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Non-motor Aspects of Parkinson’s Disease a Psychiatrist’s Perspective

Non-motor Aspects of Parkinson’s Disease a Psychiatrist’s Perspective. Geriatrics Day 2009 Ronald Bailyn , M.D. Cognitive impairment/Dementia Psychosis Depression Apathy Anxiety Fatigue Sleep Disturbance. Non-Motor Symptoms. Dopamine/serotonin. Neurotransmitters-pathways.

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Non-motor Aspects of Parkinson’s Disease a Psychiatrist’s Perspective

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  1. Non-motor Aspects of Parkinson’s Diseasea Psychiatrist’s Perspective Geriatrics Day 2009 Ronald Bailyn, M.D.

  2. Cognitive impairment/Dementia • Psychosis • Depression • Apathy • Anxiety • Fatigue • Sleep Disturbance Non-Motor Symptoms

  3. Dopamine/serotonin Neurotransmitters-pathways

  4. Deep Brain Stimulation – • Affective Events • depression (up to 25%) J Neurol Neurosurg Psychiatry2008;79:952-954 • hypomania • agitation • apathy Deep Brain Stimulation

  5. Depression

  6. Depression Prevalence in Parkinson’s Disease • Depression -- major and minor • ~ 5-10% major depression • ~ 20-30% minor depression Depression

  7. Depression • Depression is associated with reduced cognition, • faster progression of physical symptoms and • decreased treatment adherence • Retrospective studies suggest higher incidence as • long as 20 years before diagnosis • Some indication of greater depression risk with early • onset, for women and with right predominant • motor symptoms Depression

  8. From Daniel Weintraub, M.D. University of Pennsylvania Depression in Parkinsons

  9. Serotonin, norepinephrine and dopaminergic neurotransmitter changes in Parkinson’s provide • a theories for treatment, but • little clinical research to guide treatment • Limited evidence for specific medications • (3 trials -- Cochrane 2007) • Substantial use of SSRIs • (Zoloft, Prozac, Celexa/Lexapro) • possibility of aggravating motor sx • Nortriptyline (tricyclic – has best data) • ECT Depression Treatment

  10. Trial Design: Nortriptyline 25, 50, 75 mg Paroxetine CR 12.5, 25, 37.5 mg Placebo 1, 2, 3 pills 8 week randomized, double blind, Ham D Assessed 2, 4 and 8 weeks 52 patients Age 35-80 (mean 62) Nortriptyline &Paroxetine Study Menza M, Dobkin RD et al: Neurology 2008; (online Ahead of Print Dec. 17, 2008)

  11. Results • Nortriptyline › placebo (0.002) • Nortriptyline › paroxetine N.S. (0.08) • Response (= 50% improvement Ham D) • 53% nortriptyline • 11% paroxetine • 24% placebo • Remission (= Ham D of 7 or less) • 41% nortriptyline • 17% paroxetine • 12 % placebo Nortriptyline &Paroxetine Study

  12. Cognitive Behavioral Therapy (CBT) • Supported in limited trials/clinical experience Depression &Psychotherapy

  13. Antidepressant Choices Adapted from: Dialogues in Clinical Neuroscience – Parkinson’s Disease; 2004: Vol. 6 No. 3 p324

  14. Anxiety

  15. Anxiety • 20-30% frequency of anxiety disorders • General anxiety, panic attacks, obsessive-compulsive • problems can present in Parkinson’s Disease • Impulse control disorders (gambling, sex, buying) • dopamine agonist association • ~ 4% prevalence (Weintraub) Anxiety Disorders

  16. Anxiety Treatment • Very little study or even case report literature • Significant use of SSRIs and other • antidepressant medications • Low dose benzodiazepine medications • (lorazepam, clonazepam) • (monitor sedation & balance) • Cognitive Behavioral Treatment Anxiety Disorder Treatment

  17. Apathy

  18. Apathy • 10-20% frequency • – loss of goal directed behavior, life interest • Little treatment information – trials of • norepinephrine and dopaminergic agents • Wellbutrin, stimulants (ex. Ritalin, Strattera) • Education (family) • Environmental stimulation Apathy

  19. Sleep

  20. Various and frequent sleep disorders • Insomnia • sleep behavioral efforts • sleep medications (Tandberg 1999 study ~ 40% pts taking) • Parkinson’s motor symptoms • night dose Sinemet CR • Restless legs • dopaminergic medications Sleep disorders& Treatment

  21. More sleep disorders • REM behavior disorder • benzodiazepine (clonazepam) • Excessive daytime sleepiness (EDS) • thought to be direct symptom of Parkinson’s • review effects of Parkinson’s medications • Provigil study negative Sleep disorders& Treatment

  22. Behavioral/cognitive approaches to depression and sleep problems

  23. end

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