Tips for identification and treatment of cognitive fluctuations in Parkinson's disease

O’dowd and colleagues discuss in a recent paper in Brain

One of the issues that arises frequently in our clinics in the idea of “cognitive fluctuations.” Check out our video on cognitive fluctuations in Parkinson’s, Dementia with Lewy Bodies, and Alzheimer’s. Many of the folks and families I take care of are frankly confused by the concept— and its treatment(s). In this week’s blog I would like to attack the notion of the cognitive fluctuation and what we can or cannot do about it. -Michael Okun

What are cognitive fluctuations?

Lewis and colleagues in a recent edition of Brain look at potential pathophysiology of the fluctuation.

• Cognitive fluctuations or fluctuating cognition: alternating periods of cognitive issues and “normal or near-normal performance.”

• During the low points of a cognitive fluctuation, there can be “pronounced variations in attention and alertness.”

A nice review article was recently published by Van Dyke in 2016.

Van Dyk K, Towns S, Tatarina O, et al. Assessing Fluctuating Cognition in Dementia Diagnosis: Interrater Reliability of the Clinician Assessment of Fluctuation. Am J Alzheimers Dis Other Demen. 2016;31(2):137-143. doi:10.1177/1533317515603359What is a behavioral approach to cognitive

What is a behavioral approach to cognitive

fluctuations.

Recent article on cognitive fluctuations in Practical Neurology

First, recognize the potential symptoms:

• Confusion or decreased alertness.

• Motor coordination issues

• Loss of short-term or long-term memory.

• Identity confusion

• Judgment issues.

  When I encounter cognitive fluctuations, I like to educate the family to recognize the “highs” and the “lows,” and to choose activities that are appropriate for each cognitive state. For example, more serious conversations should be saved for times of mental clarity— and alternative activities can be pursued during confusion or decreased attention.

What is a medication treatment for cognitive

fluctuations?

From openpr

Far and away, in our experience, the most effective medication approach is a cholinesterase inhibitor (Donepezil, Rivastigmine, other). In some cases, these medications can have a profound effect in improving cognitive fluctuations.

What is the difference between Parkinson’s disease

dementia and Lewy Body dementia related cognitive

fluctuations?

From a paper in Nature 2021 Weintraub and colleagues

There are technically no criteria to differentiate between the possible underlying causes of cognitive fluctuations. Usually one of three dementia syndromes is involved.

• Dementia with Lewy Bodies (sometimes called LBD)

• Parkinson’s disease dementia

• Alzheimer’s or related dementias

In my experience cognitive fluctuations are most common with Dementia in Lewy Bodies (DLB). In these cases, the dementia occurs within the first few years of a diagnosis.

Dementia can also occur during later years of Parkinson’s disease and is referred to as Parkinson’s disease dementia.

Finally, there can be fluctuations in cognition in Alzheimer’s, but in my experience they are not as profound as the fluctuations in the other two diagnoses.

To read more books and articles by Michael S. Okun MD check on Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonsFromTheBedside

He also serves as the Medical Advisor for the Parkinson’s Foundation.

To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.

The blog artist is Jonny Acheson.