A 68-year-old woman with a 3-year history of idiopathic Parkinson disease comes to the office with her husband for follow-up. The patient reports adequate control of motor symptoms with levodopa-carbidopa therapy but states that for the past month, she no longer spends time with her friends or participates in her church choir due to difficulty focusing. She sleeps restlessly most nights, resulting in daytime naps, and skips dinner because she is not hungry. Medical history is otherwise noncontributory, and the patient takes no other medications. Vital signs are within normal limits. Physical examination shows reduced facial expressions and mild slowing on repeated finger tapping but no significant tremors. Posture and gait are normal. Which of the following is the best next step in management?

Question

A 68-year-old woman with a 3-year history of idiopathic Parkinson disease comes to the office with her husband for follow-up.  The patient reports adequate control of motor symptoms with levodopa-carbidopa therapy but states that for the past month, she no longer spends time with her friends or participates in her church choir due to difficulty focusing.  She sleeps restlessly most nights, resulting in daytime naps, and skips dinner because she is not hungry.  Medical history is otherwise noncontributory, and the patient takes no other medications.  Vital signs are within normal limits.  Physical examination shows reduced facial expressions and mild slowing on repeated finger tapping but no significant tremors.  Posture and gait are normal.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

This patient reports adequate control of motor symptoms of Parkinson disease (PD) but has developed nonmotor symptoms that cause impairment. Her monthlong history of decreased interest and enjoyment of social activities, impaired concentration, sleep disturbance, low energy, and loss of appetite are consistent with depression, a common complication of PD that can affect up to 50% of patients. Depression may go unrecognized and undertreated in PD due to overlapping symptoms; for example, the PD symptoms of masked facies and bradykinesia are similar to the blunted affect and psychomotor retardation seen in major depression. The presence of sadness and deliberate social withdrawal due to anhedonia (difficulty enjoying previously pleasurable activities) can be helpful in differentiating depression from apathy (decreased motivation to speak or act), a common finding in patients with PD that may occur with or without depression. When motor symptoms are well controlled (ie, no tremors, normal gait), as in this patient, targeting depressive symptoms with antidepressants and/or cognitive-behavioral therapy would be the most appropriate next step in management. Selective serotonin reuptake inhibitors are commonly used as first-line antidepressants because of their favorable adverse effect profile. (Choice A) Adding a dopamine agonist would be appropriate if the patient's motor symptoms were not adequately controlled. A dopamine agonist is unlikely to improve the depression and may increase the risk for psychosis and impulse control disorders. (Choice C) Antipsychotics have a role in the treatment of psychosis, a frequent complication of PD treatment. They are not first-line treatments for depression. (Choice D) Although stimulants may be prescribed to treat fatigue in certain neurologic disorders, there is no established role for their use in the treatment of PD-related depression. (Choice E) Levodopa-carbidopa can cause somnolence; however, this patient's daytime naps appear to be due to depressive symptoms because they are associated with restless sleep and anhedonia. This patient's current dose of levodopa-carbidopa is effectively controlling her motor symptoms, and dose reduction would risk worsening motor symptoms. Educational objective: Depression is a common complication of Parkinson disease (PD) and is often undertreated because of overlapping symptoms of depression and PD (eg, psychomotor slowing [bradykinesia], blunted affect [masked facies]). Patients with depression can be treated with antidepressant medication, psychotherapy, or both. References: Drug choices and advancements for managing depression in Parkinson's disease. (http://www.ncbi.nlm.nih.gov/pubmed/31622207) Drug treatment strategies for depression in Parkinson disease. (http://www.ncbi.nlm.nih.gov/pubmed/31120798)

A 68-Year-Old Woman with a 3-Year History of Idiopathic Parkinson