Health related quality of life in early Parkinson's disease: impact of motor and non-motor symptoms, results from Chinese levodopa exposed cohort

Assessing the non-motor symptoms of Parkinson's disease: MDS-UPDRS and NMS Scale

BACKGROUND AND PURPOSE

Although Parkinson's disease (PD) is characterized by typical motor manifestations, non-motor symptoms (NMS) are an outstanding part of the disease. At present, several specific instruments for assessment of NMS are available. The objective of our study was to determine the performance of the Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS): Part I - Non-Motor Aspects of Experiences of Daily Living (nM-EDL) compared with the Non-Motor Symptoms Scale (NMSS).

METHODS

To this purpose, 434 consecutive patients with PD were included in an international, observational, cross-sectional study. The association between scores of both scales was determined by the Spearman rank correlation coefficient. Equations for transformation of total score of a scale to the other were constructed from weighted regression models and both, transformed and observed score, contrasted by means of the Lin's Concordance Correlation Coefficient (LCCC) and Bland-Altman plot.

RESULTS

As a whole, the prevalence of the NMS according to each scale was quite similar, and most of the correlations between their corresponding components were high (r(S) > 0.60). The total score correlation of the MDS-UPDRS Part I with the NMSS was high (r(S) = 0.81). Concerning the transformed scores, estimated scores only partially approach the observed ones (sharing about 60-64% of the variance) because residual variance increased with increasing magnitudes of the scores, i.e. the most severe patients (Bland-Altman plot; LCCC < 0.60 for severe patients).

CONCLUSIONS

(i) MDS-UPDRS Part I (nM-EDL) and NMSS showed a strong convergent validity; (ii) however, transformed scores using the equations from weighted regression models showed that for patients with the most severe NMS they are not concordant.

Differentiating non-motor symptoms in Parkinson's disease from controls and hemifacial spasm

Background and Aims

Non-motor symptoms (NMS) are important manifestations of Parkinson's disease (PD) that reduce patients' health-related quality of life. Some NMS may also be caused by age-related changes, or manifested as a psychological reaction to a chronic neurological condition. This case-control study compared the NMS burden among PD patients, healthy controls and hemifacial spasm (HFS) patients. In addition, we determined the NMS that discriminated between PD and non-PD subjects.

Methods

425 subjects were recruited from a tertiary hospital in Singapore (200 PD patients, 150 healthy controls and 75 HFS patients). NMS burden in subjects was measured using the Non-Motor Symptoms Scale (NMSS).

Results

NMSS total score was significantly higher in PD patients (37.9±2.6) compared to healthy controls (11.2±0.9) (p<0.0001) and HFS patients (18.0±2.1) (p<0.0001). In addition, NMSS total score was significantly higher in HFS patients compared to healthy controls (p = 0.003). PD patients experienced a higher NMS burden than healthy controls in all domains, and a higher NMS burden than HFS patients in all but attention/memory and urinary domains. NMS burden for HFS and healthy controls differed only in the sleep/fatigue and urinary domains. Using stepwise logistic regression, problems of ‘constipation’, ‘restless legs’, ‘dribbling saliva’, ‘altered interest in sex’ and ‘change in taste or smell’ were found to have significant discriminative power in differentiating between PD patients and healthy controls and between PD patients and HFS patients.

Conclusion

PD patients experienced a greater overall NMS burden compared to both healthy controls and HFS patients. HFS patients demonstrated a higher NMS burden than controls, and some NMS may be common to chronic neurological conditions while others are more specific to PD. Differentiating patients using NMS domains may help refine the clinical management of NMS in PD patients.

Clinical determinants of health-related quality of life in Mexican patients with Parkinson's disease

BACKGROUND AND AIMS

Parkinson's disease (PD) is the second most common chronic neurodegenerative disorder. PD is clinically characterized by a constellation of motor and nonmotor symptoms that may have a direct effect on daily activities as well as in the quality of life of the patient. Identifying the symptoms more closely associated with a poor quality of life is central on improving the medical care of the patient. We undertook this study to identify and describe the clinical and demographic factors that predict health-related quality of life among Mexican patients with PD.

METHODS

One hundred seventy-seven patients with Parkinson's disease were included. Patients were evaluated using the following clinimetric instruments: motor subscale of the Unified Parkinson's disease rating scale, Hoehn and Yahr stage, Non-motor Symptoms Questionnaire, Parkinson's disease Questionnaire (PDQ-39) and the Mini Mental Status Examination.

RESULTS

Multivariate analysis showed that the main factors associated with a poor quality of life were motor impairment (β = 0.27, p <0.001) and the number of nonmotor symptoms (β = 2.17, p <0.001). The main nonmotor domains impacting on the quality of life were depression/anxiety (β = 6.36, p <0.001), cardiovascular (β = 5.39, p = 0.001), memory (β = 4.64, p <0.001) and miscellaneous (β = 3.15, p = 0.001).

CONCLUSIONS

Both motor and mainly nonmotor symptoms are negatively associated with health-related quality of life in patients with PD and should be appropriately attended in order to improve patient care.

Translation and validation of the korean version of the 39-item Parkinson's disease questionnaire

Background and Purpose

The importance of health-related quality of life (HrQoL) has been increasingly emphasized when assessing and providing treatment to patients with chronic, progressive, degenerative disorders. The 39-item Parkinson's disease questionnaire (PDQ-39) is the most widely used patient-reporting scale to assess HrQoL in Parkinson's disease (PD). This study evaluated the validity and reliability of the translated Korean version of the PDQ-39 (K-PDQ-39).

Methods

One hundred and two participants with PD from 10 movement disorder clinics at university-affiliated hospitals in South Korea completed the K-PDQ-39. All of the participants were also tested using the Unified Parkinson's Disease Rating Scale (UPDRS), Korean version of the Mini-Mental State Examination (K-MMSE), Korean version of the Montgomery-Asberg Depression Scale (K-MADS), Epworth Sleepiness Scale (ESS) and non-motor symptoms scale (NMSS). Retests of the K-PDQ-39 were performed over time intervals from 10 to 14 days in order to assess test-retest reliability.

Results

Each K-PDQ-39 domain showed correlations with the summary index scores (rS=0.559-0.793, p<0.001). Six out of eight domains met the acceptable standard of reliability (Cronbach's α coefficient ≥0.70). The Guttman split-half coefficient value of the K-PDQ-39 summary index, which is an indicator of test-retest reliability, was 0.919 (p<0.001). All of the clinical variables examined except for age, comprising disease duration, levodopa equivalent dose, modified Hoehn and Yahr stage (H&Y stage), UPDRS part I, II and III, mood status (K-MADS), cognition (K-MMSE), daytime sleepiness (ESS) and (NMSS) showed strong correlations with the K-PDQ-39 summary index (p<0.01).

Conclusions

The K-PDQ-39 has been validated for use in the Korean-speaking PD population. The questionnaire is a valid and reliable assessment tool for assessing the HrQoL of Korean PD patients.

Neurologists' diagnostic accuracy of depression and cognitive problems in patients with parkinsonism

Background

Depression and cognitive impairment (CI) are important non-motor symptoms in Parkinson’s Disease (PD) and related syndromes, but it is not clear how well they are recognised in daily practice. We have studied the diagnostic performance of experienced neurologists on the topics depression and cognitive impairment during a routine encounter with a patient with recent-onset parkinsonian symptoms.

Methods

Two experienced neurologists took the history and examined 104 patients with a recent-onset parkinsonian disorder, and assessed the presence of depression and cognitive impairment. On the same day, all patients underwent a Hamilton Depression Rating Scale test, and a Scales for Outcomes in Parkinson’s Disease-Cognition-test (SCOPA-COG).

Results

The sensitivity of the neurologists for the topic depression was poor: 33.3%. However, the specificity varied from 90.8 to 94.7%. The patients’ sensitivity was higher, although the specificity was lower. On the topic CI, the sensitivity of the neurologists was again low, in a range from 30.4 up to 34.8%: however the specificity was high, with 92.9%. The patients’ sensitivity and specificity were both lower, compared to the number of the neurologists.

Conclusions

Neurologists’ intuition and clinical judgment alone are not accurate for detection of depression or cognitive impairment in patients with recent-onset parkinsonian symptoms because of low sensitivity despite of high specificity.

Trial registration

(ITRSCC)NCT0036819.

Recognition and diagnosis of sleep disorders in Parkinson's disease

Sleep disturbances are among the most frequent and incapacitating non-motor symptoms of Parkinson’s disease (PD), and are increasingly recognized as an important determinant of impaired quality of life. Here we review several recent developments regarding the recognition and diagnosis of sleep disorders in PD. In addition, we provide a practical and easily applicable approach to the diagnostic process as a basis for tailored therapeutic interventions. This includes a stepwise scheme that guides the clinical interview and subsequent ancillary investigations. In this scheme, the various possible sleep disorders are arranged not in order of prevalence, but in a ‘differential diagnostic’ order. We also provide recommendations for the use of sleep registrations such as polysomnography. Furthermore, we point out when a sleep specialist could be consulted to provide additional diagnostic and therapeutic input. This structured approach facilitates early detection of sleep disturbances in PD, so treatment can be initiated promptly.

Non-motor symptoms of Parkinson's disease in China: a review of the literature

Parkinson's disease (PD) is generally considered as a neurodegenerative disorder commonly characterized by bradykinesia, resting tremor, rigidity and postural instability. However, increasing evidence demonstrates that serial non-motor symptoms (NMSs), including sensory symptoms, dysautonomia, neurobehavioral disorders and sleep disturbances frequently occur prior to motor signs and invariably emerge with the disease progression. Compared with motor symptoms, the NMSs are frequently under-recognized and poorly managed in clinical practice. A growing number of clinical studies on NMSs of PD have been carried out in China over the past decade. They revealed that there were not only common features, but also some differences on NMSs between Chinese patients and those in the West. Meanwhile, pharmacological and non-pharmacological strategies are available for the treatment of some NMSs associated with PD in China contained in Chinese guidelines for the treatment of PD. Large cohort studies across the country are warranted in the future to explore the epidemiological and biological features of specific NMSs in Chinese PD patients.

The impact of motor and non motor symptoms on health state values in newly diagnosed idiopathic Parkinson's disease

The aim of the study was to estimate health state utility values in newly diagnosed idiopathic Parkinson's disease (PD) for use in the assessment of health-related quality-of-life (HRQL), and in the estimation of quality-adjusted life-years (QALYs). Data from 162 patients enrolled in a community-based incidence study of PD were used to estimate health state utility values. Self-report data from the EQ-5D, a generic measure of HRQL, were used to derive preference-based health state utility values. The impact of motor and non motor symptoms, and other clinical and demographic factors, on the derived EQ-5D health state values was examined in univariate and multivariate analyses. The mean health state utility value for recently diagnosed PD patients was estimated at 0.65 ± 0.27. Significant reductions in health state values were attributable to pain (-0.18), motor functioning (-0.16), depression (-0.12), and insomnia (-0.11). Depression had its greatest impact (-0.19) in patients in the less severe stages of PD (i.e. Hoehn Yahr stages ≤2.5). This study shows, through the presentation of QALY values, that there is scope to achieve significant health gains in newly diagnosed idiopathic PD patients via improved management of pain, depression and insomnia, alongside the treatment of primary motor symptoms.

Nonmotor versus motor symptoms: how much do they matter to health status in Parkinson's disease?

Evidence suggests that both motor and nonmotor symptoms contribute to health status in Parkinson's disease. Less clear is how much change in health status can be expected if these clinical variables change. In addition, anxiety, separate from depression, has rarely been examined as a predictor of health status. We used hierarchical multiple regression analysis and standardized beta coefficients in a prevalent cohort of 462 patients with Parkinson's disease to explore the relative impact on health status (measured using the Parkinson's Disease Questionnaire) of 5 well-recognized symptom domains in Parkinson's disease: motor signs, depression, anxiety, cognition, and other nonmotor symptoms. In the health status scores, 19.6% of variance was explained by age, number of comorbidities, disease duration, and levodopa equivalent dose. Younger age predicted worse health status. A full regression model containing baseline variables and all 5 symptom domains explained 56% of the variance in health status. The standardized beta coefficient for depression was 2.1, 1.6, and 1.3 times that of motor signs, anxiety, and other nonmotor symptoms, respectively. Our findings provide a ranking order of clinical variables for their relative impact on health status in Parkinson's disease and show that depression has more than twice the impact of motor signs on health status. Anxiety and other nonmotor symptoms are also important separate determinants of poor health status in Parkinson's disease. Our results will help to guide the development of individual care and service planning for patients with Parkinson's disease.

Unilateral subthalamic nucleus deep brain stimulation improves sleep quality in Parkinson's disease

BACKGROUND

Sleep disturbances are common in Parkinson's disease (PD). Bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) is superior to best medical therapy in the treatment of motor symptoms in advanced PD, and observational studies suggest that bilateral STN DBS improves sleep in these patients as well. Unilateral STN DBS also improves motor function in PD, but its effects on sleep have not been extensively investigated.

METHODS

We report the effects of unilateral STN DBS on subjective sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) in 53 consecutive PD patients. These subjects completed the PSQI prior to surgery and at 3 and 6 months post-operatively. The primary outcome measure was the change in the global PSQI at 6 months post-operatively versus the pre-operative baseline, measured with repeated measures analysis of variance (ANOVA).

RESULTS

Patients with PD who underwent unilateral STN DBS had a significant improvement in PSQI at 6 months post-operatively (baseline 9.30 ± 0.56 (mean ± SEM), 6 months: 7.93 ± 0.56, p = 0.013). Supplemental analyses showed that subjects selected for STN DBS placed on the right had worse baseline subjective sleep quality and more improvement in PSQI at 6 months compared to patients who received left STN DBS.

CONCLUSION

This prospective case series study provides evidence that unilateral STN DBS improves subjective sleep quality in patients with PD at up to 6 months post-operatively as measured by the PSQI.

The effects of deep brain stimulation on sleep in Parkinson's disease

Sleep dysfunction is a common nonmotor symptom experienced by patients with Parkinson's disease (PD). Symptoms, including excessive daytime sleepiness, sleep fragmentation, rapid eye movement (REM) sleep behavior disorder and others, can significantly affect quality of life and daytime functioning in these patients. Recent studies have evaluated the effects of deep brain stimulation (DBS) at various targets on sleep in patients with advanced PD. Several of these studies have provided evidence that subthalamic nucleus DBS improves subjective and objective measures of sleep, including sleep efficiency, nocturnal mobility, and wake after sleep onset (minutes spent awake after initial sleep onset). Although fewer studies have investigated the effects of bilateral internal globus pallidus and thalamic ventral intermedius DBS on sleep, pallidal stimulation does appear to improve subjective sleep quality. Stimulation of the pedunculopontine nucleus has recently been proposed for selected patients with advanced PD to treat severe gait and postural dysfunction. Owing to the role of the pedunculopontine nucleus in modulating behavioral state, the impact of stimulation at this target on sleep has also been evaluated in a small number of patients, showing that pedunculopontine nucleus DBS increases REM sleep. In this review, we discuss the effects of stimulation at these various targets on sleep in patients with PD. Studying the effects of DBS on sleep can enhance our understanding of the pathophysiology of sleep disorders, provide strategies for optimizing clinical benefit from DBS, and may eventually guide novel therapies for sleep dysfunction.

Parkinson's disease: the non-motor issues

Non-motor symptoms (NMS) of Parkinson's disease remain the most under-appreciated and under-researched when taken as a whole. Data is emerging that it is the "totaL" burden of NMS that is the major determinant of quality of life not a single NMS such as depression for instance. Only recently validated tools such as the NMSQuest which empowers patients to declare NMS and the NMS scale, the SCOPA scales, and the modified version of the MDS-UPDRS have become available and validated for bedside clinical assessment of NMS. For the first time clinical trials have been incorporating non-motor measures as outcome measures and clinical recommendations for treatment of non-motor symptoms of PD are being published. This review aims to address some of these topical and "real life" aspects of modern day management of Parkinson's.

Excessive daytime sleepiness in patients with Parkinson's disease

Excessive daytime sleepiness (EDS) is described as inappropriate and undesirable sleepiness during waking hours and is a common non-motor symptom in Parkinson's disease, affecting up to 50% of patients. EDS has a large impact on the quality of life of Parkinson's disease patients as well as of their caregivers, in some cases even more than the motor symptoms of the disease. Drug-induced EDS is a particular problem as many dopamine agonists used for the treatment of Parkinson's disease have EDS as an adverse effect. Dopaminergic treatment may also render a subset of Parkinson's disease patients at risk for sudden-onset sleep attacks that occur without warning and can be particularly hazardous if the patient is driving. This demonstrates the need for early recognition and management not only to increase health-related quality of life but also to ensure patient safety. There are many assessment tools for EDS, including the Epworth Sleepiness Scale (ESS) and the Multiple Sleep Latency Test (MSLT), although only the Parkinson's Disease Sleep Scale (PDSS) and the SCales for Outcomes in PArkinson's Disease-Sleep (SCOPA-S) are specifically validated for Parkinson's disease. Polysomnography can be used when necessary. Management comprises non-pharmacological and pharmacological approaches. Non-pharmacological approaches can be the mainstay of treatment for mild to moderate EDS. Advice on good sleep hygiene is instrumental, as pharmacological approaches have yet to provide consistent and reliable results without significant adverse effects. The efficacy of pharmacological treatment of EDS in Parkinson's disease using wakefulness-promoting drugs such as modafinil remains controversial. Further areas of research are now also focusing on adenosine A(2A) receptor antagonists, sodium oxybate and caffeine to promote wakefulness. A definitive treatment for the highly prevalent drug-induced EDS has not yet been found.

Determinants of health-related quality of life in Parkinson's disease: a systematic review

This systematic review critically evaluates the literature to identify the demographic and clinical factors that predict the health-related quality of life (HRQOL) of people with Parkinson's disease (PD). Understanding how these factors relate to HRQOL in people with PD may assist clinicians minimise the functional and social impact of the disease by optimising their assessment and clinical decision making processes. A tailored search strategy in six databases identified 29 full-text reports that fulfilled the pre-defined inclusion and exclusion criteria. The quality of included studies was assessed by two independent reviewers using a customized assessment form. A best-evidence synthesis was used to summarise the demographic and clinical factors that were examined in relation to HRQOL. Depression was the most frequently identified determinant of HRQOL in people with idiopathic PD. Disease severity and disease disability were also found to be predictive of poor HRQOL outcomes in many studies. The motor symptoms that contributed most often to overall life quality were gait impairments and complications arising from medication therapy. To minimise the impact of PD on HRQOL, it may be necessary to consider the extent to which demographic factors and motor and non-motor symptoms contribute to life quality.

Sleep disturbances and brain MRI morphometry in Parkinson's disease, multiple system atrophy and progressive supranuclear palsy - a comparative study

Despite common reports in Parkinson's disease (PD), in other parkinsonian syndromes, sleep disturbances have been less frequently described. This study evaluated and compared sleep disturbances in patients with PD, multiple system atrophy (MSA) and progressive supranuclear palsy (PSP) and analyzed associations with brain magnetic resonance imaging (MRI) morphometry. This was a cross-sectional study of 16 PD cases, 13 MSA, 14 PSP and 12 control. Sleep disturbances were evaluated by Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index (PSQI), Restless Legs Scale and Berlin questionnaire. Pons area, midbrain area, medial cerebellar peduncle (MCP) width, and superior cerebellar peduncle width were measured using MRI. Poor quality sleep, risk of obstructive sleep apnea (OSA) and restless legs syndrome (RLS) were detected in all groups. Patients with MSA showed higher risk of OSA and less frequent RLS. In MSA, a correlation between PSQI scores and Hoehn and Yahr stage was observed (p<0.05). In PSP, RLS was frequent (57%) and related with reduced sleep duration and efficiency. In PD, excessive daytime sleepiness was related to atrophy of the MCP (p=0.01). RLS was more frequent in PD and PSP, and in PSP, was associated with reduced sleep efficiency and sleep duration. Brain morphometry abnormalities were found in connection with excessive daytime sleepiness and risk of OSA in PD and PSP suggesting widespread degeneration of brainstem sleep structures on the basis of sleep abnormalities in these patients.