Parkinsonian Disorders with Dementia

Transcription

1 Parkinsonian Disorders with Dementia George Tadros Consultant in Old Age Liaison Psychiatry, RAID, Heartlands Hospital Professor of Dementia and Liaison Psychiatry, Aston Medical School Aston University Professor of Dementia Care in Acute Hospitals, University of Chester

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5 Parkinsonian Disorder Dementia I) Core features 1- Diagnosis of Parkinson's disease 2 -A dementia syndrome developing within the context of established Parkinson's disease II) Associated clinical features 1- Cognitive features: Attention Executive functions Visuo-spatial functions Memory Language 2- Behavioural features: Apathy Changes in personality mood including depressive features and anxiety Hallucinations: mostly visual, Delusions: usually paranoid,

6 Dementia III) Features which do not exclude PDD, but make the diagnosis uncertain Co-existence of any other abnormality which may by itself cause cognitive impairment, e.g. vascular disease Time interval between the development of motor and cognitive symptoms not known IV) Features suggesting other conditions or diseases as cause of mental impairment, which, when present make it impossible to reliably diagnose PDD Acute confusion Major Depression Features compatible with Vascular dementia

7 PDD and DLB DLB and PDD share many pathological and clinical features, probably represent two clinical entities on a spectrum of Lewy body disease.1 There is no rational clinical or pathological basis to dictate a definite time interval between development of motor symptoms versus onset of dementia in differentiating PDD from DLB. It is recommend that a diagnosis of PDD should be made when dementia develops within the context of established PD, whereas a diagnosis of DLB is appropriate when the diagnosis of dementia precedes or coincides within 1 year of the development of motor symptoms2 McKeith IG, Burn D. Spectrum of Parkinson's disease, Parkinson's dementia, and Lewy body dementia. In: DeKoskyST, editor. Neurologic clinics. Philadelphia: WB Sauders; p Levy G, Tang MX, Louis ED, et al. The association of incident dementia with mortality in PD. Neurology 2002; 59:

8 The size of the problem (Incidence ) In community based studies, incidence is around 10% of a PD population will develop dementia per year In one of the very few incidence studies of dementia in general population including subjects with PD (diagnosis based on self-report) the odds ratio for dementia in PD was 3.5. Hobson P, Gallacher J, Meara J. Cross-sectional survey of Parkinson's disease and parkinsonism in a rural area of the United Kingdom. Mov Disord 2005; 20: Yip AG, Brayne C, Matthews FE. MRC Cognitive Function and Ageing Study. Risk factors for incident dementia in England and Wales: the Medical Research Council Cognitive Function and Ageing Study. A population-based nested case-control study. Age Ageing 2006; 35:

9 Conclusions From Epidemiological Studies The point prevalence of dementia in PD is close to 30% the incidence rate is increased 4 to 6 times as compared to controls. The cumulative prevalence has been reported to range between 48 and 78% after 8 and 15 years of follow-up, respectively. The main risk variables are: higher age, more severe parkinsonism, in particular rigidity, postural instability and gait disturbance mild cognitive impairment at baseline.

10 THE COGNITIVE AND NEUROPSYCHIATRIC PROFILE OF PATIENTS WITH PDD Cognitive Features Mean decline in MMSE over 2 years was 4.5, comparable to that seen in patients with DLB, with a mean decline of 3.9 points. Attention. Memory. both verbal and visual memory are impaired in PDD, probably less than that seen in AD, Procedural memory could remain intact for awhile longer. recognition may be less affected than recall Executive Function Language less impairment in language functions as compared to AD. Burn DJ, Rowan EN, Allan LM, Molloy S, O'Brien JT, McKeith IG. Motor subtype and cognitive decline in Parkinson's disease, Parkinson's disease with dementia, and dementia with Lewy bodies. J Neurol Neurosurg Psychiatry 2006; 77:

11 Hallucinations in PDD Mainly Visual hallucinations Visual hallucinations occur twice as frequently as auditory ones Hallucinations have been reported as common in population-based studies of PD (25%) in clinic samples (40%) When found in non-demented patients, hallucinations are a major predictor of subsequent dementia and nursing home placement The high prevalence of hallucinations in PDD and DLB contrasts with relatively low rates reported in mild-moderate AD (4 8% on NPI Related issues: What is the role of Anti-parkinsonian drugs? Charles Bonnet Syndrome How patients react to the hallucinations?

12 Delusions in PDD Delusions are less common than hallucinations in PD-D MjÖnes (1949) Paralysis Agitans Psychosis (no support) The commonest psychotic disorders are depressive in nature, rarely manic. Celesia (1972), 12% had psychosis but the majority was attributed to drugs. Non-drug-related psychosis was transient and associated with the development of dementia While occurring in 17% of patients with PD overall, their prevalence in PDD is 25 to 30%, somewhat lower than rates seen in AD, particularly in DLB where rates of 57 to 78% have been reported. Mis-identification syndromes appear to be particularly prevalent in DLB occurring in up to 40% of patients, compared to 10% in AD The prevalence of Capgras delusions is 10% in DLB, when compared with no cases in patients with PD-D.

13 Depression in PDD The association between PD and depression is well established. 1/3 of PD had depression on psychiatric wards. Could be reactive in nature. Correlation between the severity of PD symptoms and depression. Emotionalism and tearfulness in 50% of PD. In a community-based sample, the rate of major depression in PDD was 13%, compared to 9% for non-demented patients, and 19% for patients with DLB. Both severity of depressed mood and prevalence of major depression may be higher in PDD than in AD Treatment: Antidepressants ECT

14 BPSD in PDD Irritability less than 10% in non-demented patients with PD, Only a slightly higher rate in PDD (14%). Aggression Apathy is often regarded as a hallmark feature of frontotemporal dementia and progressive supranuclear palsy, where frequencies of 80% or more have been reported. Similar rates are also reported in DLB, with increasing severity with worsening dementia. However, apathy is also a significant problem in AD, with frequencies of 50%

15 Hardest for carers BPSD Behavioural Aggression (47%) Shouting Wandering Shadowing Pacing Unsafe behaviour Constant interference Psychiatric symptoms Hallucinations (28%) Delusions (56%) Misidentification Depression Anxiety Disinhibition Obsession

16 Psychiatric complications of Antiparkinsonian medications Confusion Agitation Paranoid delusions Hallucinations Suicidal ideations Depression Not dose related. In about 20% of patients in one survey.

17 Drug induced PD The psychiatrist s gift Charisma Fear Negligence How would you stop the long-term antipsychotic. Relapse Risk to others Suicide

18 Why do we need psychiatrists in the management of PDD?! Do we need psychiatrists in the management of PDD? To manage difficult cases To manage risk To Deal with that ANTIPSYCHOTIC that caused drug induced PD. Mental Heath Act section Psychiatric admission It is all based on SEVERITY and RISK management. If yes; what is the role?

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