Cognitive Changes in Parkinson's
by Dr. Margery Hutter Silver
When my husband was diagnosed with Parkinson's disease 12 years ago, I was a little more fortunate than most PD partners. In my work as a neuropsychologist I had seen a number of Parkinson's patients, and I had seen the changes that come with Parkinson's disease. Most importantly, I understood the possible changes in cognition or thinking. I found that what has helped me most is understanding when things my husband does are related to PD and why he does them.
Parkinson's disease is primarily described as a movement disorder, so it often comes as a surprise when we realize how many other areas of functioning may be affected, including vision, emotions and the autonomic nervous system which controls things like bowel and bladder function. When cognition (thinking) is affected it is because of dopamine connections between the striatum and the frontal cortex of the brain. Melvin Yahr, who devised the Yahr and Hoehn Staging of Parkinson's has stated, "Even in the classic Parkinson's patient, there are deficits in the cognitive state… although these are relatively minor and not functionally impairing." But if changes do occur, they are often not addressed, and partners may find them more difficult to cope with than the motor problems because of their impact on relationships.
With Parkinson's, change may be seen in a number of cognitive functions. I will discuss these briefly, describing how they affect behavior. Then I will present some cognitive strategies that can help individuals manage or circumvent these changes.
Cognitive changes in PD:
This means slow thinking, just as bradykinesia means slow movement. This is why people with Parkinson's often need extra time to answer questions or make decisions. They can usually think things out; it just takes more time.
2. Attention and concentration.
Attention is often affected by reduced metabolism in the frontal areas of the brain, which are not receiving enough dopamine. This affects the ability to concentrate and to ignore distractions. Often what seem like memory problems are really attention problems. If someone's attention is not focused, he or she is not going to remember.
3. Executive functions.
This refers to a group of thinking abilities that "oversee" many activities of the brain. It has been said that impairment of executive functions "knocks on the door of personality." For example, if a brilliant successful businessman sits around the house because he is unable to plan his day, it does seem like a personality change. If we don't understand the role of Parkinson's, we might think he is being unmotivated and stubborn.
Executive functions include the abilities to initiate a task or activity on one's own, to plan (for instance, what you will do during the day), to organize tasks and materials, to sequence (arrange items or things to do in order), to prioritize, to shift between activities and conversational subjects, and to inhibit (stop or refrain) an action.
In Parkinson's disease, it is usually the retrieval of information that is impaired. Unlike Alzheimer's patients who cannot store things in memory, people with Parkinson's can get memories into storage (if they've paid attention), but they have difficulty recalling them. If they are given hints or multiple choices, they can usually remember accurately.
5. Visual-spatial abilities.
This term refers not to vision per se, but to how the brain interprets a visual image. People with Parkinson's may have difficulty judging distances and relationships between objects. This can interfere with reading maps, judging where the lines are when driving, or assembling things.
Cognitive strategies can be very effective for circumventing or managing the cognitive changes in Parkinson's. Here are some suggestions that can help:
Bradyphrenia. Speak more slowly and repeat if necessary to compensate for slower mental processing.
Attention and concentration. Be sure that the person's attention is engaged before starting a discussion or giving information. (You can't recall what you haven't really heard.) Talk yourself through a task to keep your attention focused.
Executive functions. Since planning and prioritizing are difficult, talk things over together and write down a plan with steps in order. Since getting started is hard, cueing may help; for example, "Let's start by brushing your teeth." Use reminding devices like alarm clocks or alarm watches to help get started (and help memory). To help a person with Parkinson's switch mentally to a new topic or task, announce clearly that you are now going to talk about (or do) something new.
Memory. Remind frequently of things to be done. Write lists and put them in a prominent place. Always put items, like car keys in the same place so you do not have to recall where they are. An excellent book filled with memory strategies is Managing Your Memory from National Rehabilitation Services.
Visual-spatial problems. Use verbal cueing-- that is, warn in advance of a curb or a turn when a person with Parkinson's is walking. Always give the person with Parkinson's verbal directions, not a map, to compensate for visual-spatial problems.
These strategies can be very helpful, but understanding is still the most important ingredient. Understanding why my husband does certain things, and that those behaviors are related to PD, has helped both my husband and me. It is easier for him when he understands that what's happening is caused by the disease, and it gives us the basis for sitting down together and trying to figure out our own strategies for dealing with these problems--as partners.
Dr. Silver is a neuropsychologist and Clinical Instructor in the Department of Psychiatry at Harvard University Medical School. She is co-author of Living to 100: Lessons in Living to your Maximum Potential at Any Age and Co-Editor of the Journal of Geriatric Psychiatry. She lives in Boston with her husband who has Parkinson's disease.
Reprinted with Permission.