David Okai

Predictors of response to a cognitive behavioral intervention for impulse control behaviors in Parkinson's disease

Limited trial evidence suggests that cognitive‐behavioral therapy (CBT) may be effective in managing impulse control behavior (ICBs) in Parkinsons disease.

Cognitive function and advanced kidney disease: longitudinal trends and impact on decision-making

Background: Cognitive impairment commonly affects renal patients. But little is known about the influence of dialysis modality on cognitive trends or the influence of cognitive impairment on decision-making in renal patients. This study evaluated cognitive trends amongst chronic kidney disease (CKD), haemodialysis (HD) and peritoneal dialysis (PD) patients. The relationship between cognitive impairment and decision-making capacity (DMC) was also assessed. Methods: Patients were recruited from three outpatient clinics. Cognitive function was assessed 4-monthly for up to 2 years, using the Montreal Cognitive Assessment (MoCA) tool. Cognitive trends were assessed using mixed model analysis. DMC was assessed using the Macarthur Competency Assessment tool (MacCAT-T). MacCAT-T scores were compared between patients with cognitive impairment (MoCA <26) and those without. Results: In total, 102 (41 HD, 25 PD and 36 CKD) patients were recruited into the prospective study. After multivariate analysis, the total MoCA scores declined faster in dialysis compared with CKD patients [coefficient = −0.03, 95% confidence interval (95% CI) = −0.056 to − 0.004; P = 0.025]. The MoCA executive scores declined faster in the HD compared with PD patients (coefficient = −0.12, 95% CI = −0.233 to − 0.007; P = 0.037). DMC was assessed in 10 patients. Those with cognitive impairment had lower MacCAT-T compared with those without [median (interquartile range) 19 (17.9–19.6) versus 17.4 (16.3–18.4); P = 0.049]. Conclusions: Cognition declines faster in dialysis patients compared with CKD patients and in HD patients compared with PD patients. Cognitive impairment affects DMC in patients with advanced kidney disease.

Personality and addictive behaviours in early Parkinson's disease and REM sleep behaviour disorder.

Introduction Changes in personality have been described in Parkinsons disease (PD), with suggestion that those with established disease tend to be risk averse with a disinclination for addictive behaviour. However, little is known about the earliest and prodromal stages. Personality and its relationship with addictive behaviours can help answer important questions about the mechanisms underlying PD and addiction. Methods 941 population-ascertained PD subjects within 3.5 years of diagnosis, 128 patients with rapid eye movement sleep behaviour disorder (RBD) and 292 control subjects were fully characterised for motor symptoms, non-motor symptoms and across the following 5 personality domains: 1) neuroticism 2) extraversion 3) conscientiousness 4) agreeableness 5) openness using the Big Five Inventory. Results Patients with early PD were more neurotic (p < 0.001), less extraverted (p < 0.001) and less open than controls (p < 0.001). RBD subjects showed the same pattern of being more neurotic (p < 0.001), less extraverted (p = 0.03) and less open (p < 0.001). PD patients had smoked less (p = 0.02) and drunk less alcohol (p = 0.03) than controls, but caffeine beverage consumption was similar. Being more extraverted (p < 0.001), more open (p < 0.001), and less neurotic (p < 0.001) predicted higher alcohol use, while being more extravert (p = 0.007) and less agreeable (p < 0.001) was associated with smoking more. Conclusions A similar pattern of personality changes is seen in PD and RBD compared to a control population. Personality characteristics were associated with addictive behaviours, suggestive of a common link, but the lower rates of addictive behaviours before and after the onset of motor symptoms in PD persisted after accounting for personality.

Parkinson's Impulse-Control Scale for the Severity Rating of Impulse-Control Behaviors in Parkinson's Disease: A Semistructured Clinical Assessment Tool

Impulse‐control behaviors (ICBs) are increasingly recognized in Parkinsons disease (PD) as drug‐related effects of dopaminergic mediation that occur in 15% to 35% of patients with PD. The authors describe the design and evaluation of a new, clinician‐rated severity scale for the assessment of syndromal and subsyndromal forms of impulse‐control disorders (ICDs), simple (punding) and complex (hobbyism) repetitive behaviors, and compulsive overuse of medication (dopamine dysregulation syndrome).

Cognitive–behavioural therapy for non-motor symptoms of Parkinson's disease: a clinical review

Neuropsychiatric symptoms are common in Parkinsons disease (PD) and have a disproportionate impact on quality of life and carer burden. Pharmacological treatment is the main approach in dealing with these symptoms, but it is limited by variable efficacy and risk of drug interactions. Non-pharmacological approaches using the cognitive–behavioural therapy (CBT) model are viable alternatives and in this review paper we summarise the evidence of CBT for three of the most common psychiatric manifestations of PD: depression and anxiety, impulse-control disorders and insomnia. Most studies modified the usual CBT format to include modules accounting for problems specific to PD: activity scheduling around motoric function, motor symptoms as triggers of anxiety, fear of falling and preparation for disease progression as well as accommodation of materials for suspected executive dysfunction. We found a growing evidence base that CBT (modified to account for PD-specific problems) is effective in the treatment of PD psychiatric symptoms. Where controlled study design was used, moderate effect sizes are reported for the efficacy of CBT for depression, including with distance administration of CBT. The effects were sustained during follow-up which was between 1 and 6 months. In addition, there are some initial data on the effects of CBT on impulse-control disorders and insomnia. The studies were limited by their small and potentially unrepresentative samples and the quality of sample reporting (eg, concomitant antidepressant and dopaminergic therapy use). Additional well-designed and adequately powered studies are required to determine the utility of CBT in PD.

PO083 Severity of impulsive compulsive behaviours in early parkinson’s disease

Objectives Impulse control behaviours (ICBs) and impulse control disorders (ICDs) are a recognised side-effect of dopaminergic medication in Parkinson’s disease (PD). Some patients report mild ICB, while others exhibit severe symptoms requiring intervention. Previous studies have reported the prevalence of ICD diagnosis but the severity of ICBs in early Parkinson’s is not well known. In this cross-sectional study, we report the severity of ICBs in early PD. Methods We embedded a detailed cross-sectional study within the Oxford Discovery cohort. Participants (PD and healthy controls) identified as at risk of ICD using a screening questionnaire (QUIP-anytime-PD-short) underwent a semi-structured interview using the Parkinson’s impulse-control scale (PICs) to grade severity and intensity. ICDs were diagnosed using DSM 5. Results Out of 1380 participants enrolled into the Discovery cohort, 267 (19.4%, 95% CI 17.3, 21.4) were at risk of ICD following screening. 124 were interviewed. This included 92 patients with Parkinson’s, of which 38 (41.3%, 95% CI 5=31.1, 52.1%) were affected with ICB and 10 had a diagnosis of ICD (10.9%, 95% CI 6.0, 18.9%). Conclusion ICBs are common in early Parkinson’s and future studies should consider syndromal and subsyndromal symptoms. Future work will examine risk factors for ICBs in this cohort.

CREATIVITY & IMPULSIVITY: PAINTING A PICTURE OF DOPAMINE THERAPY IN PARKINSON'S

Dopamine agonists in Parkinsons disease (PD) have been reported to enhance creativity, and even change artistic style and productivity. The same treatment can cause a variety of impulse control disorders (ICDs). There is mixed evidence from case reports about their association, some of which have linked these behaviours together. The role of dopamine (while established in ICDs) in creativity remains speculative, but evidence is drawn from a number of models including PD, schizophrenia and bipolar disorder. We add to the literature by presenting a professional artist with PD who developed a complulsive shopping disorder on dopamine agonist therapy. During this period she also demonstrated a significant increase in creativity and production of artwork. Cessation of dopamine agonist therapy resulted in resolution of impulsive behaviour to a subsyndromal level but also a reduction in creativity and productivity. We explore the relationship between dopamine, impulsivity and creativity and the link with prepotent habits. We highlight the need to both beneficial and pathological consequences of these behaviors and therefore a need to grade the severity of impulsivity according to its impact on patient welfare. We also consider whether drugs such as dopamine agonists could be used as for cognitive enhancement, a ‘creativity pill’.