eMedicine Specialties > Psychiatry > Geriatric

Parkinson Disease Dementia: Differential Diagnoses & Workup

Author: Margaret M Swanberg, DO, Assistant Professor of Neurology, Uniformed Services University; Chief of Neurobehavior Service, Walter Reed Army Medical Center; Assistant Chief, Department of Neurology, Walter Reed Army Medical Center
Coauthor(s): Raj K Kalapatapu, MD, Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Apr 15, 2009

Differential Diagnoses

Alzheimer Disease
Dementia With Lewy Bodies
Depression
Frontal and Temporal Lobe Dementia
Vascular Dementia

Other Problems to Be Considered

Creutzfeldt-Jakob disease  
Multiple system atrophy
Progressive supranuclear palsy

Workup

Laboratory Studies

  • No specific tests are used for Parkinson disease dementia.
  • Although findings are not useful for diagnostic purposes, associations with specific APOE e alleles have been variably found. Studies evaluating the role of the APOE4 allele have been inconclusive; a more recent and rigorously designed study found no association between APOE4 and Parkinson disease dementia.

Imaging Studies

  • Structural imaging
    • CT scanning and MRI do not help establish the diagnosis.
    • As in Parkinson disease without dementia, patients with dementia may show decreased width of the pars compacta, decreased signal in the putamen, or both.
  • Positron emission tomography
    • Parkinson disease is associated with decreased uptake and retention of 18F-dihydroxyphenylalanine (18F-DOPA) in the basal ganglia.
    • Reports of functional imaging in patients with Parkinson disease and cognitive impairment have been few. Some have shown changes similar to those observed in Alzheimer disease (asymmetrical decreased 18fluorodeoxyglucose-positron emission tomography [18FDG-PET] uptake on the parietal and posterior temporal regions) and others have not.
    • Some studies of patients with Parkinson disease and either dementia or depression have demonstrated marked deficits in prefrontal activation and hypoperfusion in the superior temporal regions. The latter is more impaired in patients with Parkinson disease and dementia; the former, in patients with Parkinson disease and depression.

Histologic Findings

Parkinson disease is characterized by the death of a heterogeneous cell population, including neuromelanin-laden dopaminergic neurons of the substantia nigra pars compacta, aminergic brain nuclei, cholinergic neurons, neurons in the hypothalamus, and small cortical neurons (particularly in the cingulate gyrus and the entorhinal cortex).

Lewy bodies are found in the brainstem, basal forebrain, and cortex. In the first 2 regions, Lewy bodies are large, eosinophilic, hyaline inclusion bodies with clear halos and targetlike appearances. Cortical Lewy bodies are smaller and have less distinct cores.

A greater degree of medial nigral cell loss can result in more severe cognitive impairment. The degree of cognitive impairment also correlates with the density of Lewy neurites in the cornu ammonis 2 field of the hippocampus. Lewy neurites are degenerating, ubiquitin-positive neuronal processes or neurites that are different from Lewy bodies.

Senile plaques and neurofibrillary tangles are found in the cortices of patients with severe dementia, most prominently in their hippocampi. Other changes often include granulovacuolar degeneration and cortical cell loss.

More on Parkinson Disease Dementia

Overview: Parkinson Disease Dementia
Differential Diagnoses & Workup: Parkinson Disease Dementia
Treatment & Medication: Parkinson Disease Dementia
Follow-up: Parkinson Disease Dementia
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Lieberman AN. Point of view: Dementia in Parkinson's disease. Parkinsonism & Related Disorders. November 1997;3(3):151-158. [Medline].

  2. Weintraub, D., Comella, C. L., & Horn, S. Parkinson's disease--Part 3: Neuropsychiatric symptoms. American Journal of Managed Care. 2008;14(2 Suppl):S59-S69. [Medline].

  3. Lippa CF, Duda JE, Grossman M, Hurtig HI, Aarsland D, Boeve BF, et al. DLB and PDD boundary issues: diagnosis, treatment, molecular pathology, and biomarkers. Neurology. Mar 13 2007;68(11):812-9. [Medline].

  4. Goldmann Gross, R., Siderowf, A., & Hurtig, H. I. Cognitive impairment in Parkinson's disease and dementia with lewy bodies: a spectrum of disease. Neuro-Signals. 2008;16(1):24-34. [Medline].

  5. Frisina PG, Borod JC, Foldi NS, Tenenbaum HR. Depression in Parkinson's disease: Health risks, etiology, and treatment options. Neuropsychiatr Dis Treat. February 2008;4(1):81-91. [Medline].

  6. Galvin JE, Pollack J, Morris JC. Clinical phenotype of Parkinson disease dementia. Neurology. Nov 14 2006;67(9):1605-11. [Medline].

  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC: American Psychiatric Association; 2000.

  8. Wolters, E. C. Variability in the clinical expression of Parkinson's disease. Journal of the neurological sciences. March 2008;266(1-2):197-203. [Medline].

  9. Jankovic, J. Parkinson's disease: clinical features and diagnosis. Journal of neurology, neurosurgery, and psychiatry. April 2008;79(4):368-376. [Medline].

  10. Chan, D. K., Cordato, D. J., & O'Rourke, F. Management for motor and non-motor complications in late Parkinson's disease. Geriatrics. May 2008;63(5):22-27. [Medline].

  11. Borek, L. L., Chou, K. L., & Friedman, J. H. Management of the behavioral aspects of Parkinson's disease. Expert review of neurotherapeutics. June 2007;7(6):711-725. [Medline].

  12. Truong, D. D., Bhidayasiri, R., & Wolters, E. Management of non-motor symptoms in advanced Parkinson disease. Journal of the neurological sciences. March 2008;266(1-2):216-228. [Medline].

  13. Ziemssen, T., & Reichmann, H. Non-motor dysfunction in Parkinson's disease. Parkinsonism & related disorders. August 2007;13(6):323-332. [Medline].

  14. Barbas, N. R. Cognitive, affective, and psychiatric features of Parkinson's disease. Clinics in geriatric medicine. November 2006;22(4):773-796, v-vi. [Medline].

  15. [Best Evidence] Menza M, Dobkin RD, Marin H, Mark MH, Gara M, Buyske S, et al. A controlled trial of antidepressants in patients with Parkinson disease and depression. Neurology. Mar 10 2009;72(10):886-92. [Medline].

  16. Ferreri, F., Agbokou, C., & Gauthier, S. Recognition and management of neuropsychiatric complications in Parkinson's disease. Canadian Medical Association journal. December 2006;175(12):1545-1552. [Medline].

  17. Rongve, A., & Aarsland, D. Management of Parkinson's disease dementia : practical considerations. Drugs & aging. 2006;23(10):807-822. [Medline].

  18. Friedman, J. H., & Millman, R. P. Sleep disturbances and Parkinson's disease. CNS Spectrums. March 2008;13:3 (Suppl 4):12-17. [Medline].

  19. Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson's disease. Mov Disord. Oct 2005;20(10):1255-63. [Medline].

  20. Cummings JL. Frontal-subcortical circuits and human behavior. Arch Neurol. Aug 1993;50(8):873-80. [Medline].

  21. Cummings JL, Darkins A, Mendez M, Hill MA, Benson DF. Alzheimer's disease and Parkinson's disease: comparison of speech and language alterations. Neurology. May 1988;38(5):680-4. [Medline].

  22. Cummings JL, Huber SJ. Visuospatial abnormalities in Parkinson's disease. In: Huber SJ, Cummings JL, eds. Parkinson's Disease: Neurobehavioral Aspects. New York, NY: Oxford University Press; 1992:59-73.

  23. Ebmeier KP, Calder SA, Crawford JR, Stewart L, Besson JA, Mutch WJ. Clinical features predicting dementia in idiopathic Parkinson's disease: a follow-up study. Neurology. Aug 1990;40(8):1222-4. [Medline].

  24. Goetz CG, Blasucci LM, Leurgans S, Pappert EJ. Olanzapine and clozapine: comparative effects on motor function in hallucinating PD patients. Neurology. Sep 26 2000;55(6):789-94. [Medline].

  25. Harhangi BS, de Rijk MC, van Duijn CM, et al. APOE and the risk of PD with or without dementia in a population-based study. Neurology. Mar 28 2000;54(6):1272-6. [Medline].

  26. Jasinska-Myga B, Opala G, Goetz CG, Tustanowski J, Ochudlo S, Gorzkowska A, et al. Apolipoprotein E gene polymorphism, total plasma cholesterol level, and Parkinson disease dementia. Arch Neurol. Feb 2007;64(2):261-5. [Medline].

  27. Levy ML, Cummings JL, Fairbanks LA, et al. Apathy is not depression. J Neuropsychiatry Clin Neurosci. Summer 1998;10(3):314-9. [Medline].

  28. Marder K, Tang MX, Cote L, Stern Y, Mayeux R. The frequency and associated risk factors for dementia in patients with Parkinson's disease. Arch Neurol. Jul 1995;52(7):695-701. [Medline].

  29. Mayeux R. Parkinson's disease: A review of cognitive and psychiatric disorders. Neuropsychiatr Neuropsychol Behav Neurol. 1990;3:3-14.

  30. Mayeux R, Denaro J, Hemenegildo N, Marder K, Tang MX, Cote LJ, et al. A population-based investigation of Parkinson's disease with and without dementia. Relationship to age and gender. Arch Neurol. May 1992;49(5):492-7. [Medline].

  31. Miyasaki JM. New practice parameters in Parkinson's disease. Nat Clin Pract Neurol. Dec 2006;2(12):638-9. [Medline].

  32. Perl DP, Olanow CW, Calne D. Alzheimer's disease and Parkinson's disease: distinct entities or extremes of a spectrum of neurodegeneration?. Ann Neurol. Sep 1998;44(3 Suppl 1):S19-31. [Medline].

  33. Raskin SA, Borod JC, Tweedy J. Neuropsychological aspects of Parkinson's disease. Neuropsychol Rev. Sep 1990;1(3):185-221. [Medline].

  34. Stern Y, Marder K, Tang MX, Mayeux R. Antecedent clinical features associated with dementia in Parkinson's disease. Neurology. Sep 1993;43(9):1690-2. [Medline].

[ CLOSE WINDOW ]

Keywords

Parkinson disease, PD, Parkinson's disease, parkinsonism, Alzheimer disease, AD, Alzheimer's disease, dementia, senility, palsy, cognitive deficits, cognitive impairment, cognitive dysfunction, neurodegenerative disorders

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Margaret M Swanberg, DO, Assistant Professor of Neurology, Uniformed Services University; Chief of Neurobehavior Service, Walter Reed Army Medical Center; Assistant Chief, Department of Neurology, Walter Reed Army Medical Center
Margaret M Swanberg, DO is a member of the following medical societies: American Academy of Neurology and American Neuropsychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

Raj K Kalapatapu, MD, Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine
Raj K Kalapatapu, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Alan D Schmetzer, MD, Professor, Vice-Chair for Education, and Director of Residency Training in General and Addiction Psychiatry, Department of Psychiatry, Indiana University School of Medicine
Alan D Schmetzer, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Clinical Psychiatrists, American Academy of Psychiatry and the Law, American College of Physician Executives, American Medical Association, American Neuropsychiatric Association, American Psychiatric Association, and Association for Convulsive Therapy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.