Neuropsychiatry of Parkinson's disease

Doxycycline inhibits dopaminergic neurodegeneration through upregulation of axonal and synaptic proteins

Doxycycline (DOX) is a widely used antibiotic that is able to cross the blood-brain barrier. Several studies have shown its neuroprotective effect against neurodegeneration and have associated it with antioxidant, anti-apoptotic, and anti-inflammatory mechanisms. We have recently demonstrated that DOX mimics nerve growth factor (NGF) signaling in PC12 cells. However, the involvement of this mechanism in the neuroprotective effect of DOX is unknown. Axonal degeneration and synaptic loss are key events at the early stages of neurodegeneration, and precede the neuronal death in neurodegenerative diseases, including Parkinson's disease (PD). Therefore, the regeneration of the axonal and synaptic network might be beneficial in PD. The effect of DOX in PC12 cells treated with the Parkinsonian neurotoxin 1-methyl-4-phenylpyridinium (MPP+) was addressed. Doxycycline reduced the inhibition of neuritogenesis induced by MPP+, even in cells deprived of NGF. The mechanism involved the upregulation of GAP-43, synapsin I, β-III-tubulin, F-actin, and neurofilament-200, proteins that are associated with axonal and synaptic plasticity. Considering the role of axonal degeneration and synaptic loss at the initial stages of PD, the recent advances in early diagnosis of neurodegeneration, and the advantages of drug repurposing, doxycycline is a promising candidate to treat PD.

The effect of physical exercise on anxiety in people with parkinson’s disease: A systematic review of randomized control trials

BACKGROUND Anxiety is a prominent disabling non-motor neuropsychiatric complication of Parkinson’s disease (PD). Pharmacological treatments for PD and anxiety have drug interactions and negative side effects. Therefore, non-pharmacological interventions such as exercise has been proposed to reduce anxiety in people with PD (PwP). OBJECTIVE This systematic review aimed to explore the relationship between physical exercise and anxiety in PwP. METHOD Four databases (PubMed, Embase, Scopus, Ebscohost) were searched without date restrictions. English randomized control trials (RCT) including adults with PD, exposed to physical exercise interventions with anxiety as an outcome variable, were included. Quality was assessed by means of an adapted 9-point PEDro scale. RESULTS Five of the identified 5547 studies met the inclusion criteria. Sample size ranged between 11–152 participants, totaling 328 participants with majority being male. PD stage ranged from early to moderate, with disease duration ranged between 2.9 and 8.0 years. All studies measured anxiety at baseline and post-intervention. On average studies scored 7/9 (76%) on the PEDro scale. CONCLUSION There is insufficient evidence to support or refute the effect of exercise on anxiety in PwP due to noted limitations of included studies. There is an urgent need for high-quality RCTs on physical exercise and anxiety in PwP.

A Novel Approach for Investigating Parkinson's Disease Personality and Its Association With Clinical and Psychological Aspects

Objective

A complex relationship between neuropsychiatric symptoms, personality traits and neurochemical changes in patients with Parkinson’s disease (PD) has been highlighted in the past several decades. In particular, a specific Parkinson personality with obsessive traits has been described. However, despite the great amount of anecdotal evidence, this aspect, together with its neurobiological, psychological and clinical correlates, are still not clearly defined. Therefore, we performed a case-control study in order to investigate the presence and rate of obsessive personality traits in PD patients within the theoretical framework of cognitive-constructivist model. Moreover, the relationship between PD personality and clinical, psychological and quality of life (QoL) aspects in PD were investigated.

Methods

Fifty-one non-demented patients with probable or possible PD (not demented) were recruited at the inpatient-outpatient San Luca Hospital, IRCCS Istituto Auxologico Italiano. Control group was composed by forty-eight age- and education-matched healthy volunteers. Patients underwent a neurological investigation including Unified PD Rating Scale (UPDRS), Modified Hoehn and Yahr and Schwab and England staging scales. The following psychological questionnaires were administered to the overall sample: Personal Meaning Questionnaire (PMQ), State-Trait Anxiety Inventory-Form Y (STAI-Y), Beck Depression Inventory (BDI), Symptom Check List-90 (SCL-90), Short-Form Health Survey-36 (SF-36).

Results

No significant differences in personality styles were observed in PD patients and controls, with a prevalence of phobic personal meaning organization (PMO) in both groups. However, PD patients showed more anxiety, depression and obsessive-compulsive (OC) symptoms than controls at the psychological questionnaires, as well as poorer QoL levels. The intensity of personality traits, and in particular for the obsessive personality style, were negatively associated with QoL and positively with disease severity. No significant relationships were observed between personality and other clinical aspects, such as side of onset and disease duration.

Conclusion

Parkinson’s disease patients did not show a different personality profile according to the cognitive-constructivist model with respect to controls. However, in this population, a general enhancement in the tendency to codify experience by means of specific cognitive and emotional patterns was associated to disease progression and to a poorer QoL.

Sleep quality is associated with the severity of clinical symptoms in Parkinson's disease

Sleep disorders are very common in Parkinson's disease (PD), being associated with several other conditions, mainly psychiatric disorders. The present study was designed to assess sleep quality in Brazilian patients with PD and to evaluate whether sleep changes are associated with clinical variables, especially neuropsychiatric symptoms in PD. Patients diagnosed with PD were subjected to a comprehensive clinical evaluation that included the assessment of motor, cognitive and psychiatric symptoms. Our study showed that sleep complaints are frequent in PD and worse sleep quality is associated with depressive and anxious symptoms, poorer cognitive performance and greater severity of PD symptoms. In the multivariate analysis, older age, greater severity of anxiety and PD remained as significant predictors of worse sleep quality. In conclusion, sleep complaints, depressive and anxiety symptoms are frequent in PD patients. Older age, disease severity and anxiety symptoms are significant predictors of poorer sleep quality in PD patients.

Pharmacological interventions for psychosis in Parkinson's disease patients

INTRODUCTION

Psychosis is a common problem for people treated for Parkinson's disease. The syndrome is quite stereotypic, with hallucinations being the most common, followed by delusions. While the hallucinations are usually not very bothersome, the delusions are typically paranoid in nature. Treatment is often, but not always, required.

AREAS COVERED

This article reviews the therapeutic approaches of this syndrome focusing on drug treatments used once contributory factors have been removed. This includes a review of the evidence supporting the use of clozapine and, most recently, pimavanserin, the first drug with antipsychotic efficacy that has no effect on dopamine. Treatment with second generation antipsychotic drugs and cholinesterase inhibitors are also reviewed.

EXPERT OPINION

Clozapine and pimavanserin have proven efficacy for Parkinson's disease psychosis (PDP), without impairing motor function. In clozapine's favor are its antipsychotic benefits seen within 1 week and its effectiveness in improving tremor in PD. However, this is counterbalanced by the need for blood monitoring, despite the extremely low doses used, and sedation. Pimanvanserin is well tolerated, without sedation or other significant side effects. Its onset of benefit, however takes 4-6 weeks. While quetiapine is also frequently used, its efficacy is not supported by double blinded, randomized trials.

A guide to management of neuropsychiatric manifestations of Parkinson's disease

OBJECTIVE

This clinical update review focuses on treatment approaches of neuropsychiatric manifestations in Parkinson's disease.

METHODS

We conducted a systematic search of the literature using Pubmed and selected recent and relevant papers for this review.

RESULTS

Neuropsychiatric symptoms in Parkinson's disease usually require optimization of levodopa therapy as a first step. Most psychotropic drugs can be used in Parkinson's disease, however there is still lack of an evidence base due to limited studies and difficulties in diagnosis of neuropsychiatric disorders. Non-pharmacological treatments have also proved effective in Parkinson's disease. Cognitive impairment requires special consideration.

CONCLUSIONS

Management of neuropsychiatric manifestations in Parkinson's disease is complicated by the lack of evidence. Treatment should be individualized and benefits and risks must be balanced.

Behavioural Assessment of the Dysexecutive Syndrome (BADS): Adaptação e Evidências de Validade

Resumo As funções executivas são habilidades que permitem um indivíduo direcionar seu funcionamento cognitivo, comportamental e emocional a metas. Para avaliá-las existem poucos instrumentos ecologicamente válidos. Para superar essa limitação, foi desenvolvida a Behavioural Assessment of the Dysexecutive Syndrome (BADS). O objetivo deste estudo foi adaptar e investigar evidências de validade de conteúdo da BADS para o contexto brasileiro. Foram realizadas três traduções do instrumento, sintetizadas em uma única versão e encaminhada a três juízes. Posteriormente, a BADS foi submetida a um grupo focal (5 adultos saudáveis) e estudo-piloto (amostra clínica com 40 pacientes neurológicos, portadores de Parkinson). O cálculo do coeficiente de validade de conteúdo total foi considerado aceitável (> 0,80); e a média do coeficiente kappa para os subtestes foi de 0,55, e para o questionário foi de 0,75, moderado e sólido, respectivamente. Os dados sugerem que a BADS está apta a ser utilizada em novos estudos para a investigação de outras propriedades psicométricas, como validade de construto, fidedignidade e normatização.

Clinical Presentation of Anxiety in Parkinson's Disease: A Scoping Review

Up to 40% of all individuals with Parkinson's disease (PD) are estimated to experience anxiety that interferes with daily functioning. This article describes research regarding the presentation of anxiety in PD and the influence anxiety has on participation in this population. A scoping review identified 1,635 articles, of which 49 met the inclusion criteria. This review identified that anxiety in PD is often associated with a range of clinical correlates related to demographic and clinical characteristics (age, gender, disease stage, duration, progression), motor symptoms (tremor, bradykinesia, dystonia, freezing of gait, symptom severity), treatment-related complications (on/off fluctuations, on with dyskinesia, unpredictable off), and non-motor symptoms (sleep abnormalities, fatigue, cognitive impairment, depression). These findings can be used to increase clinicians' awareness toward the specific clinical correlates linked to anxiety in PD so that mental health concerns can be detected and addressed more readily in practice.

Psychosis and concurrent impulse control disorder in Parkinson's disease: A review based on a case report

Psychosis, impulse control disorders (e.g., pathological gambling and hypersexuality) and repetitive behaviors such as punding are known psychiatric complications of Parkinson's disease (PD). Impulsive, compulsive and repetitive behaviors are strongly associated with dopamine-replacement therapy. We present the case of a 58-year-old man with PD and a myriad of psychiatric symptoms. Concurrent psychosis, punding and pathological gambling developed more than six years after the introduction of pramipexole and ceased shortly after the addition of quetiapine and discontinuation of pramipexole. This report emphasizes the importance of monitoring for a wide array of psychiatric symptoms in patients on dopamine replacement therapy.

Evaluation of quality of life and psychological aspects of Parkinson's disease patients who participate in a support group

Parkinson's disease (PD) is a neurodegenerative disorder that can dramatically impair patient quality of life (QoL).

Cognitive Status Correlates with CXCL10/IP-10 Levels in Parkinson's Disease

Cognitive impairment and depressive symptoms are of great interest in Parkinson's disease (PD), since they are very common and lead to increased disability with poor quality of life. Inflammatory mechanisms have been implicated in PD and its nonmotor symptoms. In the current pilot study, we aimed to evaluate plasma levels of chemokines in PD patients and to analyze the putative association of chemokines with depressive symptoms and cognitive performance. We hypothesized that higher chemokines levels are associated with worse cognitive performance and increased depressive symptoms in PD. For this purpose, 40 PD patients and 25 age- and gender-matched controls were subjected to a clinical evaluation including cognitive and mood tests. Peripheral blood was drawn and plasma levels of CCL2/MCP-1, CCL11/eotaxin, CCL24/eotaxin-2, and CXCL10/IP-10 were measured by enzyme-linked immunosorbent assay. PD patients and control individuals presented comparable plasma concentrations of all the evaluated chemokines. In PD patients, CXCL10/IP-10 plasma levels correlated positively with Hoehn and Yahr staging scale. In addition, the higher CXCL10/IP-10 levels, the worse performance on cognitive tests. Although there was no significant difference between PD patients and control individuals regarding chemokines levels, our preliminary results showed that CXCL10/IP-10 may be associated with cognitive status in PD.

Depression and cognitive impairment in Parkinson's disease: a role for inflammation and immunomodulation?

The etiology of Parkinson's disease (PD) is complex and not fully understood, most probably because of the multiplicity of factors involved. Inflammatory and abnormal immune responses have been hypothesized to play a crucial role in PD. Not only in the brain, but also peripherally, inflammation is believed to contribute to the onset and progression of the neurodegenerative process seen in PD. Furthermore, increased inflammatory responses have been described both in the brain and peripheral blood of PD subjects. Although PD is considered a motor disorder, nonmotor symptoms are extremely frequent and disabling. Cognitive impairment and mood alterations are such symptoms that deserve increased attention since on the one hand they can appear even before typical motor disturbances are recognized, and on the other hand they are associated with high morbidity and mortality. A growing body of evidence suggests the existence of a link between inflammatory-immune responses and the occurrence of depression and cognitive impairment in PD patients. However, not all data are equally conclusive and are sometimes even conflicting. The aim of this brief review is to give an overview of the possible role that inflammation and immunomodulation may play in PD together with their putative impact on mood and cognitive alterations. What clearly emerges from this work is the fact that studies performed until now lack standardized and comparable methods to analyze both clinical and biological parameters. It is thus difficult to conclusively link mood and cognitive changes to underlying pathological mechanisms. Additional studies in this direction are warranted to convincingly establish or refute any causative relation.

Plasma levels of soluble tumor necrosis factor receptors are associated with cognitive performance in Parkinson's disease

Inflammatory mechanisms have been implicated in a series of neuropsychiatric conditions, including behavioral disturbances, cognitive dysfunction, and affective disorders. Accumulating evidence also strongly suggests their involvement in the pathophysiology of Parkinson's disease (PD). This study aimed to evaluate plasma levels of inflammatory biomarkers, and their association with cognitive performance and other non-motor symptoms of PD. PD patients and control individuals were subjected to various psychometric tests, including the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Beck's Depression Inventory (BDI). Biomarker plasma levels were measured by enzyme-linked immunosorbent assay (ELISA). PD patients exhibited worse performance on MMSE and the programming task of FAB, and presented higher soluble tumor necrosis factor receptor (sTNFR) plasma levels than control individuals. Among PD patients, increased sTNFR1 and sTNFR2 concentrations were associated with poorer cognitive test scores. After multiple linear regression, sTNFR1 and education remained a significant predictor for FAB scores. Our data suggest that PD is associated with a proinflammatory profile, and sTNFRs are putative biomarkers of cognitive performance, with elevated sTNFR1 levels predicting poorer executive functioning in PD patients.

Neuropsychiatric symptoms in Nigerian patients with Parkinson's disease

BACKGROUND

Neuropsychiatric symptoms are common in Parkinson's disease and may precede onset of motor symptoms. They are also known to increase caregiver's burden.

OBJECTIVE

The aim of this study was to assess neuropsychiatric symptoms in a cohort of Nigerian patients with idiopathic Parkinson's disease and compare with systemic hypertension.

METHOD

Fifty patients with idiopathic Parkinson's disease were compared with fifty demographically matched controls with systemic hypertension. Diagnosis of Parkinson's disease was based on the United Kingdom Parkinson Disease Society (UKPDS) Brain Bank Clinical diagnostic Criteria. Diagnosis of hypertension was based on recorded blood pressure of ≥140/90 mmHg on two different occasions. The Neuropsychiatric Inventory (NPI) was applied to caregivers of both patients and controls.

RESULTS

There were significant differences in frequency of neuropsychiatric symptoms in patients and controls (P < 0.05). Significant differences were found in mean distress scores for some neuropsychiatric symptoms and the total mean distress score. In all cases, patients with Parkinson's disease had higher scores when compared with controls. Severity of motor symptoms, as measured by the UKPDS, correlated with total NPI severity scores (P = 0.000).

CONCLUSION

Neuropsychiatric symptoms occur more frequently in Parkinson's disease than matched controls, and the presence of these symptoms is associated with caregivers' distress. There is a need for early and adequate treatment for motor and behavioural symptoms of Parkinson's disease.

Qualidade de Vida em Voz: estudo na doença de Parkinson idiopática e na disfonia espasmódica adutora

OBJETIVO: avaliar o impacto causado pela alteração vocal na qualidade de vida (QV) dos pacientes com doença de Parkinson (DP) idiopática e com disfonia espasmódica adutora (DEA). MÉTODO: o estudo foi realizado com 56 indivíduos do sexo feminino, dos quais 28 compunham o grupo controle; 14, o grupo de DEA, no período anterior ao tratamento com toxina botulínica; e 14, o grupo de DP idiopática. Os participantes preencheram o questionário de Qualidade de Vida em Voz (QVV) validado para o português brasileiro. Para verificar a diferença entre as médias dos grupos foi utilizado o método de análise de variância por postos de Kruskal-Wallis e o teste de Tamhane para comparações múltiplas, com significância <0,05. RESULTADOS: as médias de idade dos grupos foram 66,18 para o grupo controle, 67,21 DP e 59,7 DEA, não havendo diferença estatística entre as médias. No protocolo QVV as médias dos domínios sócio-emocional, físico e escore total foram maiores para o grupo controle, seguido pelo grupo de DP idiopática e por fim o grupo da DEA, sendo a diferença entre elas estatisticamente significante. Além disso, houve diferença estatística para cada par de grupos, referente aos domínios do protocolo QVV, exceto no que se refere ao par controle e DP idiopática, no domínio sócio emocional (p=0,076). CONCLUSÃO: o maior impacto negativo na QV relacionado à voz está nos indivíduos com DEA, seguido por aqueles com DP idiopática e por fim os indivíduos do grupo controle.

Neurocognitive correlates of apathy and anxiety in Parkinson's disease

Parkinson's disease (PD) is associated with various nonmotor symptoms including neuropsychiatric and cognitive dysfunction. We examined the relation between apathy, anxiety, side of onset of motor symptoms, and cognition in PD. We hypothesized that PD patients would show different neuropsychiatric and neurocognitive profiles depending on the side of onset. 22 nondemented PD patients (11 right-side onset (RPD) with predominant left-hemisphere pathology, and 11 LPD) and 22 matched healthy controls (NC) were administered rating scales assessing apathy and anxiety, and a series of neuropsychological tests. PD patients showed a higher anxiety level than NC. There was a significant association between apathy, anxiety, and disease duration. In LPD, apathy but not anxiety was associated with performance on nonverbally mediated executive function and visuospatial measures, whereas, in RPD, anxiety but not apathy correlated with performance on verbally mediated tasks. Our findings demonstrated a differential association of apathy and anxiety to cognition in PD.

Generalized anxiety disorder and the Hamilton Anxiety Rating Scale in Parkinson's disease

Anxiety is common in Parkinson's disease (PD), but studies concerning specific anxiety disorders are scarce. Essential psychometric properties of anxiety rating scales are also lacking.

OBJECTIVE

To investigate general anxiety disorder (GAD) in PD and psychometric properties of the Hamilton Anxiety Rating Scale (Ham-A).

METHOD

Ninety-one PD patients underwent neurological and psychiatric examination, which included the MINI-Plus, the Ham-A and the Hamilton Depression Rating Scale (Ham-D).

RESULTS

GAD was present in 30.8% of PD patients. Patients with GAD had longer disease duration (p=0.044) and were in use of higher doses of levodopa (p=0.034). They also tended to have more motor fluctuations and dyskinesias. The group with GAD scored higher in Ham-A (p<0.001), in the somatic (p=0.004) and psychic (p<0.001) subscales of Ham-A, and in Ham-D (p=0.004). The Ham-A showed good internal consistency (Cronbach's alpha=0.893) and a cutoff score of 10/11 is suggested to screen for GAD.

CONCLUSION

GAD is frequent in PD and the Ham-A may be a useful instrument to screen for this disorder.

Psychiatric disorders in primary focal dystonia and in Parkinson's disease

BACKGROUND

Primary focal dystonia and Parkinson's disease are movement disorders that have contrasting motor phenotypes. The aim of this study was to compare the frequency and the severity of psychiatric disorders in primary focal dystonia and Parkinson's disease.

METHODS

Two groups of 30 patients matched by gender and age underwent a neurological and psychiatric assessment.

RESULTS

Parkinson's disease patients were diagnosed with higher rates of major depression (P = 0.02) and generalized anxiety disorder (P = 0.02), and greater severity of depressive symptoms (P = 0.04), while patients with primary focal dystonia exhibited increased severity of obsessive-compulsive symptoms (P = 0.02).

DISCUSSION

The difference in pathophysiology of primary focal dystonia and Parkinson's disease may explain the different psychiatric profiles of these two diseases. The increased frequency of affective symptoms in Parkinson's disease may be related to the fact that Parkinson's disease is a neurodegenerative disease marked by the loss of monoaminergic neurons which does not happen in primary focal dystonia.

CONCLUSION

The psychiatric profile differs in movement disorders with distinct neurobiological bases.

Executive dysfunction and motor symptoms in Parkinson's disease

The aim of this study is to analyze executive function and motor symptoms in patients with idiopathic Parkinson's disease (PD). The sample consisted of 44 subjects with PD between the ages of 45 to 75, who were examined consecutively. The subjects were divided into two groups according to the duration of the disease. The control group was composed of spouses, family and accompanying members. Patients included were submitted to motor dysfunction evaluation using the UPDRS. The executive functions modalities analyzed included: operational memory, inhibitory control, planning, cognitive flexibility and inductive reasoning. Significant differences between the experimental and control groups were found in all the executive domains studied. Evidence of tremor, rigidity and bradykinesia correlation with executive dysfunction were not observed. Patients with PD, even in the initial phase of the disease, presented executive dysfunction. The cardinal motor signs of the disease were not correlated with the cognitive dysfunction found.