Parkinson’s disease management and impulse control disorders: current state and future perspectives

ABSTRACT

Introduction: Impulse control disorders (ICDs) in Parkinson’s disease (PD) are a group of impulsive behaviors most often associated, but not limited to, dopamine replacement therapy (DRT), particularly the use of dopamine agonists (DA). ICDs can impair activities of daily living and have a strong negative impact on quality of life of patients and their families.

Areas covered: This review mainly focusses on the most common ICDs in the context of currently accepted management strategies for PD and emphasizes areas of controversy in need of further research. The authors further describe the concept of dopamine agonist withdrawal (DAWS) syndrome and its implication for the treatment of ICDs, the role of recently available antiparkinsonian drugs and routes of delivery, and non-pharmacological treatments.

Expert opinion: When ICDs develop, proper management mainly consists of reducing, discontinuing or switching dopaminergic agents, especially of DA. In these scenarios, patients should be closely followed up as their motor condition may deteriorate along with occurrence of DAWS. Assessment of the presence and intensity of ICDs should be carried throughout the course of the disease and not only when a particular treatment is started or when the dosage is increased, since their occurrence is not linearly related to DRT alone.

KEYWORDS:

• Parkinson’s disease
• impulse control disorders
• dopamine replacement therapy
• dopamine agonists
• dopamine withdrawal syndrome

Article highlights

• ICDs represent a heterogeneous group of behavioral disturbances, which have been increasingly recognized as common and disabling consequences of DRT, along with an individual susceptibility

• The most common ICDs observed in PD include pathological gambling, compulsive buying, compulsive sexual behavior, and binge or compulsive eating.

• When ICDs develop, proper management mainly consists of reducing the dosage of DRT, especially of DA. Sometimes, ICD entity is severe enough to require stopping DA completely.

• After discontinuation of DA the occurrence of DAWS should be investigated as patients can perceive its consequences as difficult as the ICD that had been managed

• If treatment with DAs is deemed necessary, it might be worth considering the use of transdermal DA and/or prolonged-release oral formulations, despite there being limited evidence in this regard.

• Preliminary studies suggest the possibility of a lower rate of development of ICDs in moderate to advanced PD with infusion therapies, but further large-scale studies are required

• Treatment of ICDs with the add-on of other oral drugs (e.g. SSRI, amantadine, zonisamide, etc.) is anecdotal and cannot as for now be suggested in clinical practice

• Alternative approaches, like psychological interventions such as CBT, should be considered in serious cases

• Available data do not support definite conclusions on the relationships between clinically significant ICDs and DBS.

• Pharmacological treatment should be tailored based on individual needs and requests, neuropsychiatric profile, social support and medical comorbidities

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.