD, with special emphasis on the efficacy on cognition, quality of life aspects, brain changes, and the longitudinal maintenance of these changes.

Results

After exclusions, 13 studies were reviewed, including 6 randomized controlled trials for the efficacy on cognition, 2 randomized controlled trials regarding the brain changes after cognitive training, and 5 studies which evaluated the long-term effects of cognitive treatments.

Conclusions

Cognitive rehabilitation programs have demonstrated to be effective on improving cognitive functions, but more research is needed focusing on the efficacy on improving behavioral aspects and producing brain changes in patients with PD. Moreover, there is a need of randomized controlled trials with long-term follow-up periods.

Cognitive correlates of "pure apathy" in Parkinson's disease

INTRODUCTION

Previous studies exploring the association between apathy and cognitive deficits in Parkinson's disease (PD) employed scales and questionnaires for apathy, which did not control for the possible confounding effect of motor symptoms. Here we investigated the cognitive correlates of "pure apathy" by the Dimensional Apathy Scale, which allows us to assess apathy minimizing the influence of motor symptoms.

METHODS

Consecutive PD outpatients referred to our centre were screened. All participants underwent a neuropsychological battery to assess verbal memory, executive functions and visuospatial abilities, apathy and depressive symptoms.

RESULTS

We enrolled 56 non-depressed and non-demented PD patients, of whom 28 were apathetic and 28 were not. The two groups did not differ on demographic and clinical aspects; apathetic PD patients performed worse than non-apathetic PD patients on the part A, B and B-A of Trail Making Test and the interference task of Stroop test. No significant differences were found on memory and perceptual visuospatial tasks.

CONCLUSIONS

Our results demonstrated that "pure apathy" is associated with more severe executive dysfunctions such as alteration of set-shifting and inhibitory control, which are mediated by prefrontal cortex and subcortical regions (i.e. basal ganglia). Our findings also supported the hypothesis that co-occurrence of apathy and executive deficits may be the epiphenomenon of damage in prefrontal-striatal cortical circuitries connecting dorsolateral prefrontal cortex, anterior cingulate cortex and basal ganglia.

Resting State fMRI: A Valuable Tool for Studying Cognitive Dysfunction in PD

Cognitive impairment is a common disabling symptom in PD. Unlike motor symptoms, the mechanism underlying cognitive dysfunction in Parkinson's disease (PD) remains unclear and may involve multiple pathophysiological processes. Resting state functional magnetic resonance imaging (rs-fMRI) is a fast-developing research field, and its application in cognitive impairments in PD is rapidly growing. In this review, we summarize rs-fMRI studies on cognitive function in PD and discuss the strong potential of rs-fMRI in this area. rs-fMRI can help reveal the pathophysiology of cognitive symptoms in PD, facilitate early identification of PD patients with cognitive impairment, distinguish PD dementia from dementia with Lewy bodies, and monitor and guide treatment for cognitive impairment in PD. In particular, ongoing and future longitudinal studies would enhance the ability of rs-fMRI in predicting PD dementia. In combination with other modalities such as positron emission tomography, rs-fMRI could give us more information on the underlying mechanism of cognitive deficits in PD.