What is Parkinson’s

Disease?
Parkinson’s Disease (PD) is a neurological condition that affects
nearly one million people in the United States.
PD is caused by the death of neurons in the substantia nigra
(SN), part of the basal ganglia, a brain system that is important
for movement (and other aspects of thinking and behaving).
Neuron death in SN reduces the level of dopamine in the brain.
Dopamine is a neurotransmitter that is important for initiating
movement and is involved in many other aspects of brain
function. Dopamine loss is the cause of symptoms in PD.
 PD and Movement- TRAP
The main impact of PD is on movement. A mnemonic used to
remember movement-related symptoms of PD is T.R.A.P.
Tremor- most common symptom, unilateral at onset, then
bilateral. Common at rest, may lessen during some actions.
Rigidity- stiffness and inflexibility caused by higher muscle tone.
Akinesia- especially impacts fine motor skills, influenced by
context and emotion (in some situations skills are preserved).
Postural instability- causing impaired balance and frequent falls.
 Non-Motor Symptoms of
PD
Loss of dopamine cells that project
from the SN to the rest of the brain
have obvious consequences for
movement but they also impact non-
motor function, especially thinking
(mind), emotion (mood) and memory.
There are additional impacts on sleep
and in some severe cases, delusions
and hallucinations have been reported.
 Non-Motor Symptoms in PD
The neurology of this non-motor
impact involves neural circuits to
various parts of the subcortex
(including the hippocampus) and
cortex (the frontal lobes) that are
projected from substantia nigra.
To the right you can see the brain’s
dopamine circuits. Dopamine plays
a role not just in movement, but
via the link to hippocampus and
frontal cortex, impacts our sense
of reward, pleasure, compulsion,
and perseveration. Disrupting this
circuit can have a major impact on
all other systems of the brain.
 Non-Motor Symptoms:
Mind
Cognitive deficits are common in PD, particularly deficits
of attention and executive function. Severity correlates
with other measures of disease severity, especially
tremor.
Attention is affected in Parkinson’s Disease. The effect on
attention mostly relates to when people with PD are
required to sustain attention based on an internal cue,
i.e., a memory (for instance picking someone out of a
crowd).
Cognitive research shows people with PD can benefit from
 Non-Motor Symptoms:
Mind
Executive function is defined in various ways but can be
compared to sequencing a complex action. You have to
consider priorities (where to reach) inhibit impulses (do
not grip too soon) and then execute a planned sequence
(reach, turn the hand, grip the object, pull it towards you).
Dopamine is involved in refining this process just as it is
with movement. Lack of dopamine, or excess dopamine
(side effect of PD medication) disrupts executive function.
Patients may have trouble prioritizing actions, inhibiting
impulses, and executing a plan of actions based on goals.
 Non-Motor Symptoms:
Mind
Cognitive problems in PD can
contribute to problems with
activities of daily living. The
change can be very gradual
(varying with disease severity)
causing a slow loss of function
that can be very frustrating for
the patient and their family. It
can also be hard to figure out,
what’s the impact of motor
issues, and what’s cognition.
 Non-Motor Symptoms:
Mood
Depressive symptoms are present in 36–50% of patients
with PD. Symptoms trend towards anhedonia, apathy, and
impaired decision-making instead of guilt and self-blame.
The trend towards those more “vegetative” symptoms of
depression, may relate to loss of dopamine to frontal lobes,
specifically the orbitofrontal cortex, involved in motivation.
Anxiety and panic attacks are also frequently encountered
in PD patients. They relate to underlying brain pathology
but also to concerns about disease symptoms and
progression.
 Non-Motor Symptoms:
Mood
Daily life can be devastated
by depressive symptoms of
PD. Patients may not want to
leave the house or even leave
their bed. Since symptoms
are vegetative, i.e. not always
accompanied by “depressive
thoughts”, it can be difficult
to realize that this is the
impact of PD on mood as
opposed to movement.
 Non-Motor Symptoms:
Memory
Attention, executive function, depression, and anxiety all
have a considerable impact on the systems of memory.
PD patients have more difficulty learning new information
than retrieving old information (though general cognitive
slowing can make it seem long-term memory is impaired).
PD patients can also have difficulty with prospective memory
or “keeping in mind” what must be done in the near-future.
Dopamine loss plays a major role in this, as dopamine is used
to make some thoughts and goals more salient than others.
 Non-Motor Symptoms:
Memory
Memory loss in PD does not
usually affect the person’s self-
identity (as in some forms of
neurological illness) but can
have a frustrating impact on
learning new things, keeping in
mind what must be done in the
future, and in severe cases,
with short-term memory (as in
conversations and learning).
 Sleep Disorders in PD
Common sleep problems in patients with PD include insomnia,
excessive daytime sleepiness (EDS), and sleep phase disorder.
The most common sleep disturbance in PD is insomnia. Sleep-
onset insomnia may be associated with disease factors and
medications. Sleep-maintenance insomnia is usually a result of
akinesia and other motor problems like restless legs syndrome.
Excessive daytime sleepiness is common, affecting almost 50%
of patients with PD. Manifestations of EDS are variable; some
patients drift off to sleep, while others have rapid-onset sleep
without preceding drowsiness. EDS varies with disease severity.
 Hallucinations in PD
Hallucinations and psychosis affect
some (but not all) people with PD.
They may be caused by medication as
well as intrinsic disease factors.
Common hallucinations include: a
sensation of a person in the room,
the sideways passage of an animal,
visual and auditory hallucinations.
Some people with PD may have
blatant psychotic episodes requiring
adjustment to their medications.
 Helping Mind, Mood,
Memory
What treatments are out there to help Parkinson’s patients
affected by problems with their mind, mood, and memory?
Medication is one answer. Anti-parkinsonian medications can
help with these symptoms. They might occasionally contribute
to these symptoms, requiring that dosage levels be adjusted.
As a neuropsychological and clinical health psychologist, my
focus is on behavioral treatments. Some you may be familiar
with, like psychological counseling. Others, like exercise and
mindfulness, may be less familiar but just as helpful in healing.
 Psychological Counseling
Anti-depressant medications are the front-line treatment for
depression caused by Parkinson’s. However, patients should
consider psychological counseling as an adjunct treatment.
Psychological counseling is not always considered when
treating depression and anxiety related to a neurological
condition. Yet counseling can be very effective for PD-related
depression. A randomized control trial comparing cognitive-
behavioral therapy to non-intervention showed significant
improvements on measures of depression as well as improved
quality of life, coping, and anxiety (Dobkin et al. 2011).
 Psychological Counseling
A neuropsychologist is uniquely
equipped to offer psychological
counseling to people affected by
PD. They understand the impact
of the neurological condition on
mood and behavior and they’ll
be knowledgeable about how
anti-parkinsonian medications
can impact mood. A neurologist
or another PD specialist can
refer you to a
neuropsychologist.
 Cognitive Rehabilitation
Cognitive rehabilitation is a specialized form of therapy that
focuses on providing compensatory systems to make up for
cognitive deficits. PD patients have specific patterns of cognitive
deficit (impaired attention, executive function, and prospective
memory) and are good candidates for cognitive rehabilitation.
A study using fMRI imaging found that PD patients who
completed a cognitive rehabilitation program had improved
performance on a cognitive task, and task-related brain activity
similar to that of healthy controls, suggesting neuroplastic
changes that compensate for deficits (Nombela et al., 2011).
 Cognitive Rehabilitation
Cognitive rehabilitation is often
provided through specialized
outpatient rehab programs, that
work with patients with other
neurological conditions. A
qualified neuropsychologist can
provide cognitive rehabilitation
in their office. Some outpatient
programs can send a specialized
therapist to provide cognitive
therapy in a patient’s home.
 Mindfulness
Mindfulness is rooted in ancient meditative practices, but has
seen a resurgence in modern medical practice. These simple
practices involve paying more attention to how your body and
mind experience the present moment and learning to grasp pain
and distress as transient products of a situated mind.
The principles of mindfulness have been standardized into
medical practice and tested with patient populations. One study
found that mindfulness not only improved measures of mood,
memory and sleep function, but also helped to normalize brain
structure and function in patients with PD (Pickut et al. 2013).
 Mindfulness
Mindfulness programs can be
found in your community, as
offered by hospitals, libraries,
and non-profit fitness programs.
Some psychologists, myself
included, embrace mindfulness
practices in their own practices.
Once you start working with a
psychologist, consider asking
them if they can recommend
ways for you to incorporate
mindful practices in your life.
 Exercise
Parkinson’s patients may be concerned as to whether exercise is
safe, but there is surprising evidence for beneficial effects of
even low-intensity exercise for motor and non-motor symptoms
of PD. Exercise may reduce resting tremor and postural
instability, so the more you exercise, the safer and more
confident you will feel.
A meta-review of various exercise programs and their impact on
PD symptoms found wide-ranging beneficial effects, including
improvements in mobility, self-reported mood, sleep behavior,
memory, and daily functioning (Crizzle and Newhouse, 2006).
 Exercise
It’s important that you discuss
beginning an exercise program
with your Parkinson’s specialist.
Many hospital rehab programs
have a physical rehabilitation
specialist, called a physiatrist,
who can evaluate safety and
efficacy of exercise routines for
neurological conditions including
PD. Seeing a physiatrist is a good
place to start planning exercise.
 Treatment for Hallucinations
Hallucinations in PD are often caused by dopaminergic medications
prescribed to alleviate motor symptoms. These drugs may “hyper-
sensitize” brain pathways involved in assigning emotions to sensory
input. Genetics and PD-related brain changes may also play a role.
Initial treatment of psychosis is reduction of dopaminergic
medications. Psychiatric medications, like anti-psychotics and anti-
depressants, may also be prescribed. Care should be taken when
choosing an anti-psychotic to make sure it does not worsen PD
symptoms. Behavioral approaches such as teaching coping
strategies can also be beneficial (Zahodne & Fernandez, 2011).
 Treatment for Sleep Issues
Sleep issues in PD may have multiple causes, including but not limited
to possible side-effects from dopaminergic medications, anxiety and
panic caused by PD, or brain changes caused by PD. The treatment
approach varies accordingly, and should be planned in conjunction
with an instrument like the Parkinson’s Disease Sleep Scale (PDSS).
Treatments may include: supplementing dopaminergic medications
with drugs that alter how it is metabolized (like entacapone), or using
psychiatric medications if anxiety, panic or hallucination plays a role
in these issues. Lifestyle changes, and behavioral approaches like
those discussed in the preceding slides, can also help (Dhawan et al.
2006).
 Conclusion
You’ve learned how Parkinson’s
affects, not only the motor function
of the brain and body, but non-
motor functions such as mind
(cognition), mood (emotion) and
memory.
You have also learned there are
solutions to these problems!
I hope you enjoyed this presentation,
and found it to be helpful. Namaste!