Cognitive Issues – Understanding Memory Loss, Anxiety and Depression with Parkinson’s Disease

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Not all people diagnosed with Parkinson’s will have memory loss. To some degree, cognitive impairment affects many people with Parkinson’s Disease. The same brain changes that lead to motor symptoms can also result in slowness in memory and thinking. Stress, medication, and depression can also contribute to these changes. 

There are three categories of memory loss associated with Parkinson’s Disease:

  • Normal thinking and memory.
  • Mild cognitive loss that would be beyond the natural aging memory loss.
  • Dementia:  severe memory loss to the point that it is not possible to self-care.

Symptoms of mild cognitive impairment often do not interfere with home and work life. They may not even be noticeable, but can be detected through testing. Doctors used to believe that cognitive changes did not develop until mid to late-stage Parkinson’s disease, but recent research suggests that mild changes may be present at the time of diagnosis.

Some people with Parkinson’s Disease experience mild cognitive impairment . Feelings of distraction or disorganization can accompany cognitive impairment, along with finding it difficult to plan and accomplish tasks. It may be harder to concentrate on situations that divide your attention, like a group conversation. When facing a task or situation on their own, people with Parkinson’s Disease may feel overwhelmed by having to make choices. They may also have difficulty remembering information or have trouble finding the right words when speaking. These changes can range from being annoying to interfering with managing daily household and Executive Function responsibilities.

Parkinson’s Disease dementia is a term used for dementia that develops after years of living with Parkinson’s Disease. It is caused by the loss of dopamine-producing nerve cells.  The dementia symptoms can be quite mild. Mental and motor issues decline and tend to occur together as the disease progresses.

Dementia appears at about the same time as the Parkinsonism motor symptoms:

  • Tremors
  • Slowness; Stiffness; Balance and Gait problems
  • REM sleep behavior disorder –  Visual hallucinations
  • Fluctuating levels of alertness and attention
  • Mood changes
  • Bladder and Bowel control

It is important to do everything that you can to slow the progression of memory loss. Tell your doctor if you have concerns about cognitive changes. You may need to change your medication or see a neurologist or neuropsychologist for assessment. An occupational therapist can help find strategies for adapting and coping with these symptoms. A speech therapist can help with language difficulties.

Cognitive impairment is different from dementia. Cognitive impairments occur in more than one area of cognition and leads to more severe loss of intellectual abilities that interferes with daily, independent living. While approximately 50 percent of people with Parkinson’s Disease will experience some form of cognitive impairment, not all lead to a dementia diagnosis. TOP

What Causes Cognitive Changes in People with Parkinson’s Disease?

One cause is a drop in the level of dopamine, the neurotransmitter that is involved in regulating the body’s movements. However, the cognitive changes associated with dopamine declines are typically mild and restricted.

Other brain changes are likely also involved in cognitive decline in Parkinson’s Disease. Scientists are looking at changes in two other chemical messengers — acetylcholine and norepinephrine –  as possible additional causes of memory and executive function loss in Parkinson’s Disease.

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Effects of Cognitive Changes

The cognitive changes that accompany Parkinson’s Disease early on tend to be limited to one or two mental areas, with severity varying from person to person. Areas most often affected include:

Attention

  • Difficulty with complex tasks that require people with Parkinson’s Disease to maintain or shift their attention.
  • Problems with mental calculations or concentrating during a task.

Speed of Mental Processing

  • Slowness in thinking is often associated with depression in Parkinson’s Disease.
  • Signs include: a delay in responding to verbal or behavioral stimuli, taking longer to complete tasks and difficulty retrieving information from memory.

Problem Solving Executive Function

  • Trouble planning and completing activities.
  • Difficulties in generating, maintaining, shifting and blending different ideas and concepts.

Memory Deficits

  • The basal ganglia and frontal lobes of the brain help both organization and recall of information in the brain may be damaged in Parkinson’s Disease.
  • Difficulty with common tasks such as making coffee, balancing checkbook, etc.
  • People with dementia can experience both short-term and long-term memory impairment. 

Language Abnormalities

  • Issues with word-finding, known as “tip of the tongue” phenomenon.
  • Difficulty with language when under pressure or stress.
  • Difficulty comprehending complex sentences where the question or information is included with other details.
  • Problems in naming or misnaming objects — more common in middle to late stages of Parkinson’s Disease.

Visuospatial Difficulties

  • During early Parkinson’s Disease stages: difficulty with measuring distance and depth perception, which may interfere with parking a car or remembering where the car is parked.
  • During advanced Parkinson’s Disease: in combination with dementia, problems with processing information about their surroundings or environment.
  • Subtle visual-perceptual problems may contribute to the visual misperceptions or illusions.
  • Increased chances of visual misperceptions or illusions in low-light situations (like nighttime) and if experiencing other visual problems (like macular degeneration).
  • Problems telling apart non-familiar faces or recognizing emotional expressions.

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How are cognitive changes in Parkinson’s Disease different From Alzheimer’s Disease?

Overall, dementia produces a greater impact on social and occupational functioning in Parkinson’s Disease than with Alzheimer’s due to the combination of motor and cognitive impairments.

  • There is some overlap between symptoms and biological changes seen in Alzheimer’s and Parkinson’s disease. However, it is less likely for both disorders to occur at the same time.
  • Development of dementia in people with Parkinson’s disease represents progression of the disease, usually after several years of motor impairment.
  • Dementia may or may not occur in people with Parkinson’s Disease. According to recent research, 30 percent of people with Parkinson’s do not develop dementia as part of the disease progression.

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How are cognitive changes in Parkinson’s Disease and Lewy Body Dementia different than Alzheimer’s Disease?

Usually, symptoms appear in a different order depending upon where the Lewy bodies first form. Lewy body dementia is an umbrella term for two related clinical diagnoses: “dementia with Lewy bodies” and “Parkinson’s disease dementia”.  The reason for this is because these disorders share the same underlying changes to the brain and similar symptoms.

Lewy Body Dementia can interfere with Executive Function (problem solving, complex issues, ordering of activities, multi-tasking).  When it is severe enough, it can interfere with everyday activities. The ability to understand visual information becomes impaired.  The brain, like a muscle, will not continue to function properly if it is not used and challenged.

Scientists have discovered a breakdown in acetylcholine transmission that helps the nerve endings send out messages for autonomic functions, frontal lobe issues where thinking and memory happen as well as problems with the Basal Ganglia, originally thought to be the sole area of the brain creating Parkinson’s issues.

Acetylcholine (frequently abbreviated ACh) is the most widely spread neurotransmitter – chemical messenger assisting in carrying signals across the nerve synapse. It is the most plentiful neurotransmitter, which may be found in both the peripheral and central nervous systems. TOP

What co-existing conditions affect thinking and memory?

There are other factors that can have a negative impact on a person’s cognitive skills, such as mood disorders, anxiety and sleepiness. In some cases, these factors can make memory and thinking deficits worse as well as directly affect a person’s quality of life.

Depression

  • Up to 50 percent of people with Parkinson’s Disease experience some form of depression during the disease.
  • More likely to occur in people who experience severe cognitive impairment.
  • Successful treatment of depression with medication and psychotherapy can improve cognitive symptoms.
  • Can make it difficult to control motor symptoms (such as tremor and balance problems) in Parkinson’s Disease.
  • Tends to be more severe in people with worse motor symptoms.

Anxiety

  • May be as common as depression in Parkinson’s.
  • While less studied, up to 40 percent of people with Parkinson’s Disease experience some form of anxiety.
  • Can interfere with memory storage, attention and complex task performance.
  • Negative impact on social life. People with poorly controlled anxiety often avoid social situations, which can impact family and work relationships.
  • May experience anticipatory anxiety in situations where they have to use cognitive skills.
  • Similar to depression, successful treatment for anxiety can lead to improvement of cognitive problems related to anxiety.

Sleep Disturbance

  • The impact of poor sleep on attention, alertness and memory are well-known.
  • Mild reductions in sleep can directly impair attention, judgment and the ability to multi-task because people with Parkinson’s Disease have a lower cognitive reserve or resistance of the brain to stressors.
  • Problems with falling and staying asleep are common in Parkinson’s Disease, especially as the disease progresses.
  • Undergoing a sleep study examines sleeping patterns and how often sleep is disrupted.
  • Sleep problems are often addressed with medication and behavioral treatments. As sleep improves, its impact on thinking and memory is reduced.

Five types of sleep problems have been reported in Parkinson’s disease Parkinson’s Disease:

  1. Issues staying asleep and early morning awakening (insomnia).
  2. Involuntary movements and pain that interrupt sleep. Restless Leg Syndrome
  3. Sleep Apnea
  4. Increased nighttime urination.
  5. Nighttime agitation, vivid dreams and visual misperceptions or hallucinations.

Fatigue

  • Just as fatigue can cause problems with movement and walking in Parkinson’s Disease, it can also impair thinking and memory. For example, a person with Parkinson’s Disease may have difficulty performing a complex cognitive task.
  • Maximize attention and energy resources by dividing tasks into more manageable 10 to 15-minute segments. This helps to minimize fatigue and keep you on task.
  • Be aware that as the day wears on, people with Parkinson’s Disease may begin to fatigue — physically and cognitively.

The person with Parkinson’s Disease often needs to be the one to initiate the conversation. Tell your doctor if you or your loved one is experiencing problems that upset the family or cause interruptions at work.

Cognitive issues are never too mild to address with your care team. A doctor can provide ways to help, often referring a psychiatrist, neuropsychologist, speech or occupational therapist for further evaluation and assistance. A neuropsychological evaluation can be particularly useful, especially in the early stages of a cognitive problem. Having this baseline test can help the doctor determine whether future changes are related to medications, the progression of the PD itself or to other factors such as depression.

When reporting symptoms of mild cognitive impairment, the doctor will first want to rule out causes other than Parkinson’s Disease, such as Vitamin B-12 deficiency, depression, fatigue or sleep disturbances. It should be noted that Parkinson’s Disease does not cause sudden changes in mental functioning. If a sudden change occurs, the cause is likely to be something else, such as a medication side-effect. A urinary tract infection (UTI) that can cause severe cognition issues especially coupled with a chronic disease. TOP

How are cognitive problems treated?

Much remains to be learned about the basic biology that underlies cognitive changes in Parkinson’s Disease. Researchers work towards the development of diagnostic tests to identify people who seem to be at greatest risk for cognitive changes and to differentiate cognitive problems in people with Parkinson’s Disease from those that occur in another disorder — related but different — known as dementia with Lewy bodies. TOP

Cognitive Remediation Therapy

For those with milder cognitive deficits, cognitive remediation therapy is a treatment that emphasizes teaching alternative ways to compensate for memory or thinking problems. In this treatment, the clinician uses information from neuropsychological testing to identify cognitive strengths that can be used to help overcome weaker areas of thinking.

  • Does not reverse or cure cognitive disorders, but instead teaches strategies that can help with daily functioning and coping with cognitive problems.
  • Depending on the severity of cognitive impairment, many can use these skills independently.
  • In cases where the person is more impaired, caregivers or family members can help apply these strategies.