Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS): Process, format, and clinimetric testing plan

This article presents the revision process, major innovations, and clinimetric testing program for the Movement Disorder Society (MDS)-sponsored revision of the Unified Parkinson's Disease Rating Scale (UPDRS), known as the MDS-UPDRS. The UPDRS is the most widely used scale for the clinical study of Parkinson's disease (PD). The MDS previously organized a critique of the UPDRS, which cited many strengths, but recommended revision of the scale to accommodate new advances and to resolve problematic areas. An MDS-UPDRS committee prepared the revision using the recommendations of the published critique of the scale. Subcommittees developed new material that was reviewed by the entire committee. A 1-day face-to-face committee meeting was organized to resolve areas of debate and to arrive at a working draft ready for clinimetric testing. The MDS-UPDRS retains the UPDRS structure of four parts with a total summed score, but the parts have been modified to provide a section that integrates nonmotor elements of PD: I, Nonmotor Experiences of Daily Living; II, Motor Experiences of Daily Living; III, Motor Examination; and IV, Motor Complications. All items have five response options with uniform anchors of 0 = normal, 1 = slight, 2 = mild, 3 = moderate, and 4 = severe. Several questions in Part I and all of Part II are written as a patient/caregiver questionnaire, so that the total rater time should remain approximately 30 minutes. Detailed instructions for testing and data acquisition accompany the MDS-UPDRS in order to increase uniform usage. Multiple language editions are planned. A three-part clinimetric program will provide testing of reliability, validity, and responsiveness to interventions. Although the MDS-UPDRS will not be published until it has successfully passed clinimetric testing, explanation of the process, key changes, and clinimetric programs allow clinicians and researchers to understand and participate in the revision process.

Neuropathic features in fragile X premutation carriers

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a progressive neurological condition occurring in fragile X premutation carriers, predominantly males, and resulting in CNS dysfunction including tremor, ataxia, Parkinsonism, and cognitive decline. Neuropathic signs have also been described. The objective of this study was to compare neuropathic signs in fragile X premutation carriers versus controls and determine the relationship of these signs to CGG repeat length and tremor/ataxia. A neuropathy scale was utilized to compare distal tendon reflexes and vibration sense in subjects from a large cohort of carriers and controls undergoing neurological exam and structured videotaping sessions for movement disorder rating. The male carrier group displayed more impairment on total neuropathy, vibration and reflex scores than the corresponding control group, while female carriers were not significantly different from controls. In males, after correction for age effects, there was a correlation between CGG repeat length and both total neuropathy and reflex impairments. Age-adjusted partial correlation analyses showed an association between neuropathy scores and severity of ataxia but not tremor in carrier males and females. These data suggest that neuropathic signs are associated with the fragile X premutation, presumably occurring through the same mechanism proposed for CNS disease, namely, toxicity from expanded-CGG-repeat FMR1 mRNA.

DLB and PDD boundary issues: Diagnosis, treatment, molecular pathology, and biomarkers

For more than a decade, researchers have refined criteria for the diagnosis of dementia with Lewy bodies (DLB) and at the same time have recognized that cognitive impairment and dementia occur commonly in patients with Parkinson disease (PD). This article addresses the relationship between DLB, PD, and PD with dementia (PDD). The authors agreed to endorse "Lewy body disorders" as the umbrella term for PD, PDD, and DLB, to promote the continued practical use of these three clinical terms, and to encourage efforts at drug discovery that target the mechanisms of neurodegeneration shared by these disorders of alpha-synuclein metabolism. We concluded that the differing temporal sequence of symptoms and clinical features of PDD and DLB justify distinguishing these disorders. However, a single Lewy body disorder model was deemed more useful for studying disease pathogenesis because abnormal neuronal alpha-synuclein inclusions are the defining pathologic process common to both PDD and DLB. There was consensus that improved understanding of the pathobiology of alpha-synuclein should be a major focus of efforts to develop new disease-modifying therapies for these disorders. The group agreed on four important priorities: 1) continued communication between experts who specialize in PDD or DLB; 2) initiation of prospective validation studies with autopsy confirmation of DLB and PDD; 3) development of practical biomarkers for alpha-synuclein pathologies; 4) accelerated efforts to find more effective treatments for these diseases.

Open-label flexible-dose pilot study to evaluate the safety and tolerability of aripiprazole in patients with psychosis associated with Parkinson's disease

Psychosis affects at least 5% to 8% of medication-treated patients with idiopathic Parkinson's disease (PD). Treatment options include reducing medications used for the treatment of PD-related motor symptoms or introducing an atypical antipsychotic drug. Only clozapine has been demonstrated to be efficacious and tolerated in double-blind controlled trials. This study evaluated the effect of aripiprazole, an atypical antipsychotic, on psychosis in PD in an open-label pilot study. Fourteen patients meeting entry criteria were started on aripiprazole 1 mg/day and titrated up to a maximum dose of 5 mg as needed. Subjects were evaluated on the Unified Parkinson's Disease Rating Scale (UPDRS) part III for motor function, the Neuropsychiatric Inventory (NPI), and the Brief Psychiatric Rating Scale (BPRS) for psychiatric response. Statistically significant improvement in mean BPRS and positive BPRS subscales occurred with open-label aripiprazole, but eight subjects discontinued the study due to worsened Parkinsonism (three), worsened psychosis (two), worsening of both (two), and lack of efficacy (one). While some patients had a favorable response, aripiprazole was associated with an exacerbation of motor symptoms. In this small study on psychosis in PD, aripiprazole did not appear promising.

Apolipoprotein E Gene Polymorphism, Total Plasma Cholesterol Level, and Parkinson Disease Dementia

BACKGROUND

Apolipoprotein E gene (APOE) polymorphism is an important determinant for the development of various cardiovascular and neurodegenerative disorders. There have been conflicting reports of association of APOE polymorphism with dementia in Parkinson disease (PD).

OBJECTIVE

To determine the relationship between APOE polymorphisms and plasma cholesterol concentration, and PD with dementia (PDD).

DESIGN

Four-year (1999-2002) case-control study.

SETTING

Academic medical center with inpatient and outpatient movement disorders services. Patients Consecutive white patients of the same ethnic background with PD.

INTERVENTIONS

Strict clinical, neuropsychological, and neuroimaging criteria were used to exclude dementia with Lewy bodies, Alzheimer disease, and vascular dementia. Findings were compared in 2 clinical groups, including 98 patients (47 men and 51 women; mean age, 71 years) with PDD and 100 patients (52 men and 48 women; mean age, 62 years) with PD without dementia.

MAIN OUTCOME MEASURES

Analysis of APOE genotypes and allelic frequency (polymerase chain reaction) and plasma cholesterol concentration (enzymatic assay) were evaluated by a clinician blinded to the clinical diagnosis, and findings were compared between the groups with PDD or PD without dementia. Multiple stepwise regression analysis and the Spearman rank correlation coefficient were used to evaluate relationships between dementia and both APOE polymorphism and cholesterol concentration. Statistical significance was set at P<.05.

RESULTS

Epsilon4 allele frequencies were similar in PDD and PD without dementia (16.8% vs 19%, respectively). Cholesterol concentration, APOE genotypes, and allelic frequencies did not relate to PDD.

CONCLUSIONS

In contrast to Alzheimer disease, when PDD is carefully defined, it is clearly not associated with APOE polymorphisms or with a distinctive plasma cholesterol profile. Ongoing longitudinal follow-up with emphasis on autopsy recruitment will enable further analyses of biochemical alterations underlying PDD.

Sarizotan as a treatment for dyskinesias in Parkinson's disease: A double-blind placebo-controlled trial

The objective of this study is to conduct a dose-finding study of sarizotan in Parkinson's disease (PD) patients with dyskinesia to identify a safe dose and to identify a sensitive dyskinesia rating measure. Sarizotan is a novel compound with full 5-HT(1A) agonist properties and additional high affinity for D(3) and D(4) receptors. An open label study documented improvements in PD patients with levodopa-induced dyskinesia. There is no precedent for study designs or outcome measures in pivotal trials of antidyskinesia therapies. The approach used here was a multicenter, randomized, placebo-controlled, double-blind, parallel study. Included were PD patients optimized to levodopa and dopaminergic drugs with moderately disabling dyskinesias present greater than or equal to 25% of the waking day. Interventions included sarizotan 2, 4, or 10 mg/day or matching placebo, given in two doses. There were two outcome measures: the primary measure was change from baseline in diary-based on time without dyskinesia; the secondary measures were change from baseline in scores on the Abnormal Involuntary Movement Scale (AIMS), the composite score of Unified Parkinson's Disease Rating Scale (UPDRS) Items 32+33 (dyskinesia duration and disability) and total UPDRS. A total of 398 subjects were randomized, with 381 included in the intention-to-treat population. No significant changes occurred on sarizotan compared to placebo on any diary-based measure of dyskinesia or the AIMS score. The composite score of UPDRS Items 32+33 was significantly improved with 2 mg/day sarizotan, with a trend at 10 mg/day. Adverse events were not significantly different in sarizotan- and placebo-treated patients, but off time significantly increased with sarizotan 10 mg/day. Sarizotan 2 mg/day is a safe agent in PD patients with dyskinesia. To test its role in abating dyskinesia, future studies should focus on this dose and will use the composite score of UPDRS Items 32+33 as the primary outcome.

Age-related influences on the clinical characteristics of new-onset hallucinations in Parkinson's disease patients

The objective of this study was to determine the demographic influences on the sensory characteristics (pure visual vs. nonvisual or mixed visual/nonvisual) of new-onset hallucinations in Parkinson's disease (PD). We utilized 6-year longitudinal interview data from 60 PD patients who had never hallucinated at baseline and reinterviewed them at 6, 18, 48, and 72 months to assess the presence and type of hallucination that developed as the first form of hallucination. We analyzed data by Generalized Estimating Equations methods and by nonparametric tests. Over 6 years, 37 of 60 patients developed hallucinations, and the first hallucinations were pure visual in 18, pure nonvisual in 9, and mixed visual/nonvisual in 10. At the time of first onset of hallucinations, patients whose hallucinations were nonvisual or mixed were significantly older than those with purely visual hallucinations (mean age, 69.8+/-8.3 vs. 61.9+/-10.6; P=0.031). PD duration in the two groups, however, was statistically comparable (9.6+/-4.4 vs. 12.9+/-8.6 years). Though classically described as visual, hallucinations in PD frequently involve other sensory modalities. Age-related disinhibition may facilitate wider cortical activation in PD and potentiate aberrant signaling that invokes other types of hallucinations besides the classic visual forms.

Early cinematographic studies of generalized dystonia

Among movement disorders, dystonia is a particularly complex phenomenon and difficult to describe. For this reason, cinematographic documents were particularly important to the establishment of this disorder within the neurological nosology. The seminal 1944 article on dystonia by E. Herz anchored its arguments in moving film documentation, published with frame-by-frame demonstrations of dystonic patients. Although the original films that comprised the basis of this article have not been located, two related contemporaneous films, one by Herz in association with T.J. Putnam, and one by S.P. Goodhart and B.H. Balser, have been located. Incorporating standard and several innovative filming techniques, these films and their accompanying text material capture the particular movements of dystonia, revealing the anatomical patterns of the twisting spasms, and emphasize their action exacerbation. The films demonstrate the variety of dystonic movements appreciated during this period, consider psychogenic, postencephalitic, and hereditary forms, and refer to the treatment of dystonia by surgery and plaster casts.

Movement disorders associated with encephalitis lethargica: a video compilation

Encephalitis lethargica (EL; epidemic encephalitis; von Economo's disease) often presented with a movement disorder, and the motor consequences of postencephalitic parkinsonism (PEP) were characteristic of the chronic sequelae of this condition. PEP was similar to Parkinson's disease but was more variable and had some distinct features such as oculogyric crises. Although two previous publications have included video images of the movement disorders associated with EL and PEP, the sequences presented were typically short, showed only a few patients, and did not include the work of several neurologists who had the foresight to preserve filmed images of their patients. We describe the most complete record of EL and PEP moving images that have been preserved and make them available in edited form.

The malignant course of "benign hallucinations" in Parkinson disease

OBJECTIVE

To monitor progression of "benign hallucinations" in Parkinson disease (PD).

METHODS

We searched our data repository for subjects with PD with 3 sets of neuropsychological testing during 3 years and Unified Parkinson's Disease Rating Scale thought disorder scores taken at 4- to 12-month intervals during this period. We found 48 patients with benign hallucinations, defined as a thought disorder score of 2 (benign hallucinations, insight retained), receiving no treatment for hallucinations. We followed up thought disorder scores under best medical management for at least 3 years or until a thought disorder score of 3 (loss of insight) or 4 (delusions) occurred. In subjects whose thought disorder scores remained at 2, we assessed neuroleptic use and decreases in PD medications to abate hallucinations.

RESULTS

Most subjects (81%) progressed to thought disorder scores of 3 or 4. In 7 (78%) of 9 subjects who retained a thought disorder score of 2, PD medications were reduced to treat hallucinations, and 3 subjects (33%) also received neuroleptics. If the composite end point (any of the criteria) was used, 96% of subjects progressed, with only 2 subjects continuing with stable, untreated benign hallucinations.

CONCLUSIONS

Because hallucinations progress, the concept of benign hallucinations is prognostically misleading. Though hallucinations with retained insight may be "benign" for the moment, they portend serious consequences. The term benign hallucinations of PD should be considered generally unsound and dropped from operative vocabulary.

Motor function in Parkinson's disease and supranuclear palsy: simultaneous factor analysis of a clinical scale in several populations

BACKGROUND

In order to better understand the similarities and differences in the motor behaviour of different groups of patients, their scores on the Motor Examination section of the Unified Parkinson's Disease Rating Scale (UPDRS) were analysed simultaneously. The three groups consisted, respectively, of patients with Parkinson's disease (PD) on medication, patients with Parkinson's disease withdrawn from anti-parkinsonian medication for at least 12 hours, and patients diagnosed with a specific Parkinsonism syndrome: Progressive Supranuclear Palsy (PSP).

METHODS

A total of 669 consecutively sampled patients from three separate hospital-based clinics participated (294 PD on medication; 200 PD off medication: 175 PSP). The Motor Examination section of the UPDRS was administered by neurologists at the three participating clinics. The patient scores on each item were recorded. To assess similarities and differences among the components of the UPDRS in these samples, we performed simultaneous or multigroup factor analysis on the covariance matrices of the three groups. In addition, it was investigated whether a single model for the Motor Examination section of the UPDRS could be developed which would be valid for all three groups at the same time.

RESULTS

A single six-dimensional factor solution was found that fitted all groups, although this was not straightforward due to differences between the tremor-at-rest variables. The factors were identified as Tremor-at-rest, Postural Tremor, Axial Dysfunctioning, Rigidity, Left Bradykinesia and Right Bradykinesia. The analysis also pointed to a somewhat lower lateralization in bradykinesia for PSP patients. The groups differed in intensity of motor impairment, especially with respect to Tremor-at-Rest, but the overall relationships between the variables were shared by the three groups. In addition, apart from the common factor structure evidence of differences in body part-specific and motor-specific variances was found.

CONCLUSION

From a clinical point of view, the analyses showed that using the Motor Examination section of the UPDRS is also appropriate for patients with PSP, because the correlational structure of the items is directly comparable to that of Parkinson's patients. Methodologically, the analysis of all groups together showed that it is possible to evaluate similarities and differences between factor structures in great detail.

Safety of rasagiline in elderly patients with Parkinson disease

The authors examined age effects on adverse events from two randomized, controlled trials of rasagiline, comparing younger (younger than 70 years) and older (70 years and older) subjects. Older patients were more prone to serious adverse effects than younger patients, but there was no statistical interaction between age and rasagiline exposure. This absence of an age-rasagiline interaction suggests that rasagiline does not require special safety precautions for elderly subjects with Parkinson disease.

Hallucinations in Parkinson disease in the prelevodopa era

Whether chronic hallucinations belong to the natural history of untreated Parkinson disease (PD) remains undetermined. For early authors such as Gowers or Charcot and his followers, hallucinations that occurred in the course of PD either accompanied the final phase of the disease or reflected comorbidities. However, a few authors observed that hallucinations could occur in PD patients with severe depression, confusion, or dementia. Interest in hallucinations with parkinsonism increased with the outbreak of von Economo encephalitis, as they were more frequent than in PD, provoking new pathophysiologic questions. Later studies on mental symptoms in parkinsonism were often based on series that pooled patients with PD and postencephalitic syndromes, confounding a clear analysis. It remains difficult to estimate the prevalence of hallucinations in the natural course of PD before the introduction of levodopa therapy. The lack of prospective studies, the wide early use of anticholinergics and ergots compounds, and the absence of dementia with Lewy bodies in the nosology of the time are further limitations. Even with these limitations, historical descriptions of PD from the prelevodopa era suggest that hallucinations may be part of PD itself, especially in the context of late dementia, depression, or nonspecific encephalopathy.

Non-linearity of Parkinson's disease progression: implications for sample size calculations in clinical trials

BACKGROUND

Estimation of sample size for long-term studies of neuroprotection in Parkinson's disease requires information on expected clinical decline. Values may be obtained by analyzing existing long-term data sets or by prediction models of clinical decline applied to available data from shorter-term trials. The most commonly used measure to track clinical decline is the Unified Parkinson's Disease Rating Scale (UPDRS) but this measure is also affected by symptomatic therapy. Models can help better understand behavior of the UPDRS after initiation of symptomatic therapy when scores will improve and eventually start deteriorating again.

PURPOSE

To understand how UPDRS scores progress after initiation of symptomatic therapy and how this progression impacts sample size calculations.

METHODS

We developed a non-linear model of UPDRS after introduction of symptomatic therapy. The model is specified as a non-linear mixed effects model and is applied to three different data sets from clinical trials. The model is then used to produce estimates for the change in UPDRS and its associated variance for a period of up to five years of follow-up. The estimates produced by the model serve as the basis for sample-size calculations for different lengths of follow-up (one through five years) and for different values of clinically meaningful change in UPDRS.

RESULTS

Despite differences in the short-term benefit of the dopaminergic drugs, after a period of approximately six months UPDRS scores progress linearly at an estimated rate of approximately three points a year. The sample size that is required for a clinical trial where the baseline coincides with initiation of symptomatic therapy is very large. On the other hand, if baseline is set at six months after initiation of symptomatic therapy then the sample size required decreases with length of follow-up.

LIMITATIONS

Model specification and estimation is based on a set of simplifying assumptions regarding the progression of individual level UPDRS scores.

CONCLUSIONS

Sample size calculations based on these estimates indicate a substantial reduction in sample size if patients are required to be on symptomatic treatment for a period of time before being randomized to a neuroprotective trial.

Does seasonal variation affect hallucinations in PD? a longitudinal study

The objective of this study was to examine the chronobiology of visual hallucinations in Parkinson's disease (PD) patients to test whether hallucinations are more severe during darker months (winter) than summer months. We extracted longitudinal data on the UPDRS Thought Disorder (TD) score, taken as part of regular patient management on sequential visits through a 1-year cycle in hallucinating PD patients. To reduce the confounding effects of medication adjustments, analysis was restricted to patients with a baseline evaluation that did not involve a medication change. The primary outcome was the seasonal change in hallucination severity, defined as a change in TD score or neuroleptic use. Using Wilcoxon rank-sum tests, we compared the exacerbation of hallucination by season, focusing on winter (December through February) versus summer (June through August). A total of 51 hallucinating patients met entry criteria, and their longitudinal data were analyzed. There was no difference in hallucination severity with changing season; the level of wintertime exacerbation was no greater than summertime exacerbation (P = 0.42). Although hallucinations frequently develop in dimmed environments and evening hours, the darkness of wintertime does not exacerbate hallucinations in PD subjects on stable medications. Because we found no evidence of seasonal variations, we cannot recommend phototherapy or other strategies affecting chronobiological systems as research priorities to treat PD hallucinations. (c) 2006 Movement Disorder Society.

Charcot in contemporary literature

Charcot and his medical observations remain an enduring topic of scientific study in neurology, but he is also the topic of modern literary works. This essay examines the depiction of Jean-Martin Charcot (1825-1893) as a character in late-twentieth-century literature as an index of the contemporary nonmedical literary public's interest in neurology and Charcot. It focuses on three contemporary works that involve Charcot as a central figure with comparison between primary source documents and the rendered context, character development, and plot lines of these literary works. The two French novels [Slumbers of Indiscretion and Dr. Charcot of the Salpêtrière] and one American play [Augustine (Big Hysteria)] approach Charcot and neurology with differing levels of historical accuracy. All create a figure of authority, each with a different coloration of the balance between power and its abuse. Two focus almost exclusively on his work with hysteria and inaccurately amplify Charcot's concern with symbolic sexual conflict as the origin of hysteria and fictionalize more extensive interactions with Freud than historical documents support. The three works demonstrate that Charcot retains an enduring fascination with an enigmatic personality, a controversial career, and a pivotal role in the development of studies involving the brain and behavior. Neurologists should not look to these works as replacements for more seriously composed historical studies, but as enrichments anchored in the imaginative possibilities of Charcot and his fin de siècle era.

What's new? Clinical progression and staging of Parkinson's disease

Several new advances facilitate current understanding of the progression of Parkinson's disease. The application of statistical modeling techniques has helped to estimate rates of clinical decline in the context of symptomatic interventions. These approaches may allow a new means for testing neuroprotection effects even when patients are on dopaminergic treatment. Further, the development of new rating scales, specifically the Movement Disorder Society-initiated revision of the Unified Parkinson's Disease Rating Scale has capitalized on a greater clinical appreciation of non-motor elements of Parkinson's disease. Finally, adaptations of new technologies that are computer-based and enable data transmission from at-home environments allow researchers to capture disease impairment and disability with potentially greater precision and much more frequently than permissible in a hospital clinic or practice setting.

Gilles de la Tourette syndrome: Patient's knowledge and concern of adverse effects

The objective of this study was to assess awareness and concern of neuroleptic (NL)-induced side effects in Gilles de la Tourette syndrome (GTS) patients. Although NLs are effective tic suppressants, they can be associated with various side effects. Data on patient knowledge and concern about side effects can guide educational efforts. One hundred consecutive GTS patients or parents in a tertiary referral medical center responded to a standardized, in-person questionnaire. They were given a list of 15 side effects and asked which could be ascribed to NLs (9) or not (6). Side effect concern was rated on a 0 (none) to 10 (extreme) scale. The mean age for the 100 patients was 19.4+/-14 years; 55 had a history of NL use, and 45 were NL-naive. Less than half the cohort met criteria for being well informed. Only one third of the listed NL side effects were accurately identified by at least 75% of the respondents. Patients with past or current NL treatment were more accurate in identifying NL side effects but less concerned about them than NL-naive patients. The side effects of greatest concern were seizures, tardive dyskinesia, thinking and emotion disturbances, and cardiac irregularities. Overall, patient awareness of NL side effects is insufficient, and although past exposure to NLs enhances knowledge, it decreases concern.

Single-blind clinical trial of psychotherapy for treatment of psychogenic movement disorders

BACKGROUND

PMD are disabling, but lack any generally accepted treatment strategies.

DESIGN/METHODS

Ten patients with PMD received treatment with Psychodynamic Psychotherapy. Patients were assessed with psychiatric rating scales and the movement disorder was rated by a blinded rater with the Psychogenic Movement Disorder Rating Scale (PMDRS).

RESULTS

Total mean PMDRS (p = 0.0195), total PMDRS function scores (p = 0.0142), Hamilton depression scores (p = 0.009), Beck anxiety scores (p = 0.002), and GAF (p = 0.0083) all improved with psychotherapeutic intervention.

CONCLUSIONS

Psychotherapy and appropriate use of adjunct psychiatric medication can be a successful intervention for PMD.

Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium

The dementia with Lewy bodies (DLB) Consortium has revised criteria for the clinical and pathologic diagnosis of DLB incorporating new information about the core clinical features and suggesting improved methods to assess them. REM sleep behavior disorder, severe neuroleptic sensitivity, and reduced striatal dopamine transporter activity on functional neuroimaging are given greater diagnostic weighting as features suggestive of a DLB diagnosis. The 1-year rule distinguishing between DLB and Parkinson disease with dementia may be difficult to apply in clinical settings and in such cases the term most appropriate to each individual patient should be used. Generic terms such as Lewy body (LB) disease are often helpful. The authors propose a new scheme for the pathologic assessment of LBs and Lewy neurites (LN) using alpha-synuclein immunohistochemistry and semiquantitative grading of lesion density, with the pattern of regional involvement being more important than total LB count. The new criteria take into account both Lewy-related and Alzheimer disease (AD)-type pathology to allocate a probability that these are associated with the clinical DLB syndrome. Finally, the authors suggest patient management guidelines including the need for accurate diagnosis, a target symptom approach, and use of appropriate outcome measures. There is limited evidence about specific interventions but available data suggest only a partial response of motor symptoms to levodopa: severe sensitivity to typical and atypical antipsychotics in approximately 50%, and improvements in attention, visual hallucinations, and sleep disorders with cholinesterase inhibitors.

Transcultural comparison of psychogenic movement disorders

Prompted by the lack of cross-cultural comparative data, and because a better understanding in the different clinical presentations of psychogenic movement disorders (PMDs) is relevant to neurological assessment and interventions, we compared the phenomenology, anatomical distribution, and functional impairment of PMDs in the United States and Spain. Consecutive patients diagnosed with PMD by a movement disorder specialist from one US site and from eight Spanish university centers were included in the study. The two groups were similar in their movement types, anatomical distribution, and functional impairment. PMDs were more prevalent in women than in men and were most common in upper and lower extremities. Gait and speech dysfunctions were distributed similarly in both countries. We found action tremor to be the most frequent PMD in both countries.

Hallucinations and sleep disorders in PD: six-year prospective longitudinal study

OBJECTIVE

To prospectively assess the relationship of hallucinations to sleep disorders in patients with Parkinson disease (PD) over 6 years.

BACKGROUND

Several studies suggest an association between hallucinations and sleep disruption, but no longitudinal study has examined their progression and relationship, nor whether sleep alterations predict future hallucinations.

METHODS

Eighty-nine PD patients were recruited to fill cells of normal sleep without hallucinations (n = 20); sleep fragmentation only (n = 20); vivid dreams/nightmares (n = 20); hallucinations with insight (n = 20); hallucinations without insight (n = 9). At baseline, 6 months, 18 months, 4 years, and 6 years, sleep disorders and hallucinations were assessed by standardized scales with the longitudinal data analyzed by generalized estimating equations and other nonparametric tests.

RESULTS

At 6 years, we could account for all subjects (49 interviewed, 40 deceased or too ill for interview). Hallucination prevalence and severity increased over time (p < 0.0001). The odds of being a hallucinator increased by a factor of 1.39 at each successive time point. Sleep disorders, however, fluctuated widely among patients and time points, with no evidence of progression in severity (p = 0.73). The prevalence of sleep fragmentation did not differ between subjects with vs without hallucinations (OR = 1.43, p = 0.13). The presence of vivid dreams/nightmares, however, was highly correlated with the concurrent presence (OR = 2.32) and severity of hallucinations (OR = 3.02, both p < 0.0001). Vivid dreams/nightmares among non-hallucinators did not predict future development of hallucinations (OR = 0.94, p = 0.51).

CONCLUSIONS

Hallucinations and global sleep disorders follow different patterns of progression in Parkinson disease and are separate behavioral abnormalities. Sleep alterations are not necessarily harbingers of hallucinations.