Assessment and Management of Neuropsychiatric Symptoms in Parkinson’s Disease

Abstract

Neuropsychiatric symptoms are highly prevalent in Parkinson's disease and associated with decreased quality of life and adverse health outcomes. In this review, the assessment and management of common neuropsychiatric symptoms are discussed: depression, anxiety, psychosis, cognitive impairment, dementia and apathy. Validated assessment scales are now available for the majority of symptoms. Balancing dopaminergic therapy plays an important role in their management as increasing doses of dopaminergic agents might address depression and anxiety related to 'off' phases, non-motor fluctuations and apathy, while dose reduction might alleviate psychotic symptoms. More targeted treatment is possible through medications utilising different pathways. Although efficacy profiles of individual agents require further exploration, antidepressants as a drug class have shown utility in depression and anxiety in Parkinson's disease. Psychological therapies, especially cognitive behavioural approaches, are effective. Pimavanserin allows the treatment of psychosis in Parkinson's disease without directly affecting the dopaminergic and cholinergic system. The cholinergic system is currently the only target in Parkinson's disease dementia, and antagonists of this system, as are many psychotropic drugs, need to be used with caution. Management of apathy largely relies on non-pharmacological strategies adapted from dementia care, with antidepressants being ineffective and the role of stimulant therapy needing further evaluation.

Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management

“…The starting point is a review of medical or pharmacological triggers and a delirium screen with advice on general coping strategies. 63 64 A reduction in PD medication may be necessary while monitoring for worsening motor symptoms, dopamine withdrawal syndrome or neuroleptic malignant syndrome. Medications should be withdrawn, starting with those most likely to provoke VH, that is, anticholinergics, amantadine and MAO-B inhibitors, followed by dopamine agonists and COMT inhibitors.…”

Current treatment of behavioral and cognitive symptoms of Parkinson's disease

“…The relationship between visual hallucinations and reduced cortical cholinergic activity suggests that cholinergic agents may improve psychotic symptoms in PD. However, although several case reports, case series, and small open-label trials report some positive effects of cholinesterase inhibitors (and rivastigmine in particular) in reducing visual hallucinations [118][119][120], there have not yet been well designed randomized double-blind studies. The results of the EXPRESS study [121], which assessed the efficacy of rivastigmine in treating PD dementia in a double blind placebo-controlled trial, revealed that twice as many of the patients without visual hallucinations at baseline developed hallucinations in the placebo group as in the rivastigmine group, suggesting that rivastigmine may protect against the development of visual hallucinations in PD.…”

Pharmacologic Approaches for the Management of Apathy in Neurodegenerative Disorders

“…Considering the important negative impact of apathy in the evolution of AD, therapeutic options are needed. Current therapeutic treatments mainly rely on non-pharmacological approaches (Mueller et al, 2018). Moreover, conventional psychotropic drugs often overprescribed in AD, such as antipsychotics and Selective-Serotonin Reuptake Inhibitors (SSRI) antidepressants may increase levels of apathy in neurodegenerative disorders and may have overall insufficient effect to alleviate levels of BPSD (Anand et al, 2018).…”