Understand the mental and psychological symptoms of Parkinson's disease, intervene early, and benefit long-term!

Author: Xie Manqing, attending physician at Peking Union Medical College Hospital

Jiang Yinan, deputy chief physician, Peking Union Medical College Hospital

Reviewer: Wang Han, Chief Physician, Peking Union Medical College Hospital

Parkinson's disease (PD) is a common degenerative disease of the nervous system in middle-aged and elderly people. Every PD patient may experience motor and non-motor symptoms successively or simultaneously. Motor symptoms are still the core of disease diagnosis; non-motor symptoms involve many types and can appear at all stages of PD. Some non-motor symptoms such as depression, loss of smell, constipation, etc. can appear in the prodromal stage of the disease, earlier than motor symptoms, seriously affecting the patient's quality of life. Therefore, we need to pay attention to the patient's non-motor symptoms while managing the motor symptoms of PD patients.

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Neuropsychiatric symptoms are one of the most common non-motor symptoms, including not only affective disorders such as anxiety, depression, and apathy, but also mental disorders such as hallucinations, delusions, and impulsive compulsive behaviors. The neuropsychiatric symptoms of Parkinson's disease patients are not only associated with adverse clinical outcomes of patients, but also seriously increase the burden on caregivers. Although it is said that a person's mood can only be experienced when there are both sadness and joy, and a life can only be complete when there are both bitterness and sweetness, some pathological conditions deserve the attention of all Parkinson's patients and their families. The following describes the common affective and mental disorders of PD, hoping to help everyone identify abnormal mental and psychological states early, intervene early, and benefit in the long run.

1. Affective disorders such as anxiety and depression

(1) Manifestations: Anxiety and depression are the most common neuropsychiatric symptoms in the early stages of PD. 30% to 35% of patients have significant clinical symptoms. The prevalence gradually increases with age, and about 60% of patients in the advanced stage will experience depression. Anxiety most often manifests as generalized anxiety disorder, but it can also manifest as panic attacks, social phobia, and agoraphobia, and is often accompanied by depression.

(2) Drug treatment: The main treatment strategies for anxiety and depression in PD include psychological counseling and drug intervention. When depression affects the quality of life and daily life, dopamine receptor agonists (DAs), serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs) can be added. At present, there is sufficient evidence for pramipexole and venlafaxine in the DAs class (MDS Guidelines: Evidence is valid and clinically useful). Dear Parkinson's friends, please note that flupentixol-melitracen tablets may aggravate the motor symptoms of PD and are not recommended for long-term use. In addition, the monoamine oxidase B (MAO-B) inhibitor drug selegiline is strictly prohibited from being used in combination with SSRIs or SNRIs antidepressants. Although rasagiline can be used in combination with some antidepressants, there are strict requirements for the type and dosage of drugs, otherwise it is easy to induce serotonin syndrome, so please keep this in mind.

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(3) Self-management: It is estimated that the misdiagnosis rate of anxiety and depression in PD patients is about 50%. The occurrence of misdiagnosis may be related to the low awareness of related symptoms and high stigma among patients or caregivers. The PHQ-9 depression self-rating scale and the GAD-7 anxiety self-rating scale have been widely used in clinical practice. They have good reliability and validity, are convenient and quick, and can be completed in 3 to 5 minutes. It is recommended that all PD patients and caregivers conduct regular self-evaluations, and seek medical treatment and timely intervention as soon as possible if problems are found.

2. Hallucinations and delusions in mental disorders

(1) Manifestations: Psychiatric symptoms such as hallucinations and delusions are common in patients with mid- to late-stage PD, with an incidence of 13% to 60%. Visual hallucinations are the most common symptom, which is associated with the use of anti-PD drugs and disease progression.

(2) Drug treatment: The principle of treating PD psychiatric symptoms is to exclude drug factors, especially anticholinergic drugs, amantadine and DAs. If the psychiatric symptoms are not alleviated after drug adjustment, it may be caused by the disease itself, and symptomatic treatment is required if necessary. Clozapine or quetiapine is recommended for medication, but clozapine has a 1% to 2% probability of causing agranulocytosis, so the white blood cell count needs to be monitored. In addition, the clinical evidence for the selective 5-hydroxytryptamine 2A inverse agonist pimavanserin (MDS evidence-based: evidence-based, clinically useful) is also sufficient. Because it does not aggravate motor symptoms, it has been approved for the treatment of PD-related psychiatric symptoms abroad. Other antipsychotics such as olanzapine are not recommended because they can aggravate motor symptoms. For irritable states, lorazepam and diazepam are very effective.

(3) Self-management: When patients experience the above symptoms, caregivers should try to comfort them, avoid arguments and conflicts with them, and record the specific type, frequency and intensity of their symptoms in detail for the doctor's reference when they see a doctor.

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Dear Parkinson's friends, the above antidepressants and antipsychotics are all prescription drugs. The specific drug selection and dosage adjustment should be combined with individual conditions. It is recommended that you exercise moderately and cultivate hobbies. It is recommended to receive professional neuropsychological evaluation at the neurology or psychiatry clinic every 6 to 12 months. If problems are found, they should be treated and intervened as soon as possible under the scientific guidance of specialists.

References

[1]WEINTRAUB D, AARSLAND D, CHAUDHURI KR, et al. The neuropsychiatry of Parkinson's disease: advances and challenges[J]. The Lancet Neurology, 2022, 21(1): 89-102.

[2]Seppi K, Ray Chaudhuri K, Coelho M, et al. Update on treatments for nonmotor symptoms of Parkinson's disease-an evidence-based medicine review[J]. Mov Disord, 2019, 34(2): 180-198.