Two routes to value-based decisions in Parkinson's disease: differentiating incremental reinforcement learning from...

Patients with Parkinson's disease are impaired at incremental reward-based learning. It is typically assumed that this impairment reflects a loss of striatal dopamine. However, many open questions remain about the nature of reward-based learning deficits in Parkinson's. Recent studies have found that a combination of different cognitive and computational strategies contribute even to simple reward-based learning tasks, suggesting a possible role for episodic memory. These findings raise critical questions about how incremental learning and episodic memory interact to support learning from past experience and what their relative contributions are to impaired decision-making in Parkinson's disease. Here we addressed these questions by asking patients with Parkinson's disease (n=26) both on and off their dopamine replacement medication and age- and education-matched healthy controls (n=26) to complete a task designed to isolate the contributions of incremental learning and episodic memory to reward-based learning and decision-making. We found that Parkinson's patients performed as well as healthy controls when using episodic memory, but were impaired at incremental reward-based learning. Dopamine replacement medication remediated this deficit while enhancing subsequent episodic memory for the value of motivationally relevant stimuli. These results demonstrate that Parkinson's patients are impaired at learning about reward from trial-and-error when episodic memory is properly controlled for, and that learning based on the value of single experiences remains intact in patients with Parkinson's disease.