Dementia with Parkinson’s Disease: Understanding Cognitive Symptoms

Dementia with Parkinson’s disease is a syndrome that involves a decline in memory and other cognitive domains, leading to social and occupational dysfunction. Along with motor problems, non-motor symptoms such as cognitive, behavioral, and psychological issues can also arise. There is debate over whether Lewy body dementia and dementia due to Parkinson’s are different conditions. Drugs used to treat Parkinson’s can interfere with cognitive function, and people with this type of dementia tend to have marked problems with executive function. Cholinesterase inhibitors can improve cognitive performance, but they are not well tolerated and can cause side effects. Understanding the cognitive symptoms of dementia with Parkinson’s disease is crucial for effective clinical management.

The term used to refer to the individual who creates a will is the testator, which is why the ability to create a will is known as testamentary capacity (derived from the Latin word testator).

Testamentary Capacity

Testamentary capacity is a crucial aspect of common law that pertains to a person’s legal and mental ability to create a will. To meet the requirements for testamentary capacity, there are four key factors that a testator must be aware of at the time of making the will. These include knowing the extent and value of their property, identifying the natural beneficiaries, understanding the disposition they are making, and having a plan for how the property will be distributed.

Suicide in the Elderly

Self-harm in older individuals should be approached with caution as approximately 20% of completed suicides occur in those over the age of 65. Studies have consistently found that more than half of those who commit suicide after the age of 65 are suffering from a depressive disorder at the time of death. Personality traits also appear to play a role, with an association between suicide in older individuals and anankastic (obsessional) and anxious personality traits observed in one study. Dissocial of borderline disorders are more commonly found in younger suicide victims. It is important to be aware of these factors when assessing and treating suicidal behavior in the elderly.

Delirium Management

Pharmacological management of delirium includes the use of haloperidol as a prophylactic measure. NICE guidelines recommend short-term use of haloperidol in cases where delirium is associated with distress of risk to self/others. Quetiapine is also considered a first-choice option in many units. Lorazepam can be used as an alternative if haloperidol is contraindicated, but it is more likely to cause respiratory depression, over-sedation, and paradoxical excitement.

Non-pharmacological management of delirium includes appropriate lighting and clear signage, talking to the person to reorient them, cognitively stimulating activities, regular visits from family and friends, and promoting good sleep patterns. Additional options such as donepezil, rivastigmine, melatonin, trazodone, and sodium valproate are not recommended. It is important to carefully consider the individual’s needs and medical history when choosing a management plan for delirium.

While some believe that Alzheimer’s disease falls under the category of Parkinson’s plus syndrome, this viewpoint is not widely accepted.

Parkinsonian Plus Syndromes: Additional Features to Parkinsonism

The Parkinsonian plus syndromes are a group of neurological disorders that share the core features of Parkinsonism, such as tremors, rigidity, and bradykinesia. However, they also have additional features that distinguish them from Parkinson’s disease. These syndromes include multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia, Pick’s disease, and Parkinson’s disease with amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease).

Multiple system atrophy is a rare disorder that affects the autonomic nervous system, causing symptoms such as orthostatic hypotension, urinary incontinence, and constipation. Progressive supranuclear palsy is characterized by the inability to move the eyes vertically, leading to difficulty with balance and coordination. Corticobasal degeneration affects both the motor and cognitive functions, causing symptoms such as apraxia, dystonia, and aphasia. Lewy body dementia is a type of dementia that shares symptoms with both Parkinson’s disease and Alzheimer’s disease. Pick’s disease is a rare form of dementia that affects the frontal and temporal lobes of the brain, leading to personality changes and language difficulties. Finally, Parkinson’s disease with amyotrophic lateral sclerosis is a rare combination of Parkinson’s disease and Lou Gehrig’s disease, which affects both the motor neurons and the muscles.

In summary, the Parkinsonian plus syndromes are a group of disorders that share the core features of Parkinsonism but also have additional features that distinguish them from Parkinson’s disease. These syndromes can be challenging to diagnose and manage, and early recognition is crucial for appropriate treatment and care.

The individual is displaying a visual representation of hydrocephalus, which may result from a past intracranial hemorrhage that obstructs the flow of cerebrospinal fluid (CSF) due to debris. Periventricular lucency (PL) in hydrocephalus is a result of either acute edema of chronic retention of CSF in the periventricular white matter, caused by an increase in water content. This phenomenon can be partially reversed and may serve as an indication for a shunt.

FTD is more likely to impact social behavior, resulting in decreased sociability. Meanwhile, SD primarily affects conceptual knowledge.

Management of Non-Cognitive Symptoms in Dementia

Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

Frontotemporal Lobar Degeneration

Frontotemporal lobar degeneration (FTLD) is a group of neurodegenerative disorders that involve the atrophy of the frontal and temporal lobes. The disease is characterized by progressive dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. FTLD is the third most common form of dementia across all age groups and a leading type of early-onset dementia.

The disease has common features such as onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems. There are three recognized subtypes of FTLD: behavioral-variant (bvFTD), language variant – primary progressive aphasia (PPA), and the language variant is further subdivided into semantic variant PPA (aka semantic dementia) and non-fluent agrammatic variant PPA (nfvPPA).

As the disease progresses, the symptoms of the three clinical variants can converge, as an initially focal degeneration becomes more diffuse and spreads to affect large regions in the frontal and temporal lobes. The key differences between the subtypes are summarized in the table provided. The bvFTD subtype is characterized by poor personal and social decorum, disinhibition, poor judgment and problem-solving, apathy, compulsive/perseverative behavior, hyperorality of dietary changes, and loss of empathy. The nfvPPA subtype is characterized by slow/slurred speech, decreased word output and phrase length, word-finding difficulties, apraxia of speech, and spared single-word comprehension. The svPPA subtype is characterized by intact speech fluency, word-finding difficulties (anomia), impaired single-word comprehension, repetitive speech, and reduced word comprehension.

In conclusion, FTLD is a progressive, heterogeneous, neurodegenerative disorder that affects the frontal and temporal lobes. The disease is characterized by dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. There are three recognized subtypes of FTLD, and as the disease progresses, the symptoms of the three clinical variants can converge.

Delirium (also known as acute confusional state) is a condition characterized by a sudden decline in consciousness and cognition, with a particular impairment in attention. It often involves perceptual disturbances, abnormal psychomotor activity, and sleep-wake cycle impairment. Delirium typically develops over a few days and has a fluctuating course. The causes of delirium are varied, ranging from metabolic disturbances to medications. It is important to differentiate delirium from dementia, as delirium has a brief onset, early disorientation, clouding of consciousness, fluctuating course, and early psychomotor changes. Delirium can be classified into three subtypes: hypoactive, hyperactive, and mixed. Patients with hyperactive delirium demonstrate restlessness, agitation, and hyper vigilance, while those with hypoactive delirium present with lethargy and sedation. Mixed delirium demonstrates both hyperactive and hypoactive features. The hypoactive form is most common in elderly patients and is often misdiagnosed as depression of dementia.

Delirium Management

Pharmacological management of delirium includes the use of haloperidol as a prophylactic measure. NICE guidelines recommend short-term use of haloperidol in cases where delirium is associated with distress of risk to self/others. Quetiapine is also considered a first-choice option in many units. Lorazepam can be used as an alternative if haloperidol is contraindicated, but it is more likely to cause respiratory depression, over-sedation, and paradoxical excitement.

Non-pharmacological management of delirium includes appropriate lighting and clear signage, talking to the person to reorient them, cognitively stimulating activities, regular visits from family and friends, and promoting good sleep patterns. Additional options such as donepezil, rivastigmine, melatonin, trazodone, and sodium valproate are not recommended. It is important to carefully consider the individual’s needs and medical history when choosing a management plan for delirium.

Frontotemporal dementia, also referred to as Pick’s disease, is a type of dementia that worsens over time and is caused by tauopathy. Unfortunately, it is irreversible.

Reversible causes of dementia should be screened for in all cases of dementia. The mnemonic DEMENTIA can help remember the most common causes, including drugs and alcohol (especially those with anticholinergic activity), emotions such as depression, metabolic disorders like hypo and hyperthyroidism, decline in eyes and ears, normal pressure hydrocephalus, tumors of space-occupying lesions, infections like syphilis and AIDS, and anemia due to vitamin B12 of folate deficiency. Other notable metabolic causes include Wilson’s disease, Hashimoto’s encephalitis, hypo and hyperparathyroidism, Cushing’s disease, and Addison’s disease. Additional infectious causes include Whipple’s disease, sarcoidosis, and meningitis. The most common causes are alcohol and medication-related dementia, depression, brain lesions such as normal pressure hydrocephalus, tumors and chronic subdural hematomas, metabolic disorders such as hypothyroidism, hypoparathyroidism, vitamin B12 deficiency, and central nervous system infections such as neurosyphilis and HIV.

According to a study, the combination of clopidogrel and an SSRI was found to be more effective in reducing the risk of cardiovascular events compared to dual antiplatelet therapy alone. However, the risk of bleeding was higher among patients taking clopidogrel and an SSRI, although the sample size was not sufficient to confirm this finding. The results were consistent regardless of the affinity of the SSRI. (Labos, 2011)

SSRI for Post-MI Depression

Post-myocardial infarction (MI), approximately 20% of people develop depression, which can worsen prognosis if left untreated. Selective serotonin reuptake inhibitors (SSRIs) are the preferred antidepressant group for post-MI depression. However, they can increase the risk of bleeding, especially in those using anticoagulation. Mirtazapine is an alternative option, but it is also associated with bleeding. The SADHART study found sertraline to be a safe treatment for depression post-MI. It is important to consider the bleeding risk when choosing an antidepressant for post-MI depression.

References:
– Davies, P. (2004). Treatment of anxiety and depressive disorders in patients with cardiovascular disease. BMJ, 328, 939-943.
– Glassman, A. H. (2002). Sertraline treatment of major depression in patients with acute MI of unstable angina. JAMA, 288, 701-709.
– Goodman, M. (2008). Incident and recurrent major depressive disorder and coronary artery disease severity in acute coronary syndrome patients. Journal of Psychiatric Research, 42, 670-675.
– Na, K. S. (2018). Can we recommend mirtazapine and bupropion for patients at risk for bleeding? A systematic review and meta-analysis. Journal of Affective Disorders, 225, 221-226.

Benzodiazepines with a longer duration of action, such as diazepam, pose more difficulties than those with a shorter duration of action.

Risk Factors for Delirium

Delirium is a common condition that affects many elderly individuals. There are several risk factors that can increase the likelihood of developing delirium. These risk factors include age, cognitive impairment, severe medical illness, previous history of delirium of neurological disease, psychoactive drug use, polypharmacy, and anticholinergic drug use.

Medications are the most common reversible cause of delirium and dementia in the elderly. Certain classes of drugs, such as opioids, benzodiazepines, and anticholinergics, are strongly associated with the development of drug-induced dementia. Long-acting benzodiazepines are more troublesome than shorter-acting ones. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients. Pethidine, a member of the opioid class, appears to have a higher risk of delirium compared with other opioids due to its accumulation in individuals with impaired renal function and conversion to a metabolite with anticholinergic properties.

Overall, it is important to be aware of these risk factors and to carefully monitor medication use in elderly individuals to prevent the development of delirium.

The use of mianserin for post-stroke depression has been found to be ineffective.

Depression is a common occurrence after a stroke, affecting 30-40% of patients. The location of the stroke lesion can play a crucial role in the development of major depression. Treatment for post-stroke depression must take into account the cause of the stroke, medical comorbidities, and potential interactions with other medications. The Maudsley guidelines recommend SSRIs as the first-line treatment, with paroxetine being the preferred choice. Nortriptyline is also an option, as it does not increase the risk of bleeding. If the patient is on anticoagulants, citalopram and escitalopram may be preferred. Antidepressant prophylaxis has been shown to be effective in preventing post-stroke depression, with nortriptyline, fluoxetine, escitalopram, duloxetine, sertraline, and mirtazapine being effective options. Mianserin, however, appears to be ineffective.

It’s important to note that DaT-SCAN and SPECT are not the same thing. DaT-SCAN specifically refers to the radioactive isotope called Ioflupane, which is utilized in the creation of a SPECT image.

SPECT Imaging for Alzheimer’s Diagnosis

SPECT imaging has been found to be a useful tool in differentiating between patients with Alzheimer’s disease and healthy older individuals. Studies have shown that temporal and parietal hypoperfusion can be indicative of Alzheimer’s disease. Additionally, SPECT imaging has been effective in distinguishing between Alzheimer’s disease and Lewy body dementia. A SPECT scan of a patient with Alzheimer’s disease versus one with Lewy body dementia showed lower perfusion in medial temporal areas for Alzheimer’s disease and lower perfusion in occipital cortex for Lewy body dementia. These findings suggest that SPECT imaging can be a valuable diagnostic tool for Alzheimer’s disease and related dementias.

Dementia is a condition that can be diagnosed and supported with the use of neuroimaging techniques. In Alzheimer’s disease, MRI and CT scans are used to assess volume changes in specific areas of the brain, such as the mesial temporal lobe and temporoparietal cortex. SPECT and PET scans can also show functional changes, such as hypoperfusion and glucose hypometabolism. Vascular dementia can be detected with CT and MRI scans that show atrophy, infarcts, and white matter lesions, while SPECT scans reveal a patchy multifocal pattern of hypoperfusion. Lewy body dementia tends to show nonspecific and subtle changes on structural imaging, but SPECT and PET scans can reveal posterior deficits and reduced D2 receptor density. Frontotemporal dementia is characterized by frontal lobe atrophy, which can be seen on CT and MRI scans, while SPECT scans show anterior perfusion deficits. NICE recommends the use of MRI for early diagnosis and detection of subcortical vascular changes, SPECT for differentiating between Alzheimer’s disease, vascular dementia, and frontotemporal dementia, and DaTscan for establishing a diagnosis of dementia with Lewy bodies.

Frontotemporal Lobar Degeneration

Frontotemporal lobar degeneration (FTLD) is a group of neurodegenerative disorders that involve the atrophy of the frontal and temporal lobes. The disease is characterized by progressive dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. FTLD is the third most common form of dementia across all age groups and a leading type of early-onset dementia.

The disease has common features such as onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems. There are three recognized subtypes of FTLD: behavioral-variant (bvFTD), language variant – primary progressive aphasia (PPA), and the language variant is further subdivided into semantic variant PPA (aka semantic dementia) and non-fluent agrammatic variant PPA (nfvPPA).

As the disease progresses, the symptoms of the three clinical variants can converge, as an initially focal degeneration becomes more diffuse and spreads to affect large regions in the frontal and temporal lobes. The key differences between the subtypes are summarized in the table provided. The bvFTD subtype is characterized by poor personal and social decorum, disinhibition, poor judgment and problem-solving, apathy, compulsive/perseverative behavior, hyperorality of dietary changes, and loss of empathy. The nfvPPA subtype is characterized by slow/slurred speech, decreased word output and phrase length, word-finding difficulties, apraxia of speech, and spared single-word comprehension. The svPPA subtype is characterized by intact speech fluency, word-finding difficulties (anomia), impaired single-word comprehension, repetitive speech, and reduced word comprehension.

In conclusion, FTLD is a progressive, heterogeneous, neurodegenerative disorder that affects the frontal and temporal lobes. The disease is characterized by dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. There are three recognized subtypes of FTLD, and as the disease progresses, the symptoms of the three clinical variants can converge.

The patient has been diagnosed with post-stroke pathological crying, a condition characterized by episodes of crying triggered by minor stimuli without any accompanying changes in mood. This condition is associated with disrupted serotonergic neurotransmission. Treatment options include the use of antidepressants, with SSRIs being the preferred choice over venlafaxine and tricyclics due to their better tolerability and greater efficacy.

Patients with Huntington’s disease have a suicide rate that is four to six times higher than the general population.

Psychiatric and Behavioural Symptoms of Huntington’s Disease

Huntington’s disease is a condition that affects individuals with a triad of symptoms, including motor, cognitive, and psychiatric symptoms. While the symptoms typically begin in the third and fourth decades of life, individuals with a high number of CAG repeats may experience symptoms before the age of 20, known as juvenile Huntington’s disease.

The psychiatric symptoms of Huntington’s disease can include depression, apathy, dementia, psychosis, anxiety, mania, sexual dysfunction, and even suicide. These symptoms can significantly impact an individual’s quality of life and require appropriate treatment. Advances in psychiatric treatment have been made to address these symptoms and improve the overall well-being of individuals with Huntington’s disease.