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Neurodegenerative Disease Parkinson’s Disease


Table 1: Classification of Non-motor Symptoms in Parkinson's Disease by System or Function


Cognition Domains


• Executive dysfunction • Abnormalities in attention • Visuospatial abnormalities • Memory loss


Stages


• Mild cognitive impairment • Dementia


Vision


• Reduced contrast sensitivity and acuity • Reduced spatial and motion perception • Reduced processing speed and attention • Reduced visuoconstructional abilities


Psychiatry • Depression • Anxiety • Psychosis • Impulse control disorders • Apathy


Gastroenterology • Constipation • Delayed gastric emptying


Cardiovascular System • Orthostatic hypertension • Cardiac denervation


Genitourinary System • Urinary urgency and incontinence • Erectile dysfunction


Respiratory System • Abnormal breathing • Aspiration


Sleep


• Sleep fragmentation • Restless leg syndrome and periodic limb movements of sleep • Obstructive sleep apnea • Excessive daytime sleepiness • REM sleep behavior disorder


Others


• Weight loss • Loss of smell


REM = rapid eye movement.


cortex–ventral striatal circuitry) deteriorates with use of dopaminergic medications.33


Psychiatry Depression


Depression is the most common neuropsychiatric disturbance seen in PD.50 life.51


how it is defined.52


of major depressive disorder in PD was 17 %, minor depression was 22 %, and dysthymia was 13 %.52


It may present at any time and contributes to decreased quality of The prevalence of depression ranges from 2.7 to 90 %, depending on In a recent systematic review, the weighted prevalence


Depression may be difficult to recognize in PD


because of commonly shared features, such as blunted facial expression, psychomotor slowing, appetite changes, fatigue, and sleep disturbances. Women, those with a family history of depression, and those with other psychiatric comorbidities (anxiety, apathy, etc.) may be at higher risk of developing depression.53–55


Limited randomized trials exist to guide


treatment for depression in PD. In randomized, placebo-controlled trials of antidepressants in PD, the tricyclics nortriptyline and desipramine have been demonstrated to improve depressive symptoms compared with placebo, whereas selective serotonin re-uptake inhibitors (SSRIs) have not been found to be as effective.56,57


with depression are generally prescribed an SSRI,58


Despite this, most PD patients likely because of its


adverse effect profile. Pramipexole, used to treat motor symptoms in PD, also appears to have an antidepressant effect.59


Anxiety Anxiety is estimated to occur in up to 40 % of patients with PD.60,61 Similar


to depression, the presence of anxiety is associated with a worse quality of life.60


Panic disorder and generalized anxiety disorder have been reported to be the most common anxiety syndromes in PD, but a recent study demonstrated that anxiety disturbances in PD tend not to fall into discrete subtypes.60


Very little is known about the pathophysiology


of anxiety in PD. Anxiety is highly associated with ‘on–off motor fluctuations in PD, with worsened anxiety and panic attacks during ‘off’ periods and improvement during ‘on’ states.62


Although the exact


While deep brain stimulation (DBS) of the subthalamic nucleus greatly improves motor function and overall quality of life, a mild decline in various cognitive functions (e.g. verbal fluency, information processing) has been observed.34–36


trials have shown modest benefits for central acetylcholine esterase inhibitors37


(e.g. rivastigmine,38 donepezil39 ) and memantine40,41 in PD


dementia. There are currently no systematic clinical trials in PD-MCI.29 Behavioral treatment options (e.g. cognitive behavioral therapy, exercise) are under investigation.


Vision PD affects visual function across all levels: ocular,42 basic sensory functions (visual acuity, color vision, contrast sensitivity), perception (information 114 Randomized controlled


underlying mechanism for this is unclear, patients may experience anxiety because of the immobility associated with ‘off’ periods. There are no randomized controlled trials of anxiety agents in the PD population. In the general population, antidepressants and benzodiazepines have shown to be beneficial. If the anxiety seems to occur only with wearing off, adjusting PD medications to prolong ‘on’ times may be helpful.


Psychosis


Psychosis is estimated to occur in 20–40 % of PD patients, usually in the advanced stages of the illness.50,63


It is the single greatest risk factor for


nursing home placement in patients with PD and contributes to caregiver stress.64


hallucinations.63,65 delusions may also be present, though less frequently.65


The most common manifestations of psychosis in PD are visual Non-visual hallucinations (auditory, tactile, olfactory) and Advanced age,


impaired vision, depression, sleep disorders, and longer disease duration US NEUROLOGY


Visual perception and cognition abnormalities are associated with dysfunction ranging from retinal to cortical levels.17


dysfunction is associated with gait and balance impairment, and visual cues can improve freezing of gait.46–48


processing speed, attention, spatial orientation, motion perception), and higher functions (cognitive level) such as non-verbal memory and construction.9,43–45


Visual Driving is a primarily visual


task, and visual function deficits at different levels are important risk factors for unsafe driving and driving cessation in PD.14,15,49


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