Effect of age at onset on frequency of depression in Parkinson's disease

Case report: Early-onset Parkinson's disease with initial spastic paraparesis and hyperreflexia caused by compound heterozygous PRKN-gene exon 2 and 4 deletions

Pathogenic variants in the Parkin-gene (PRKN) are among the most common genetic causes of early onset Parkinson's disease (EOPD). Patients with EOPD can present with atypical clinical features and misdiagnosis is frequent. Here, we report a clinical phenotype with atypical signs and symptoms of a 35-year-old male patient with EOPD caused by a compound heterozygous PRKN-gene deletion of exons 2 and 4. After the initial diagnosis of stiff person syndrome, the patient was admitted to our department for a second opinion after 8 years of untreated disease progression. The patient presented with prominent spastic paraparesis pronounced on the right side and hyperreflexia as well as Parkinsonism with rigidity predominantly affecting the upper limbs, bradykinesia, and resting tremor. In the diagnostic assessment, magnetic evoked potentials to the anterior tibial muscles showed a low amplitude on the right side, compatible with pyramidal tract disturbance. However, an MRI of the head and the spine did not show any pathologies or atrophy. A [123I] FP-CIT SPECT scan revealed profoundly and left-pronounced reduced striatal uptake suggesting a neurodegenerative Parkinson's syndrome. Even though an acute levodopa challenge did not show marked improvement of symptoms, the chronic levodopa challenge with up to 450 mg/day significantly reduced the rigidity and bradykinesia. Surprisingly, spastic paraparesis and hyperreflexia diminished under dopaminergic treatment. Finally, genetic analysis by next-generation sequencing via copy number variant analysis (CNV) and multiplex ligation-dependent probe amplification (MLPA) confirmed compound heterozygous deletions of exons 2 and 4 in the PRKN-gene. As presented in this case, the awareness of atypical clinical symptoms of EOPD is essential to prevent misdiagnosis in young patients.

A Practical Approach to Early-Onset Parkinsonism

Early-onset parkinsonism (EO parkinsonism), defined as subjects with disease onset before the age of 40 or 50 years, can be the main clinical presentation of a variety of conditions that are important to differentiate. Although rarer than classical late-onset Parkinson’s disease (PD) and not infrequently overlapping with forms of juvenile onset PD, a correct diagnosis of the specific cause of EO parkinsonism is critical for offering appropriate counseling to patients, for family and work planning, and to select the most appropriate symptomatic or etiopathogenic treatments. Clinical features, radiological and laboratory findings are crucial for guiding the differential diagnosis. Here we summarize the most important conditions associated with primary and secondary EO parkinsonism. We also proposed a practical approach based on the current literature and expert opinion to help movement disorders specialists and neurologists navigate this complex and challenging landscape.

Prevalence and associations for symptoms of depression in patients with Parkinson's disease: a Sri Lankan experience

Background

The prevalence and associations for depression in patients with Parkinson’s disease vary widely between studies. This reflects the influence of cultural, demographic and socioeconomic confounders within communities that make generalizations invalid. Therefore it is important to identify unique attributes within a community on this phenomenon. This is the first study from Sri Lanka on the prevalence and associations for co-morbid depression in patients with Parkinson’s disease.

Methods

We conducted this cross sectional study at the Institute of Neurology, National Hospital of Sri Lanka. All patients with a diagnosis of idiopathic Parkinson’s disease followed up at the movement disorder clinic of the institute were enrolled. The patients were interviewed by investigators (medical practitioners) with an interviewer administered questionnaire that collected data on (a) demography, (b) clinical symptoms of Parkinson’s disease and (c) socioeconomic background. Symptoms of depression were assessed with Hamilton rating scale for depression.

Results

We enrolled 75 patients [males; 54 (75 %), mean age; 63.6 years, SD ± 6.8]. Forty-six (61.3 %) patients had been either formally diagnosed with depression or showed symptoms of depression. Bradykinesia, monthly income below Rs. 10,000 and having a family history of depression were significantly associated with a diagnosis of life-time post Parkinson’s disease depression (p < 0.05).

Conclusion

Given the potential benefit in treatment (for depression), all patients with Parkinson’s disease should be screened for depression regularly. HAM-D would be a good screening tool for this purpose as it has good reliability, validity and can be administered within a reasonable time limit.

Associated and predictive factors of depressive symptoms in patients with Parkinson's disease

Depression is one of the most common non-motor symptoms in Parkinson's disease (PD). A thorough understanding of factors associated with depressive symptomatology may facilitate early detection and guide future intervention strategies. The objective of the study was to determine associated and predictive factors of depression in patients with PD. Analyses were performed in data of the SCOPA-PROPARK cohort, a 5-year hospital-based longitudinal cohort of over 400 PD patients who have been examined annually. Linear mixed models using data of all patients were used to identify factors associated with longitudinal changes in Beck Depression Inventory (BDI) scores. A survival analysis using data of patients without depression at baseline was performed to identify risk factors for future depression (i.e. BDI ≥ 15). The proportion of patients with depression was approximately 20 % and remained stable during follow-up, with approximately half of cases showing a persistent course. Female gender, more severe disability, more severe motor fluctuations, autonomic and cognitive dysfunction, poorer nighttime sleep and daytime sleepiness were independently associated with higher BDI scores over time. Higher baseline BDI score, daytime sleepiness and a higher levodopa dosage were risk factors for future depression. Depression is common in PD, where it may follow a persistent or non-persistent course. Apart from motor fluctuations and levodopa dose, depressive symptoms in PD are mainly associated with factors of non-dopaminergic origin. This suggests that depression in PD is an inherent consequence of the progressive pathobiology of the disease, which may render its treatment with currently available treatment options difficult.

Comparison of frequencies of non motor symptoms in Indian Parkinson's disease patients on medical management versus deep brain stimulation: A case-control study

BACKGROUND

Non motor symptoms (NMS) of idiopathic Parkinson's disease (PD) are a major cause of disability and recognition of these symptoms and treatment is important for comprehensive health care. Deep brain stimulation of bilateral subthalamic nucleus deep brain stimulation (STN DBS) has been shown to improve motor symptoms in PD and effects on NMS are unknown. To investigate the NMS among PD patients who underwent STN DBS.

METHODS

We recruited prospectively 56 patients with PD, who had undergone bilateral STN DBS and 53 age and duration of illness matched PD patients on dopaminergic therapy (controls). NMS were assessed using 30 item questionnaire NMS Quest. These questions evaluated 9 domains, gastrointestinal, urinary, cardiovascular, sexual, cognition (apathy/attention/memory), anxiety/depression, hallucinations/delusions, sleep and miscellaneous. Comparison was done on individual symptoms as well as in various domains. This study was carried at Nizam's Institution of Medical Sciences and study period was from January 2011 to December 2012.

RESULTS

Patients who underwent STN DBS had a significantly lower mean total score on NMS quest (6.7 ± 3.8) compared to controls (8.4 ± 3.7) (P < 0.00100). Symptoms in the domains of cardiovascular, gastrointestinal, sleep were significantly less frequent while sexual disturbances were significantly more frequent among patients compared to controls. On individual symptom analysis, nocturia  (P < 0.00010), unexplained pains (P < 0.00010), nausea and vomiting, constipation, lightheadedness, depression, and insomnia were less prevalent, while sexual disturbances were significantly more common in STN DBS group compared to controls.

CONCLUSION

Bilateral STN DBS not only improves the motor symptoms but also improves many NMS in PD patients.

Comparison of the Psychological Symptoms and Disease-Specific Quality of Life between Early- and Typical-Onset Parkinson's Disease Patients

The impact of Parkinson's disease (PD) on psychological status and quality of life (QoL) may vary depending on age of disease onset. The aim of this study was to compare psychological symptoms and disease-specific QoL between early onset versus the rest of the PD patients. A total number of 140 PD patients with the mean current age of 61.3 (SD = 10.4) yr were recruited in this study. PD patients with the onset age of ≤50 yr were defined as “early-onset” (EOPD) group (n = 45), while the ones with >50 yr at the time of diagnosis were categorized as the “typical-onset” (TOPD) patients (n = 95). Different questionnaires and scales were used for between-group comparisons including PDQ39, HADS (hospital anxiety and depression scale), FSS (fatigue severity scale), MNA (mininutritional assessment), and the UPDRS. Depression score was significantly higher in EOPD group (6.3 (SD = 4.5) versus 4.5 (SD = 4.2), P = 0.02). Among different domains of QoL, emotion score was also significantly higher in the EOPD group (32.3 (SD = 21.6) versus 24.4 (SD = 22.7), P = 0.05). Our findings showed more severe depression and more impaired emotional domain of QoL in early-onset PD patients. Depression and anxiety play an important role to worsen QoL among both EOPD and TOPD patients, while no interaction was observed in the efficacy of these two psychiatric symptoms and the onset age of PD patients.

Frequency of known mutations in early-onset Parkinson disease: implication for genetic counseling: the consortium on risk for early onset Parkinson disease study

OBJECTIVE

To assess the frequency and clinical characteristics of carriers of previously identified mutations in 6 genes associated with early-onset Parkinson disease (PD) and provide empirical data that can be used to inform genetic counseling.

DESIGN

Cross-sectional observational study.

SETTING

Thirteen movement disorders centers.

PATIENTS

Nine hundred fifty-three individuals with early-onset PD defined as age at onset (AAO) younger than 51 years. Participants included 77 and 139 individuals of Hispanic and Jewish ancestry, respectively. Intervention Mutations in SNCA, PRKN, PINK1, DJ1, LRRK2, and GBA were assessed. A validated family history interview and the Unified Parkinson Disease Rating Scale were administered. Demographic and phenotypic characteristics were compared among groups defined by mutation status. Main Outcome Measure Mutation carrier frequency stratified by AAO and ethnic background.

RESULTS

One hundred fifty-eight (16.6%) participants had mutations, including 64 (6.7%) PRKN, 35 (3.6%) LRRK2 G2019S, 64 (6.7%) GBA, and 1 (0.2%) DJ1. Mutation carriers were more frequent in those with an AAO of 30 years or younger compared with those with AAO between 31 and 50 years (40.6% vs 14.6%, P < .001), in individuals who reported Jewish ancestry (32.4% vs 13.7%, P < .001), and in those reporting a first-degree family history of PD (23.9% vs 15.1%, P = .01). Hispanic individuals were more likely to be PRKN carriers than non-Hispanic individuals (15.6% vs 5.9%, P = .003). The GBA L444P mutation was associated with a higher mean Unified Parkinson Disease Rating Scale III score after adjustment for covariates.

CONCLUSION

Individuals of Jewish or Hispanic ancestry with early-onset PD, those with AAO of 30 years or younger, and those with a history of PD in a first-degree relative may benefit from genetic counseling.

Treatment of young-onset Parkinson's disease: role of dopamine receptor agonists

For mostly arbitrary reasons, the term "juvenile parkinsonism" is restricted to patients aged 20 years or younger, and "young-onset PD" (YOPD) is onset between ages 21 and 40 years. Previous studies suggest that YOPD has a slower disease progression and a greater incidence and earlier appearance of L-dopa-induced dyskinesias and motor fluctuations. Therefore, our therapeutic strategies have to respect the fact that YOPD patients face many years of gradual progression of disease and disability, a greater probability for developing various adverse effects of treatment, and worsening of quality of life. As an individually tailored treatment should be our primary goal, we must bear in mind that the needs and expectations of YOPD patients are different from those of their older counterparts. The therapeutic strategy for YOPD patients should include a relatively low threshold for initiation of treatment, and initiating treatment with a dopamine receptor agonist while maintaining an individually adjusted, moderately high threshold for switching to or adding L-dopa in cases where treatment response is suboptimal or if problematic adverse effects develop. It has been shown that some dopamine receptor agonists may also have antidepressive efficacy, thus potentially managing an additional problem associated with PD.

Self-report of cognitive impairment and mini-mental state examination performance in PRKN, LRRK2, and GBA carriers with early onset Parkinson's disease

While little is known about risk factors for cognitive impairment in early onset Parkinson disease (EOPD), postmortem studies have shown an association between dementia with Lewy bodies (DLB) and glucocerebrosidase (GBA) mutation. We compared Mini-Mental State Examination (MMSE) performance and self-reported cognitive impairment in 699 EOPD participants genotyped for mutations in parkin (PRKN), leucine-rich repeat kinase-2 (LRRK2), and GBA. Logistic regression was used to assess the association between reported cognitive impairment and MMSE score, as well as between GBA group membership and self-reported impairment and MMSE. GBA carriers reported more impairment, but MMSE performance did not differ among genetic groups. Detailed neuropsychological testing is required to explore the association between cognitive impairment and GBA mutations.

The recognition of facial emotion expressions in Parkinson's disease

A limited number of studies in Parkinson's Disease (PD) suggest a disturbance of recognition of facial emotion expressions. In particular, disgust recognition impairment has been reported in unmedicated and medicated PD patients. However, the results are rather inconclusive in the definition of the degree and the selectivity of emotion recognition impairment, and an associated impairment of almost all basic facial emotions in PD is also described. Few studies have investigated the relationship with neuropsychiatric and neuropsychological symptoms with mainly negative results. This inconsistency may be due to many different problems, such as emotion assessment, perception deficit, cognitive impairment, behavioral symptoms, illness severity and antiparkinsonian therapy. Here we review the clinical characteristics and neural structures involved in the recognition of specific facial emotion expressions, and the plausible role of dopamine transmission and dopamine replacement therapy in these processes. It is clear that future studies should be directed to clarify all these issues.

Impact of psychogenic movement disorders versus Parkinson's on disability, quality of life, and psychopathology

Patients with psychogenic movement disorders (PMD) often report severe impairment, yet the impact of PMD on disability and quality of life has not been examined. We compared 66 patients with PMD and 704 patients with Parkinson's disease (PD) on measures of disability (Older Americans Resources and Services Scale, OARS); quality of life (QOL; SF-12v2 Health Survey) and psychiatric symptomatology (Brief Symptom Inventory 18, BSI-18). On the total OARS, PMD and PD patients reported similar levels of disability (17.6 +/- 6.6, 19.8 +/- 10.9, P = 0.490 at "best" function and 24.1 +/- 11.2, 26.2 +/- 14.3, P = 0.497 at their "worst" function). PMD patients reported similar Physical Health QOL to PD patients (38.9 +/- 14.5, 39.8 +/- 11.6, P = 0.652) but worse mental health QOL (41.6 +/- 13.4 vs. 48.9 +/- 11.0, P < 0.001). On the BSI-18, PMD patients reported higher levels of distress on the Global Symptom Index (62.03 +/- 9.6 vs. 53.7 +/- 9.9, P < 0.001) and on Anxiety, Depression and Somatization subscales (PMD vs. PD scores: Anxiety 58.9 +/- 12.0 vs. 52.3 +/- 10.1, P < 0.001; Depression 58.8 +/- 11.9 vs. 51.3 +/- 10.3, P < 0.001; Somatization 60.5 +/- 11.0 vs. 54.7 +/- 8.7, P < 0.001). Thus, severity of disability reported by the PMD group was equal to that seen in a progressive neurodegenerative condition. Quality of life and mental health implications of PMD were also evident. PMD impacts several aspects of patient function and daily life.

Management of the behavioral aspects of Parkinson's disease

Parkinson's disease is a progressive and debilitating movement disorder that is diagnosed by its motor signs. The behavioral manifestations of Parkinson's disease are prevalent and frequently complicate the course of the disease. These may be due to the illness itself or its treatment and are often more disabling than the motor symptoms. This review focuses on the management of the most common behavioral symptoms of Parkinson's disease, including depression, anxiety, psychosis, dementia, delirium, sleep disorders, fatigue, apathy, emotionalism and compulsive behaviors.

Early-onset Parkinson's disease and depression

Patients with Parkinson’s disease (PD) in whom symptoms start before the age of 45 years (EOPD) present different clinical characteristics from those with the late-onset form of the disease. The incidence of depression is believed to be greater in patients with EOPD than with the late-onset form of the disease, although there is no risk factor or marker for depression in patients with PD. We studied 45 patients with EOPD to define the frequency of depression and to identify possible differences between the groups with and without depression. Depression was diagnosed in 16 (35.5%) of the patients, a higher incidence than in the population at large but similar to the figure for late-onset Parkinson disease; 8 (50%) of the patients had mild depression, 4 (25%) moderate depression and 4 (25%) were in remission. There was no relationship between depression and any of the clinical characteristics of the disease, although the EOPD patients with depression presented earlier levodopa-related complications and were more affected on the Hoehn-Yahr, UPDRS and Schwab-England scales.

Non-motor aspects of Parkinson's disease

Parkinson's disease is primarily considered to be a movement disorder and is defined by its motor signs. Yet, the behavioral manifestations of the disease are often more debilitating than its motor complications. This review will focus on the non-motor aspects of Parkinson's disease, including mood, psychosis, cognitive, sleep, fatigue, apathy, delirium, and repetitive disorders, that may occur. The phenomenology, pathology, and treatment of the behavioral symptoms of Parkinson's disease will be discussed.

Quality of life and depression in Parkinson's disease

This paper reviews the literature on health-related quality of life (Hr-QoL) and depressive disorders, and the relationship between them, in patients with Parkinson's disease (PD). PD is associated with reduced Hr-QoL, including motor and non-motor physical consequences of the disease, emotional well-being and social functioning. While this effect is greater in advanced disease stages, there is no close relationship between disease duration and impact on quality of life, and the relationship between clinical rating scales and Hr-QoL scores is only moderate. On the other hand, presence and severity of depression in PD strongly correlates with Hr-QoL scores, and a number of studies have reported depression as the main determinant of poor HR-QoL scores. Despite being the main determinant of poor Hr-QoL and being recognized as an important problem by clinicians, until recently depression in PD has received relatively little attention in research studies. It is known that depression and anxiety occur more frequently in PD than in controls. Depression occurs in a bimodal pattern in PD, with increased rates at the onset and a later peak in advanced disease. Both anxiety and depression can also occur before the first motor symptoms of PD and predate the diagnosis of PD, indicating that these co-morbidities are manifestations of the underlying disease process of PD. Imaging studies have demonstrated abnormalities of dopaminergic, noradrenergic and serotonergic functioning with some correlation with severity of depression. The overall relationship between disease severity and rate of depression (except for off-period related depression) is poor, suggesting that nigrostriatal dysfunction alone is not sufficient to explain depressive symptoms in PD. Other factors are likely to contribute to occurrence and severity of depression in PD, either due to extrastriatal pathology or due to psychological and environmental factors leading to reactive depression. Thus, it is likely that depression in PD is multifactorial. The investigation of depression in PD is complicated by diagnostic difficulties in measuring and diagnosing depression in patients with PD due to the considerable overlap between symptoms of PD and depression. While a number of treatment approaches have been suggested, double-blind randomized controlled trials to demonstrate improvement of depression and overall Hr-QoL in PD are warranted.

Late-life depression: a neuropsychiatric approach

Late-life depression refers to depressive syndromes defined in the American Psychiatric Association's Diagnostic and Statistical Manual and in the International Classification of Diseases that arise in adults older than 65 years of age. Late life depressive syndromes often arise in the context of medical and neurologic disorders. There is a high prevalence of depression in various neurodegenerative disorders such as Alzheimer's disease, Lewy body disease, Parkinson's disease, cerebrovascular disease and frontotemporal dementias. It has been well recognized that late life depression may itself be the presenting symptom of a latent neurodegenerative disorder. Therefore, an accurate diagnosis of late-onset depression may serve to identify a high-risk group that would benefit from initiation of therapies with the goal of delaying or possibly even preventing the onset of dementia.

Depression in Parkinson's disease: study of 60 cases

Depression is very frequent in Parkinson's disease (PD) and largely unrecognized by neurologists, emphasizing the need of an approach to psychiatric symptoms by non psychiatrists in order to ensure an early diagnosis of depression in PD; clinical characteristics and the prevalence rate of depression in PD were evaluated and the relationship of depression in PD with other variables were determined. Sixty PD subjects, who fulfilled the clinical criteria for primary PD, 56.6% males, age range from 44 to 85 years old, in different stages of the disease were investigated. All subjects were submitted to the UPDRS-III, V and VI, Clinical Interview Schedule and the Hamilton depression scale. A significant correlation was found between depression and UPDRS-III, V and VI, anxiety and irritability. The frequency of depression in PD in this study was nearly 40% possessing specific features. Structured interviews and evaluation scales are essential for an accurate diagnosis and proper treatment of depression in PD.

The effect of depression on motor function and disease severity of Parkinson's disease

OBJECTIVES

Approximately 40% of patients with Parkinson's disease (PD) experience symptoms of depression. Our aim was to evaluate the effect of depression on disease severity, motor function and other phenotypic characteristics of PD.

PATIENTS AND METHODS

We studied 32 PD patients with major depression (PD-D) according to the DSM-IV criteria and 32 PD patients with no depression (PD-C) matched for gender, age of onset and duration.

RESULTS

Major depression in PD patients was associated with increased disease severity, poorer motor function and worse performance in the activities of daily living as measured by UPDRS scores. Furthermore, there was an association of depression with the severity of bradykinesia and axial rigidity.

CONCLUSIONS

Depression in PD can have a profound negative impact on a patient's sense of wellbeing and motor functioning. Therefore, PD patients should be routinely and carefully screened for the presence of depression and appropriate management should be considered. Larger studies on the subject are warranted.

Depression in Parkinson's disease is related to a genetic polymorphism of the cannabinoid receptor gene (CNR1)

Depression is a common symptom in Parkinson's disease (PD) and it is present in up to 40% of the patients. The cause of depression in PD is thought to be related to disturbance of monoamine neurotransmission. The endogenous cannabinoid system mediates different brain processes that play a role in the control of behaviour and emotions. Cannabinoid function may be altered in neuropsychiatry diseases, directly or through interactions with monoamine, GABA and glutamate systems. For this reason, we have investigated whether there is a genetic risk factor for depression in PD linked to the polymorphisms of CB1 receptor gene. Depression was more frequent in patients with PD than in controls with osteoarthritis. The presence of depression did not correlate with the stage of the disease but it was more frequent in patients with pure akinetic syndrome than in those with tremoric or mixed type PD. The CB1 receptor gene polymorphism (AAT)n is considered to modify the transcription of the gene and, therefore, it may have functional relevance. We analysed the length of the polymorphic triplet (AAT)n of the gene that encodes CB1 (CNR1) receptor in 89 subjects (48 PD patients and 41 controls). In patients with PD, the presence of two long alleles, with more than 16 repeated AAT trinucleotides in the CNR1 gene, was associated with a reduced prevalence of depression (Fisher's exact test: P=0.003). This association did not reach significant differences in the control group, but the number of control individuals with depression was too small to allow for statistical analysis. Since the alleles with long expansions may have functional impact in cannabinoid neurotransmission, our data suggest that the pharmacological manipulation of cannabinoid neurotransmission could open a new therapeutic approach for the treatment of depression in PD and possibly in other conditions.

Brain Ferritin Iron as a Risk Factor for Age at Onset in Neurodegenerative Diseases

Tissue iron can promote oxidative damage. Brain iron increases with age and is abnormally elevated early in the disease process in several neurodegenerative disorders, including Alzheimer's disease (AD) and Parkinson's disease (PD). Higher iron levels in males may contribute to higher risk for younger-onset PD and recent studies have linked the presence of the hemochromatosis gene with a younger age at onset of AD. We examined whether age at onset of PD and AD was associated with increased brain ferritin iron. Ferritin iron can be measured with specificity in vivo with MRI utilizing the field-dependent relaxation rate increase (FDRI) method. FDRI was assessed in three basal ganglia regions (caudate, putamen, and globus pallidus) and frontal lobe white matter for younger- and older-onset male PD and AD patients and healthy controls. Significant increases in basal ganglia FDRI levels were observed in the younger-onset groups of both diseases compared to their respective control groups, but were absent in the older-onset patients. The results support the suggestion that elevated ferritin iron and its associated toxicity is a risk factor for age at onset of neurodegenerative diseases such as AD and PD. Clinical phenomena such as gender-associated risk of developing neurodegenerative diseases and the age at onset of such diseases may be associated with brain iron levels. In vivo MRI can measure and track brain ferritin iron levels and provides an opportunity to design therapeutic interventions that target high-risk populations early in the course of illness, possibly even before symptoms appear.

Young- versus older-onset Parkinson's disease: Impact of disease and psychosocial consequences

The effect of Parkinson's disease (PD) on young patients' lives is likely to differ from that in older patients. For this study, 75 patients with onset of PD before the age of 50 and 66 patients with later onset completed a booklet of questionnaires on demographic and clinical variables, quality of life, and psychosocial factors. Apart from a higher rate of treatment-related dyskinesias in the younger onset group, the two groups did not differ in self-reported disease severity or disability. A higher percentage of young-onset patients was unemployed due to disability or had retired early. Quality of life as measured on the PDQ-39 was significantly worse in young-onset patients than in older-onset patients. Young-onset patients also had worse scores on the stigma and marital satisfaction scales, and were depressed more frequently. Differences between the two groups in their most commonly employed coping strategies and in terms of their satisfaction with emotional support did not reach significance. We conclude that young-onset patients more frequently experience loss of employment, disruption of family life, greater perceived stigmatization, and depression than do older-onset patients with PD. In addition to more severe treatment-related motor complications, social and psychosocial factors may contribute to greater impairment of quality of life in young patients with PD.

Prevalence, etiology, and treatment of depression in Parkinson's disease

Parkinson's disease (PD) is primarily a disease of elderly individuals with a peak age at onset of 55 to 66 years. It is characterized by bradykinesia, rigidity, tremor, and postural instability; and affects approximately 1 million individuals in the US and is the second most common neurodegenerative disease next to Alzheimer's disease. The motor symptoms of PD are the focus of pharmacotherapy, yet the nonmotor symptoms (e.g., dementia, psychosis, anxiety, insomnia, autonomic dysfunction, and mood disturbances) can be the most disturbing, disabling, and misunderstood aspects of the disease. Depressive symptoms occur in approximately half of PD patients and are a significant cause of functional impairment for PD patients. There is accumulating evidence suggesting that depression in PD is secondary to the underlying neuroanatomical degeneration, rather than simply a reaction to the psychosocial stress and disability. The incidence of depression is correlated with changes in central serotonergic function and neurodegeneration of specific cortical and subcortical pathways. Understanding comorbid depression in PD may therefore add to the understanding of the neuroanatomical basis of melancholia.

Treatment of advanced stage patients with Parkinson's disease

Most patients with Parkinson's disease (PD) receiving chronic levodopa therapy eventually manifest one or more motor response complications, including 'wearing-off' phenomena and on-off phenomena. Additionally, as the disease progresses, motor, neurologic, and neuropsychiatric complications increase and may include freezing spells, falls, dementia, depression and psychosis. The management of patients with advanced PD presents a special clinical challenge because patients may experience an enhanced sensitivity to small changes in plasma levodopa levels and because they may suffer adverse reactions to antiparkinsonian drugs. Management of advanced PD is directed toward decreasing the dose of the offending drug while raising the dose of alternative drug with the goal of maintaining symptom control. In this article, the spectrum of late complications experienced by patients with advanced PD and their management are discussed.

Therapeutic efficacy of bilateral prefrontal slow repetitive transcranial magnetic stimulation in depressed patients with Parkinson's disease: an open study

Recent studies have suggested that both high- and low-frequency repetitive transcranial magnetic stimulation (rTMS) have antidepressant effects in patients with major depression. We conducted an open study to assess the effects of slow rTMS on mood changes in patients with depression associated with Parkinson's disease (PD). Ten depressed patients with PD (four with major depression and six with dysthymia) received daily sessions of rTMS (frequency, 0.5 Hz; pulse duration, 0.1 msec; field intensity, 10% above the motor threshold) over both prefrontal regions (a total of 100 stimuli per prefrontal region daily) over 10 consecutive days. This treatment resulted in a moderate but significant decrease in scores of the Hamilton Depression Rating Scale (33-37%) and the Beck Depression Inventory (24-34%), which persisted 20 days after finishing the stimulation. In parallel, we observed mild improvement (18-20%) of motor symptoms. No significant adverse effects were reported. These preliminary results suggest the therapeutic potential of daily prefrontal low-frequency rTMS (0.5 Hz) in depression associated with PD.

Depression in Parkinson's disease

Depression is common in Parkinson's disease (PD), and its identification and treatment are critically important in disease management. Despite depression's high prevalence and major impact on patient quality of life, questions remain regarding its epidemiology and preferred treatment. The authors of this paper summarize available information on the epidemiology of depression in PD, review treatment options, and discuss possible interactions between antidepressants and other agents. This information may help guide clinical treatment and define the need for further studies.

Non-recognition of depression and other non-motor symptoms in Parkinson's disease

BACKGROUND

Depression, anxiety, fatigue and sleep disorders occur commonly in patients with Parkinson's disease (PD). These non-motor symptoms often contribute to the reduction of functional abilities in PD patients.

OBJECTIVE

This study was designed to evaluate the diagnostic accuracy of the treating neurologist for a variety of behavioral symptoms commonly associated with PD.

METHODS

A prospective evaluation of 101 patients with PD selected in no particular order was conducted. All patients were evaluated with the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn & Yahr Stage (H/Y), and the Schwab & England Scale (S/E). The patients completed a brief screening questionnaire for depression and anxiety followed by the administration of a battery of standardized tests including the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Fatigue Severity Scale (FSS), and the Pittsburgh Sleep Quality Inventory (PSQI).

RESULTS

Standardized testing showed evidence of a problem with depression in 44% of patients, anxiety in 39%, fatigue in 42% and sleep disturbance in 43%. The prevalence of these conditions, identified by the treating neurologist was lower: 21% with depression, 19% with anxiety, 14% with fatigue and 39% with sleep disturbance. The diagnostic accuracy for the treating neurologists was 35% for depression, 42% for anxiety, 25% for fatigue, and 60% for sleep disturbance.

CONCLUSION

This study demonstrates that during routine office visits, neurologists failed to identify the presence of depression, anxiety, and fatigue more than half of the time and failed to recognize sleep disturbance in 40% of patients. Awareness of the likelihood of underrecognition of behavioral symptoms in PD should generate approaches to improve diagnostic accuracy and facilitate timely therapeutic interventions.

Bereitschaftspotential in depressed and non-depressed patients with Parkinson's disease

Impaired initiation and slowed execution of movements are two of the principal characteristics of Parkinson's disease (PD). A similar pattern of movement impairments (psychomotor retardation) can be seen frequently in patients with idiopathic depression. In addition, affective disorders have been frequently reported in patients with different basal ganglia disorders. The aim of this study was to determine whether there are some particularities in the cerebral electrical activity during the preparation and execution of voluntary internally paced movements (i.e., Bereitschaftspotential, BP) in depressed PD patients, which can distinguish them from non-depressed PD patients, as well as from healthy controls. The BPs were recorded in 16 patients with idiopathic PD, eight of whom were depressed (PD-D), and eight of whom were not (PD-ND). Additional recordings were taken from a group of eight age- and sex-matched healthy subjects. Depression was classified using the Research Diagnostic Criteria and the two PD groups were matched for age, disease severity, and disease duration. The amplitudes and slopes of the BPs from PD patients were generally smaller than in controls, but there was no specific pattern of BP changes that distinguished depressed from non-depressed PD patients. In addition, there was no particular association between measures of depression severity and BP parameters. The data suggest that presence of depression in PD might not have any additional deteriorating influence on already impaired preparation for self-paced spontaneous movements.

Personality traits in young patients with Parkinson's disease

OBJECTIVES

It has been hypothesized that the dopaminergic deficit of older patients with Parkinson's disease (PD) is associated with a reduction in the dopamine-dependent personality trait "novelty seeking". It is unknown whether this may also be found in younger patients with PD whose dopaminergic deficit is considered to be purely motor.

MATERIAL AND METHODS

We interviewed 122 patients below 51 years of age and 122 age- and sex-matched healthy controls with regard to clinical and sociodemographic data. Both groups had to fill out the Tridimensional Personality Questionnaire (TPQ) of Cloninger. Neuropsychological testing of formal intelligence and depression was also applied.

RESULTS

"Novelty seeking" was not different between both groups. Patients were more often depressed than controls, explaining their difference in "harm avoidance" on the TPQ. "Persistence", a sub-scale of the third TPQ dimension "reward dependence", was significantly higher in patients. Neither sex, nor age, nor educational status were correlated with one of the three personality traits.

CONCLUSIONS

The higher rate of depression explains our finding of more "harm avoidance" among young PD patients. According to a literature review the choice and performance of controls is crucial whether personality traits in PD patients may be assessed as abnormal.

Management of behavioral and psychiatric problems in Parkinson's disease

Behavioral and psychiatric problems associated with idiopathic Parkinson's disease (PD) include cognitive dysfunction, drug-related psychosis, depression, anxiety, apathy, fatigue and sleep disturbance. These nonmotor symptoms are a significant cause of disability at all stages of illness. Cognitive dysfunction spans a continuum from circumscribed cognitive impairments to severe global dementia which can occur in up to 10-30% of advanced PD patients. Psychosis develops in 20-30% of PD patients receiving chronic antiparkinsonian therapy. Visual hallucinations and paranoid delusions are the most frequent symptoms. The gradual elimination of drugs of lesser priority that may affect cognition and/or cloud the sensorium constitutes the first step in the management of cognitive and psychotic symptoms. Atypical neuroleptic agents are an invaluable tool in those cases in which maximum drug regimen simplification is not adequate or results in unacceptable immobility. Depression and anxiety often go unrecognized although they are eminently treatable and may be important contributors to the morbidity of PD. They are present in 30-40% of PD patients and frequently occur together in association with other nonmotor symptoms such as apathy, fatigue and sleep disturbance. A combination of early recognition, counseling, antidepressant therapy, antianxiety and well-balanced antiparkinsonian therapy sets the stage for improved quality of life for patients with PD.

Cognitive and motor function in patients with Parkinson's disease with and without depression

The objective of this study was to define risk factors for depression in patients with idiopathic Parkinson's disease (PD) and to evaluate the correlation of depression with cognitive function and the primary domains of parkinsonian motor dysfunction tremor, bradykinesia, rigidity, gait and balance impairment. The risk factors for depression in patients with PD remain controversial. Several investigators have demonstrated a significant association between cognitive dysfunction and depression, but motoric and disease variables can confound this evaluation and have shown an inconsistent relation to depression. A consecutive series of 88 patients with PD were examined using the motor subscale of the Unified Parkinson's Disease Rating Scale (UPDRSm), Hoehn-Yahr stage (HY), and Hamilton Rating Scale for Depression (HRSD). Major depression was diagnosed according to the criteria in the Diagnostic and Statistic Manual of Mental Disorders, 4th edition. Gender, age, handedness, PD duration, side of PD onset, motor fluctuations, UPDRSm total score, daily Levodopa dose, and Mini-Mental State Examination score (MMSE) were analyzed using multivariate and univariate logistic regression, Fisher's Exact test, and Pearson correlations. Major depression was diagnosed in 12 patients (7.3%). Low MMSE score, axial bradykinesia, gait and balance impairment were strongly significant predictors of depression. In conclusion, depression and physical function are important factors impairing the quality of life for patients with PD, and regular depression screening and treatment should focus on patients with PD who have cognitive impairment, high axial bradykinesia, gait and balance impairment.

The validity of the Hamilton and Montgomery-Asberg depression rating scales as screening and diagnostic tools for depression in Parkinson's disease

The concurrent validity of the Hamilton Rating Scale for Depression (HAMD-17) and the Montgomery-Asberg Depression Rating Scale (MADRS) against the DSM-IV diagnosis 'depressive disorder' was assessed in patients with Parkinson's disease (PD). Sixty-three non-demented Parkinson's Disease (PD) patients who attended the outpatient department of an academic hospital were diagnosed according to a standardised research protocol. This protocol consisted of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) to establish the presence or absence of 'depressive disorder' according to the DSM-IV criteria, as well as the HAMD-17 and the MADRS. Receiver Operating Characteristics curves (ROC curves) were obtained and the positive and negative predictive values (PPV, NPV) were calculated for different cut-off scores. Maximum discrimination between depressed and non-depressed patients was reached at a cut-off score of 13/14 for the HAMD-17, and at 14/15 for the MADRS. At lower cut-offs, like 11/12 for the HAMD-17 and 14/15 for the MADRS, the high sensitivity and NPV make these scales good screening instruments. At higher cut-offs, such as 16/17 for the HAMD-17 and 17/18 for the MADRS, the high specificity and PPV make these instruments good diagnostic instruments. The diagnostics performance of the HAMD-17 is slightly better than that of the MADRS. This study shows that it is justified to use the HAMD-17 and the MADRS to measure depressive symptoms in both non-depressed and depressed PD patients, to diagnose depressive disorder in PD, and to dichotomize patient samples into depressed and non-depressed groups.

Psychiatric complications in Parkinson's disease

Parkinson's disease (PD) is caused by an abnormal degeneration of the dopamine (DA) producing cells in the substantia nigra (SN) and ventral tegmentum area (VTA) in combination with a varying decay of the noradrenergic (locus coeruleus), cholinergic forebrain (nucleus basalis of Meynert) and serotoninergic (dorsal raphe nuclei) systems, leading to a multitude of motor and non-motor behavioral disturbances, known as parkinsonism. Normally, main dopamine depletion is restricted to the SN region with manifest (non)motor behavioral abnormalities caused by the inability to spontaneously switch between intern-cued cortical behavioral programmes. Clinical symptoms comprise motoric abnormalities, though subtle cognitive disturbances as well as psychological dysfunction with loss of mental flexibility and reactive depressive symptoms might be seen. These symptoms might be compensated in part by externally-cued behavior.

MRI evaluation of brain iron in earlier- and later-onset Parkinson's disease and normal subjects

Tissue iron levels in the extrapyramidal system of earlier- and later-onset Parkinson's disease (PD) subjects were evaluated in vivo using a magnetic resonance imaging (MRI) method. The method involves scanning subjects in both high- and low-field MRI instruments, measuring tissue relaxation rate (R2), and calculating the field-dependent R2 increase (FDRI) which is the difference between the R2 measured with the two MRI instruments. In tissue, only ferritin iron is known to increase R2 in a field-dependent manner and the FDRI measure is a specific measure of this tissue iron pool. Two groups of male subjects with PD and two age-matched groups of normal control males were studied. The two groups of six subjects with PD consisted of subjects with earlier- or later-onset (before or after age 60) PD. FDRI was measured in five subcortical structures: the substantia nigra reticulata (SNR), substantia nigra compacta (SNC), globus pallidus, putamen, and caudate nucleus, and in one comparison region; the frontal white matter. Earlier-onset PD subjects had significant (p < 0.05) increases in FDRI in the SNR, SNC, putamen, and globus pallidus, while later-onset PD subjects had significantly decreased FDRI in the SNR when compared to their respective age-matched controls. Controlling for illness duration or structure size did not meaningfully alter the results. Published post-mortem studies on SN iron levels indicate decreased ferritin levels and increased free iron levels in the SN of older PD subjects, consistent with the decreased FDRI observed in our later-onset PD sample, which was closely matched in age to the post-mortem PD samples. The FDRI results suggest that disregulation of iron metabolism occurs in PD and that this disregulation may differ in earlier- versus later-onset PD.

Depression in Parkinson's disease. Pharmacological characteristics and treatment

Parkinson's disease (PD) is a common neurological illness and various degrees of depression frequently complicate its course. Risk factors for developing depression with PD include right-sided hemiparkinsonism, akinesia, increased severity of disability, anxiety and psychosis. Onset of parkinsonism at a younger age, female gender and the use of levodopa are arguable risk factors. Depression may be difficult to diagnose in patients with PD because the signs of the 2 disorders overlap. In addition, patients with atypical PD more commonly have depression than patients with classical PD presentations. Antidepressant response to antiparkinsonian treatment has been limited. Enhancement of catecholamine levels in the CNS by selegiline (deprenyl), a monoamine oxidase (MAO) type B inhibitor, has shown potential antidepressant as well as neuroprotective effects. Other MAO inhibitors have shown antidepressant efficacy in animal models but have not been well tolerated by patients with PD. A catechol-O-methyltransferase (COMT) inhibitor combined with an MAO inhibitor might synergistically maximise the levels of catecholamines in the CNS. Antidepressant medications used in patients without PD include tricyclic antidepressants (TCAs) and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs), but only TCAs have been carefully studied for their antidepressant effects in PD. Electroconvulsive therapy has proven efficacy as antidepressant therapy in patients with PD, and transcranial magnetic stimulation has provided temporary relief of depression under experimental conditions. Adverse effects of polypharmacy in the attempted treatment of depression in patients with PD are common in the elderly. A 'serotonin syndrome' has occurred frequently enough to preclude the coadministration of selegiline with SSRIs or TCAs, and multiple interactions between antiparkinsonian and antidepressant medications further complicate treatment strategies in patients with PD. An algorithmic approach to the pharmacological treatment of depression is described in this article.

Depression in Parkinson's disease

Depression occurs in 40% to 50% of Parkinson's disease (PD) patients. From research over the last decade, this co-occurrence appears to be more than an emotional reaction to disability. Replacement of the neurotransmitter, dopamine, benefits the PD motor functions, and the neurotransmitter, serotonin, in antidepressants, reduces depressive symptoms. However, identification of the physiological linkage between PD and depression continues to evade research efforts.