Diagnosis and Treatment of Cognitive and Neuropsychiatric Symptoms in Parkinson Disease and Dementia With Lewy Bodies

Daniel Weintraub, MD; David Irwin, MD Movement Disorders p. 1314-1332 October 2022, Vol.28, No.5 doi: 10.1212/CON.0000000000001151
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PURPOSE OF REVIEW This article summarizes the underlying biology and current diagnostic and treatment strategies for the cognitive and neuropsychiatric features of Parkinson disease (PD) and dementia with Lewy bodies (DLB).

RECENT FINDINGS Cognitive impairment and neuropsychiatric symptoms have been increasingly recognized in PD and DLB, leading to improved diagnosis and treatment strategies. While PD is most associated with and diagnosed by the presence of motor symptoms, nonmotor symptoms can often be the most debilitating for patients. Neuropsychiatric symptoms are highly prevalent nonmotor features and include cognitive impairment, depression, anxiety, psychosis, impulse control disorders, and apathy. Neuropsychiatric symptoms can be difficult to recognize and diagnose in patients with PD, in part because of comorbidity and symptom overlap with core PD features. Treatment strategies are a combination of pharmacologic and nonpharmacologic interventions used in the general population and those specific to PD. DLB is a clinical dementia syndrome, often with similar cognitive, behavioral, autonomic, and motor features as PD. Moreover, DLB has shared underlying pathophysiology with PD, as both are associated with postmortem findings of α-synuclein neuropathology at autopsy and have shared genetic risk and prodromal symptoms. DLB is clinically differentiated from PD by the presenting features of cognitive impairment in DLB, compared with the variable onset of cognitive impairment occurring 1 year or more after established motor onset in PD. Thus, diagnosis and treatment of cognitive impairment and neuropsychiatric symptoms in DLB are similar to that of PD and have important implications for maintaining patient independence and providing support for caregivers because motor, cognitive, and neuropsychiatric symptoms have an additive effect on patient functional disability.

SUMMARY A careful history and physical examination are often needed to accurately diagnose and treat the heterogeneous cognitive and behavioral symptoms of PD and DLB. Accurate diagnosis and treatment of neuropsychiatric symptoms and cognitive impairment in PD and DLB are important, as these are a considerable source of patient disability and caregiver burden.

Address correspondence to Dr Daniel Weintraub 3615 Chestnut St, #330, Philadelphia, PA 19104, [email protected].

RELATIONSHIP DISCLOSURE: Dr Weintraub has received personal compensation in the range of $10,000 to $49,999 for serving as a consultant for Clintrex and on a scientific advisory or data safety monitoring board for Acadia Pharmaceuticals Inc. Dr Weintraub has received personal compensation in the range of $500 to $4,999 for serving as a consultant for Eisai Co, Ltd; Jansen Global Services, LLC; Sage Therapeutics, Inc; Scion Pharmaceuticals, Signant Health, and Sunovian Pharmaceuticals Inc, and for serving as an editor, associate editor, or editorial advisory board member for the Movement Disorder Society. Dr Weintraub has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr Weintraub has received research support from The Michael J. Fox Foundation, the International Parkinson and Movement Disorder Society, and the National Institutes of Health. Dr Irwin has received personal compensation in the range of $500 to $4,999 for serving on a scientific advisory or data safety monitoring board for Denali Therapeutics. The institution of Dr Irwin has received research support from the National Institutes of Health (U19-AG062418).

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Drs Weintraub and Irwin discuss the use of several medications and treatments for the neuropsychiatric symptoms of Parkinson disease and dementia with Lewy bodies, none of which are approved by the US Food and Drug Administration, except for rivastigmine for the treatment of Parkinson dementia and pimavanserin for the treatment of psychosis in Parkinson disease.

© 2022 American Academy of Neurology.