1. Depression, Anxiety, and Apathy in Parkinson’s Disease
I Don’t Care!
Depression, Anxiety, and Apathy in Parkinson’s Disease
Rebecca Radue, MD
with Art Walaszek, MD

2. Introductions Raised in Stevens Point, WI
Graduated from UW School of Medicine and Public Health in 2014
PGY-3 in Psychiatry
American Association of Geriatric Psychiatry Honor Scholar
Former Certified Nursing Assistant in Long Term Care
Granddaughter and caregiver to my grandma with Parkinson’s Disease

3. What will we cover?
Apathy
Depression
Anxiety

4. Apathy A lack of interest, enthusiasm, or concern Apathy will affect
40% of people without cognitive impairment and PD
60% of people with cognitive impairment and PD

5. Who is at risk for apathy?
Older Men
Cognitive Impairment
More severe PD symptoms

6. What does apathy look like?
Lack of motivation to do things
Feeling that usually enjoyable or routine activities will take too much effort
Not wanting to go anywhere
Requiring constant prompting to get things done
If left to their own devices and without prompting, people may just sit on the couch or watch TV
People may not eat or drink without prompting

7. Depression Low mood, sadness, irritability Trouble with sleep
Trouble with appetite
Feelings of guilt or worthlessness
Poor concentration
Lack of enjoyment in things that the person used to enjoy
Low energy
Thoughts of suicide

8. Depression is common in people with Parkinson’s Disease
Lyketsos et al JAMA 2002; Sutor et al Mayo Clinic Proc 1998; Jiang et al CNS Drugs 2002;
Rejinders et al Mov Disord 2008

9. Who is at risk for PD Depression?
Women > Men
Family history of depression
Early onset of PD

10. PD Depression versus non-PD Depression
more anxiety, pessimism, and suicidal ideation (without suicidal behavior)
less guilt and self-reproach
most common symptoms: low energy, difficulty with concentration or making decisions, feeling blue, feeling hopeless, poor sleep
depression may be prodromal to (coming before) PD

11. Depression versus Apathy
Only Depression will have associated low mood, and may come with feelings of worthlessness or sadness
Apathy and Depression both can lead to people not enjoying things they used to enjoy doing

12. Parkinson’s Dementia versus Lewy Body Dementia
In Lewy Body Dementia:
cognitive and motor symptoms begin within one year of each other
cognitive impairment usually comes first
tremor does not occur early on, rather, rigidity and trouble walking do
Thinking and memory ability tends to fluctuate
In Parkinson’s Disease Dementia
Some minor cognitive impairment is common in all people living with PD
Major cognitive issues don’t usually become a problem for years after motor symptoms start

13. Anxiety Constant feelings of anxiety, nervousness, or worry
Anxiety about “wearing off” of PD medications
Panic Attacks
Can make PD motor symptoms worse
Can be a side effect of some PD medications

14. Anxiety in Parkinson’s Disease
An estimated 25-45% of people living with PD will experience bothersome anxiety

15. How do we manage these issues?

16. Apathy: Tips for people living with PD and their caregivers
Try not to get frustrated
Maintain social relationships
Create a daily schedule
Set weekly goals
Increase enjoyable activities – dance, garden, fish…

17. Treatment Options for Apathy
Optimize PD medication regimen
Optimize sleep
Stimulant medications
Less evidence for cholinesterase inhibitors, antidepressants

18. Depression: Tips for people living with PD and their caregivers
Keep in mind that depression is common, frequently associated with PD, and is treatable
Work with your doctor to find the right treatment for you
Keep close with your social supports
Try to do as many activities as you enjoy – “fake it till you make it”

19. Non-Medication Treatments for Depression
light therapy
electroconvulsive therapy
repetitive transcranial magnetic stimulation
Exercise
Psychotherapy

20. Medication Options for Depression
Optimize medication treatment of PD
Antidepressant Medications
TCAs (nortriptyline)
SSRIs (sertraline/Zoloft, escitalopram/Lexapro, citalopram/Celexa)
SNRIs (venlafaxine/Effexor, duloxetine/Cymbalta)
Mirtazapine/Remeron
Augmentation Strategies with Other Meds

21. Anxiety: Tips for People Living with PD and their Caregivers
Keep a diary of your anxiety and PD symptoms
Try to determine what your triggers are
Work with your doctor to find the best treatment for you
Keep close with social supports

22. Treatment Options for Anxiety
Optimize treatment for PD, especially if “wearing off” makes anxiety worse
Antidepressants
Exercise
Psychotherapy

23. Psychotherapy: A safe and effective treatment for anxiety and depression
Cognitive Behavioral Therapy is the most evidence-based approach
Mindfulness
Other therapies may also be effective

24. Other Medical Issues that can lead to Anxiety or Depression
Thyroid problems
Cardiac or other vascular problems
Certain medication side effects
Be sure to see your doctor if you or your loved one has a sudden change in behavior

25. Take Home Points Anxiety, Depression, and Apathy are common in PD
Anxiety, Depression, and Apathy are treatable
Work with your doctors to find the best treatments for you or your loved one

26. Thank you!