Guidance for switching from off-label antipsychotics to pimavanserin for Parkinson's disease psychosis: an expert consensus.

Patients with Parkinson's disease psychosis (PDP) are often treated with an atypical antipsychotic, especially quetiapine or clozapine, but side effects, lack of sufficient efficacy, or both may motivate a switch to pimavanserin, the first medication approved for management of PDP. How best to implement a switch to pimavanserin has not been clear, as there are no controlled trials or case series in the literature to provide guidance. An abrupt switch may interrupt partially effective treatment or potentially trigger rebound effects from antipsychotic withdrawal, whereas cross-taper involves potential drug interactions. A panel of experts drew from published data, their experience treating PDP, lessons from switching antipsychotic drugs in other populations, and the pharmacology of the relevant drugs, to establish consensus recommendations. The panel concluded that patients with PDP can be safely and effectively switched from atypical antipsychotics used off label in PDP to the recently approved pimavanserin by considering each agent's pharmacokinetics and pharmacodynamics, receptor interactions, and the clinical reason for switching (efficacy or adverse events). Final recommendations are that such a switch should aim to maintain adequate 5-HT2A antagonism during the switch, thus providing a stable transition so that efficacy is maintained. Specifically, the consensus recommendation is to add pimavanserin at the full recommended daily dose (34 mg) for 2-6 weeks in most patients before beginning to taper and discontinue quetiapine or clozapine over several days to weeks. Further details are provided for this recommendation, as well as for special clinical circumstances where switching may need to proceed more rapidly.

Neuropsychiatric Issues in Parkinson's Disease.

Cognitive and neuropsychiatric symptoms are common in Parkinson's Disease and may surpass motor symptoms as the major factors impacting patient quality of life. The symptoms may be broadly separated into those associated with the disease process and those that represent adverse effects of treatment. Symptoms attributed to the disease arise from pathologic changes within multiple brain regions and are not restricted to dysfunction in the dopaminergic system. Mood symptoms such as depression, anxiety, and apathy are common and may precede the development of motor symptoms by years, while other neuropsychiatric symptoms such as cognitive impairment, dementia, and psychosis are more common in later stages of the disease. Neuropsychiatric symptoms attributed to treatment include impulse control disorders, pathologic use of dopaminergic medications, and psychosis. This manuscript will review the current understanding of neuropsychiatric symptoms in Parkinson's Disease.

Initial Clinical Outcome With Bilateral, Dual-Target Deep Brain Stimulation Trial in Parkinson Disease Using Summit RC + S.

BACKGROUND: Deep brain stimulation (DBS) is an effective therapy in advanced Parkinson disease (PD). Although both subthalamic nucleus (STN) and globus pallidus (GP) DBS show equivalent efficacy in PD, combined stimulation may demonstrate synergism. OBJECTIVE: To evaluate the clinical benefit of stimulating a combination of STN and GP DBS leads and to demonstrate biomarker discovery for adaptive DBS therapy in an observational study. METHODS: We performed a pilot trial (n = 3) of implanting bilateral STN and GP DBS leads, connected to a bidirectional implantable pulse generator (Medtronic Summit RC + S; NCT03815656, IDE No. G180280). Initial 1-year outcome in 3 patients included Unified PD Rating Scale on and off medications, medication dosage, Hauser diary, and recorded beta frequency spectral power. RESULTS: Combined DBS improved PD symptom control, allowing >80% levodopa medication reduction. There was a greater decrease in off-medication motor Unified PD Rating Scale with multiple electrodes activated (mean difference from off stimulation off medications -18.2, range -25.5 to -12.5) than either STN (-12.8, range -20.5 to 0) or GP alone (-9, range -11.5 to -4.5). Combined DBS resulted in a greater reduction of beta oscillations in STN in 5/6 hemispheres than either site alone. Adverse events occurred in 2 patients, including a small cortical hemorrhage and seizure at 24 hours postoperatively, which resolved spontaneously, and extension wire scarring requiring revision at 2 months postoperatively. CONCLUSION: Patients with PD preferred combined DBS stimulation in this preliminary cohort. Future studies will address efficacy of adaptive DBS as we further define biomarkers and control policy.

Telemedicine and Deep brain stimulation - Current practices and recommendations.

The use of telemedicine in the management of chronic neurological conditions including movement disorders has expanded over time. In addition to enabling remote access to specialized care, telemedicine has also been shown to reduce caregiver burden and to improve patient satisfaction. With the COVID-19 pandemic, implementation of telehealth for patients with movement disorders, particularly those with more severe mobility issues, has increased rapidly. Although telemedicine care has been shown to be effective for patients with various movement disorders, its utilization for patients with device aided therapies such as deep brain stimulation (DBS) is limited due to challenges related to adjusting these devices remotely and to the lack of consensus recommendations for using telemedicine in this patient population. Thus, guidelines for telemedicine and DBS will assist clinicians on the appropriate implementation of telemedicine to provide care to DBS patients. Optimizing the use of telemedicine for DBS will expand this type of therapy to remote locations with limited access to programming expertise, and also reduce the need for patient travel. Telemedicine is particularly important during the ongoing pandemic due to infection risk and limited access to clinic visits. In this article we review the currently available and emerging strategies for telemedicine and remote care for DBS. We then outline common principles and recommendations for telemedicine care in patients with DBS, review patient selection and best practices. Finally, we briefly discuss the current state of reimbursement for DBS telemedicine visits.

Mindfulness based stress reduction in people with Parkinson's disease and their care partners.

BACKGROUND: Parkinson's Disease (PD) leads to poor quality of life and caregiver burden. Mindfulness-based stress reduction (MBSR) may improve these symptoms. We assessed the impact of a 9-week MBSR course on people with PD (PwP) and their care partners (CPs). METHODS: Participants completed questionnaires at screening, at the end of the course, and at 3-month follow-up: Parkinson's Disease Quality-39 (PDQ-39, PD only), Zarit Burden Inventory (ZBI, CP only) and Mindful Attention Awareness Scale (MAAS, both). The primary outcome measure was change in PDQ-39 (for PwP) or ZBI (for CP). Patient-reported scales were analyzed quantitatively; qualitative data on perceived effectiveness was collected. RESULTS: 53.8% PwP and 100% CPs completed the course. Among PwP, there was a significant reduction in MAAS(p < 0.001) and in PDQ-39 (p = 0.008). CPs experienced an increase in MAAS (p = 0.02) but no change in ZBI (p = 0.239). Qualitatively, both PwP and CPs expressed satisfaction with the course. DISCUSSION: MBSR improves mindful awareness in CPs and improves health-related quality of life in PwP.

Top-down suppression deficit underlies working memory impairment in normal aging.

In this study, we assess the impact of normal aging on top-down modulation, a cognitive control mechanism that supports both attention and memory by the suppression and enhancement of sensory processing in accordance with task goals. Using fMRI (functional magnetic resonance imaging), we show that healthy older adults demonstrated a prominent deficit in the suppression of cortical activity associated with task-irrelevant representations, whereas enhancement of task-relevant activity was preserved. Moreover, this suppression-specific attention deficit correlated with impaired working memory performance.

Corticobasal syndrome in a man with Gaucher disease type 1: Expansion of the understanding of the neurological spectrum.

Gaucher disease (GD) is an autosomal recessive condition that results from a deficiency of the enzyme ß-glucocerebrosidase. The increased risk of primary parkinsonism symptoms among individuals affected with GD and carriers for the disorder is well-documented in the literature. However, these risks and case reports often reflect patients with classical Parkinson's disease (PD) symptoms. We report a patient with GD type 1 who was diagnosed with corticobasal syndrome (CBS), a clinical atypical parkinsonism diagnosis, in his sixth decade of life. Our case highlights the need to consider forms of atypical parkinsonism such as CBS in addition to PD in the differential diagnosis of cognitive and motor changes in patients with GD type 1. We also recommend careful assessment and routine monitoring of cognition, mood, behavior, sleep patterns, olfaction, and memory in patients with GD type 1 to identify early symptoms indicative of neurological involvement.

Age-related deficits in component processes of working memory.

Working memory deficits in normal aging have been well documented, and studies suggest that high memory load plus the presence of distraction negatively impacts successful memory performance to a greater degree in older individuals. However, characterization of the component processes that are impaired by these task manipulations is not clear. In this behavioral study, younger and older subjects were tested with a delayed-recognition and recall task in which the encoding and delay period were both manipulated. During the encoding period, the subjects were presented with either a single letter or multiple letters at their predetermined forward letter span, and the delay period was either uninterrupted or interrupted with a visual distraction. There was an age-related impairment of working memory recognition accuracy only in the combination of high memory load and distraction. These results suggest that when working memory maintenance systems are taxed, faulty recognition processes may underlie cognitive aging deficits in healthy older individuals.

Hierarchical cognitive control deficits following damage to the human frontal lobe.

Cognitive control permits us to make decisions about abstract actions, such as whether to e-mail versus call a friend, and to select the concrete motor programs required to produce those actions, based on our goals and knowledge. The frontal lobes are necessary for cognitive control at all levels of abstraction. Recent neuroimaging data have motivated the hypothesis that the frontal lobes are organized hierarchically, such that control is supported in progressively caudal regions as decisions are made at more concrete levels of action. We found that frontal damage impaired action decisions at a level of abstraction that was dependent on lesion location (rostral lesions affected more abstract tasks, whereas caudal lesions affected more concrete tasks), in addition to impairing tasks requiring more, but not less, abstract action control. Moreover, two adjacent regions were distinguished on the basis of the level of control, consistent with previous functional magnetic resonance imaging results. These results provide direct evidence for a rostro-caudal hierarchical organization of the frontal lobes.

Is the prefrontal cortex necessary for delay task performance? Evidence from lesion and FMRI data.

Although the prefrontal cortex (PFC) is consistently found to be associated with various working memory processes, the necessity of the PFC for such processes remains unclear. To elucidate PFC contributions to storage and rehearsal/maintenance processes engaged during verbal working memory function, we assessed behavior of patients with lesions to the left or right lateral PFC, and neural activity of healthy young subjects during fMRI scanning, during performance of working memory tasks. We found that PFC lesions did not affect storage processes--which is consistent with the notion that posterior cortical networks can support simple retention of information. We also found that PFC lesions did not affect rehearsal/maintenance processes, which was in contrast to our finding that healthy subjects performing a verbal delayed recognition task showed bilateral PFC activation. These combined imaging and behavioral data suggest that working memory rehearsal/maintenance processes may depend on both hemispheres, which may have implications for recovery of function and development of rehabilitation therapies after frontal injury.

Top-down enhancement and suppression of the magnitude and speed of neural activity.

Top-down modulation underlies our ability to selectively attend to relevant stimuli and to ignore irrelevant stimuli. Theories addressing neural mechanisms of top-down modulation are driven by studies that reveal increased magnitude of neural activity in response to directed attention, but are limited by a lack of data reporting modulation of neural processing speed, as well as comparisons with a perceptual (passive view) baseline necessary to evaluate the presence of enhancement and suppression. Utilizing functional MRI (fMRI) and event-related potential recordings (ERPs), we provide converging evidence that both the magnitude of neural activity and the speed of neural processing are modulated by top-down influences. Furthermore, both enhancement and suppression occur relative to a perceptual baseline depending on task instruction. These findings reveal the fine degree of influence that goal-directed attention exerts upon activity within the visual association cortex. We further document capacity limitations in top-down enhancement corresponding with working memory performance deficits.

Neurological disorders and the structure of human consciousness.

Recent studies that identify distinct neural correlates of perceptual awareness offer a promising step towards improved understanding of the neurological underpinnings of conscious experience. Such studies indicate that perceptual awareness is modular in nature, with neural correlates of awareness consisting of the specialized structures involved in perceptual processing. However, the integrative, multimodal nature of conscious experience appears to require a functional architecture that overcomes this modular segregation of function. We propose a model in which experience emerges from the dynamic interactions of specialized component processes via a distributed neural network. Such a model offers a mechanism to explain several empirical observations of the neural correlates of perceptual awareness, cognitive function, and symptoms of neurological damage.