Psychiatric complications of PD and their treatment

Psychiatric complications of PD and their treatment PowerPoint PPT Presentation

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Parkinson's disease: A movement disorder

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Psychiatric complications of PD and their treatment

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1. Psychiatric complications of PD and their treatment Dag Årsland Alderspsykiatrisk seksjon Psykiatrisk klinikk, SiR

2. Parkinson’s disease: A movement disorder…. ….or a neuropsychiatric disorder?

3. Overview Dementia, depression, hallucinations Epidemiology Causes and consequences Treatment

4. Frequency In addition, sleep disturbances OCD, fatigue and other symptoms occur frequentlyIn addition, sleep disturbances OCD, fatigue and other symptoms occur frequently

5. Consequences of psychopathology in PD Health-related quality of life (Herlofson 1998, 1999, 2000) Caregiver burden (Miller 1996, Aarsland 2001) Cognitive impairment (Troster 1995) Progression of PD (Starkstein 1992) Nursing home placement (Goetz 1998, Aarsland 2000) Mortality (Marder 1991)

6. Hallucinations predict nursing home admission in PD

7. Potential mechanisms

8. Extrastriatal pathologies in PD Subcortical: VTA Raphe 30-60% loss Loc coeruleus 50-80% Nucl. Basalis 30-80% Cortical: Frontal hypometabolism Fronto-subcort. Circuits Amyloid plaques Lewy bodies

10. Depression in PD Common Important clinical consequences Underdiagnosed Undertreated Treatable

11. PD and depression: an enigmatic relationship 1. PD is associated with more depression; (Tandberg 1996) i.e. ”PD causes depression” 2. Previous depression: increased risk of PD (Nilsson et al, Acta Scand Psych 2001) i.e. ”Depression causes PD” 3. Depression/anxiety may occur before motor symptoms (Shiva Mov Disord 2000) ”Common etiology”

12. Antidepressant trials in PD

13. Evidence for antidepressive treatment in PD

14. Progressive pattern of hallucinations in PD 1. Initial: Vivid dreams, nightmares 2. Hallucinations (visual) during daytime 3. Gradual loss of insight in non-reality of phenomena 4. May become paranoid and associated with delusions, affect and changes in behaviour

15. Arguments against simple ”drug-induced etiology” of hallucinat. Hallucinations in PD before use of L-DOPA motor fluctuations & dyskinesias not associated with hallucinations no dose-relationship with hallucinations iv-injection of l-dopa did not induce hallucinations (Goetz 1998) Phenomenological similar to dementia with Lewybodies (Int J Geriatri Psych 2001)

16. Psychosis in PD: RCT

17. Atypical antipsychotics in PD: open label studies

18. Evidence of antipsychotic treatment in PD

19. Management of psychosis in PD 1. Diagnose and treat underlying cause 2. Reduce number of antiparkinson agents: anticholinerg, selegilin, agonist, amantadin, COMT-inhibit., L-DOPA 3. If necessary, symptomatic treatment: 1) quetiapin (Seroquel) 12.5 mg, increase to 50-100 mg/d 2) clozapin (Leponex) 6.25 mg, increase to 50-100 mg 3) olanzapin (Zyprexa) 2.5mg 4) risperidon (Risperdal) 0.25-0.5 mg

20. Cum. prevalence of dementia in PD Non-demented patients: 55% cognitively intact 45% mild cognitive impairment

22. Progresjon av MMSE etter 4-5 år

23. Cognitive impairment in PD: Potential treatment strategies Neuroprotection: selegiline + vitamine - estrogen + Symptomatic: dopaminergic+ cholinergic++ serotonergic- noradrenergic-

24. Cholinesteraseinhibitors in PD: tacrine

25. Galantamine in PDD: Galantamine: ChEI + allost. eff. on nicot. rec N=16, two centres, open label 3 drop-outs: 1 GI AE, 2 worse PD 7/16 (44%) marked improvement Parkinsonism worse in 5/16 (31%), but improved in 7/16 (44%)

26. Placebo-controlled trial of donepezil in PD with dementia

27. Cholinesterase-inhibitors in PD Marked cholinergic deficit Open label studies with tacrine, donepezil, rivastigmine and galantamine positive One placebo-controlled trial RCT in dementia with Lewy-bodies Usually no worsening of parkinsonism

28. Conclusions: Psychiatric symptoms in PD are ….common …..integral part of the disease …..have important clinical implications …...potentially treatable…... with drugs which do not worsen parkinsonism

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