Cognitive impairment and dementia in Parkinson's disease: Practical issues and management

Authors

  • Murat Emre MD,

    Corresponding author
    1. Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Behavioral Neurology and Movement Disorders Unit, Istanbul, Turkey
    • Correspondence to: Dr. Murat Emre, Istanbul Tip Fakultesi, Noroloji ABD, Capa, Sehremini, 34093 Istanbul, Turkey; muratemre@superonline.com

    Search for more papers by this author
  • Paul J. Ford PhD,

    1. NeuroEthics Program, Department of Bioethics, Cleveland Clinic, Cleveland, Ohio, USA
    Search for more papers by this author
  • Başar Bilgiç MD,

    1. Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Behavioral Neurology and Movement Disorders Unit, Istanbul, Turkey
    Search for more papers by this author
  • Ergun Y. Uç MD

    1. Department of Neurology, University of Iowa, Iowa City, Iowa, USA
    2. Neurology Service, Veterans Affairs Medical Center, Iowa City, Iowa, USA
    Search for more papers by this author

  • Relevant conflicts of interest/financial disclosures: Nothing to report.

  • Full financial disclosures and author roles may be found in the online version of this article.

ABSTRACT

Cognitive impairment and dementia pose particular challenges in the management of patients with Parkinson's disease (PD). Decision-making capacity can render patients vulnerable in a way that requires careful ethical considerations by clinicians with respect to medical decision making, research participation, and public safety. Clinicians should discuss how future decisions will be made as early in the disease course as possible. Because of cognitive, visual, and motor impairments, PD may be associated with unsafe driving, leading to early driving cessation in many. DBS of the STN and, to a lesser degree, globus pallidus interna (GPi) has consistently been associated with decreased verbal fluency, but significant global cognitive decline is usually not observed in patients who undergo rigorous selection. There are some observations suggesting lesser cognitive decline in GPi DBS than STN DBS, but further research is required. Management of PD dementia (PDD) patients involves both pharmacological and nonpharmacological measures. Patients with PDD should be offered treatment with a cholinesterase inhibitor taking into account expected benefits and potential risks. Treatment with neuroleptics may be necessary to treat psychosis; classical neuroleptics, as well as risperidone and olanzapine, should be avoided. Quetiapine might be considered first-line treatment because it does not need special monitoring, although the strongest evidence for efficacy exists for clozapine. Evidence from randomized, controlled studies in the PDD population is lacking; selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors may be used to treat depressive features. Clonazepam or melatonin may be useful in the treatment of rapid eye movement behavior disorder. © 2014 International Parkinson and Movement Disorder Society

Ancillary