“Understanding Thinking Changes in Parkinson’s” – Webinar notes

“Understanding Thinking Changes in Parkinson’s” – Webinar notes

In early April, the Parkinson’s Foundation hosted the webinar “Understanding Thinking Changes in Parkinson’s” with speaker Dr. Jennifer Goldman.  Dr. Goldman addressed cognitive changes in people with Parkinson’s Disease (PD).  It is important to note that not everyone with PD will experience cognitive symptoms.

Cognition is the mental process of how we perceive the world, interact with the world, and acquire knowledge and understanding things through our thoughts, experiences, and senses.  In PD, five main cognitive domains are affected:  attention, working memory, executive function, language and visual spatial function. 

There are multiple ways to treat cognitive changes, such as rivastigmine (a cholinesterase inhibitor), physical exercise, cognitive training, and some compensatory strategies. 

Cognitive changes occur because of changes in brain chemicals such as dopamine or acetylcholine. There are also non-PD related factors that can affect cognition such as hearing loss, vision loss, medications, underlying strokes, or head trauma. 

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

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

Please see below for notes on the April 7th session.


– Joëlle Kuehn

“Understanding Thinking Changes in Parkinson’s” – Webinar notes

Speaker: Jennifer Goldman, MD, movement disorder specialist, Northwestern University Feinberg School of Medicine, Chicago

Webinar Host:  Parkinson’s Foundation

Webinar Date:  April 7, 2021 

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

What is cognition?

  • Mental processes of how we:
    • Perceive the world
    • Interact with the world
    • Acquire knowledge and understand things through our thoughts, experiences, senses
  • Cognitive domains (which put similar cognitive features into one area):
    • Attention
    • Learning and memory
    • Working memory
    • Comprehension
    • Language
    • Judgement and problem solving
    • Reasoning
    • Visual spatial functioning
  • In Parkinson’s Disease (PD) we focus on five:
    • Attention
    • Working memory
      • Remembering something while you are thinking of something else
      • Other memory: facts, knowledge, procedural
      • Short-term: something you were just told
      • Long-term: where you got married, grew up, high school
    • Executive function
      • Ability to plan, organize, stop/start activities, mental flexibility
      • Ex. paying bills, driving, following a recipe
    • Language
      • Word finding
    • Visual spatial function 
      • Where we are in our environment, judgement of distances
      • Hard time navigating around, wrong turns while driving, getting lost

To help people, give choices, prompts or cues.

Cognition Anatomy and Processes of the Brain:

  • Areas of the Brain:
    • Basal ganglia
    • Frontal lobe
    • Temporal lobe
    • Parietal lobe
    • Occipital lobe
    • Visual spatial and visual perceptual processing

Why cognitive changes occur in PD:

  • Changes in brain chemicals
    • Dopamine 
      • Attention
      • Working memory
      • Executive function
    • Acetylcholine
      • Attention
      • Working memory
      • Gait and balance
    • Lewy body: pathological hallmark of PD that we see under a microscope as a protein aggregate

How do we define cognitive changes in PD?

  • Bradyphrenia: slow thinking
  • Mild cognitive impairment (MCI): not affecting someone’s ability to do day-to-day tasks
  • Dementia: gradual process, develops over years, more than one area of cognitive are affected, changes are significant enough to affect day-to-day life (work, tasks at home like paying bills, cooking, driving)
    • Dementia in PD is different than dementia in Alzheimer’s 
      • More common in PD to have certain cognitive domains affective (attention, working memory, executive function, visuo spatial deficits)
      • In Alzheimer’s, memory deficits are central (can also have many other things affected)
      • Can have mixed pathologies, PD patients can have changes in their brain that reflect Alzheimer’s

How common are cognitive changes in PD?

  • Frequencies can vary by study
  • Some say mild cognitive impairment may occur in 25-50% of people with PD
  • Can be present at time of diagnosis or early in PD
  • Dementia: may develop in 40% of people with PD
  • Not every person with PD will experience cognitive changes or dementia

Motor and non-motor symptoms:

  • Greater sleepiness during daytime
  • Fatigue or apathy
  • Hallucinations
  • Psychosis
  • Mood changes
  • Depression
  • Anxiety

How do we assess cognition?

  • Ask and understand if someone is having challenges in these areas and do they represent a change from where they were previously
  • Good to establish a baseline assessment of cognition (just like you would have a baseline physical assessment)
  • Have repeated assessments of cognition over time to see if anything changes
  • Tests can be short (screening assessments) or long (neuropsychological testing batteries)
  • Important to understand how cognitive changes affect someone’s function (what does this mean on a day to day basis at home, work)

Non-PD factors affecting cognition:

  • Important to exclude in case they may be contributing to someone’s cognitive changes
  • Hearing loss
  • Vision loss
  • Underlying strokes, seizures or head trauma 
  • Medications 

Management of cognitive changes in PD:

  • Cognitive changes are gradual
    • If something happens during a short period of time, the health care team needs to look for other causes (infections, head trauma, underlying stroke, new medication etc.)
  • Important to review all medications
  • Address sticky topics (can affect a person’s independence)
    • Driving
    • Working 
    • Paying bills
    • Managing accounts
  • There is always an adjustment (affect function, relationships, etc.)

Treating cognitive changes:

  • Rivastigmine: only FDA-approved medication for PD dementia
    • Cholinesterase inhibitors
  • Can be treated in research studies (but a lot are small and don’t show an impact of the medicines)
  • Lots of different studies to participate in
  • Non-pharmacological therapies;
    • Physical exercise
    • Cognitive training
    • Mindfulness 
  • Compensatory strategies
    • Keeping a list
    • Putting labels on items
    • Writing things down
    • Having pull reminders

Question & Answer:

Question: How do you know if a cognitive problem is caused by PD, or is a symptom of dementia for Alzheimer’s?

Answer: A way we can distinguish between PD or a different symptom is looking at the profile of cognitive changes and the timing of the symptoms. In someone with Alzheimer’s, it’s more typical that their first symptoms relate to thinking and memory. We can also use neuropsychological testings, biomarkers, or scans like MRIs. 

Question: Is there any way in your early years of PD to know if you will experience cognitive changes?

Answer: There are some clues, such as certain genetic types, or types of PD (GBA mutations have a higher rate of cognitive and neuropsychiatric symptoms). History of prior head trauma and strokes are also possible clues. 

Question: Do you have strategies to help with executive functioning?

Answer: Executive function is broad, it includes staying organized, staying on task, multi-tasking, mental flexibility. Some strategies could be to take some tasks and try to break them down into smaller increments to have them manageable, keep lists, and involve family members. Give yourself time when shifting from one task to another. Speech-language pathologists and occupational and physical therapists can help as well. 

Question: If you are noticing changes in your partner with PD, how to bring it up?

Answer: It can be hard to bring up these topics. It’s important to bring it up in a non-confrontational and non-judgemental way. 

Question: Are there any blood tests to see if you’re deficient in nutrients that can affect cognitive and execute function?

Answer: We can sometimes use blood tests to see if other issues are involved (B12 levels, thyroid issues). 

Question: Is there anything a person with PD can do to minimize the chances of cognitive decline?

Answer: We want to be as proactive as possible. We’re noticing trends in research such as being active mentally (reading, hobbies, work, ways to keep the brain active and engaged), keeping up a social network and environment. 

Question: How do you treat mood symptoms such as anxiety and depression?

Answer: Anxiety and depression can be common in PD throughout its course. I’d consult a psychiatrist, or a social worker.

Question: Regarding the language piece of the five domains…  Is it common?

Answer: We most typically hear that people have challenges in finding the right words, it’s slow to get from the brain through the mouth to be said. People’s sentences can be reduced. Word substitutions may not be as common in PD.

Question: What impact does sleep and REM disorder have on cognition?

Answer: Sleep can be affected in PD in many ways, such as trouble with nighttime sleep, dream enactment, sleepiness during the day. There’s an importance for getting as best of a good night’s sleep as possible. REM sleep disorder can precede the onset of PD motor symptoms for decades, and can help us see who might develop PD. Medicine can make people drowsy during the day, and depression or apathy can also cause drowsiness. Some of the dopamine medicines can be linked to daytime sleepiness. Short naps can help, but don’t let them get too long. 

Question: Is there any research in cognition and PD you can share?

Answer: There’s a lot of research going on, and there is a lot of interest in non-motor and psychiatric issues.  You can find clinical studies near you at clinicaltrials.gov, and some are looking at cognitive medications or rehabilitation strategies.