Ep. 190: Parkinson’s disease – more than a movement disorder

00:00:00: Welcome to EANcast, your weekly source for education research and updates from

00:00:21: the European Academy of Neurology.

00:00:35: And they are both well-known experts on neurocognition movement in healthy population and in neurodegenerative diseases as well.

00:00:44: More focusing on the complex relationships of cognition, emotions, and motor functioning in Parkinson's disease which is also very close to my heart.

00:00:53: so welcome Dr.

00:00:54: Maurice!

00:00:54: Welcome Dr.

00:00:55: Julie.

00:00:56: thank you for joining us today.

00:00:59: Thank You!

00:01:01: Lovely.

00:01:02: As I told you, it's a very hot topic for me and very close to my house.

00:01:07: Thank you for accepting our invitation again.

00:01:09: So let's start with the general overview Regarding two expertise.

00:01:16: i would like To Start With None.

00:01:18: What A Profile Of Parkinson's Disease.

00:01:20: So Marit maybe in regarding your cognitive research And Interests so You Can Give Us Some Clues About The Frequency And how often do we see cognitive problems in patients with Parkinson's disease?

00:01:35: I would love to hear the mood and behavioral problems from you, Julie as well.

00:01:40: Thank You!

00:01:42: Sure yeah i think when most people think of Parkinson's diseases they mainly consider those physical symptoms.

00:01:48: there are also often them most clearly visible symptoms, but indeed nearly all people with Parkinson's will also experience what we call non-motor problems.

00:01:57: And these concern a very broad set of problems and they can include bladder issues problem with the senses like reduced smell or physical hallucinations.

00:02:06: But it is so pain in the fatigue and indeed also cognitive changes which are not visible from outside In general, but also people with Parkinson's may not always be aware that it can actually be part of the disease itself.

00:02:23: But what we see is that people with parkinsons can develop problems in the domains of memory attention executive functions or more than higher order planning functions as well as visual spatial skills.

00:02:37: And in terms of the frequency, about twenty-five percent people with Parkinson's have moderate difficulties in these domains which indicates mild cognitive impairment.

00:02:49: Approximately half of people with parkinsons can develop dementia after being diagnosed for ten years.

00:02:58: but that also means that half of them do not and I just want to emphasize it as well.

00:03:05: Thank you, Marie.

00:03:06: You just started it with a very good clue about that because the non-motor profile including your cognitive changes and all the items can give as much burden as the motor problems actually, right?

00:03:26: For sure.

00:03:26: Yeah a lot of people with Parkinson's themselves actually indicate that non-motor symptoms are particularly challenging for them in daily life and we also know from research there is negative impact on these symptoms on their experience quality.

00:03:41: so they're very important.

00:03:42: Thank you indeed.

00:03:43: And Julie, I really am so keen on listening to the behavioural and mood changes in Parkinson's disease as a non-motor profile.

00:03:52: from your perspective or expertise How common do we see it?

00:03:57: What is frequency?

00:03:59: Both anxiety and depression are very common.

00:04:03: The studies had a different range, so some of them report about five percent but it can go up to about eighty percent.

00:04:11: But the literature seems around third-of-the-patients that experience anxiety... ...but my guess would actually be there is still on the lower side because many of the anxiety symptoms can overlap with disease.

00:04:27: So we see people with trembling or tremor for example sweating be attributed to Parkinson's itself, the medication effect but also to anxiety.

00:04:38: And we see that patients sometimes find it hard to articulate their emotion or avoid situations in which they feel anxious and not a great coping strategy.

00:04:51: We also see that not all neurologists might still touch upon these behavioural changes so this number may actually be higher than one third.

00:05:01: And then we also see that a lot of patients have this sub threshold clinical symptoms, so they experience height and profile but may not be classified as anxious or disordered.

00:05:14: I'm not sure if you agree, but what do you think?

00:05:16: it's not as easy.

00:05:18: As we talk to recognize these problems right in terms of this depression and anxiety whether its from the Parkinson's profile or with comorbid disease?

00:05:28: We have to think about it to ask for it regularly.

00:05:31: Right?

00:05:32: yeah absolutely yes.

00:05:34: um.

00:05:35: And also know all the patients recognize anxiety themselves because sometimes they say it comes as a wave, together with my motor symptoms or my trembling gets worse in busy situations.

00:05:50: So I think there needs to be more awareness of that.

00:05:53: these symptoms are actually also related to Parkinson's disease.

00:05:56: Great indeed.

00:05:57: so um i was wondering Are there any particular forms of this depression or anxiety?

00:06:03: As a clinical picture if you think about Patients with Parkinson's disease, is there a specific type that differs from the general population?

00:06:11: The anxiety and depression we see in general populations.

00:06:15: Yeah!

00:06:16: We see these classical types of general population for anxiety like panic attacks or social anxiety or generalized anxiety also happened to people who have Parkinson's diseases but many are classified as not otherwise specified which means that their symptoms don't perfectly map onto the usual DSM categories.

00:06:41: So there might also be something very unique to anxiety in Parkinson's disease?

00:06:47: I would like to keep these two conditions together, because it is not easy to separate right Cognition and anxiety, let's think about it together.

00:06:57: Marit can you please describe the cognitive problems seen in Parkinson's disease patients?

00:07:03: Is there a specific clinical picture that we see?

00:07:07: for example just to give a clue is there any differences in the cognitive profile decline that we've seen Alzheimer's disease patient when look at the Parkinson's?

00:07:21: Yeah, in people with Alzheimer's disease there is a really strong focus on the memory aspect.

00:07:28: In Parkinson's disease we see that memory can also be affected but it's a bit broader than dead.

00:07:33: The executive functioning is often compromised.

00:07:37: so executive function refers to higher order cognitive processes like planning.

00:07:42: So if you are cooking and want make sure all your elements of your dish done at same time Can you still oversee that?

00:07:51: Things like attention and visual spatial functioning are also often affected, which is not something that would be specific for Alzheimer's.

00:08:01: So that's where you can really see differences between the two profiles.

00:08:06: Great indeed!

00:08:08: A little bit more deepening into your main research areas.

00:08:12: but starting with you and Merit what do?

00:08:19: and patients with Parkinson's disease.

00:08:22: I mean, are there any cognitive tests to detect the cognitive decline earlier in patients who have Parkinson's diseases for early diagnosis or recognition?

00:08:31: Yeah that is a really fantastic an important question.

00:08:34: We were just before talking about frequency of cognitive problems And we see.

00:08:39: roughly half people develop dementia over ten years but other half doesn't.

00:08:44: It still very difficult which patients will and which patient's will not develop such problems.

00:08:52: But for adequate treatment, indeed early intervention this is actually very important to signal as early as possible.

00:09:00: There are no specific cognitive tests that can do it at this point in time but we have looked into something called practice effects on cognitive test.

00:09:08: so see if you use those as early predictors And we were actually inspired by the Alzheimer's research field, where they already have looked into such effects and a possibility of predicting cognition in the future.

00:09:23: By this approach I wanted to see if it also applies to Parkinson's.

00:09:27: so maybe explain what practice affects are for people unfamiliar with them?

00:09:32: They relate to improvements on neuropsychological tests If you perform them repeatedly because often times You need to remember a certain list of words or copy a certain drawing.

00:09:46: If you do that multiple times, your performance gets better.

00:09:49: it's the learning effect and as neuropsychologists we often initially tend to treat this as noise right something that makes it difficult to measure what we exactly want to measure.

00:09:59: but Alzheimer's disease has shown us there is actually very valuable information in these.

00:10:06: This is really a very important thing to address.

00:10:10: I echo you in this term, Marit.

00:10:12: And I want to address the same question for you about depression and anxiety.

00:10:17: Are there any specific tools or screening tests... ...for the earlier detection of anxiety or depression in Parkinson's disease?

00:10:27: For early detection I'm not too sure actually.

00:10:31: In research how anxiety is often... diagnosed or measured using different questionnaires, and until recently they were quite generic.

00:10:42: There's been some attempts to make it a bit more specific.

00:10:45: so there is the Parkinson anxiety skill for example that looks at different subtypes of anxiety such as persistent anxiety or episodic and avoidance behavior That can delineate or be more specific To disease.

00:11:00: very recently also A new questionnaire has being developed that looked at triggers for anxiety.

00:11:07: So they are not specifically anchored earlier detection, but there are efforts to be more specific for Parkinson's leaks.

00:11:17: Thank you this is very important to detect as early as we can in terms of these behavioural changes or cognitive changes To cope with the non-motor profile as well.

00:11:30: The Parkinson's

00:11:32: disease Anxiety and depression are also symptoms that occur very early in the disease, so oftentimes way earlier than the motor symptoms appear.

00:11:43: So having a good detection system for those mood changes is very important for Parkinson's.

00:11:50: Thank you so much!

00:11:53: I was thinking about the effects of these conditions both the cognitive decline, as well as the mood changes in depression and anxiety.

00:12:03: The impact of these two conditions on the motor profile of patients with Parkinson's disease?

00:12:10: Do you think they have an impact overall?

00:12:13: thinking over all... You know do that They haven't been parked under motor profile?

00:12:18: what a functioning of the patient's Parkinson's Disease?

00:12:23: Yes absolutely.

00:12:24: Anxiety exacerbates motor symptoms like freezing of gait but also tremor.

00:12:30: Anxiety might also manifest as fear falling, so people might avoid certain situations.

00:12:37: and it has not just on motor symptoms or non-motor symptoms... ...but can have a really big impact on someone's independence and quality of life.

00:12:48: So they affected daily living activities right?

00:12:51: As the result What do you think about cognition?

00:12:58: In one of the other episodes, we've already touched upon the link between cognition and movement.

00:13:04: And how there's also cognitive processes involved in motor behavior.

00:13:08: So I'm not aware studies that have specifically looked into The relation between cognitive functioning in the sense of intact or not intact.

00:13:19: But we have definitely seen, my work and that others there are strong links between cognition movement also with Parkinson's.

00:13:28: these two processes can be differentially affected by medication And if you talk about for example problems with impulse control That could happen to people with Parkinson We see both a motor component and cognitive components at behavioural but also neural level

00:13:46: And as we talk, we emphasize and recognize that they are burdened for the motor profile.

00:13:55: The daily living activities... ...and even other non-motor symptoms of patients with Parkinson's disease.

00:14:02: Now

00:14:02: I was thinking about stigmatizing in disabling mode of this Parkinson's Disease Counting anxiety & depression in cognitive decline.

00:14:13: We have to treat the patients, right?

00:14:15: How do we give them some care and help in overcoming these problems.

00:14:21: What are the algorithmic approaches for treating this problem?

00:14:26: How shall we approach cognitive decline?

00:14:29: This is a question of humour obviously!

00:14:32: For mood disorders and psychiatric aspects, how can you cope with it?

00:14:39: I'll start about the cognitive part.

00:14:43: Neuropsychologists and psychologists can play a really big role in this.

00:14:47: Mostly there's strategies, like tips and tricks that we can share with people who are experiencing cognitive problems And sometimes these are seemingly really simple right?

00:14:58: If you're forgetting your groceries when what groceries do you want to buy?

00:15:02: When go the grocery store?

00:15:04: Maybe make a list while at home then bring it back to the grocery shop While shopping.

00:15:10: This may seem very simple Tricks, they can actually make a big change in people's lives.

00:15:16: So there is a lot of very practical tips that psychologists and can share with people with Parkinson's who experience cognitive problems.

00:15:26: And then are specific treatment guidelines for the cognitive problem?

00:15:31: In terms of pills, pharmacological agents...

00:15:35: That isn't something I am aware or have an answer to.

00:15:42: Now Julie, I really am wondering about your perspective in terms of approaching to patients.

00:15:49: To overcome these problems or are there any guidelines?

00:15:54: Yes well at first i think we need to create more awareness that anxiety is common and also it can look different than typical anxiety in the general population.

00:16:04: And some clinicians do ask like how's you're mood?

00:16:08: but might not more explore anxiety and depression in detail.

00:16:14: So how it differently manifests in different patients is really important, some patients for example have this wearing off anxiety which is very much related to their medication.

00:16:25: so then medication adjustments may help.

00:16:28: but some patients have these more generalized anxiety or persistent anxiety And there has been some studies that showed here.

00:16:35: the cognitive behavioral therapy might be helpful Whereas in situational anxiety or panic attacks, then exposure therapy might be useful.

00:16:46: Of course there's also pharmacological treatments such as SSRIs similar to the medication and general population.

00:16:55: but many patients do not want additional medication, pharmacological medications.

00:17:02: so we need look at different treatment approaches like exercise for acceptance behavioral therapy

00:17:09: Very nice indeed.

00:17:09: And cognitive behavioral therapy, what do you think about impact of this therapy on patients with Parkinson's disease?

00:17:19: I think it can be a really useful technique especially in the population that has already many medications but might not be helpful for everyone and not all patients want to have want to talk about their motor problems but also some patients are cognitively impaired and then it's much more difficult to apply such a therapy.

00:17:39: So we can summarize that the treatment options, the approaches should be tailored according these non-mod problems, which are very important.

00:17:54: Well thank you both so much!

00:17:55: It was so delightful to hear this very interesting topic and as I told before it's very close to my heart And i learned a lot from you.

00:18:07: Thank you for sharing your knowledge and expertise.

00:18:10: Last but not least do you have anything to share with our audience?

00:18:13: As a take home message

00:18:17: Together at Marit we're also looking into how anxiety differently manifests in patients.

00:18:23: We're looking not just at the anxiety questionnaires but also other measures like tolerance for uncertainty or sense of control, fear falling to get a better picture and then we combine this with behavioral tasks such as virtual reality which created different situations that can evoke different stressful events.

00:18:42: so you are trying Manifesting in patients with Parkinson's disease.

00:18:51: Yeah, I would the hope of also then opening the avenues new avenues for treatment right if we see that there is different types Of profiles than maybe those Profiles also require individualized treatment strategies.

00:19:03: That's really brilliant and this it's really so interesting.

00:19:06: We definitely should arrange another podcast just focusing on your research?

00:19:12: That's that's brilliant indeed If you definitely ask or not podcast regarding your research areas.

00:19:20: Thank you both so much, it was a pleasure to be with here today and thanks to our audience I hope they enjoyed as much as i enjoy

00:19:41: listening.

00:19:45: You can also listen to this and all of our previous episodes on the EAN campus, E&Cast weekly neurology is your unbiased and independent source for educational and research-related neurological content.

00:20:22: Although all the contents are provided by experts in their field, it should not be considered official medical advice!