Parkinson’s Disease
and the Geriatrician
Developed by the American Academy of Neurology’s
Geriatric Neurology Section
Moderator
Alexander P. Auchus, MD, AGSF, FAAN
Professor and McCarty Chair of Neurology
University of Mississippi Medical Center
No relevant financial relationships to disclose.
Faculty
Jorge L. Juncos, MD
Assoicate Professor of Neurology
Emory University School of Medicine
“Parkinson’s Disease:
Diagnosis and Medical Management”
Erwin B. Montgomery, Jr., MD
Professor of Neurology
University of Alabama at Birmingham
“How and When to Consider DBS in the Older Patient”
Learning Objectives
1.
2.
3.
4.
Recognize presenting phenotypes and diagnosis
Describe principles of medical management
Review risks, benefits, and selection process
for surgical therapy
Recognize cognitive, behavioral, and
autonomic aspects of PD
Faculty Presentations
Cognitive and Behavioral
Complications in PD
Alexander P. Auchus, MD, AGSF, FAAN
Professor and McCarty Chair of Neurology
University of Mississippi Medical Center
No relevant financial relationships to disclose.
Off-label therapies will be discussed.
Literature Sources
(AAN Practice Parameters)
Miyasaki JM, et al. Practice Parameter: Evaluation and
treatment of depression, psychosis, and dementia in
Parkinson disease (an evidence-based review). Neurology
2006;66:996-1002.
Zesiewicz TA, et al. Practice Parameter: Treatment of
nonmotor symptoms of Parkinson disease. Neurology
2010;74:924-931.
James Parkinson
Parkinson’s Disease

bradykinesia

rest tremor

cogwheel rigidity

impaired postural reflexes

non-motor features
Nonmotor Features of PD

cognitive

neuropsychiatric

autonomic dysfunction

sleep disorders

fatigue

sialorrhea
Cognition in Parkinson’s Disease

normal cognition ~ 30%

dysexecutive syndrome ~ 30%

dementia ~ 40%
Dementia
1.
The acquired and persistent loss of
cognitive abilities
2.
Deficits in at least 2 cognitive domains
(memory, language, spatial, executive)
3.
Severe enough to interfere with normal
daily functioning
Two helpful sub-syndromes:
cortical
subcortical
the “4 A’s”
inattention
true amnesia
forgetfulness
recall and recognition failure
recognition > recall
few motor signs
early gait trouble
personality changes
affective changes
cortical grey matter
deep white matter
Dementia in Parkinson’s Disease

overall prevalence = 41%

increases with advancing age

less often in ‘tremor-predominant’ PD

subcortical pattern on neuropsychology

associated cholinergic deficit

“PDD” vs. “DLB” (“one year rule”)
Dementia in PD:
Screening & Treatment
Screening

MMSE should be considered (Level B)

CAMCog should be considered (Level B)
Treatment

donepezil should be considered in PDD (Level B)

rivastigmine should be considered in PDD or
DLB (Level B)
Neuropsychiatry of
Parkinson’s Disease

depression ~ 40%

psychosis ~ 10%
– visual hallucinations +/or delusions
– clear sensorium (cf. delirium)
Depression in PD
Screening

BDI-I should be considered (Level B)

HAM-D should be considered (Level B)
Treatment

amitriptyline should be considered in
non-demented patients (Level C)
Psychosis in PD

clozapine should be considered (Level B)

quetiapine should be considered (Level C)

olanzapine should NOT be considered (Level B)
Q&A