New onset heightened interest or drive for gambling, shopping, eating or sexual activity in patients with Parkinson's disease: the role of dopamine agonist treatment and age at motor symptoms onset

Alterations of impulse control that have recently been associated with Parkinson's disease (PD) are serious behavioural disturbances with significant impact on PD patients and their families.A total of 193 consecutive PD patients with no history of psychiatric illness and 190 age/gender-matched healthy controls were queried on the presence of new onset heightened interest or drive for gambling, shopping, eating or sexual activity (GSES). Clinical data were retrieved from medical charts and interviews. logistic regressions models assessed risk factors for these specific troublesome behaviours. New or heightened interests or drives for GSES behaviours were reported by 27 patients (14% vs 0% for controls). Younger age at PD motor symptoms onset (OR = 0.99, p = 0.0172), male gender (OR = 1.10, p = 0.0576) and longer duration of treatment with dopamine agonists (DAs)(OR = 1.18, >/=6 years versus never treated, p = 0.0459) contributed additively to the risk of developing one or more of these behavioural features. New onset heightened interests or drives for GSES are not rare behavioural disturbances among patients with PD. Age, gender and duration of treatment with DAs have an independent and additive effect on the risk to develop such behavioural changes. Patients should be informed about potential treatment-associated behavioural changes.

Exaggerated crying and tremor with a cerebellar cyst

The authors describe clinical, neuropsychological, and neuroimaging findings in a 70-year-old man with a cystic lesion in the midline cerebellum. He presented with pathological crying in parallel to a worsening of his ataxia. This report suggests a role for the cerebellum in the regulation of emotional expression.

CGG repeat length correlates with age of onset of motor signs of the fragile X-associated tremor/ataxia syndrome (FXTAS)

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a late-onset neurological disorder among carriers of premutation CGG-repeat expansions within the FMR1 gene. Principal features of FXTAS include progressive action tremor and gait ataxia, with associated features of parkinsonism, peripheral neuropathy, dysautonomia, and cognitive decline. Although both clinical and neuropathologic features of FXTAS are known to be highly associated with CGG repeat length, the relationship between repeat length and age-of-onset is not known. To address this issue, the ages of onset of action tremor and gait ataxia were documented by history for 93 male carriers. For this cohort, the mean ages of onset were 62.6 +/- 8.1 years (range, 39-78 years) for tremor, and 63.6 +/- 7.3 years (range, 47-78 years) for ataxia; the mean CGG repeat number was 88.5 +/- 14 (range, 60-133). Analysis of the relationship between clinical onset and molecular measures revealed significant correlations between CGG repeat number and onset of both tremor (P = 0.001) and ataxia (P = 0.002), as well as overall onset (P < 0.0001). Our findings indicate that the CGG repeat number is a potential predictor of the age of onset of core motor features of FXTAS.

Onset and progression of dystonia in complex regional pain syndrome

Complex regional pain syndrome (CRPS) may lead to movement disorders (MDs) in some patients. Reliable information on the nature, chronology and clinical determinants of MDs in CRPS patients is lacking but could provide better insight in to the underlying pathophysiological mechanism. We retrospectively evaluated the clinical and temporal characteristics of MDs in patients with CRPS. Cox's proportional hazards model was used to evaluate factors influencing the onset of MDs. One-hundred and eighty-five patients suffered CRPS in one or more extremities. MDs occurred in 121 patients, with dystonia (91%) being the most prevalent. Sixty-two percent of these patients displayed dystonia in multiple extremities. Patients with dystonia were on average 11 years younger and more often had CRPS in multiple extremities. The interval between the onset of CRPS and dystonia in the first affected extremity varied from less than 1 week in 26% of the patients to more than 1 year in 27%. The hazard of developing dystonia in subsequent extremities increased with the number of extremities affected by dystonia. We conclude that dystonia in CRPS shows highly variable onset latency and is associated with younger age at onset and increased risk of developing dystonia in other extremities. The delayed onset and progression of dystonia in CRPS may indicate the involvement of a different underlying mechanism, possibly associated with maladaptive neuroplasticity.

Long-term psychological outcome of 1999 Taiwan earthquake survivors: a survey of a high-risk sample with property damage

OBJECTIVE

Severe natural disasters can cause long-term psychological impact on the survivors. This study aimed to examine the prevalence and risk factors of posttraumatic stress symptoms and psychiatric morbidity among survivors of the severe earthquake that occurred in Chi-Chi, Taiwan, in September 21, 1999.

METHODS

A total of 6412 earthquake survivors whose houses were destroyed by earthquake were recruited about 2 years after the disaster. They completed a self-report questionnaire assessing posttraumatic stress symptoms, psychiatric morbidity, and information of demographics, trauma exposure, and current living status.

RESULTS

The estimated rates of posttraumatic stress disorder caseness and psychiatric morbidity were 20.9% and 39.8%, respectively. Psychiatric morbidity occurred mainly in survivors who were female, older, with low education level, and currently living in a prefabricated house. The risk factors for posttraumatic stress disorder caseness were female sex, currently living in a prefabricated house, low education level, and experienced complete destruction of property.

CONCLUSION

These results showed that severe earthquake can cause long-term psychological impact in the survivors. The findings of risk factors suggest avenues for targeting postdisaster interventions.

Psychogenic tremor and related disorders

Psychogenic tremor is the most common form (55%) of all psychogenic movement disorders. Almost 75% of presenting patients are female. Onset is often abrupt. Preceding events include work related injuries and other accidents. Important clinical characteristic include variability of direction, amplitude and frequency. A positive entrainment test, presence of the co-contraction sign, absence of finger tremor and slowness of voluntary movements are suggestive of psychogenic origin. Co-morbidity with psychiatric disorders is common and includes somatoform disorders (35%), such as pain, diffuse sensory loss, conversion disorders and depression (14%). One fifth (21%) of patients are involved in litigation or compensation issues. Diagnosis is based on history, clinical signs and investigations. A multimodal approach including neuropsychiatric evaluation and psychotherapy should be offered. Prognosis, however, is relatively poor particularly if the condition has persisted for over a year and in the long-term up to 80-90% of patients continue to have abnormal movements.

Progression of tremor and ataxia in male carriers of the FMR1 premutation

Premutation alleles of the fragile X mental retardation 1 (FMR1) gene give rise to a late-onset movement disorder, fragile X-associated tremor/ataxia syndrome (FXTAS), characterized by progressive intention tremor and gait ataxia, with associated dementia and global brain atrophy. The natural history of FXTAS is largely unknown. To address this issue, a family-based, retrospective, longitudinal study was conducted with a cohort of 55 male premutation carriers. Analysis of the progression of the major motor signs of FXTAS, tremor and ataxia, shows that tremor usually occurs first, with median onset at approximately 60 years of age. From the onset of the initial motor sign, median delay of onset of ataxia was 2 years; onset of falls, 6 years; dependence on a walking aid, 15 years; and death, 21 years. Preliminary data on life expectancy are variable, with a range from 5 to 25 years.

Directional bias of limb tremor prior to voluntary movement

Taking a cue from recent discoveries of directional bias in microsaccades during visual fixation, we investigated directional bias in tremor during manual pointing. Subjects memorized and then performed patterns of alternating postures and voluntary movements. The directions of the tiny movements occurring during periods of intended stillness were predictive of subsequent target-directed movements such that in the horizontal axis, relative to baseline, the frequency of tremor decreased and the amplitude of tremor increased before horizontal movements, but not before vertical movements. This effect was less pronounced in the finger than in the arm, forearm, and hand. Possible explanations of the effect are based on eye-limb coupling, decreasing stiffness in the axis of forthcoming movement, and release of inhibition. The discovery of directionally specific preparatory activity suggests that the simple task of holding still before moving may provide a new window into the processes that allow for the translation of intentions into actions.

Tremor in multiple sclerosis

Tremor is estimated to occur in about 25 to 60 percent of patients with multiple sclerosis (MS). This symptom, which can be severely disabling and embarrassing for patients, is difficult to manage. Isoniazid in high doses, carbamazepine, propranolol and gluthetimide have been reported to provide some relief, but published evidence of effectiveness is very limited. Most trials were of small size and of short duration. Cannabinoids appear ineffective. Tremor reduction can be obtained with stereotactic thalamotomy or thalamic stimulation. However, the studies were small and information on long-term functional outcome is scarce. Physiotherapy, tremor reducing orthoses, and limb cooling can achieve some functional improvement. Tremor in MS remains a significant challenge and unmet need, requiring further basic and clinical research.

Cortical tremor (FCMTE: familial cortical myoclonic tremor with epilepsy)

For 15 years, 50 Japanese and European families with cortical myoclonic tremor and epilepsy were reported in the literature under various names. More recently, the acronym familial cortical myoclonic tremor with epilepsy (FCMTE) has been proposed for this new clinical entity based on both clinical and electrophysiological criteria: irregular postural myoclonic tremor of the distal limbs, familial history of epilepsy, autosomal dominant inheritance, and a rather benign outcome. The diagnosis is confirmed by electrophysiological features favoring cortical reflex myoclonus (enhanced C reflex at rest, giant somatosensory evoked potentials (SEPs), premyoclonus cortical spikes detected by the jerk-locked back-averaging method), and a good response to antiepileptic drugs. The genetic analysis of these families shows heterogeneity with a linkage to chromosome 8q24 for Japanese families, a linkage to chromosome 2p for Italian families, the exclusion of 8q24 locus for a Spanish family, and the exclusion of both loci for a Dutch family. The similarities of this syndrome with the group of myoclonic epilepsy suggest an abnormality of a gene encoding ion channels.

The prevalence of neuroleptic drug-induced tardive movement subsyndromes among schizophrenic and schizoaffective patients residing in the southern region of Israel

The aim of the current study was to assess the prevalence of tardive movement disorders (TMD) among a group of institutionalized schizophrenic and schizoaffective patients in southern region of Israel. Chronic schizophrenic and schizoaffective inpatients of a psychiatric hospital and its affiliated hostels were screened for the presence of TMD subsyndromes. Twenty percent (107 patients) of 523 patients with schizophrenia and schizoaffective disorder exhibited TMD. Of those with TMD, 36% had only one subsyndrome, whereas 64% had a combination of several TMD subsyndromes. With regard to patients with TMD, the most frequent TMD subsyndrome was tardive tremor (TT). TT appeared more often in males compared to females and at a younger age (44.3+/-8 vs. 54.3+/-11 years, P<0.04). TD appearing in combination with other TMD subsyndromes was significantly more prevalent among females than in males (57% vs. 35%; P<0.02). TMD generally appears in a combined fashion. Further prospective studies from different geographical areas are recommended.

Physical and psychomotor functioning of females the morning after consuming low to moderate quantities of beer

OBJECTIVE

Individuals in society typically consume alcohol in "standard" units (e.g., bottles/cans of beer, glasses of wine, shots of distilled spirits) over a reasonable period of time whereas in many hangover studies, participants consume a single large dose of alcohol relative to their body weight in a short period of time. The purpose of this study was to examine how consuming low to moderate "standard" quantities of alcohol over an evening affected subjective hangover ratings, physical, physiological, and psychomotor functioning of adult females the next morning.

METHOD

Twelve females consumed zero, two, four, or six bottles of beer (341 ml; 5% weight by volume) in a within-subjects design. Blood alcohol concentration, resting heart rate, resting blood pressure, and grip strength were measured prior to consumption, 1 hour after consumption, and the following morning (9 hours after consumption). In the morning, participants rated the presence of eight hangover symptoms, completed a four-choice reaction time test, and performed tests of submaximal and maximal endurance on a treadmill; blood lactate, blood glucose, and perceived exertion were recorded during submaximal and maximal exercise.

RESULTS

Heart rate, blood pressure, grip strength, blood lactate, blood glucose, and reaction time did not significantly change the next morning as a function of alcohol dose. Participants made more choice reaction errors after consuming six than zero bottles of beer.

CONCLUSION

These results suggest that consuming moderate quantities of beer affects decision making but not physical and physiological performance in adult females the next morning.

Olfaction in neurodegenerative disorder

There has been gradual increase of interest in olfactory dysfunction since it was realised that anosmia was a common feature of idiopathic Parkinson's disease (IPD) and Alzheimer-type dementia. It is an intriguing observation that a premonitory sign of a disorder hitherto regarded as one of movement or cognition may be that of disturbed sense of smell. In this review of aging, IPD, parkinsonian syndromes, tremor, Alzheimer's disease (AD), motor neuron disease (MND), Huntington's chorea (HC) and inherited ataxia, the following observations are made: (1) olfactory senescence starts at about the age of 36 years in both sexes and accelerates with advancing years, involving pleasant odours preferentially; (2) olfactory dysfunction is near-universal, early and often severe in IPD and AD developing before any movement or cognitive disorder; (3) normal smell identification in IPD is rare and should prompt review of diagnosis unless the patient is female with tremor-dominant disease; (4) anosmia in suspected progressive supranuclear palsy and corticobasal degeneration is atypical and should likewise provoke diagnostic review; (5) subjects with hyposmia and one ApoE4 allele have an approximate 5-fold increased risk of later AD; (6) impaired sense of smell may be seen in some patients at 50% risk of parkinsonism, and possibly in patients with unexplained hyposmia; (7) smell testing in HC and MND where abnormality may be found is not likely to be of clinical value, and (8) biopsy of olfactory nasal neurons reveals non-specific changes in IPD and AD and at present will not aid diagnosis.

Phenotypic Commonalities in Familial and Sporadic Parkinson Disease

BACKGROUND

Parkinson disease (PD) is a clinically well-documented neurodegenerative disorder. However, the mechanism or mechanisms of its phenotypic expressions are still unknown.

OBJECTIVE

To compare phenotypes by examining demographic and clinical features of patients with familial PD and sporadic PD and with or without a family history of PD.

DESIGN

Historical review of patients with sporadic PD in clinic-based samples and individual patients diagnosed with PD from families whose linkage to mutations or loci has been identified.

SETTING

Movement disorder clinic in a referral center.

PATIENTS

A total of 1277 patients with sporadic PD and 40 patients with familial PD.

MAIN OUTCOME MEASURES

Clinical features, including distribution by sex, initial motor symptom, location of initial motor symptom, and frequency of asymmetric motor symptoms.

RESULTS

Despite different etiologic backgrounds, both familial and sporadic PD exhibited several interesting commonalities, including a higher incidence in men, tremor as the initial motor symptom (predominantly involving the upper extremities), and asymmetric parkinsonism during disease course.

CONCLUSIONS

The increased incidence of parkinsonism in men with familial PD suggests that the sex disparity is more likely the result of a protective effect against development of PD in women than of an increased risk in men that is associated with environmental factors. Phenotypic similarity among familial and sporadic PD indicates that a similar topographic distribution of the nigrostriatal lesion exists in patients with either form of PD regardless of apparent genetic influence.

Betel quid: Its tremor-producing effects in residents of Araihazar, Bangladesh

Betel quid consists of a betel nut (Areca catechu) and other additives. It is chewed throughout Asia and is the fourth most commonly used addictive substance in the world. Its stimulant properties are mediated by arecoline and other toxins. The neurological effects of betel quid use have not been studied extensively. To assess tremor, 100 residents of Araihazar, Bangladesh, were asked to draw spirals, which were rated by a blinded neurologist. The average tremor rating was 50% higher in exposed versus unexposed individuals. Betel quid use can produce clinically evident tremor. Population-based epidemiological studies of tremor in Asia should begin to take the effect of this stimulant into account.

Infantile tremor syndrome in Iraqi Kurdistan

OBJECTIVE

To describe a rare condition that occurred for the first time in Iraqi Kurdistan during the UN Sanctions on Iraq in the nireties. Literature review was made to fine possible causes.

METHODS

Patients were collected from various sources including private clinics, hospital outpatient clinics and the Centre for Handicapped Children in the city of Arbil. Clinical features and proper history were the main diagnostic tools. Different treatment regimes were used on those patients.

RESULTS

24 patients were collected; the majority was between 6-18 months. Males were more affected than females. Half of the patients were exclusively breast-fed and three quarter have received blood for anemia.

CONCLUSION

Infantile tremor syndrome is a rare condition which was described both in India and outside India as well. It was observed among children in Iraqi Kurdistan during the difficult economic situation under the UN Sanctions. The condition has the same features inside and outside India. The etiology is not very clear yet.

The effect of depression on motor function and disease severity of Parkinson's disease

OBJECTIVES

Approximately 40% of patients with Parkinson's disease (PD) experience symptoms of depression. Our aim was to evaluate the effect of depression on disease severity, motor function and other phenotypic characteristics of PD.

PATIENTS AND METHODS

We studied 32 PD patients with major depression (PD-D) according to the DSM-IV criteria and 32 PD patients with no depression (PD-C) matched for gender, age of onset and duration.

RESULTS

Major depression in PD patients was associated with increased disease severity, poorer motor function and worse performance in the activities of daily living as measured by UPDRS scores. Furthermore, there was an association of depression with the severity of bradykinesia and axial rigidity.

CONCLUSIONS

Depression in PD can have a profound negative impact on a patient's sense of wellbeing and motor functioning. Therefore, PD patients should be routinely and carefully screened for the presence of depression and appropriate management should be considered. Larger studies on the subject are warranted.

Manual for the Extrapyramidal Symptom Rating Scale (ESRS)

The Extrapyramidal Symptom Rating Scale (ESRS) was developed to assess four types of drug-induced movement disorders (DIMD): Parkinsonism, akathisia, dystonia, and tardive dyskinesia (TD). Comprehensive ESRS definitions and basic instructions are given. Factor analysis provided six ESRS factors: 1) hypokinetic Parkinsonism; 2) orofacial dyskinesia; 3) trunk/limb dyskinesia; 4) akathisia; 5) tremor; and 6) tardive dystonia. Two pivotal studies found high inter-rater reliability correlations in both antipsychotic-induced movement disorders and idiopathic Parkinson disease. For inter-rater reliability and certification of raters, >or=80% of item ratings of the complete scale should be +/-1 point of expert ratings and >or=70% of ratings on individual items of each ESRS subscale should be +/-1 point of expert ratings. During a cross-scale comparison, AIMS and ESRS were found to have a 96% (359/374) agreement between TD-defined cases by DSM-IV TD criteria. Two recent international studies using the ESRS included over 3000 patients worldwide and showed an incidence of TD ranging from 10.2% (2000) to 12% (1998). ESRS specificity was investigated through two different approaches, path analyses and ANCOVA PANSS factors changes, which found that ESRS measurement of drug-induced EPS is valid and discriminative from psychiatric symptoms.

Phenotypic variability in Kennedy's disease: implication of the early diagnostic features

OBJECTIVES

The clinical diagnosis of Kennedy's disease (KD) is not easy when the typical manifestations are lacking, especially in early stage of the disease. In our study, we tried to identify the relative frequency of common clinical features and early symptoms in KD.

METHOD

Eighteen Korean patients with KD were included. Clinical findings were subdivided into two parts: the age at onset of each clinical symptoms and characteristic signs on investigations. With detailed clinical examinations, the serum creatine kinase (CK) level, electrophysiologic study and DNA analysis were performed and analyzed in detail.

RESULTS

In KD, the most consistent clinical findings at evaluations included perioral fasciculation with variable bulbar paresis, limb weakness with wasting, hyporeflexia, hand tremor, and elevated CK level. Some distinguishing features, such as X-linked family history, gynecomastia, and sensory abnormalities were absent in a half of cases. Frequent initial clinical findings include tremor (50%) and symptoms other than weakness, such as cramps and fatigability (33.3%).

CONCLUSION

We conclude that KD shows variable clinical and electrophysiological features. Our description on the onset and subsequent progression of each clinical finding might help to identify KD in early stage and avoid misdiagnosis.

Motor signs during the course of Alzheimer disease

BACKGROUND

Motor signs (MOSIs) are common in Alzheimer disease (AD) and may be associated with rates of cognitive decline, mortality, and cost of care.

OBJECTIVE

To describe the progression and identify predictors of individual MOSIs in AD.

METHODS

A cohort of 474 patients with AD at early stages was followed semiannually for up to 13.1 years (mean 3.6 years) in five centers in Europe and the United States. MOSIs were rated using a standardized portion of the Unified Parkinson's Disease Rating Scale. Overall, 3,030 visits/assessments of MOSIs (average 6.4/patient) were performed. Prevalence and incidence rates were calculated, and cumulative risk graphs were plotted for individual non-drug-induced MOSI domains. Rates of change over time taking into account potential covariates were also estimated. With use of each MOSI domain as outcome in Cox models, predictors of MOSI incidence were identified.

RESULTS

At least one MOSI was detected in 13% of patients at first examination and in 36% for the last evaluation. Total MOSI score increased at an annual rate of 3% of total possible score. Rates of annual change for speech/facial expression (4%), rigidity (2.45%), posture/gait (3.9%), and bradykinesia (3.75%) were of similar magnitude, and their occurrence increased from first (3 to 6%) to last (22 to 29%) evaluation. Tremor was less frequent throughout the course of the disease (4% at first and 7% at last evaluation) and worsened less (0.75% increase/year).

CONCLUSIONS

Most motor signs occur frequently and progress rapidly in Alzheimer disease. Tremor is an exception in that it occurs less frequently and advances at slower rates.

Bilateral thalamic deep brain stimulation: midline tremor control

OBJECTIVES

To determine the efficacy of bilateral deep brain stimulation (DBS) for management of midline tremor (head, voice, tongue, trunk) in patients with essential tremor.

DESIGN

Prospective assessment of tremor at baseline (presurgical), and postoperatively at 1, 3, and 12 months, and annually thereafter.

METHODS

A clinical series of 22 individuals undergoing staged, bilateral DBS for treatment of essential tremor. The tremor rating scale was the primary outcome measure.

RESULTS

Midline tremor showed significant improvement with stimulation "on" at nearly every postoperative interval when compared with stimulation "off" and with baseline tremor. Bilateral stimulation was associated with a significant incremental improvement in midline tremor control compared with unilateral stimulation: average "stimulation on" percentage change in midline tremor from the unilateral to bilateral period was 81%. Head and voice tremor showed the most consistent improvement. Among those requiring a change in stimulation parameters because of side effects, dysarthria, disequilibrium, motor disturbances, and paraesthesiae were the most common. Dysarthria was more common with bilateral (n = 6; 27%) than with unilateral (n = 0) stimulation. Stimulation parameters remained largely unchanged after the first three months. Nine of 44 leads placed (20%) required subsequent repositioning or replacement.

CONCLUSIONS

Unilateral thalamic stimulation significantly improves midline tremor, and subsequent bilateral thalamic stimulation offers an additional incremental improvement in midline tremor control.

Long-term efficacy and safety of pramipexole in advanced Parkinson's disease: Results from a European multicenter trial

A double-blind, placebo-controlled study with a subsequent open-label phase was conducted in 354 patients with Parkinson's disease (PD) and motor fluctuations under individually adjusted therapy with levodopa. During the double-blind phase 174 patients received pramipexole and 180 placebo. In agreement with previous studies, pramipexole treatment improved UPDRS sum scores of parts II and III by 30% and off times by approximately 2.5 hours per day. Differences between the treatment groups became significant at a daily dose of 0.75 mg of pramipexole dihydrochloride. We, furthermore, performed post hoc analyses with respect to resting tremor and depression. Patients with pronounced resting tremor derived a clear benefit from pramipexole treatment compared with placebo. In addition, pramipexole significantly improved the subitems motivation/initiative and depression in a subpopulation with increased Unified Parkinson's Disease Rating Scale I scores at the time of inclusion. There were 262 patients who were subsequently enrolled into the open-label study featuring a maximum duration of up to 57 months. Statistical analysis revealed good long-term efficacy and tolerability of pramipexole. Overall, only a low prevalence of somnolence was found. In summary, this study provides additional level I evidence of the usefulness of pramipexole, suggests a particular tremorlytic and a possible antidepressant action of this compound, and addresses for the first time its efficacy and safety during long-term administration in advanced PD.