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Chapter 13 - Neuropsychiatric Manifestations in Parkinson Disease

from Section 2: - Hypokinetic Movement Disorders

Published online by Cambridge University Press:  07 January 2025

By
Daniel Weintraub ,
Julia Gallagher  and
Matthew Stern
Edited by
Erik Ch. Wolters  and
Christian R. Baumann
Erik Ch. Wolters
Affiliation:
Universität Zürich
Christian R. Baumann
Affiliation:
Universität Zürich
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Summary

Although Parkinson’s disease (PD) is most associated with and diagnosed by the presence of motor symptoms, non-motor symptoms (NMS) can often be the most debilitating for patients. Highly prevalent among non-motor features are neuropsychiatric symptoms (NPS), including depression, anxiety, psychosis, impulse control disorders, apathy and cognitive impairment, the latter being particularly burdensome and occurring in the majority of PD patients long term. The neurobiological underpinnings of NPS are a mix of disease-related, other neurodegenerative disease processes, PD treatment effects and psychosocial factors. NPS can be difficult to recognize and diagnose in PD patients; therefore, PD-specific assessments have been developed to better identify and treat them. Treatment strategies are a mix of those used in the general population for these conditions and those specific to PD, and are a combination of pharmacologic and non-pharmacologic interventions. Although significant advances have been made in our understanding and management of NPS in PD, etiology or biologically informed management strategies are needed to further advance the field.

Keywords

Neuropsychiatricdepressionanxietycognitiondementiapsychosisapathyimpulse control disorders
Type
Chapter
Information
International Compendium of Movement Disorders , pp. 155 - 165
Publisher: Cambridge University Press
Print publication year: 2025

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References

Hommel, A, Meinders, MJ, Lorenzl, S, et al. The prevalence and determinants of neuropsychiatric symptoms in late-stage parkinsonism. Mov Disord Clin Pract 2020;7(5):531–542.CrossRefGoogle ScholarPubMed
Schrag, A, Horsfall, L, Walters, K, Noyce, A, Petersen, I. Prediagnostic presentations of Parkinson’s disease in primary care: a case-control study. Lancet Neurol 2015;14:57–64.CrossRefGoogle ScholarPubMed
Weintraub, D, Caspell-Garcia, C, Simuni, T, et al. Neuropsychiatric symptoms and cognitive abilities over the initial quinquennium of Parkinson disease. Ann Clin Transl Neurol 2020;7:449–461.CrossRefGoogle ScholarPubMed
Kazmi, H, Walker, Z, Booij, J, et al. Late onset depression: dopaminergic deficit and clinical features of prodromal Parkinson’s disease: a cross-sectional study. J Neurol Neurosurg Psychiatry 2021;92(2):158–164.CrossRefGoogle ScholarPubMed
Marinus, J, Zhu, K, Marras, C, Aarsland, D, van Hilten, JJ. Risk factors for non-motor symptoms in Parkinson’s disease. Lancet Neurol 2018;17(6):559–568.CrossRefGoogle ScholarPubMed
Patterson, L, Rushton, SP, Attems, J, Thomas, AJ, Morris, CM. Degeneration of dopaminergic circuitry influences depressive symptoms in Lewy body disorders. Brain Pathol 2019;29(4):544–557.CrossRefGoogle ScholarPubMed
Saari, L, Heiskanen, L, Gardberg, M, Kaasinen, V. Depression and nigral neuron density in Lewy body spectrum diseases. Ann Neurol 2021;89:1046–1050.CrossRefGoogle ScholarPubMed
Ray, S, Agarwal, P. Depression and anxiety in Parkinson disease. Clin Geriatr Med 2020;36(1):93–104.CrossRefGoogle ScholarPubMed
Seppi, K, Ray Chaudhuri, K, Coelho, M, et al. Update on treatments for nonmotor symptoms of Parkinson’s disease—an evidence-based medicine review. Mov Disord 2019;34:180–198.CrossRefGoogle ScholarPubMed
Mills, KA, Greene, MC, Dezube, R, et al. Efficacy and tolerability of antidepressants in Parkinson’s disease: a systematic review and network meta-analysis. Int J Geriatr Psychiatry 2018;33(4):642–651.CrossRefGoogle ScholarPubMed
Barone, P, Santangelo, G, Morgante, L, et al. A randomized clinical trial to evaluate the effects of rasagiline on depressive symptoms in non-demented Parkinson’s disease patients. Eur J Neurol 2015;22(8):1184–1191.CrossRefGoogle ScholarPubMed
Barone, P, Poewe, W, Albrecht, S, et al. Pramipexole for the treatment of depressive symptoms in patients with Parkinson’s disease: a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2010;9:573–580.CrossRefGoogle ScholarPubMed
Peball, M, Krismer, F, Knaus, HG, et al. Non-motor symptoms in Parkinson’s disease are reduced by nabilone. Ann Neurol 2020;88:712–722.CrossRefGoogle ScholarPubMed
Dobkin, RD, Mann, SL, Gara, MA, et al. Telephone-based cognitive behavioral therapy for depression in Parkinson disease: a randomized controlled trial. Neurology 2020;94(16):e1764–e1773.CrossRefGoogle ScholarPubMed
Dobkin, RD, Mann, SL, Weintraub, D, et al. Innovating Parkinson’s care: a randomized controlled trial of telemedicine depression treatment. Mov Disord 2021;36(11):2549–2558.CrossRefGoogle Scholar
Wu, PL, Lee, M, Huang, TT. Effectiveness of physical activity on patients with depression and Parkinson’s disease: a systematic review. PLoS One 2017;12(7):e0181515.CrossRefGoogle ScholarPubMed
Li, S, Jiao, R, Zhou, X, Chen, S. Motor recovery and antidepressant effects of repetitive transcranial magnetic stimulation on Parkinson disease: a PRISMA-compliant meta-analysis. Medicine (Baltimore) 2020;99(18):e19642.CrossRefGoogle ScholarPubMed
Lin, F, Su, Y, Weng, Y, et al. The effects of bright light therapy on depression and sleep disturbances in patients with Parkinson’s disease: a systematic review and meta-analysis of randomized controlled trials. Sleep Med 2021;83:280–289.CrossRefGoogle ScholarPubMed
Broen, MP, Narayen, NE, Kuijf, ML, Dissanayaka, NN, Leentjens, AF. Prevalence of anxiety in Parkinson’s disease: a systematic review and meta-analysis. Mov Disord 2016;31:1125–1133.CrossRefGoogle ScholarPubMed
van der Velden, RMJ, Broen, MPG, Kuijf, ML, Leentjens, AFG. Frequency of mood and anxiety fluctuations in Parkinson’s disease patients with motor fluctuations: a systematic review. Mov Disord 2018;33(10):1521–1527.CrossRefGoogle ScholarPubMed
Pontone, GM, Dissanayka, N, Apostolova, L, et al. Report from a multidisciplinary meeting on anxiety as a non-motor manifestation of Parkinson’s disease. NPJ Parkinsons Dis 2019;5:30.CrossRefGoogle ScholarPubMed
Joling, M, van den Heuvel, OA, Berendse, HW, Booij, J, Vriend, C. Serotonin transporter binding and anxiety symptoms in Parkinson’s disease. J Neurol Neurosurg Psychiatry 2018;89(1):89–94.CrossRefGoogle ScholarPubMed
Leentjens, AF, Dujardin, K, Pontone, GM, et al. The Parkinson Anxiety Scale (PAS): development and validation of a new anxiety scale. Mov Disord 2014;29(8):1035–1043.CrossRefGoogle ScholarPubMed
Schneider, RB, Auinger, P, Tarolli, CG, et al. A trial of buspirone for anxiety in Parkinson’s disease: safety and tolerability. Parkinsonism Relat Disord 2020;81:69–74.CrossRefGoogle ScholarPubMed
Moonen, AJH, Mulders, AEP, Defebvre, L, et al. Cognitive behavioral therapy for anxiety in Parkinson’s disease: a randomized controlled trial. Mov Disord 2021;36(11):2539–2548.CrossRefGoogle ScholarPubMed
Kwok, JYY, Kwan, JCY, Auyeung, M, et al. Effects of mindfulness yoga vs stretching and resistance training exercises on anxiety and depression for people with Parkinson disease: a randomized clinical trial. JAMA Neurol 2019;76(7):755–763.CrossRefGoogle ScholarPubMed
Estevao, C, Fancourt, D, Dazzan, P, et al. Scaling-up health-arts programmes: the largest study in the world bringing arts-based mental health interventions into a national health service. BJPsych Bull 2021;45(1):32–39.CrossRefGoogle ScholarPubMed
Cummings, J, Pinto, LC, Cruz, M, et al. Criteria for psychosis in major and mild neurocognitive disorders: International Psychogeriatric Association (IPA) consensus clinical and research definition. Am J Geriatr Psychiatry 2020;28:1256–1269.CrossRefGoogle ScholarPubMed
Fenelon, G, Soulas, T, Zenasni, F, de Langavant, L. The changing face of Parkinson’s disease-associated psychosis: a cross-sectional study based on the new NINDS-NIMH criteria. Mov Disord 2010;25:763–766.CrossRefGoogle ScholarPubMed
Pagonabarraga, J, Martinez-Horta, S, Fernandez de Bobadilla, R, et al. Minor hallucinations occur in drug−naive Parkinson’s disease patients, even from the premotor phase. Mov Disord 2016;31:45–52.CrossRefGoogle ScholarPubMed
Barrett, MJ, Smolkin, ME, Flanigan, JL, et al. Characteristics, correlates, and assessment of psychosis in Parkinson disease without dementia. Parkinsonism Relat Disord 2017;43:56–60.CrossRefGoogle ScholarPubMed
Guo, Y, Xu, W, Liu, FT, et al. Modifiable risk factors for cognitive impairment in Parkinson’s disease: a systematic review and meta-analysis of prospective cohort studies. Mov Disord 2019;34:876–883.CrossRefGoogle ScholarPubMed
Dafsari, HS, Martinez-Martin, P, Rizos, A, et al. EuroInf 2: subthalamic stimulation, apomorphine, and levodopa infusion in Parkinson’s disease. Mov Disord 2019;34(3):353–365.CrossRefGoogle ScholarPubMed
Ballanger, B, Strafella, A, van Eimeren, T, et al. Serotonin 2A receptors and visual hallucinations in Parkinson disease. Arch Neurol 2010;67:416–421.CrossRefGoogle ScholarPubMed
Barrett, MJ, Blair, JC, Sperling, SA, Smolkin, ME, Druzgal, TJ. Baseline symptoms and basal forebrain volume predict future psychosis in early Parkinson disease. Neurology 2018;90:e1618–e1626.CrossRefGoogle ScholarPubMed
Lenka, A, Ingalhalikar, M, Shah, A, et al. Abnormalities in the white matter tracts in patients with Parkinson disease and psychosis. Neurology 2020;94:e1876–e1884.CrossRefGoogle ScholarPubMed
O’Brien, J, Taylor, JP, Ballard, C, et al. Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management. J Neurol Neurosurg Psychiatry 2020;91(5):512–519.CrossRefGoogle ScholarPubMed
Friedberg, G, Zoldan, J, Weizman, A, Melamed, E. Parkinson Psychosis Rating Scale: a practical instrument for grading psychosis in Parkinson’s disease. Clin Neuropharmacol 1998;21:280–284.Google Scholar
Cummings, J, Isaacson, S, Mills, R, et al. Pimavanserin for patients with Parkinson’s disease psychosis: a randomised, placebo-controlled phase 3 trial. Lancet 2014;383:533–540.CrossRefGoogle ScholarPubMed
Sawada, H, Oeda, T, Kohsaka, M, et al. Early use of donepezil against psychosis and cognitive decline in Parkinson’s disease: a randomised controlled trial for 2 years. J Neurol Neurosurg Psychiatry 2018;89:1332–1340.CrossRefGoogle ScholarPubMed
Tariot, PN, Cummings, JL, Soto-Martin, ME, et al. Trial of pimavanserin in dementia-related psychosis. N Engl J Med 2021;385(4):309–319.CrossRefGoogle ScholarPubMed
Weintraub, D, Chiang, C, Kim, HM, et al. Association of antipsychotic use with mortality risk in patients with Parkinson disease. JAMA Neurol 2016;73(5):535–541.CrossRefGoogle ScholarPubMed
Takamiya, A, Seki, M, Kudo, S, et al. Electroconvulsive therapy for Parkinson’s disease: a systematic review and meta-analysis. Mov Disord 2021;36(1):50–58.CrossRefGoogle ScholarPubMed
Corvol, JC, Artaud, F, Cormier-Dequaire, F, et al. Longitudinal analysis of impulse control disorders in Parkinson disease. Neurology 2018;91:e189–e201.CrossRefGoogle ScholarPubMed
Weintraub, D, Koester, J, Potenza, M, et al. Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients. Arch Neurol 2010;67:589–595.CrossRefGoogle ScholarPubMed
Martinez-Martin, P, Wan, YM, Ray Chaudhuri, K, Schrag, AE, Weintraub, D. Impulse control and related behaviors in Parkinson’s disease with dementia. Eur J Neurol 2020;27:944–950.CrossRefGoogle ScholarPubMed
Okun, M, Weintraub, D. Should impulse control disorders and dopamine dysregulation syndrome be indications for deep brain stimulation and intestinal levodopa? Mov Disord 2013;28:1915–1919.CrossRefGoogle ScholarPubMed
Weintraub, D, Papay, K, Siderowf, A, Parkinson’s Progression Markers Initiative. Screening for impulse control disorder symptoms in patients with de novo Parkinson disease: a case-control study. Neurology 2013;80:176–180.CrossRefGoogle ScholarPubMed
Garcia-Ruiz, P, Castrillo, J, Alonso-Canovas, A, et al. Impulse control disorders in patients with Parkinson’s disease under dopamine agonist therapy: a multicentre study. J Neurol Neurosurg Psychiatry 2014;85:840–844.CrossRefGoogle ScholarPubMed
Steeves, T, Miyasaki, J, Zurowski, M, et al. Increased striatal dopamine release in parkinsonian patients with pathological gambling: a 11C raclopride PET study. Brain 2009;132:1376–1385.CrossRefGoogle ScholarPubMed
Ray, N, Miyasaki, J, Zurowski, M, et al. Extrastriatal dopaminergic abnormalities of DA homeostasis in Parkinson’s patients with medication-induced pathological gambling: a [11C] FLB-457 and PET study. Neurobiol Dis 2012;48:519–525.CrossRefGoogle ScholarPubMed
Claassen, DO, Stark, AJ, Spears, CA, et al. Mesocorticolimbic hemodynamic response in Parkinson’s disease patients with compulsive behaviors. Mov Disord 2017;32:1574–1583.CrossRefGoogle ScholarPubMed
Smith, KM, Xie, SX, Weintraub, D. Incident impulse control disorder symptoms and dopamine transporter imaging in Parkinson disease. J Neurol Neurosurg Psychiatry 2016;87(8):864–870.CrossRefGoogle ScholarPubMed
Kraemmer, J, Smith, K, Weintraub, D, et al. Clinical–genetic model predicts incident impulse control disorders in Parkinson’s disease. J Neurol Neurosurg Psychiatry 2016;87(10):1106–1111.CrossRefGoogle ScholarPubMed
Eisinger, RS, Cagle, JN, Alcantara, JD, et al. Distinct roles of the human subthalamic nucleus and dorsal pallidum in Parkinson’s disease impulsivity. Biol Psychiatry 2022;91(4):370–379.CrossRefGoogle ScholarPubMed
Wen, MC, Thiery, A, Tseng, WI, et al. Apathy is associated with white matter network disruption and specific cognitive deficits in Parkinson’s disease. Psychol Med 2022;52(2):264–273.CrossRefGoogle ScholarPubMed
Thobois, S, Lhommee, E, Klinger, H, et al. Parkinsonian apathy responds to dopaminergic stimulation of D2/D3 receptors with piribedil. Brain 2013;136:1568–1577.CrossRefGoogle ScholarPubMed
Le Heron, C, Plant, O, Manohar, S, et al. Distinct effects of apathy and dopamine on effort-based decision-making in Parkinson’s disease. Brain 2018;141(5):1455–1469.CrossRefGoogle ScholarPubMed
Thobois, S, Prange, S, Sgambato-Faure, V, Tremblay, L, Broussolle, E. Imaging the etiology of apathy, anxiety, and depression in Parkinson’s disease: implication for treatment. Curr Neurol Neurosci Rep 2017;17(10):76.CrossRefGoogle ScholarPubMed
Dujardin, K, Moonen, AJ, Behal, H, et al. Cognitive disorders in Parkinson’s disease: confirmation of a spectrum of severity. Parkinsonism Relat Disord 2015;21(11):1299–1305.CrossRefGoogle ScholarPubMed
Hauser, RA, Slawek, J, Barone, P, et al. Evaluation of rotigotine transdermal patch for the treatment of apathy and motor symptoms in Parkinson’s disease. BMC Neurol 2016;16:90.CrossRefGoogle ScholarPubMed
Devos, D, Moreau, C, Maltete, D, et al. Rivastigmine in apathetic but dementia and depression-free patients with Parkinson’s disease: a double-blind, placebo-controlled, randomised clinical trial. J Neurol Neurosurg Psychiatry 2014;85(6):668–674.CrossRefGoogle ScholarPubMed
Zoon, TJC, van Rooijen, G, Balm, G, et al. Apathy induced by subthalamic nucleus deep brain stimulation in Parkinson’s disease: a meta-analysis. Mov Disord 2020;36:317–326.CrossRefGoogle ScholarPubMed
Santin, MDN, Voulleminot, P, Vrillon, A, et al. Impact of subthalamic deep brain stimulation on impulse control disorders in Parkinson’s disease: a prospective study. Mov Disord 2021;36(3):750–757.CrossRefGoogle ScholarPubMed
Pigott, K, Rick, J, Xie, S, et al. Longitudinal study of normal cognition in Parkinson disease. Neurology 2015;85(15):1276–1282.CrossRefGoogle ScholarPubMed
Backstrom, D, Granasen, G, Domellof, ME, et al. Early predictors of mortality in parkinsonism and Parkinson disease: a population-based study. Neurology 2018;91(22):e2045–e2056.CrossRefGoogle ScholarPubMed
Genier Marchand, D, Montplaisir, J, Postuma, RB, Rahayel, S, Gagnon, JF. Detecting the cognitive prodrome of dementia with Lewy bodies: a prospective study of REM sleep behavior disorder. Sleep 2017;40:1–11.Google ScholarPubMed
Guo, Y, Liu, FT, Hou, XH, et al. Predictors of cognitive impairment in Parkinson’s disease: a systematic review and meta-analysis of prospective cohort studies. J Neurol 2021;268(8):2713–2722.CrossRefGoogle ScholarPubMed
Zarkali, A, McColgan, P, Leyland, LA, Lees, AJ, Weil, RS. Visual dysfunction predicts cognitive impairment and white matter degeneration in Parkinson’s disease. Mov Disord 2021;36(5):1191–1202.CrossRefGoogle ScholarPubMed
Oxtoby, NP, Leyland, LA, Aksman, LM, et al. Sequence of clinical and neurodegeneration events in Parkinson’s disease progression. Brain 2021;144(3):975–988.CrossRefGoogle ScholarPubMed
Mata, IF, Leverenz, JB, Weintraub, D, et al. GBA variants are associated with a distinct pattern of cognitive deficits in Parkinson’s disease. Mov Disord 2016;31(1):95–102.CrossRefGoogle ScholarPubMed
Liu, G, Peng, J, Liao, Z, et al. Genome-wide survival study identifies a novel synaptic locus and polygenic score for cognitive progression in Parkinson’s disease. Nat Genet 2021;53(6):787–793.CrossRefGoogle ScholarPubMed
Biondetti, E, Gaurav, R, Yahia-Cherif, L, et al. Spatiotemporal changes in substantia nigra neuromelanin content in Parkinson’s disease. Brain 2020;143(9):2757–2770.CrossRefGoogle ScholarPubMed
Prasuhn, J, Prasuhn, M, Fellbrich, A, et al. Association of locus coeruleus and substantia nigra pathology with cognitive and motor functions in patients with Parkinson disease. Neurology 2021;97(10):e1007–e1016.CrossRefGoogle ScholarPubMed
Ray, NJ, Bradburn, S, Murgatroyd, C, et al. In vivo cholinergic basal forebrain atrophy predicts cognitive decline in de novo Parkinson’s disease. Brain 2018;141(1):165–176.CrossRefGoogle ScholarPubMed
Pereira, JB, Hall, S, Jalakas, M, et al. Longitudinal degeneration of the basal forebrain predicts subsequent dementia in Parkinson’s disease. Neurobiol Dis 2020;139:104831.CrossRefGoogle ScholarPubMed
Albin, RL, Muller, M, Bohnen, NI, et al. Alpha4beta2(*) nicotinic cholinergic receptor target engagement in Parkinson disease gait–balance disorders. Ann Neurol 2021;90:130–142.CrossRefGoogle ScholarPubMed
Backstrom, D, Eriksson Domellof, M, Granasen, G, et al. Polymorphisms in dopamine-associated genes and cognitive decline in Parkinson’s disease. Acta Neurol Scand 2018;137(1):91–98.CrossRefGoogle ScholarPubMed
Matar, E, Shine, JM, Halliday, GM, Lewis, SJG. Cognitive fluctuations in Lewy body dementia: towards a pathophysiological framework. Brain 2020;143(1):31–46.CrossRefGoogle ScholarPubMed
Litvan, I, Goldman, J, Troster, A, et al. Diagnostic criteria for mild cognitive impairment in Parkinson’s disease: Movement Disorder Society Task Force Guidelines. Mov Disord 2012;27(3):349–356.CrossRefGoogle ScholarPubMed
Hoogland, J, Boel, JA, de Bie, RMA, et al. Mild cognitive impairment as a risk factor for Parkinson’s disease dementia. Mov Disord 2017;32(7):1056–1065.CrossRefGoogle ScholarPubMed
Hoogland, J, van Wanrooij, LL, Boel, JA, et al. Detecting mild cognitive deficits in Parkinson’s disease: comparison of neuropsychological tests. Mov Disord 2018;33:1750–1759.CrossRefGoogle ScholarPubMed
Dalrymple-Alford, J, MacAskill, M, Nakas, C, et al. The MoCA: well-suited screen for cognitive impairment in Parkinson disease. Neurology 2010;75:1717–1725.CrossRefGoogle ScholarPubMed
Mantri, S, Fullard, M, Gray, S, et al. Patterns of dementia treatment and frank prescribing errors in Parkinson disease. JAMA Neurol 2019;76:41–49.CrossRefGoogle Scholar
Knox, MG, Adler, CH, Shill, HA, et al. Neuropathological findings in Parkinson’s disease with mild cognitive impairment. Mov Disord 2020;35(5):845–850.CrossRefGoogle ScholarPubMed
Centi, J, Freeman, R, Gibbons, CH, et al. Effects of orthostatic hypotension on cognition in Parkinson disease. Neurology 2017;88(1):17–24.CrossRefGoogle ScholarPubMed
Kaminska, M, Mery, VP, Lafontaine, AL, et al. Change in cognition and other non-motor symptoms with obstructive sleep apnea treatment in Parkinson disease. J Clin Sleep Med 2018;14(5):819–828.CrossRefGoogle ScholarPubMed
Svenningsson, P, Odin, P, Dizdar, N, et al. A phase 2a trial investigating the safety and tolerability of the novel cortical enhancer IRL752 in Parkinson’s disease dementia. Mov Disord 2020;35:1046–1054.CrossRefGoogle ScholarPubMed
Sawada, H, Oeda, T, Kohsaka, M, et al. Early-start vs delayed-start donepezil against cognitive decline in Parkinson disease: a randomized clinical trial. Exp Opin Pharmacother 2021;22(3):363–371.CrossRefGoogle ScholarPubMed

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