Risks and Benefits

One of the key areas of debate at the 2014 Rallying to the Challenge meeting at The Van Andel Research Institute in Grand Rapids was the understanding of Risk and Reward. Risk and reward is personal. It will change depending on how long someone has been living with Parkinson's, doctors and patients and regulators will all have their own interpretation.

The PM team has been exploring this in more depth and is developing a simple questionnaire to help understand and define an individual's risk and reward and through the Research Club, Jon Stamford has been investigating how judgement can be affected by Parkinson's.

A Question of Judgement

Jon StamfordThe vast majority of us in the patient community take medication for our condition. And as often as not we do so without second thoughts to the effects these medications have on us. But of course the medications have profound effects on our brains and minds. In many respects that's why we take them. The majority of the medicines available for Parkinson's acts, directly or indirectly, on the dopamine systems in the brain. The therapeutic effects are mediated through the corpus striatum and putamen. At the same drugs also act on other dopamine systems in the brain in the limbic system and cortex. These systems control many aspects of behaviour including impulsivity and executive function. They are key components of decision-making processes.

Decision-making in the brain is of course based on perception and judgement. Our ability to assess risk and reward is a key aspect of judgement. Gamblers for instance have an entirely different approach to risk compared to those who do not gamble. In many respects, and I recognise that this is simplistic, gamblers have an overactive limbic and cortical dopamine system. In biochemical terms, this makes gamblers more amenable to reward, and encourages them to take greater risks.

This is also precisely what our medications do. They boost the dopamine function in the limbic system and cortex, encouraging us to take greater risks. This can manifest itself in gambling, or in other reward based behaviour such as shopping, Internet obsession, and hypersexuality. In essence, dopaminergic drugs have the capacity to scramble judgement.

We make judgements all the time. Whether the road is clear enough in both directions to safely cross. Whether one can have a glass of wine before driving home. Whether anyone saw you take the last chocolate. All of these judgements and many more can be influenced by our medication regime in ways that may be subtle and unnoticed or immediately obvious.

The latter are, in some ways, easier to deal with. When an effect is obvious such as a sudden interest in gambling, it is maybe easier to seek help. When an effect is subtle, it may be easier to deny it than to admit a problem. And this of course extends also to decisions we make about our own health care. For instance, if considering deep brain stimulation, it is possible that one's decision may be different in a drug naive state rather than in a less risk averse, highly medicated condition.

Judgement is exercised all the time. It's interesting to speculate on whether our judgement differs throughout the course of our illness.