Depression, Psychosis, and Dementia in PD: 1997 EPDA Conference

[janet paterson <janet313@xxxxxxxxxxx>]

Depression, Psychosis, and Dementia in Parkinson's Disease,
EPDA one day conference  London 23rd-26th March, 1997

Professor Jenner, Professor of Pharmacology, King's College Hospital, London

Between 30 and 50% of Parkinson's patients experience depression; 20 to 40% 
dementia; 5 to 10% psychosis; and 15 to 20% drug induced psychosis. Clinicians 
often fail to deal with the neurobehavioural consequences of the disease. 
Treatment with dopamine agonists does not improve symptoms and may exacerbate 
other aspects of the disease; SSRI drugs can help. Dopaminergic cells 
throughout the brain are lost in the course of Parkinson's disease and are 
replaced by Lewy bodies, but it is not known if these changes produce the 
characteristic depression of the disease. Similarly, noradrenaline is also 
reduced by up to 50% in the limbic system and brainstem of sufferers and by 
over 75% in the frontal cortex: again, it is not known whether this causes 
dementia in patients; 5 HT reduction is associated with depression and 
psychosis, but is it cause or effect? Vascular disease and Alzheimer's disease 
symptoms may also be present, complicating the picture. What constitutes true 
Parkinson'
 s!
 dis
ease pathology?

Professor Poewe, Department of Neurology, University Hospital, Innsbruck, 
Austria

The prevalence of depression in Parkinson's disease averages about 40%, and may 
precede the appearance of motor symptoms in a third of patients, suggestive of 
the pre morbid personality theory of Parkinson's disease. There is no 
correlation between the degree of depression and severity of disease, but 
depression is a risk factor for cognitive decline and more rapid progression to 
disability. Treatment comprises psychosocial support; behavioural therapies; 
drugs: 'levodopa', dopamine agonists, 'deprenyl'; tricyclic antidepressants; 
'SSRIs' and ECT or 'TMS'. The three step treatment comprises substitution of 
brain dopamine, followed by tricyclic antidepressants, and then an SSRI. 
Symptoms include: loss of interest and initiative; indecisiveness; guilt 
feelings; loss of self-esteem; suicidal thoughts (but rarely suicide itself, 
which distinguishes it from non Parkinson depression); poor concentration; 
anxiety and panic attacks; fatigue; disrupted sleep patterns.

The areas of clinical overlap between motor symptoms, depression, and cognitive 
decline include reduced levels of: concentration and judgment; memory; 
psychomotor speed; cognitive processing speed; and higher levels of sleep 
disorders and mood swings. Patients often fail to discern voice tones and can 
no longer recognise humour.

Professor Cote, Columbia Presbyterian Medical Center, Neurological Institute, 
New York, USA

Depression may be present for many years before Parkinson's disease is 
diagnosed, but it is very difficult to recognise, because there are so many 
neurobehavioural changes in Parkinson's that could be mistaken for depression. 
The pre morbid personality traits include introversion, inflexibility, being a 
non drinker, having difficulty making sexual contacts, lack of competitive 
spirit, and inability to fantasise. An indicator of future disease in smokers 
may be giving up smoking some 5 to 15 years before diagnosis, because of the 
dependency of addictive drives on dopamine. The mental changes caused by 
Parkinson's disease include depression which often occurs early in the course 
of the disease. Treatment with tricyclics disguises Parkinson symptoms; SSRIs, 
on the other hand, can exacerbate symptoms. Depression may last from a few days 
to several weeks at a time. Symptoms of Parkinson's depression include: 
feelings of hopelessness/worthlessness; no interest in pleasure; guilt; s
 u!
icid
al thoughts; fearfulness; reduced appetite; weight loss; disrupted sleep. 
Parkinson patients who are not depressed have significant reductions in 
serotonin metabolites, but in those who are depressed, the degree of reduction 
parallels the degree of depression. Treatment with levodopa can increase motor 
symptoms and provoke a withdrawal syndrome, which can itself generate 
depressive feelings. Low dose tricyclics with low levels of cholinergic action, 
SSRIs, ECT, psychotherapy, and light therapy are recommended.

Dr Eric Wolters, Department of Neurology, Academic Hospital, Wrije 
Universiteit, Amsterdam, The Netherlands

Degeneration of dopaminergic cells and their replacement by Lewy bodies in the 
brain tissue is a hallmark of Parkinson's disease. The process is diffuse, 
occurring in the brainstem, striatal, frontal, and limbic regions. Striatal 
changes produce motor symptoms, those in the frontal and limbic regions 
psychiatric symptoms, including dementia and psychosis. Drug treatments induce 
a range of psychiatric symptoms, as a result of their anticholinergic and 
dopaminergic actions. Neuropsychiatric side effects are seen in about 20% of 
non demented and in 80% of demented patients. Dose is thought to be an 
important factor. Delirium is more common in elderly patients because 
acetylcholine production reduces with age, especially in dementing illnesses. 
Efforts must be made to reduce sensory deprivation. Psychosis is characterised 
by delusions and/or hallucinations, which subsequently become extremely 
frightening. Mild neuroleptics or atypical neuroleptics are advised; dopamine 
agonists s
 h!
ould
 be discontinued. Carers need to be informed about the consequences of drug 
treatment in Parkinson's disease.

Professor Melamed, Department of Neurology, Rabin Medical Center, Tel Aviv 
University, Sackler School of Medicine, Israel

Psychosis is the major non motor problem in Parkinson's disease, because it is 
a significant marker of disease deterioration and progression, and it's the 
most limiting factor in the treatment of motor symptoms in advanced disease. 
This is because of the requirement for high doses of levodopa and other drugs, 
long term use of which produce psychiatric symptoms. Psychosis is also the most 
common cause of admission of Parkinson patients into nursing homes. It may 
develop or worsen after infection, physical injury, surgery, or mental stress, 
and tends to be more common in older and demented patients. Several mechanisms 
are probably involved in its development. It is characterised by 
hallucinations, which at first are often benign, but these gradually become 
more frightening and disabling, resulting in aggression and severe agitation. 
Treatment has traditionally been to reduce levodopa and other antiparkinson 
drugs and substitute neuroleptics. However, these can produce a rapid a
 n!
d so
metimes life threatening deterioration in motor symptoms. Ondansetron, an anti 
emetic used in the treatment of cancer, is well tolerated, with minimal side 
effects, but it is very expensive, and needs to be given in high doses.

Professor Oertel, Neurology Clinic, Centre for Nervous Diseases, Philipps 
University, Marburg, Germany

Dementia is acquired global impairment of higher cortical function, with a 
decline in memory, abstract thinking, and visuo spatial processing. It is a 
'syndrome', with between 15 and 30% of patients with Parkinson's disease 
affected. Dementia can be part of depression, or, result from vascular disease 
or concurrent Alzheimer's disease: up to 20% of demented patients have both. 
About 5% of Parkinson patients also have Alzheimer's disease. Young onset 
Parkinson patients (35-40) rarely become demented, even at 65 and older, and 
Parkinson's is not a risk factor for dementia. Depression and dementia are, 
however, significantly correlated with Parkinson's disease. Dementia occurs 
when the neurofibrillary tangles strangle the nuclei of nerve cells in the 
brain, and plaques develop in the cortical areas. It begins in the temporal 
lobe, with a lesio                       
nthesizeofa50pcoin,andspreads.Dopaminelevelsarereducedasarelevelsofacetylcholine,hallmarksofbothAlzheimer'sandParki
 n!
son'
s disease, but although patients with Apo E deposits develop cognitive 
impairments earlier than those without, these deposits are only a risk factor 
for Alzheimer's disease. Symptoms include apraxia, aphasia, personality 
changes, compromised short term memory, confusion, hallucinations, bradyphrenia 
and depression. Treatment is limited and may exacerbate other Parkinson's 
symptoms. Behavioural and occupational therapies, and psychosocial support are 
vital for the patient and his/her family.

Professor Ellgring, Institute for Psychology, University of Wuerzburg, Germany

Depression, dementia, and psychosis stretch the emotional resources of the 
families and carers of Parkinson's patients. Demands for care and social 
interaction are increased; there are adverse effects on health; stress 
increases; social isolation may result; and there are financial implications. 
These are compounded when the carer is elderly. The major concerns for carers 
of patients with Parkinson's and Alzheimer's focus on worries about the future, 
fear of leaving the patient unattended, and being misunderstood by the family. 
Carers are conflicted over encouraging independence in the patient; having to 
assume all the responsibility; restrictions on their own lifestyle; and feeling 
impatient and angry. Mental health problems among carers are common, and often 
become worse when the patient is transferred to a nursing home because of the 
attendant guilt, loneliness, and loss of identity. Sleep disorders and somatic 
illness are also common. There are times when both patient and
  !
care
r are depressed. Depression in the carer often arises out of learned 
helplessness where the individual feels powerless to effect change lack of 
positive feedback, and a deteriorating relationship with the patient. The 
degree of physical impairment of the patient and the level of family support 
are critical factors. Men suffer from the somatic aspects of depression because 
they find it difficult to talk about their stress. The care giving process 
reflects the progress of the disease: at the outset the needs of patient and 
the autonomy of the carer are equally matched, but the carer's autonomy 
decreases in proportion to the increasing needs of the patient. It is very 
important that carers seek to find meaning in their lives beyond the reach of 
Parkinson's Disease, maintain social contacts, retain their interests and 
hobbies, and seek to reduce and prevent stress in their lives. Facing negative 
emotions is vital, and this can be facilitated by psychotherapy and support 
groups.

Dr Douglas MacMahon, Cornwall Healthcare Trust, Camborne Redruth Community 
Hospital

The average age of onset of Parkinson's disease is 64: 35% have dementia, which 
is severe in 11%. It is a very stressful disease, with two thirds of patients 
experiencing anxiety and depression. The earlier diagnosis and advice are 
provided, the easier it is to reduce stress and improve prognosis. Specialist 
nurses have an important role. They are ideally suited to coping with the 
myriad physical and mental problems of both patients and carers, because they 
are best placed to bring together all the different aspects needed to manage 
the disease, including the provision of information and counselling, the 
alleviation of symptoms, and the cross-linking of relevant resources. They do 
not suffer from the authority gap, a frequent complaint by patients in relation 
to their dealings with doctors. They also have an important role in public 
information, for example, telephone helplines, and lessening the poor public 
perception of ECT, which can be very helpful in Parkinson's disease.
  !
Ther
e are now over 50 nurses with the specialist qualification for Parkinson's 
disease (ENB A43). There is much more that they could do, and eventually they 
may be able to offer a comprehensive Parkinson's disease service, covering 
diagnosis and treatment, education and advice. Issues that remain to be 
resolved are the definition of the specialist nurse's role, guidelines for 
prescribing drugs, an organised system of care, the need to train in a 
multidisciplinary environment, and an effective and appropriate means of 
evaluation.

Dr Andersen, Silkeborg, Denmark

Depression is common Parkinson's disease: the physiological reductions in 
serotonin and noradrenaline and the loss of identity and inability to work are 
major factors. The patient has to learn to adapt, and learn how to live, 
despite the limitations of their disease. Every patient has the option to 
'break down' or 'break through', and the active patient is one who participates 
in treatment, who focuses on the good aspects of life, and sees the disease as 
a challenge to be met. The change process involves going from contentment to 
crisis and loss, to grieving, to adjustment, to a new sense of contentment. 
Treatment of the disease needs to be about the whole person which means drugs, 
psychosocial support, education, and information. For that, the patient needs 
to take responsibility for him/herself, develop a trusting relationship with 
the doctor, and have a good supportive network. The 'depression reaction' is 
caused by failure to meet goals, because Parkinson's alters the abi
 l!
ity
to meet those goals. Learned helplessness is acquired early in life and teaches 
people that they don't have to look for solutions to their problems themselves 
or find ways of coping, and that what happens is inevitable. However, it is 
important that patients recognise that they can regain control of their lives 
by the way in which they choose to deal with the disease.

Copyright EPDA, 1997


janet paterson, an akinetic rigid subtype parkie
53 now /44 dx cd / 43 onset cd /41 dx pd / 37 onset pd
TEL: 613 256 8340 SMAIL: POBox 171 Almonte Ontario K0A 1A0 Canada
EMAIL: janet313@xxxxxxxxxxx URL: