Managing dementia and Parkinson’s disease

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Managing dementia and Parkinsons disease

• Graham Lennox
• Addenbrookes Hospital, Cambridge
• Regents College, September 2006

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Plan

• The concept of Lewy body disease
• Prodromes to dementia
• Dementia in Parkinsons disease

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Pathology
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The concept of Lewy body disease
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In the brainstem Parkinsons disease
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In the brainstem Parkinsons diseaseIn the
cortex dementia
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Prodromes to dementia
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Prodromes to dementia

• Parkinsons disease

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Prodromes to dementia

• Parkinsons disease
• Subtle cognitive impairment is the norm

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Prodromes to dementia

• Parkinsons disease
• Subtle cognitive impairment is the norm
• Cross-sectional prevalence of dementia is about
  30

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Prodromes to dementia

• Parkinsons disease
• Subtle cognitive impairment is the norm
• Cross-sectional prevalence of dementia is about
  30
• Cumulative incidence of dementia is about 80

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Prodromes to dementia

• Parkinsons disease
• Subtle cognitive impairment is the norm
• Cross-sectional prevalence of dementia is about
  30
• Cumulative incidence of dementia is about 80
• Age is the main risk factor

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Prodromes to dementia

• Parkinsons disease
• Sleep disturbance

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Prodromes to dementia

• Parkinsons disease
• Sleep disturbance
• REM sleep behaviour disorder
• Daytime somnolence

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REM sleep behaviour disorder

• Acting out dreams

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REM sleep behaviour disorder

• Acting out dreams
• Common, potentially hazardous

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REM sleep behaviour disorder

• Acting out dreams
• Common, potentially hazardous
• Clonazepam
• Long half-life, titrate up from 0.125mg

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Daytime somnolence

• Poor night-time sleep

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Daytime somnolence

• Poor night-time sleep
• RSBD
• Sleep apnoea
• Restless legs/periodic limb movements
• Depression
• Discomfort from immobility
• Incidental causes eg nocturia

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Daytime somnolence

• Poor night-time sleep
• RSBD
• Sleep apnoea
• Restless legs/periodic limb movements
• Depression
• Discomfort from immobility
• Incidental causes eg nocturia
• Medication

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Daytime somnolence

• Siesta
• Treat the cause if possible
• Perhaps amantadine or selegiline
• Possibly modafinil

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Prodromes to dementia

• Parkinsons disease
• Sleep disturbance
• Depression

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Depression

• Common, part of the disease
• Look for it
• Ask about low mood, anhedonia and apathy

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Depression

• Common, part of the disease
• Look for it
• Ask about low mood, anhedonia and apathy
• Easy to treat
• Trials in progress
• Citalopram, venlafaxine, chlomipramine

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Dementia

• The dark secret of Parkinsons disease

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The pattern of dementia

• Memory
• Language
• Visuospatial skills

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but

• More frontal than Alzheimers patients

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but

• More frontal than Alzheimers patients
• And more visuospatial impairment

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(No Transcript)
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Additional features

• Visual hallucinations
• Cognitive fluctuations

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Visual hallucinations
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Visual hallucinations

• Detailed but sometimes distorted

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Visual hallucinations

• Detailed but sometimes distorted
• People and animals
• (or grids and patterns)

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Visual hallucinations

• Detailed but sometimes distorted
• People and animals
• (or grids and patterns)
• Often some insight misperceptions

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Visual hallucinations

• Sometimes accompanying auditory or sensory
  hallucinations
• Often accompanying delusions

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Cognitive fluctuations

• Variable attention

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Cognitive fluctuations

• Variable attention
• Episodes of confusion
• Good and bad days
• Fluctuation over hours
• Daytime drowsiness
• Staring into space

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Epidemiology

• Dementia in PD
• Cross-sectional prevalence 20-40
• Cumulative incidence 80
• Prevalence in over 65 population 0.3
• Dementia with Lewy bodies
• Dementia autopsies 15-20
• Finnish over 75s with dementia 22
• Prevalence in entire over 65 population 0.7

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• More than 20 of the workload of old age
  psychiatry services

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Differential diagnosis

• PD plus coincidental dementia
• Small vessel ischaemia
• Alzheimers disease
• Rare secondary dementia

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Investigations

• Dementia screen blood tests
• Very low yield in typical cases

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Investigations

• Dementia screen blood tests
• Very low yield in typical cases
• CT brain scan
• Picks up vascular disease in cases with risk
  factors for this
• Rules out hydrocephalus and frontal meningioma in
  very frontal cases

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Treatment
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Treatment

• Explanation

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Treatment

• Explanation
• Timing this is sensitive and difficult

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Treatment

• Explanation
• Timing this is sensitive and difficult
• Dementia is the last taboo

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Treatment

• Explanation
• Timing this is sensitive and difficult
• Dementia is the last taboo
• It helps that the discussion is usually in the
  context of treatment

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Treatment

• Cholinesterase inhibitors
• Good for hallucinations
• Quite good for cognitive fluctuations
• Sometimes help baseline cognition

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Treatment

• Cholinesterase inhibitors
• Good for hallucinations
• Quite good for cognitive fluctuations
• Sometimes help baseline cognition
• NNT about 2
• Agitation and diarrhoea
• Rivastigmine/galantamine gt donepezil

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Other treatment options

• Withdraw non-essential aggravating PD drugs
• anticholinergics
• selegiline
• amantadine
• dopamine agonists
• Usually leave levodopa

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Other treatment options

• Withdraw aggravating PD drugs
• Improve eyesight/lighting

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Other treatment options

• Withdraw aggravating PD drugs
• Improve eyesight/lighting
• Very atypical neuroleptics
• Clozapine
• Possibly (high-dose) quetiapine
• Possibly aripiprazole etc

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Other treatment options

• Withdraw aggravating PD drugs
• Improve eyesight/lighting
• Very atypical neuroleptics
• Consider depression

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Other treatment options

• Withdraw aggravating PD drugs
• Improve eyesight/lighting
• Very atypical neuroleptics
• Consider depression
• Practical support

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Prognosis

• The combination of physical and mental disability
  is bad for
• Carer burden
• Care cost
• Survival

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Prevention

• Education and mental activity

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Prevention

• Education and mental activity
• Neuroprotection?

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Prevention

• Education and mental activity
• Neuroprotection?
• Dementia should be an endpoint in neuroprotection
  studies

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Summary

• Dementia with Lewy bodies and Parkinsons disease
  with dementia are different faces of the same
  disease

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Summary

• Dementia with Lewy bodies and Parkinsons disease
  with dementia are different faces of the same
  disease
• Dementia is very common in older people with
  Parkinsons disease

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Summary

• Think of Parkinsons disease as a dementia with a
  motor prodrome
• Think of better approaches to prevention and
  treatment existing therapies help, but managing
  dementia remains our biggest challenge in
  Parkinsons disease