In mid-April, the Parkinson’s Foundation hosted neuropsychiatrist Dr. Gregory Pontone and Parkinson’s research advocate Lisa Cone to speak on mental well-being and memory. The speakers compared the different cognitive changes that occur during normal aging versus during Parkinson’s disease (PD). They discussed the impact medications may have on cognition, and how PD can affect memory over time.

For more information on cognition in PD, please see the Stanford Parkinson’s Community Outreach webpage here.

The session recording can be found on the Parkinson’s Foundation YouTube channel here.

Please see below for notes on the April 20th webinar.

Regards, 

– Joëlle Kuehn

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“Mental Well-being and Memory in Parkinson’s Disease” – Webinar Notes

Speakers: Gregory Pontone, MD, neuropsychiatrist, Johns Hopkins University School of Medicine, Baltimore; Lisa Cone, Parkinson’s research advocate, People with Parkinson’s Council

Webinar Host: Parkinson’s Foundation

Webinar Date:  April 20, 2021 

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

What is wellness: 

• The World Health Organization defines health as “a state of optimal well-being, not merely the absence of disease and infirmity”
• Wellness: The active pursuit of activities, choices, and lifestyles that lead to a state of health
• Acceptance of your health is a large part of feeling well
• Is on a continuum – it is a verb/action/lifestyle
  • Poor wellness can be symptoms, disability, or premature death
  • And the higher optimal level can be awareness, growth, education and high level of wellness
• The pursuit of wellness has to be an active process

Mind-body dualism:

• Rene Descartes split the mind from the brain and body
• Today we know the mind and body function independently
• Stigma toward mental illness is a consequence
• Mental health is very important to achieving wellness
• Parkinson’s is a great model for this
  • Changes in your brain (level of dopamine) causes movement ability 
  • Other changes in your brain also can cause depression and anxiety
  • Both are from the same source, so they should be de-stigmatized

Normal age-related cognitive changes:

• Cognitive changes affects all of us regardless of if we have PD
• What stays the same?
  • Procedural and semantic memory are well preserved with normal aging 
    • Procedural: how to ride a bike
    • Semantic – how we use words
  • Vocabulary, general knowledge remain stable or even improve through the 7th decade
  • Visual perception of objects remain stable and older people may be more accurate in judging distances
    • Visual acuity may decrease (prescription is different)
  • Language is stable, at least until age 70
• What changes: 
  • Ability to stay focused and divided attention decreases
  • Working memory
    • Take things and manipulate them before you store them
  • Executive functioning
    • Ability to organize, plan, go from one activity to another
    • Can be more difficult to organize thoughts
  • Processing speed
    • Can still get the right answer but takes longer
  • With “advanced age” most cognitive domains change
    • Advanced age is 80+
  • Only the people closest to you notice it immediately 
• Montreal Cognitive Assessment (MoCA) is a brief screen test that may be used

Strategies to stay well:

• Exercise:
  • Especially aerobic exercise
  • Improves global cognitive ability
  • Reduces medical risk factors for dementia
• Cognitive leisure activities:
  • Education and activities that require mental effort 
  • Examples:  education, and cognitive reserve, scrabble, video games
• Social interaction:
  • “meaningful” interpersonal and community engagement
  • Go on walks, campfires
  • Studies show that social people score higher on memory tests than those that aren’t
  • There’s also an emotional component
• Sleep:
  • A minimum of 6-6.5 hours per night
  • Helps recover from exercising 
  • Sleep is most important for attention and executive tasks
  • Sleep also plays a role in memory stabilization and integration (i.e., new learning)
  • Sleep is important for the brain-metabolite clearance
    • Glymphatic system collects bad proteins, and when you sleep they get cleared out 
  • Older adults wake up more at night and have lower “quality” sleep; therefore the concept of “Sleep opportunity” and sleep efficiency is important
  • Naps can help 
  • Try to have a consistent time to wake up and a consistent time to go to sleep
• Reduce stress
  • Use coping mechanisms 

Reversible causes of cognitive impairment:

• Sleep disturbances (ex. Obstructive sleep apnea)
• Vitamin B12 deficiency or hypothyroidism
• Depression
  • Severe depression can masquerade as dementia
• Medication side effects
  • Benadryl is a problematic one 

Executive dysfunction:

• Earliest PD symptoms 
• Still able to do everything but there is a larger margin of error

Memory impairment:

• Alzheimer’s is strongest form
• In PD, it is a different version
• File cabinet example:
  • Our ability to learn new information and then store it is like putting documents into a file cabinet
  • In order to remember it, you have to find the memory in the file to retrieve it
  • Process of learning new information and storing it: encoding
  • Remembering and bringing information out for use: retrieval
• In Alzheimer’s, encoding is difficult compared to for PD
• In both, retrieval is difficult (more difficult for Alzheimer’s)

Impact of cognitive impairment on daily function:

• Memory Loss:
  • Repeating same comment or question
  • Difficulty learning new information
• Difficulty performing familiar tasks
  • No longer able to use remote control, microwave, computer, etc
  • Can’t organize medications
• Language deficits
  • Forgetting simple words or using wrong or non-specific words 
    • Example: give me the “thing”
  • Difficulty following directions or conversations
• Time and place disorientation
  • Getting lost, especially in familiar places
• Poor Judgment
  • Irresponsibility, forgetting appointments, ignoring risks

Action items:

• Reduce distractions
• Focus on one thing at a time
• Talk to your doctor about depression
• Exercise
• Quality sleep
• Social interaction
• Stress reduction
• Avoid medications that may worsen cognition
• Try to accept that your memory abilities have changed

What is the timeframe of change in cognition?

• PD changes cognition gradually
• If something changes suddenly, it probably isn’t PD
• Sudden changes in cognition – over hours, days, weeks – are usually not due to PD
• Something else could be:
  • Delirium (usually due to a medical issue like infection, dehydration)
  • Depression
  • Medication side effect
    • PD results in loss of dopamine producing neurons
    • PD is also associated with lower levels of acetylcholine
      • Antipsychotics and bowel movement medication can cause issues
      • Allergy medication can be anticholinergic 
    • Up to 70% of people with PD have autonomic nervous system dysfunction (i.e. orthostatic hypotension)
      • Anything that helps with blood pressure can cause cognitive problems and an increased risk of falls
  • Stroke or brain bleed

American Geriatric Society: Beers criteria

• A guide for older people and health professionals for potentially inappropriate medication use

Action items you can do to be cognitively at your best:

• Actively pursue your own wellbeing
• Allow for an 8-hour sleep opportunity
• Exercise (helps physically, mentally and emotionally)
• Stay active and social
• Sudden changes in memory or thinking should be evaluated by your doctor
• Understand your medications and trade-offs 

Question & Answer:

Question: Is it worthwhile when getting diagnosed to get neuropsych workup? When does someone do that to understand where they are as a baseline?

Answer: The main time is if there is a change in function. The other one is candidacy for deep brain stimulation. As we develop more treatments in the future, we might be doing it more. You might want it to have all the information, but you don’t need it. 

Question: How can people with PD overcome the stress and anxiety of public speaking?

Answer: Try to talk as a patient and speak from experience and as a patient it is ok to fumble. You don’t have to be the expert. Try to have some notes on what you want to say.

Question: My husband is having cognitive issues. How do I convince someone they have cognitive issues when they don’t want to recognize it?

Answer: Some people will be less aware of the changes, but they may notice on their own through the demands in job, daily activities. Talk in terms of normal aging versus an accelerated path. Try to normalize the cognitive issues, and recognize that it is a relief to acknowledge it and not have to pretend that you don’t have these challenges.

Question: How do you advise people with PD to manage sleep? Do you recommend naps?

Answer: There’s many sleep problems that involve more than one issue. A common issue is if your dopamine issue stops at some time during the night and you may wake up from cramping or restlessness. Sometimes people have too much dopamine and can’t calm down to fall asleep. There will always be some issue, so give yourself the opportunity and not let anything interfere with that opportunity. A short nap is probably a good idea, but be very deliberate about it. Set a timer and try to take that nap at the same time every day. Try to do the best you can. 

Question: Why is aerobic exercise best? What impact can it have on sleep?

Answer: Exercise can help with sleep, it is highly correlated with sleeping longer and more restfully at night. Don’t exercise right before bed. Aerobic exercise’s intensity has the best evidence although it is also a lot more studied than others, so others could also be helpful. 

Question: As people go on and off, does that lead to fluctuations in cognition?

Answer: Fluctuations are inevitable consequences of disease progression. Some cognitive domains do better in the on state, and some do better in the off state. Because of this there can be an overdosing or an underdosing in certain areas of the brain, because your brain is losing dopamine in a differential pattern.