The neuropsychiatry of Parkinson's disease: advances and challenges

In people with Parkinson's disease, neuropsychiatric signs and symptoms are common throughout the disease course. These symptoms can be disabling and as clinically relevant as motor symptoms, and their presentation can be similar to, or distinct from, their counterparts in the general population. Correlates and risk factors for developing neuropsychiatric signs and symptoms include demographic, clinical, and psychosocial characteristics. The underlying neurobiology of these presentations is complex and not well understood, with the strongest evidence for neuropathological changes associated with Parkinson's disease, mechanisms linked to dopaminergic therapy, and effects not specific to Parkinson's disease. Assessment instruments and formal diagnostic criteria exist, but there is little routine screening of these signs and symptoms in clinical practice. Mounting evidence supports a range of pharmacological and non-pharmacological interventions, but relatively few efficacious treatment options exist. Optimising the management of neuropsychiatric presentations in people with Parkinson's disease will require additional research, raised awareness, specialised training, and development of innovative models of care

A waitlist-controlled trial of group cognitive behavioural therapy for depression and anxiety in Parkinson’s disease

Background: The aim of this study was to evaluate the efficacy of a group Cognitive Behavioural Therapy (CBT) treatment for depression and anxiety in Parkinson’s disease (PD). Methods: A waitlist-controlled trial design was used. Eighteen adults with PD and a comorbid DSM-IV-TR diagnosis of depression and/or anxiety were randomised to either Intervention (8-week group CBT treatment) or Waitlist (8-week clinical monitoring preceding treatment). The Depression, Anxiety, Stress Scale-21 (DASS-21) was the primary outcome. Assessments were completed at Time 1 (pretreatment), Time 2 (posttreatment/post-waitlist) and 1-month and 6-month follow-ups. Results: At Time 2, participants who received CBT reported greater reductions in depression (Mchange = -2.45) than Waitlist participants (Mchange = .29) and this effect was large, d = 1.12, p = .011. Large secondary effects on anxiety were also observed for CBT participants, d = .89, p = .025. All treatment gains were maintained and continued to improve during the follow-up period. At 6-month follow-up, significant and large effects were observed for both depression (d = 2.07) and anxiety (d = 2.26). Conclusions: Group CBT appears to be an efficacious treatment approach for depression and anxiety in PD however further controlled trials with larger numbers of participants are required

A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy

Background: Optimal treatment remains uncertain for patients with cognitive impairment that persists or returns after standard IV antibiotic therapy for Lyme disease. Methods: Patients had well-documented Lyme disease, with at least 3 weeks of prior IV antibiotics, current positive IgG Western blot, and objective memory impairment. Healthy individuals served as controls for practice effects. Patients were randomly assigned to 10 weeks of double-masked treatment with IV ceftriaxone or IV placebo and then no antibiotic therapy. The primary outcome was neurocognitive performance at week 12—specifically, memory. Durability of benefit was evaluated at week 24. Group differences were estimated according to longitudinal mixed-effects models. Results: After screening 3368 patients and 305 volunteers, 37 patients and 20 healthy individuals enrolled. Enrolled patients had mild to moderate cognitive impairment and marked levels of fatigue, pain, and impaired physical functioning. Across six cognitive domains, a significant treatment-by-time interaction favored the antibiotic-treated group at week 12. The improvement was generalized (not specific to domain) and moderate in magnitude, but it was not sustained to week 24. On secondary outcome, patients with more severe fatigue, pain, and impaired physical functioning who received antibiotics were improved at week 12, and this was sustained to week 24 for pain and physical functioning. Adverse events from either the study medication or the PICC line were noted among 6 of 23 (26.1%) patients given IV ceftriaxone and among 1 of 14 (7.1%) patients given IV placebo; these resolved without permanent injury. Conclusion: IV ceftriaxone therapy results in short-term cognitive improvement for patients with posttreatment Lyme encephalopathy, but relapse in cognition occurs after the antibiotic is discontinued. Treatment strategies that result in sustained cognitive improvement are needed

Health for sale: the medicinal plant markets in Trujillo and Chiclayo, Northern Peru

Traditional methods of healing have been beneficial in many countries with or without access to conventional allopathic medicine. In the United States, these traditional practices are increasingly being sought after for illnesses that cannot be easily treated by allopathic medicine. More and more people are becoming interested in the knowledge maintained by traditional healers and in the diversity of medicinal plants that flourish in areas like Northern Peru. While scientific studies of medicinal plants are underway, concern has arisen over the preservation of both the large diversity of medicinal plants and the traditional knowledge of healing methods that accompanies them. To promote further conservation work, this study attempted to document the sources of the most popular and rarest medicinal plants sold in the markets of Trujillo (Mayorista and Hermelinda) and Chiclayo (Modelo and Moshoqueque), as well as to create an inventory of the plants sold in these markets, which will serve as a basis for comparison with future inventories. Individual markets and market stalls were subjected to cluster analysis based on the diversity of the medicinal plants they carry. The results show that markets were grouped based on the presence of: (1) common exotic medicinal plants; (2) plants used by laypeople for self-medication related to common ailments ("everyday remedies"); (3) specialized medicinal plants used by curanderos or traditional healers; and (4) highly "specialized" plants used for magical purposes. The plant trade in the study areas seems to correspond well with the specific health care demands from clientele in those areas. The specific market patterns of plant diversity observed in the present study represent a foundation for comparative market research in Peru and elsewhere

Shadows of the colonial past – diverging plant use in Northern Peru and Southern Ecuador

This paper examines the traditional use of medicinal plants in Northern Peru and Southern Ecuador, with special focus on the Departments of Piura, Lambayeque, La Libertad, Cajamarca, and San Martin, and in Loja province, with special focus on the development since the early colonial period. Northern Peru represents the locus of the old Central Andean "Health Axis." The roots of traditional healing practices in this region go as far back as the Cupisnique culture early in the first millennium BC

Long-term dementia prevalence in Parkinson Disease: Glass half-full?

Introduction: Dementia occurs in up to 80% of Parkinson’s disease (PD) patients long-term, but studies reporting such high rates were published years ago and had relatively small sample sizes and other limitations. Objective: To determine long-term, cumulative dementia prevalence rates in PD using data from two large, ongoing, prospective observational studies. Design: Analyses of data from the Parkinson’s Progression Markers Initiative (PPMI) and a longstanding PD research clinical core at the University of Pennsylvania (Penn). Setting: PPMI is a multi-site international study, and Penn is a single site study at a tertiary movement disorders center. Participants: PPMI enrolls de novo, untreated PD participants at baseline, and Penn enrolls a convenience cohort from a large clinical center. Methods: For PPMI a cognitive battery and MDS-UPDRS Part I are administered annually, and the site investigator assigns a cognitive diagnosis annually. At Penn a comprehensive cognitive battery is administered either annually or biennially, and a cognitive diagnosis is made by expert consensus. Main Outcomes: Kaplan-Meier (KM) survival curves were fit for time from PD diagnosis to stable dementia diagnosis for each cohort, using assigned cognitive diagnosis of dementia as the primary endpoint (for both PPMI and Penn), and MoCA score <21 and MDS-UPDRS Part I cognition score ≥3 as secondary endpoints (for PPMI). In addition, cumulative dementia prevalence by PD disease duration was tabulated for each study and endpoint. Results: For the PPMI cohort, 417 PD participants were seen at baseline; estimated cumulative probability of dementia at year 10 disease duration were: 7% (site investigator diagnosis), 9% (MoCA) or 7.4% (MDS-UPDRS Part I cognition). For the Penn cohort, 389 PD participants were followed over time, with 184 participants (47% of cohort) eventually diagnosed with dementia. The KM curve for the Penn cohort had median time to dementia diagnosis =15 years (95% CI: 13-15) disease duration; the estimated cumulative probability of dementia was 27% at year 10, 50% at year 15, and 74% at year 20. Conclusions and Relevance: Results from two large, prospective studies suggest that dementia in Parkinson disease occurs less frequently, or later in the disease course, than often-cited previous research studies have reported