Neuropsychiatric Symptoms in Parkinson's Disease: Beyond Complications

White matter hyperintensities and smaller cortical thickness are associated with neuropsychiatric symptoms in neurodegenerative and cerebrovascular diseases

BACKGROUND

Neuropsychiatric symptoms (NPS) are a core feature of most neurodegenerative and cerebrovascular diseases. White matter hyperintensities and brain atrophy have been implicated in NPS. We aimed to investigate the relative contribution of white matter hyperintensities and cortical thickness to NPS in participants across neurodegenerative and cerebrovascular diseases.

METHODS

Five hundred thirteen participants with one of these conditions, i.e. Alzheimer's Disease/Mild Cognitive Impairment, Amyotrophic Lateral Sclerosis, Frontotemporal Dementia, Parkinson's Disease, or Cerebrovascular Disease, were included in the study. NPS were assessed using the Neuropsychiatric Inventory - Questionnaire and grouped into hyperactivity, psychotic, affective, and apathy subsyndromes. White matter hyperintensities were quantified using a semi-automatic segmentation technique and FreeSurfer cortical thickness was used to measure regional grey matter loss.

RESULTS

Although NPS were frequent across the five disease groups, participants with frontotemporal dementia had the highest frequency of hyperactivity, apathy, and affective subsyndromes compared to other groups, whilst psychotic subsyndrome was high in both frontotemporal dementia and Parkinson's disease. Results from univariate and multivariate results showed that various predictors were associated with neuropsychiatric subsyndromes, especially cortical thickness in the inferior frontal, cingulate, and insula regions, sex(female), global cognition, and basal ganglia-thalamus white matter hyperintensities.

CONCLUSIONS

In participants with neurodegenerative and cerebrovascular diseases, our results suggest that smaller cortical thickness and white matter hyperintensity burden in several cortical-subcortical structures may contribute to the development of NPS. Further studies investigating the mechanisms that determine the progression of NPS in various neurodegenerative and cerebrovascular diseases are needed.

Compound Dihuang Granule Inhibits Nigrostriatal Pathway Apoptosis in Parkinson's Disease by Suppressing the JNK/AP-1 Pathway

Compound Dihuang Granule (CDG) is widely used in traditional Chinese medicine (TCM) for the treatment of Parkinson's disease (PD). It has been shown to alleviate PD symptoms. However, the molecular mechanisms of its action have not been established. To establish the molecular mechanisms of CDG against PD, we used TCM network pharmacology methods to predict its molecular targets and signaling pathways, followed by experimental validation. The Core Protein protein interaction (PPI) network of the 150 intersections between CDG and PD-related genes, comprising 23 proteins, including CASP3 (caspase-3), MAPK8 (JNK), FOS (c-Fos), and JUN (c-Jun). KEGG and GO analyses revealed that apoptotic regulation and MAPK signaling pathways were significantly enriched. Since c-Jun and c-Fos are AP-1 subunits, an important downstream JNK effector, we investigated if the JNK/AP-1 pathway influences CDG against apoptosis through the nigrostriatal pathways in PD rat models. Molecular docking analysis found that the top three bioactive compounds exhibiting the highest Degree Centrality following online database and LC-MS analysis had high affinities for JNK. Experimental validation analysis showed that CDG decreased the number of rotating laps and suppressed the levels of phosphorylated c-Jun, c-Fos, and JNK, as well as the number of TUNEL positive cells and the cleaved caspase-3 level in the nigrostriatal pathway. Furthermore, CDG treatment elevated the number of TH neurons, TH expression level, and Bcl-2/Bax protein ratio in a 6-OHDA-induced PD rat. These findings are in tandem with those obtained using SP600125, a specific JNK inhibitor. In conclusion, CDG suppresses the apoptosis of the nigrostriatal pathway and relieves PD symptoms by suppressing the JNK/AP-1 signaling pathway.

COVID-19 Pandemic and Psychiatric Symptoms: The Impact on Parkinson's Disease in the Elderly

Background: The coronavirus disease 2019 (COVID-19) pandemic represents a condition of increased vulnerability and frailty for elderly patients with Parkinson's disease (PD). Social isolation may worsen the burden of the disease and specifically exacerbate psychiatric symptoms, often comorbid with PD. This study aimed at identifying risk/protective factors associated with subjective worsening of psychiatric symptomatology during the COVID-19 outbreak in a sample of individuals with PD aged 65 years or older. Methods: Patients with PD routinely followed at the outpatient clinic of Gemelli University Hospital, Rome, were assessed for subjective worsening of psychiatric symptoms through a dedicated telephone survey, after Italy COVID-19 lockdown. Patients' medical records were reviewed to collect sociodemographic and clinical data, including lifetime psychiatric symptoms and pharmacological treatment. Results: Overall, 134 individuals were assessed and 101 (75.4%) reported lifetime psychiatric symptoms. Among those, 23 (22.8%) presented with subjective worsening of psychiatric symptomatology during the COVID-19 outbreak. In this group, the most frequent symptom was depression (82.6%), followed by insomnia (52.2%). Subjective worsening of neurological symptoms (Wald = 24.03, df = 1, p = 0.001) and lifetime irritability (Wald = 6.35, df = 1, p = 0.020), together with younger age (Wald = 5.06, df = 1, p = 0.038) and female sex (Wald = 9.07 df = 1, p = 0.007), resulted as specific risk factors for ingravescence of psychiatric presentation. Lifetime pre-existing delusions, having received antipsychotics, and not having received mood stabilizer were also associated with subjective worsening of psychiatric symptomatology due to the COVID-19 pandemic. Conclusions: Individuals with PD and lifetime history of psychiatric symptoms may be exposed to increased vulnerability to the stressful effect of COVID-19 outbreak. Interventions aimed at reducing irritability and mood instability might have an indirect effect on the health of patients with PD during the COVID-19 pandemic.

A Systematic Review and Case Series of Ziprasidone for Psychosis in Parkinson's Disease

The atypical antipsychotic ziprasidone has been considered inappropriate for use in patients with Parkinson’s disease (PD), as most atypical antipsychotics worsen parkinsonism. However, the current evidence for safety and efficacy of ziprasidone in PDP has not been evaluated in a systematic fashion. We review published experience with ziprasidone for treating psychosis in PD via systematic search of MEDLINE, Embase, Cochrane CENTRAL, and Clinicaltrials.gov with terms related to “ziprasidone” and “Parkinson’s disease”, inclusive of case reports and prospective studies. We also add seven cases of ziprasidone exposure in patients in our center with idiopathic PD or Lewy body dementia (DLB), selected by retrospective query of all clinical data since 1996. In our review, two prospective trials and 11 case reports or series were found, with ziprasidone found to be generally effective for treatment of psychosis and with few adverse events reported. Our case series did not support efficacy of ziprasidone; it was generally safe in PD, but two patients with DLB had adverse motor events. We conclude that, although ziprasidone occasionally can produce substantial worsening of motor signs, it usually is well tolerated, and may provide in some cases a useful alternative to quetiapine, clozapine and pimavanserin, particularly in the acute care setting. Further randomized controlled studies are needed.

Dopamine Buffering Capacity Imaging: A Pharmacodynamic fMRI Method for Staging Parkinson Disease

We propose a novel pharmacological fMRI (phMRI) method for objectively quantifying disease severity in Parkinson disease (PD). It is based on the clinical observation that the benefit from a dose of levodopa wears off more quickly as PD progresses. Biologically this has been thought to represent decreased buffering capacity for dopamine as nigrostriatal cells die. Buffering capacity has been modeled based on clinical effects, but clinical measurements are influenced by confounding factors. The new method proposes to measure the effect objectively based on the timing of the known response of several brain regions to exogenous levodopa. Such responses are robust and can be quantified using perfusion MRI. Here we present simulation studies based on published clinical dose-response data and an intravenous levodopa infusion. Standard pharmacokinetic-pharmacodynamic methods were used to model the response. Then the effect site rate constant k e was estimated from simulated response data plus Gaussian noise. Predicted time - effect curves sampled at times consistent with phMRI differ substantially based on clinical severity. Estimated k e from noisy input data was recovered with good accuracy. These simulation results support the feasibility of levodopa phMRI hysteresis mapping to measure the severity of dopamine denervation objectively and simultaneously in all brain regions with a robust imaging response to exogenous levodopa.

Da-Bu-Yin-Wan and Qian-Zheng-San Ameliorate Mitochondrial Dynamics in the Parkinson's Disease Cell Model Induced by MPP. Front Pharmacol 2019;10:372. [PMID: 31068806 PMCID: PMC6491701 DOI: 10.3389/fphar.2019.00372]

To investigate the effect of Da-Bu-Yin-Wan and Qian-Zheng-San (DBYW and QZS) on mitochondrial mass in Parkinson’s disease (PD) cell model induced by 1-Methyl-4-phenylpyridinium Ion (MPP⁺). The SH-SY5Y cell was selected and treated with MPP⁺. The PD model was intervened with DBYW and QZS. CCK-8 method was used to detect the survival rate of cells in each group. Mitochondria was labeled by mitoTracker^®Red CMXRos probe and observed by laser scanning confocal microscope, and ImageJ software was used to process images and measure mitochondrial form factors; Tetramethylrhodamine methyl ester was used to detect mitochondrial membrane potential (ΔΨm); Luciferase method was used to detect cellular ATP levels; Western-Blot technique was applied to detect the expression levels of Parkin protein, and the expression levels of Mfn1, Mfn2, OPA1, Drp1, and Fis1. We found that DBYW and QZS treatment significantly increased the cell survival rate, form factor (F-factor), mitochondrial activity and ΔΨm after MPP⁺ treatment, while the increase of ATP levels was not significant. In addition, the results of western blot analysis showed that the MPP⁺ induced increase in the expression of Drp1 and Fis1, as well as decrease in Parkin, Mfn1, Mfn2, and OPA1 were all partially revised by DBYW and QZS. In summary, our data strongly suggested that DBYW and QZS treatment can exert protective effects against PD related neuronal injury through regulation the homeostasis between mitochondrial fission and fusion.

Management of Psychosis in a Patient with Probable Dopa-Responsive Dystonia

Dopa-responsive dystonia is a rare childhood neurological disorder characterized by asymmetric dystonia, predominantly of the lower limb, that responds excellently to levodopa replacement therapy. Although it is known that behavioral changes, such as depression, anxiety disorders, and sleep disturbances, typically follow onset of motor symptoms, there is limited literature on the psychiatric symptoms of this disorder. This report describes a novel case of a 20-year-old male with a history of dopa-responsive dystonia and schizoaffective disorder who presented with both dystonia and psychosis after a period of medication noncompliance. This case provides a reference for the management of psychosis in patients with dopa-responsive dystonia and highlights the need for more research on the nonmotor symptoms that accompany this neurological disorder.

Mapping movement, mood, motivation and mentation in the subthalamic nucleus

The anatomical connections of the subthalamic nucleus (STN) have driven hypotheses about its functional anatomy, including the hypothesis that the precise anatomical location of STN deep brain stimulation (DBS) contributes to the variability of motor and non-motor responses across patients with Parkinson's disease (PD). We previously tested the hypothesis using a three-dimensional (3D) statistical method to interpret the acute effects of unilateral DBS at each patient's clinically optimized DBS settings and active contact. Here, we report a similar analysis from a new study in which DBS parameters were standardized and DBS locations were chosen blind to clinical response. In 74 individuals with PD and STN DBS, STN contacts were selected near the dorsal and ventral borders of the STN contralateral to the more affected side of the body. Participants were tested off PD medications in each of three unilateral DBS conditions (ventral STN DBS, dorsal STN DBS and DBS off) for acute effects on mood, apathy, working memory, response inhibition and motor function. Voltage, frequency and pulse width were standardized, and participants and raters were blind to condition. In a categorical analysis, both dorsal and ventral STN DBS improved mean motor function without affecting cognitive measures. Ventral STN DBS induced greater improvement in rigidity and anxiety than dorsal STN DBS. In the 3D analysis, contact location was significant for body hypokinesia, rigidity and resting tremor, with the greatest improvement occurring with DBS in dorsal STN and zona incerta. The 3D results provide new, direct functional evidence for the anatomically derived model of STN, in which motor function is best represented in dorsal STN. However, our data suggest that functional segregation between motor and non-motor areas of the STN is limited, because locations that induced improvements in motor function and mood overlapped substantially.

Treatment of Parkinson's disease psychosis

Early in the course of Parkinson disease (PD), treatment usually goes well. However, after five to ten years, things start to change as treatment requires higher doses of medications and side effects become more problematic. One of the most difficult problems is the development of hallucinations or delusions. Throughout the 20th century, treatment options were unproven and unsatisfactory, but the past 20 years have brought important changes. Two medications that are well tolerated in PD have now proved efficacious in randomized, controlled trials, and others are in development. Here I summarize this history briefly and provide a general plan for treating the patient with PD complicated by psychotic symptoms.