Psychiatric Issues in Parkinson's Disease

Parkinson's disease is a progressive neurodegenerative disorder characterized by motor, somatic, and neuropsychiatric features. It leads to significant disability for the patient and burden for the caregivers. Providing care for patients with Parkinson's disease can be very challenging. A biopsychosocial approach best meets these difficulties, and editors Menza and Marsh provide a comprehensive practical guide to these ends. The book is divided into 4 sections. The first section offers an “introductory” overview to help the reader understand the clinical aspects of Parkinson's disease and its management. The information in this section is probably too basic for a neurologist but adequate for a nonneurologist clinician. The discussion on the etiology and pathogenesis of Parkinson's disease is brief but sufficient from a clinical perspective. Differentiating Parkinson's disease from other conditions with parkinsonian features is crucial for effective clinical management, patient and family education, and predicting clinical progression and outcome. A concise section in the first chapter tabulates the main features of other parkinsonian conditions to help in the differential diagnosis. Medical management of early Parkinson's disease is the focus of chapter 2. Antiparkinsonian medications are reviewed in this chapter with a brief section on the nonmedical treatments. The chapter guides prescribing practices and assessing patient's response to treatment. Motor complications related to disease progression and dopaminergic treatment are common in advanced Parkinson's disease. A concise discussion of these complications appears in chapter 3. An overview of the nonmotor somatic symptoms is offered in chapter 4. Section 2 focuses on cognitive dysfunction in Parkinson's disease. Cognitive impairment not meeting the threshold of dementia is common in patients with Parkinson's disease and can adversely affect their social, recreational, and occupational functioning. Because of its “subthreshold” nature, such cognitive impairment may not draw enough clinical attention. We were pleased to see a complete chapter on this topic in the book. Dementia associated with Parkinson's disease is the topic of the next chapter. After a concise and clinically relevant review of the definition of dementia and epidemiology of dementia in Parkinson's disease, the authors discuss assessment and management in more detail. Once Parkinson's disease dementia has developed, it is extremely difficult to differentiate it from dementia with Lewy bodies. The last chapter in this section reviews the differences between these 2 types of dementia and provides guidelines for clinical management of related issues that are found in both of these conditions. Section 3 addresses topics that one would expect based on the title of the book. Depression as a symptom is very common in patients with Parkinson's disease, but the true prevalence of the syndrome of major depression is hard to establish because of this symptom-syndrome overlap. The first chapter of this section addresses these issues and provides guidelines for clinical assessment and management of depression. Anxiety disorders in Parkinson's disease are discussed in the subsequent chapter. The information in these chapters is probably too basic for a psychiatrist but quite sufficient for non-psychiatrist clinicians. Sleep disturbances are common in patients with Parkinson's disease and may contribute to other symptoms such as daytime tiredness, depression, and psychosis. A chapter in this section describes the range of possible sleep disturbances in Parkinson's disease and their management. For readers of the Journal, perhaps the greatest challenge in managing Parkinson's disease is treating both the disease itself and psychosis either deriving from or running parallel with this condition. Medications used to treat the neurobiologic deficits in this condition may initiate or exacerbate psychosis. Many medications used to treat psychosis will likely worsen Parkinson's disease. Particularly valuable in this context are the chapters entitled “Psychosis” and “Behavioral Disturbances.” Clinical management of psychosis includes a series of general steps, nonpharmacologic treatments, and medication management. Particularly important in the management of psychosis is early detection, when small adjustments in medications for Parkinson's disease and behavioral management or small doses of newer antipsychotic drugs will likely reverse or effectively control psychotic features. Emerging reports are finding a place for acetylcholinesterase inhibitors in patients with a parkinsonian syndrome and disruptive behavior. Behavioral disturbances are common in Parkinson's disease and pose problems for both the patient and the caretaker. An early task for the caretakers is to determine whether the stimulus leading to disruptive behavior is internally derived, such as in psychosis, or externally derived through interactions with the environment or staff and other patients. The authors guide us through the conundrum. The fourth and final section truly makes this book comprehensive. Here, various psychosocial issues related to Parkinson's disease are discussed under the chapter headings of “Disability,” “Coping,” “Personality Issues,” “Rehabilitation,” “Long-Term Care and Nursing Home Issues,” “Advocacy and the Parkinson's Disease Community: A True Triumph of the Spirit,” and “Caregiving.” This section adds topics that round out caring for patients with Parkinson's disease. In summary, Psychiatric Issues in Parkinson's Disease: A Practical Guide enhances our general understanding of this condition and provides insight into both the behavioral management and drug treatment of Parkinson's disease. Readers from a wide background will find this a valuable addition to their library. Mehrul Hasnain, M.D. Western Regional Integrated Health Authority, Sir Thomas Roddick Hospital, Stephenville, Newfoundland, Canada W. Victor R. Vieweg, M.D. Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia