Rating impairment and disability in Parkinson's disease: evaluation of the Unified Parkinson's Disease Rating Scale

Although the Unified Parkinson's Disease Rating Scale (UPDRS) is widely used to monitor disease progression and drug efficacy, no attempts have been made to evaluate its scientific and clinical quality. Poor clinical sensibility of items in the activities of daily living (ADL) section and redundancy of items in the motor examination (ME) section prompted us to determine if the number of items in these sections could be reduced to a smaller, equally sensitive set that would describe the data as reliably as did the original set of items. Therefore, we assessed 111 patients with idiopathic Parkinson's disease on the UPDRS and Hoehn and Yahr staging scales. Our results show that the ADL (13 items) and ME (14 items) sections can be reduced to 8 items each without loss of reliability or validity. Our report is preliminary and needs validation.

Dynamic mutation in Dutch Huntington's disease patients: increased paternal repeat instability extending to within the normal size range

Analysis of the distribution of normal and expanded alleles of the polymorphic (CAG)n repeat in the IT15 gene in the Dutch population confirmed the presence of an expanded repeat on all Huntington's disease (HD) chromosomes. Our results show that the size distributions of normal and affected alleles overlap. Normal alleles range from 11 to 37 repeats and HD alleles contain 37 to 84 repeats. A clear correlation is found between age at onset and repeat length, but the spread of the age at onset in the major repeat range producing characteristic HD is too wide to be of diagnostic value. In the available parent-offspring pairs, maternal HD alleles show a moderate instability with a slight preponderance of size increase over size decrease. Paternal alleles have a bimodal distribution: the majority (69%) behave similarly to the maternal alleles, while the remainder (31%) show a dramatic expansion, the degree of which appears proportional to the initial size. This is shown in three out of four juvenile patients, who have repeats of 71, 74, and 84 copies, respectively, originating from expanded paternal HD alleles in the previous generation. Two sporadic cases are caused by expansion of 'large' normal paternal alleles of 32 and 34 repeats, respectively, to 46 copies. This not only confirms the diagnosis of HD in two de novo cases, but it also underlines the increased paternal instability. In addition paternal repeat instability was once detected within the normal range in two sibs who inherited 21 and 22 repeats, respectively, on the same paternal chromosome. In two Dutch HD families the segregation of the expanded (CAG)n repeat was found. Analysis of the (CAG)n repeat in our previously reported recombinants confirmed their disease status.

Characterization and localization of the Huntington disease gene product

The recent identification of the Huntington's disease (HD) gene, enabled us to synthesize oligopeptides corresponding with the carboxy-terminal end of the predicted HD-gene (IT15) product. Immunobiochemcial studies with polyclonal antibodies directed against this synthetic peptide (position 3114-3141) on lymphoblastoid cells from normal individuals and patients with Huntington disease, revealed the presence of a protein (huntingtin) with a molecular mass of approximately 330 kDa. Immunocytochemical studies showed a cytoplasmic localization of huntingtin in various cell types including neurons. In most of the neuronal cells the protein was also present in the nucleus. No difference in molecular mass or intracellular localization was found between normal and mutant cells.

Protease nexin-2/amyloid beta protein precursor. A tight-binding inhibitor of coagulation factor IXa

Protease nexin-2/amyloid beta protein precursor (PN-2/A beta PP) is an abundant, secreted platelet protein which is a potent inhibitor of coagulation Factor XIa. We examined other potential anticoagulant activities of PN-2/A beta PP. Purified Kunitz protease inhibitor domain of PN-2/A beta PP and PN-2/A beta PP itself were found to prolong the coagulation time of plasma and pure Factor IXa. The Kunitz protease inhibitor domain also inhibited the ability of Factor IXa to activate Factor X. PN-2/A beta PP inhibited Factor IXa with a Ki of 7.9 to 3.9 x 10(-11) M in the absence and presence of heparin, respectively. When the second-order rate constant of PN-2/A beta PP's inhibition of Factor IXa (2.7 x 10(8) M-1min-1) was compared to that of antithrombin III (3.8 x 10(6) M-1min-1), PN-2/A beta PP was at least a 71-fold more potent inhibitor of Factor IXa than antithrombin III. PN-2/A beta PP formed a complex with Factor IXa as detected by gel filtration and ELISA. The finding that PN-2/A beta PP is a potent inhibitor of Factor IXa could help to explain the spontaneous intracerebral hemorrhages seen in patients with hereditary cerebral hemorrhage with amyloidosis Dutch-type where there is an extensive accumulation of PN-2/A beta PP in their cerebral blood vessels.

Presymptomatic DNA testing for Huntington disease: identifying the need for psychological intervention

In the Dutch presymptomatic DNA-testing program for Huntington disease (HD), 29 individuals with increased risk and 44 with decreased risk were followed-up 6 months after test results. A prognostic model was built aimed at identifying individuals at risk for psychological maladjustment, as measured by the Impact of Event Scale, the Beck Hopelessness Scale, the General Health Questionnaire, and the Social Support Questionnaire.

RESULTS

1) The more that applicants suffered from intrusive feelings about HD and tried to avoid HD-related situations, prior to the test, the greater the chance that they will experience this 6 months after the test if they proved to be at increased risk; 2) the more that both individuals with increased risk and those with decreased risk who suffered from the threat of having HD tried to avoid HD-related situations prior to the test and the less satisfied they were with available support, the greater the probability that they will show avoidance behavior after the test; 3) the more pessimistic that individuals with increased risk as well as those with decreased risk were about their future prior to the test, the more they avoided HD-related situations and the more dissatisfied they were about their available support (pretest), the greater the probability that they will become depressive and suicidal. Psychological adjustment was also studied as a function of a) intrusion/denial-avoidance pattern over time and b) healthy mental functioning/future expectancies. Most individuals with increased risk (86%) seem to cope well thus far, although this was based largely on strong psychological defenses and dependent on satisfactory relationships.(ABSTRACT TRUNCATED AT 250 WORDS)

Where to record motor activity: an evaluation of commonly used sites of placement for activity monitors

The aim of this study was to evaluate the role of the site of attachment of activity monitors. We compared mean diurnal and nocturnal motor activity measures as well as the daily pattern of motor activity of dominant and non-dominant wrist recordings over 5 successive days of 10 healthy right-handed and 10 left-handed subjects. In a second study we evaluated the relationship between truncal motor activity and wrist motor activity. No differences emerged between the diurnal and nocturnal measures as well as the diurnal activity pattern of the dominant and the non-dominant wrist. Additionally, no differences were found in relation to handedness. Our results show that it is inaccurate to regard wrist motor activity measurements as representative of an invariable percentage of truncal motor activity; the relation between the measurements of these two recording sites varies across the daytime period. During the nocturnal period bilateral wrist motor activity occurred frequently in absence of truncal motor activity. The reverse situation, however, may occur sporadically. This finding most likely reflects that integrated generalized movements like postural shifts are measured at all recording sites, while the small movements that occur at the distal extremities are predominantly recorded by wrist-worn monitors. In conclusion, it is apparent that for both diurnal and nocturnal studies on the assessment of motor activity, either wrist can be chosen as the recording site. Across the diurnal period the relation between motor activity recorded at the wrist and waist is subject to considerable variability.(ABSTRACT TRUNCATED AT 250 WORDS)

Sleep, excessive daytime sleepiness and fatigue in Parkinson's disease

The objective of this questionnaire-based survey was to evaluate the prevalence and causes of sleep disturbances in 90 nondepressive patients with Parkinson's disease (PD) and 71 age-matched healthy subjects. We also assessed the prevalence and characteristics of excessive daytime sleepiness (both groups) and excessive fatigue (PD patients). A high prevalence of sleep disturbances in PD patients was found; this is to a large extent probably the result of aging. As compared with controls, patients had a more severely disturbed sleep maintenance because of nycturia, pain, stiffness, and problems with turning in bed. The prevalence of excessive dreaming is similar in both groups, but altered dream experiences almost exclusively occurred in PD. Patients rated themselves more often to be morning-types than controls. This finding may account for the reported adaptation effects in experimental settings and the reduced REM latency in PD patients. The prevalence of daytime sleepiness was similar in both groups. Excessive daytime sleepiness showed a clear diurnal pattern with a peak in the early afternoon. As for excessive fatigue, the majority of the patients did not report a preferential time for this symptom. Our findings further argue against an association of fatigue with any circadian factor, and instead suggest a relationship with the motor deficits of PD.

Autonomic nervous system dysfunction in Parkinson's disease: relationships with age, medication, duration, and severity

Heart rate variability at rest, during deep breathing, or standing up and with the Valsalva manoeuvre did not differ significantly between 67 patients with idiopathic Parkinson's disease (PD) and 31 healthy age matched controls. Blood pressure (BP) responses to standing up and sustained handgrip revealed diminished autonomic function in the PD group. In a preliminary analysis of the PD group older age, anti-Parkinson medication and higher Hoehn and Yahr (HY) stages were each associated with poor autonomic responsiveness. Disease duration was only related to the systolic BP fall on standing up. Multiple stepwise regression analysis showed that older age explained most of the variance of heart rate variability (up to 36%), and the only significant PD related factor was the use of medication, which explained less than 7%. The HY stage accounted for 12.7% of the variance in the standing up BP test, and the use of medication explained 10.6% of the variance of the systolic BP change in the sustained hand grip test. The unmedicated PD subgroup (n = 33), who had mild disease of short duration, showed no evidence of autonomic dysfunction. Cardiovascular autonomic dysfunction in PD is mild, mainly affects blood pressure responses, and occurs only in advanced cases.

The influence of a standard meal on Sinemet CR absorption in patients with Parkinson's disease

We studied the influence of dietary protein intake on the plasma level profile of levodopa, carbidopa, and 3-O-methyldopa and clinical efficacy in 12 patients with idiopathic Parkinson's disease after intake of one levodopa-carbidopa 200/50 controlled release tablet (Sinemet CR; LC-CR). The tablet was given 1 h before the protein rich meal on one day (fasted) and together with the meal on an other day (non-fasted). Higher levodopa and carbidopa concentrations were reached when the LC-CR was taken 1 h before the meal, but the plasma level profile for levodopa was flatter in the non-fasted state. The area under the curve for levodopa was slightly higher in the fasted condition. For the clinical variables walking and tapping slightly better clinical results (P = 0.08) were found in the fasted condition with the higher levodopa levels. If the patient on levodopa is in a clinically satisfactory condition, then non-fasted condition could be preferred because of the smooth plasma level profile demonstrated. However, if the initial levodopa concentrations are not in the critical range to be effective for the patient, the advice should be to take the drug in a fasted condition.

A double-blind study of the efficacy of apomorphine and its assessment in 'off'-periods in Parkinson's disease

Five patients with idiopathic Parkinson's disease with severe response fluctuations were selected for a randomized double-blind placebo-controlled study, concerning the clinical effects of subcutaneous apomorphine and its assessment in 'off'-periods. The study was designed as five n = 1 studies, in which every patient was his own control. The effect of apomorphine was studied by using the Columbia rating scale and quantitative assessments, using tapping, walking and pinboard. There was a significant positive effect of apomorphine, in a mean optimal dose of 2.7 mg, with a mean latency of onset of 7.3 min and a mean duration of response of 96 min. After pretreatment with domperidone, no significant adverse effects were observed. Tapping showed the highest correlation with rigidity and bradykinesia. Walking showed a high correlation with stability and gait. Pinboard testing did not give additional information. The first conclusion was that apomorphine proved to be a significantly effective dopamine agonist, proven now also by a double blind placebo-controlled study. Secondly it was concluded that assessment of clinical effect in parkinsonian patients can be performed best by combining the Columbia item tremor with tapping and walking scores.

Diurnal effects of motor activity and fatigue in Parkinson's disease

Wrist motor activity was monitored continuously in 65 patients with Parkinson's disease (PD) to assess the influence of disease severity and excessive fatigue on the diurnal motor activity pattern. Mildly or moderately affected PD patients had a similar diurnal pattern to that of 68 healthy controls, with a late morning peak; however, mean levels of motor activity were lower. The most severely affected patients showed an overall flattened diurnal pattern. Results refute the existence of end of day deterioration, but instead suggest a "depressed morning start" in the most severely affected patients with PD. Excessive fatigue was not reported at a particular time of day and did not influence the diurnal motor activity pattern.

On attitudes and appreciation 6 months after predictive DNA testing for Huntington disease in the Dutch program

We have studied the 6-month follow-up attitudes of 63 individuals, after predictive testing for Huntington disease (HD). Reducing uncertainty (81%) and family planning (60%) were the major reasons for taking the test. Twenty-four individuals were diagnosed as having an increased risk (+/- 98%), and 39 a decreased risk (+/- 2%). Among those with an increased risk, denial or minimization of the ultimate impact of the increased risk result was observed. Most of them (84%) rated their current life situation, at the very least, as being good. Twenty-one percent of individuals with an increased risk who originally planned to have a family, decided to refrain from having children. Sixty percent of those with increased risk who still wished to have children, would choose to have prenatal testing. In most individuals with increased risk, the test result did not increase the previously expected control over their own future. Half of the partners of persons with increased risk acknowledged the burden of the future disease. Half had no one in whom they could confide. They showed loyalty to the denial and avoidance reactions of their spouses. Half of the individuals with decreased risk denied the impact of the result, as reflected by absence of relief, and emotional numbness. A third of persons with decreased risk experienced involvement with problems of affected relatives. We found that 20% of all participants were discontented with the support given by their general practitioner, who is normally regarded as being the most significant professional for aftercare. Our findings suggest that the perpetuation

Tourette's syndrome and right hemisphere dysfunction

Poor performances of patients with Tourette's syndrome (TS) on tests requiring visual-perceptual abilities had led previous authors to the suggestion of right hemisphere involvement. We have compared the results of neuropsychological examination of 16 children with TS, with those of 16 children with a lesion of the right hemisphere. No evidence was found of a dysfunction of the right hemisphere in TS.

Acetaminophen sulfation in patients with Parkinson's disease or Huntington's disease is not impaired

We studied acetaminophen sulfation, plasma sulfate levels, and the activity of sulfotransferase in blood platelets in patients with Parkinson's disease, Huntington's disease, and in controls and did not find any abnormality in the patient groups, independent of the use of medication.

Presymptomatic DNA-testing for Huntington disease: pretest attitudes and expectations of applicants and their partners in the Dutch program

We studied the baseline attitudes, prior to testing, of 70 applicants at risk for Huntington disease (HD) and their partners in the Dutch presymptomatic DNA-testing program. Two thirds of the applicants were female; 36% already had children. The main reason (60%) for undertaking the test was for family planning. Other reasons were either to reduce uncertainty (43%) or to obtain certainty (38%). Partners of applicants stated that planning for the future was for them the most important reason (76%). Significantly more at-risk females (42%) than males (16%) anticipated an unfavorable test outcome. Quite remarkably, most applicants and partners denied that a positive result might have adverse effects on either personal mood, quality of life, or marriage. Only a few did not expect that a favorable result would induce relief. The eventual outcome of the test was expected to enable applicants to gain control over their future, whatever the results. Hence, we propose that the applicants form a self-selected group, based on their expectation that they will not be emotionally affected by either result.

Distribution of beta/A4 protein and amyloid precursor protein in hereditary cerebral hemorrhage with amyloidosis-Dutch type and Alzheimer's disease

Brain amyloidosis with abundant beta/A4 protein deposition in plaques and cortical and meningeal vessels is found in Alzheimer's disease (AD) and hereditary cerebral hemorrhage with amyloidosis-Dutch type (HCHWA-D). In contrast to AD, no neuritic pathology or classical congophilic plaques are found in HCHWA-D. Unlike most AD cases, the congophilic angiopathy in HCHWA-D is very severe. It is still unknown whether beta/A4 deposits in plaques and vessels have the same origin. In this study, we have used frozen cortical tissue of HCHWA-D and AD patients to investigate the beta/A4 amyloid protein and the amyloid precursor protein (APP) in different types of plaques and congophilic angiopathy. Immunohistochemical staining was conducted using antibodies against synthetic beta/A4 proteins and antibodies against APP including MAbP2-1, a monoclonal antibody against purified protease nexin-2, which is the secreted form of APP. In contrast to immunohistochemical studies on formalin-fixed, paraffin-embedded tissue, frozen tissue of HCHWA-D patients revealed a very high number of beta/A4 plaques resembling AD. All plaques were of the diffuse type. Double-staining with MabP2-1 and beta/A4 antisera revealed: 1) the presence of APP immunoreactivity in classical plaques and transitional forms; 2) the absence of APP immunoreactivity in diffuse plaques in HCHWA-D and AD; and 3) pronounced APP immunoreactivity in congophilic vessels in HCHWA-D in contrast to weak APP staining in congophilic vessels in AD. Together these findings suggest that: a) the presence of APP in plaques is related to neuritic changes; b) different processes occur in amyloid formation in plaques and vessels; and c) differences exist between the process of amyloid formation in HCHWA-D and AD.

Assessment of response fluctuations in Parkinson's disease by ambulatory wrist activity monitoring

The aim of this study was to examine the influence of response fluctuations with dyskinesia on the 24-h motor activity pattern and measures of diurnal and nocturnal activity and immobility. Motor activity was recorded during 5 successive days in 5 patients with advanced Parkinson's disease (PD) suffering from severe response fluctuations with dyskinesia, as well as in 10 PD patients with a stable levodopa response and 10 healthy subjects. The 24-h motor activity pattern of the patients with response fluctuations provides insight into the relationship between the therapeutic regimen and 1) the frequency and duration of "on" and "off" periods, 2) the severity of the dyskinesias, and 3) the degree of sleep disruption. In accordance with the severity of their motor fluctuations, patients with response fluctuations showed a large intra- and interindividual variability of diurnal motor activity measures. Overall, the nocturnal motor activity measures in the patients with response fluctuations indicated a severely disturbed sleep when compared with the two control groups. Factors as simplicity and the potential to record unrestrained motor activity for several days continuously in all settings, make activity monitoring a welcomed acquisition in the assessment of response fluctuations in PD.

Quantitative assessment of parkinsonian patients by continuous wrist activity monitoring

The aim of this study was to examine the quantitative relationship between activity monitor measures and clinical scores of patients with Parkinson disease (PD). Motor activity was recorded continuously for 5 to 6 days at home with a wrist-worn activity monitor in 69 PD patients and 59 healthy controls. Clinical scores of the patients, age, and sex were submitted to multiple regression analysis to examine the quantitative relationship with measures reflecting the activity level and the proportion of activity and immobility over time. The patients' age, sex, and scores representing hypokinesia and rigidity and resting tremor explained approximately 50% of the variance of the motor activity measures. All motor activity measures declined with age; the rate of decline was similar for the patients and controls. Sex emerged as a predictor of the motor activity measures in the patients only. Male patients with PD showed significantly lower values for all motor activity measures than female patients and controls. Our results show that activity monitoring can be used as an objective quantitative assessment in PD.

Correction for the influence of background muscle activity on stretch reflex amplitudes

Background muscle activity (BGR) exerts a strong influence on stretch reflex amplitudes. While it is considered important to correct for this influence, which method best able to eliminate the effects of BGR remains unknown. We have therefore compared one previously described and one novel correction method which respectively consisted of calculating (1) the difference between reflex amplitude and BGR, and (2) the ratio of reflex amplitude to BGR. These correction methods were evaluated in a group of 23 healthy individuals. BGR and stretch reflexes were recorded from the gastrocnemius muscle of standing subjects who received sudden toe-up perturbations of a supporting platform upon which they were standing. Calculation of differences markedly reduced the influence of BGR on stretch reflex amplitudes in most, although not all, subjects. Calculation of ratios failed to correct for BGR in most subjects and caused a net increase in the influence of BGR on stretch reflex amplitudes. Because both correction methods insufficiently corrected for BGR in normal subjects, we introduce the use of analysis of covariance (ANCOVA) to reliably remove the influence of BGR on stretch reflex amplitudes. The use of ANCOVA is exemplified by showing that stretch reflex amplitudes are enhanced in patients with Parkinson's disease even if the influence of high BGR is completely taken into account.

Duration of illness in Huntington's disease is not related to age at onset

The age at onset and duration of illness were studied in patients with Huntington's disease in the Leiden Roster which at 1 July 1990 contained 2787 patients. Of 1106 patients, 800 deceased and 306 alive, the age at onset was known. The median duration was 16.2 (range 2-45) years. In contrast to the current opinion, the median duration was independent of the age of onset. The median duration in juvenile Huntington's disease was 17.1 years, which is much longer than reported in the literature, and comparable with the categories for the age of onset of 20-34 and 35-49 years. Only in the group where onset was over 50 years of age was the median duration somewhat shorter (15.6 years), which can be ascribed to unrelated causes of death. As age of onset and duration of illness are not related, at least two mechanisms to determine the clinical course have to be postulated: one for age of onset and another for duration of illness. Duration was shorter for males, especially for those with an affected father.