The pharmacological management of the behavioral aspects of Parkinson’s disease: an update

ABSTRACT

Introduction

Behavioural symptoms are common manifestations of Parkinson’s disease and include depression, anxiety, impulse control disorders, hallucinations, psychosis, and cognitive dysfunction. They remain inadequately addressed in many patients despite their relevance for quality of life and disability. This applies also to impulse control disorders where the most common approach in recent literature is to refrain from using dopamine agonists without consideration about their potential benefit on motor complications.

Areas covered

We conducted a narrative review searching for articles on behavioral symptoms in Parkinson disease and selected those which included involved neurotransmitters such as dopamine, noradrenaline, serotonin, acetylcholine. We specifically focused our search on open-label and randomized double-blind studies and biomarkers which could best characterize these clinical manifestations.

Expert opinion

Management of Parkinson disease behavioural manifestations lacks clear guidelines and standardized protocols beside general suggestions of dose adjustments in dopamine replacement therapy and use of antidepressants or antipsychotic drugs with little consideration of patients’ age, sex, comorbidities, and motor status. We suggest a pragmatic approach which includes education of affected patients and caring people, dealing with complex cases by experienced multidisciplinary teams, use of cognitive behavioural therapy, and psychological counselling to complement drug treatment.

KEYWORDS:

• Parkinson's Disease
• Depression
• Neuropsychiatric symptoms
• Neuropsychiatric Symptoms
• Anxiety

Article highlights

• Behavioral symptoms in Parkinson’s disease have a profound impact on quality of life and patients well-being but are inadequately addressed especially in women and people of non-Caucasian ethnicity

• Many behavioral symptoms are poorly responsive to dopaminergic therapy and are due to degeneration in cholinergic, noradrenergic, and serotoninergic neurotransmitter systems

• Adjustments in dopaminergic therapy are needed in presence of impulsive and compulsive behaviors or psychosis but acute withdrawal of medications is almost invariably associated with motor worsening and increased disability

• Medications targeting non-dopaminergic systems (serotonin, noradrenaline) may improve affective symptoms

• A thorough neuropsychological assessment in patients with clinically significant behavioral symptoms should always be considered to detect features supportive of cognitive impairment

• Education of people with Parkinson and caring people as well as involvement of an experienced multidisciplinary team dealing with complex cases should be warranted

Declaration of interest

A Antonini has received compensation for consultancy and speaker-related activities from UCB, Britannia, AbbVie, Zambon, Bial, Ever Pharma, Ferrer, Theravance Biopharma, Bayer, TreeFrog Therapeutics, Oligy, Medscape. He receives research support from Horizon2020 Grant 825785, Horizon2020 Grant 101016902, Ministry of Education University and Research (MIUR) Grant ARS01_01081, Cariparo Foundation.

The authors have no other 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 apart from those disclosed.

Reviewer disclosures

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

Additional information

Funding

This paper was not funded.