This document provides an overview of neuropsychiatric manifestations of Parkinson's disease. It discusses common conditions like depression, anxiety, apathy, psychosis, impulse control disorders, sleep disorders, and dementia. Depression is one of the most prevalent neuropsychiatric symptoms, affecting up to 90% of patients. Anxiety, apathy, and impulse control disorders are also linked to dopaminergic medications. The document outlines risk factors, diagnostic tools, and treatment approaches for each condition. Overall, it comprehensively reviews the wide range of neuropsychiatric issues that can arise for patients with Parkinson's disease.

1. z NEUROPSYCHIATRIC
MANIFESTATIONS OF
PARKINSON’S DISEASE
By Dr.A.ABINAYAA
CHAIR PERSON : Dr.LAKSHMI

2. HISTORY OF PARKINSON’S DISEASE:
• Parkinson’s Disease was first described by James Parkinson in his
Essay on the Shaking Palsy in 1817.
• John Hunter –”Paralysis Agitans”
• In 1870s,Jean Martin Charcot coined the term “Parkinson’s Disease”.

3. • Parkinson’s Disease (PD) is the second most common
neurodegenerative disorder.
• Affects 1% of individuals over the age of 65.Men > Women
• Hypokinetic movement disorder.
• Due to loss of Dopaminergic neurons that projects from Substantia
Niagra in midbrain to Basal ganglia.
• By the time symptoms emerge 50-80% of dopaminergic neurons have
already degenerated.

4. FEATURES:
Tremors
Rigidity
Akinesia/Bradykinesia
Postural instability
TREMORS:
• Typically Unilateral,Rhythmic and Resting tremors(4-6Hz) causes
“Pill Rolling” movements between thumb & index finger.
• Increased by emotion,Fatigue,Stress & Anxiety, absent during
sleep.
• Tremors of protruded tongue is not uncommon,whereas tremors of
the head,lips and jaw are less frequent.

5. BRADYKINESIA
• Most disabling manifestation of PD
• Reduction in speed & amplitude of voluntary movement
• Hypomimia(Loss of facial expression)
• Micrographia
• Hypophonia(Reduced vocal volume)
• Slowing in walking,Dressing and Turning in bed.
RIGIDITY
• Involuntary increase in muscle tone present throughout the range of
movement.
• Cog-Wheel Rigidity.
POSTURAL INSTABILITY
• Stooped posture.
• Reduced arm swing
• Shuffling gait
• Freezing

6. *WATCH OUT FOR FALL

7. AUTONOMIC SYMPTOMS:
• Orthostatic hypotension
• Dysphagia
• Delayed gastric emptying,Constipation
• Urinary incontinence
• Dry mouth
• Disturbed thermoregulation with drenching sweats.
NEUROPSYCHIATRIC MANIFESTATIONS:
• Depression
• Anxiety
• Apathy
• Impulse control disorders
• Dementia
• Psychosis

8. DEPRESSION:
Epidemiology:
• Widely ranges from 2.7% to more than 90%
• Average prevalence of major depressive disorder(17%),minor
depression(22%) and dysthymia(13%)
• May occur earlier to motor symptoms
• Depression is considered as the risk factor for the development of
Dementia.
Risk factors:
• Female sex
• F/H/O Depression
• Early age onset
• Right sided symptoms

9. Clinical Features:
• Nonsomatic depressive features, such as excessive pessimism, negative ruminations,
tearfulness, hopelessness, and guilt, help distinguish depressed from nondepressed
PD patients.
• Guilt,Self-blame,Worthlessness are relatively low.
Major depression Parkinson’s
disease
Motor
phenomenon
Psychomotor retardation,
stooped posture,
restricted/depressed
affect, agitation
Bradykinesia, stooped
posture, masked face/
hypomimia, tremor
Other somatic
complaints
Physical complaints, muscle tension,
gastrointestinal
symptoms, sexual dysfunction
Vegetative
changes
Decreased energy, fatigue, sleep and appetite
changes
Cognitive
disturbances
Poor concentration, decreased memory,
impaired problem-solving

10. Diagnostic Tools:
• HAM-D
• Beck Depression Inventory (BDI)
• Hospital Anxiety And Depression Scale (HADS)
• Montgomery Asberg Depression Rating Scale (MADRS)
• Geriatric Depression Scale (GDS)
Treatment :
• TCA-Desipramine,Nortriptyline
• SSRI-Citalopram
• SNRI-Atomoxetine
• Dopamine agonist-Pramipexole
• Cognitive Behaviour Therapy

11. ANXIETY:
• Anxiety symptoms are common in PD than in general population,but
their frequency has been reported to vary widely.
• None of the anxiety rating scales are suitable for use in PD.
• Generalised anxiety disorder(most common),Social phobia,Panic
attacks.
• Anxiety in PD is associated with increased subjective motor symptoms,
more severe gait problems & dyskinesias, freezing.
• Risk factors: Female sex,Severity of PD symptoms,the presence of
motor fluctuations & previous H/O depression or anxiety.
• Anxiety symptoms in PD patients also have a negative impact on
health-related Quality of Life.
Rx:
• Escitalopram is used in PD with anxiety.
• Others: Paroxetine,Venlafaxine,Benzodiazepines

12. APATHY:
Definition:
Lack of goal directed behaviour,which can be divided into:
1) Diminished or blunted emotions,
2) Loss of or diminished initiative and
3) Loss of or diminished interest.
Epidemiology:
Prevalence estimates between 17 and 42%
Pathology:
• PD patients have had Lesion in Basal ganglia.
Rating scales:
• Apathy Inventory
• Apathy Evaluation Scale
• Unified Parkinson’s Disease Rating scale(UPDRS)

13. Prognosis:
• Apathy has negative effects .
• Worsen the prognosis with a faster rate of cognitive & functional
decline.
Management:
• Rivastigmine,cholinesterase inhibitor licensed for the treatment of
PDD.
• Donapezil,Galantamine,Modafenil does not appear to be beneficial.
• Pramipexole,dopamine agonist improve apathy.
• Sertraline,Venlafaxine benefit patients with Depression & Apathy.
• MAOI
• Deep Brain Stimulation

14. SLEEP IN PARKINSON’S DISEASE:
• The estimated frequency of abnormal sleepiness in PD ranges from 15
to 81%
• Excessive daytime sleepiness and Sleep Attacks( an event of falling
asleep suddenly & unexpectedly while engaged in some activity) are
sserious clinical issues.
• Excessive daytime sleepiness is now part of the proposed criteria for
Dementia associated with PD.
• Multiple Sleep Latency Test (MSLT)‘Gold Standard’ for the objective
assessment of daytime sleepiness.
• Drugs like bromocriptine,pergolide,pramipexole show an increased risk
of daytime sleepiness.

15. SLEEP DISORDERS:
It is important to consider an underlying sleep disorder as the potential
culprit or as exacerbating factor.
Insomnia
In a study of 231 patients with PD,delayed sleep initiation was reported in
23-30%,frequent awakenings in 23-43%
Restless legs syndrome
4 essential features:
i. The urge to move the legs,accompanied by uncomfortable sensations
in the legs
ii. Onset/Worsening of symptoms during rest
iii. Partial/Total relief by movement
iv. Worsening of symptoms in the evening or at night

16. Periodic Limb Movements of Sleep
• About 80% of patients with RLS also have PLMS,but those with PLMS
do not necessarily have RLS.
• PLMS are repetitive,stereotypic flexion movements of the legs thet occur
semi-rhythmically(upto 5s in duration) separated by an interval of usually
20-40s.
• They may cause arousals that fragment sleep & result in daytime
sleepiness.
Obstructive Sleep Apnea
• OSA has been observed in 20-30 % of PD patients.
• OSA may cause sleep fragmentation,oxygen desaturation and daytime
sleepiness.
REM Sleep Behaviour Disorder(RBD)
• Loss of normal muscle atonia during REM sleep associated with
coordinated limb movements.
• 46-58% in PD
• Clonazepam & Melatonin are used in treatment.

17. PSYCHOSIS AND PARKINSON’S DISEASE:
• The prevalence of psychotic symptoms may be as high as 60% in PD
population.
Etiology:
• Exposure to dopaminergic medications
• Advancing age
• Increasing impairment in executive functions
• Dementia
• Comorbid depression/ Anxiety
• Sleep disorders
• Increasing severity and duration of PD
• Polypharmacy
Rating scales:
1. BPRS
2. Parkinson’s Psychosis Rating Scale
3. Clinical Global Impression of Improvement(CGI)
4. Unified Parkinson’s Disease Rating Scale Thought Disorder

18. Features:
1. Hallucination:
• Visual with persistent images superimposed on natural environment.
• Patients demonstrate ‘false sense of presence’ hallucinations in which
the person has the strong sensation of being in the presence of
another person
2. Delusion:
• Paranoid in nature typically related to
jealousy,infedelity,abandonment,parasitosis.
Management:
• Atypical Antipsychotics
• Clozapine is “Gold Standard”
• Quetiapine- Better side effect profile.
• Risperidone and Olanzapine-Sedation & worsen parkinsonism-
Aripiprazole
• AA-Sedation,Postural hypotension.
• Ondansetron-12-24mg/daily showed moderate improvement in
hallucinations,paranoid delusion & confusion.

19. IMPULSE CONTROL DISORDER:
• Impulse control disorder(ICDs) associated with dopaminergic
medication in Parkinson’s disease.
• The recent multicenter cross-sectional DOMINION study surveying
3,090 PD patients demonstrated that ICDs are common,occurring in
13.6% of patients with:
Compulsive shopping(5.7%)
Problem gambling(5%)
Binge eating disorder(4.3%)
Compulsive sexual behavior(3.5%)
• Patients with single ICD were common,with multiple ICDs occurring in
>25%
• More recently,behaviours such as hoarding,kleptomania & impulsive
smoking have been reported.
• Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s
Disease Validated for screening of ICDs in PD.

20. Epidemiology:
30% of PD patients presents with Dementia.
Risk factor:
• Older age at the onset of PD
• Male
• Severe motor symptoms
• Pre-existing MCI
• F/H/O PD
Onset-Unclear
Coarse-Progressive
Survival duration - 5-8 years
Rx:Rivastigmine,Memantine
DEMENTIA IN PARKINSON’S DISEASE:

22. THANK YOU !!!