I Dont Care Depression Anxiety and Apathy in

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

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

What will we cover? – Apathy –Depression –Anxiety

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

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

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

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

Depression is common in people with Parkinson’s Disease 52% 45% 42% 27% 23% 17% heart disease cancer diabetes Lyketsos et al JAMA 2002; Sutor et al Mayo Clinic Proc 1998; Jiang et al CNS Drugs 2002; Rejinders et al Mov Disord 2008 stroke Alzheimer's Parkinson's

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

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

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

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 10 -15 years after motor symptoms start

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

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

How do we manage these issues?

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…

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

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”

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

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

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

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

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

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

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 your loved one

Thank you! rradue@uwhealth. org