Comorbidity of the nonmotor symptoms of Parkinson's disease

Circadian and sleep disorders in Parkinson's disease

Impaired sleep and alertness, initially recognized by James Parkinson in his famous monograph "An Essay on the Shaking Palsy" in 1817, is one of the most common and disabling nonmotor symptoms of Parkinson's disease (PD). It is only recently, however, that sleep disturbances in PD have received the attention of medical and research community. Dopamine, the major neurotransmitter implicated in the pathogenesis of PD, plays a pivotal role in the regulation of sleep and circadian homeostasis. Sleep dysfunction affects up to 90% of patients with PD, and may precede the onset of the disease by decades. Sleep dysfunction in PD may be categorized into disturbances of overnight sleep and daytime alertness. Etiology of impaired sleep and alertness in PD is multifactorial. Co-existent primary sleep disorders, medication side effects, overnight re-emergence of motor symptoms, and primary neurodegeneration itself, are main causes of sleep disruption and excessive daytime sleepiness among patients with PD. Increasing body of evidence suggests that the circadian system becomes dysregulated in PD, which may lead to poor sleep and alertness. Treatment options are limited and frequently associated with unwanted side effects. Further studies that will examine pathophysiology of sleep dysfunction in PD, and focus on novel treatment approaches are therefore very much needed. In this article we review the role of dopamine in regulation of sleep and alertness and discuss main sleep and circadian disturbances associated with PD.

Nonmotor symptoms in Parkinson's disease in 2012: relevant clinical aspects

Nonmotor symptoms (NMSs) of Parkinson's disease (PD) are common, but they are often underrecognized in clinical practice, because of the lack of spontaneous complaints by the patients, and partly because of the absence of systematic questioning by the consulting physician. However, valid specific instruments for identification and assessment of these symptoms are available in 2012. The administration of the self-completed screening tool, NMSQuest, associated with questioning during the consultation, improves the diagnosis of NMSs. NMSs play a large role in degradation of quality of life. More relevant NMSs are described in this review, mood disorders, impulse control disorders, cognitive deficits, hallucinations, pain, sleep disorders, and dysautonomia.

Emerging roles of microglial activation and non-motor symptoms in Parkinson's disease

Recent data has indicated that the traditional view of Parkinson's disease (PD) as an isolated disorder of the nigrostriatal dopaminergic system alone is an oversimplification of its complex symptomatology. Aside from classical motor deficits, various non-motor symptoms including autonomic dysfunction, sensory and cognitive impairments as well as neuropsychiatric alterations and sleep disturbances are common in PD. Some of these non-motor symptoms can even antedate the motor problems. Many of them are associated with extranigral neuropathological changes, such as extensive α-synuclein pathology and also neuroinflammatory responses in specific brain regions, i.e. microglial activation, which has been implicated in several aspects of PD pathogenesis and progression. However, microglia do not represent a uniform population, but comprise a diverse group of cells with brain region-specific phenotypes that can exert beneficial or detrimental effects, depending on the local phenotype and context. Understanding how microglia can be neuroprotective in one brain region, while promoting neurotoxicity in another, will improve our understanding of the role of microglia in neurodegeneration in general, and of their role in PD pathology in particular. Since neuroinflammatory responses are in principle modifiable, such approaches could help to identify new targets or adjunctive therapies for the full spectrum of PD-related symptoms.

Fatigue in early Parkinson's disease. Minor inconvenience or major distress?

BACKGROUND AND PURPOSE

  Although fatigue is recognized as a common and debilitating symptom in patients with Parkinson's disease (PD), little is known on how and when this symptom emerges during disease progression. The aim of the study was to explore the presence and severity of fatigue in patients with PD at the time of diagnosis, before dopaminergic treatment has been instituted.

METHODS

  The present study is part of the Norwegian ParkWest project, a large cohort study of patients with incident PD in Norway. PD was diagnosed according to the Gelb criteria. The study population comprised 199 patients with untreated, newly diagnosed PD and 172 control subjects, matched for gender and age. Fatigue was measured by the Fatigue Severity Scale (FSS).

RESULTS

  Fifty-five percent of the patients with PD had clinical significant fatigue (FSS > 4), compared with about 20% of the controls (RR = 2.9). The mean score in patients on the FSS was 4.4 (SD 1.7) and in controls 3.1 (SD 1.3). In addition, there were highly significant differences between patients and controls in each of the nine FSS items. In a regression analysis, only the Montgomery and Åsberg Depression Rating Scale and Unified Parkinson's Disease Rating Scale-Activities of Daily Living scores were significantly associated with fatigue. There was no correlation between fatigue and cognitive impairment and hypersomnia.

CONCLUSION

  Fatigue is a common symptom in PD, also in patients with early, untreated disease, and it has a negative impact on these patients' activity of daily living. Also in early PD, fatigue is an important consideration in the management of patients with the disease.

Parkinson's disease

Parkinson's disease (PD) is the most common age-related motoric neurodegenerative disease initially described in the 1800's by James Parkinson as the 'Shaking Palsy'. Loss of the neurotransmitter dopamine was recognized as underlying the pathophysiology of the motor dysfunction; subsequently discovery of dopamine replacement therapies brought substantial symptomatic benefit to PD patients. However, these therapies do not fully treat the clinical syndrome nor do they alter the natural history of this disorder motivating clinicians and researchers to further investigate the clinical phenotype, pathophysiology/pathobiology and etiology of this devastating disease. Although the exact cause of sporadic PD remains enigmatic studies of familial and rare toxicant forms of this disorder have laid the foundation for genome wide explorations and environmental studies. The combination of methodical clinical evaluation, systematic pathological studies and detailed genetic analyses have revealed that PD is a multifaceted disorder with a wide-range of clinical symptoms and pathology that include regions outside the dopamine system. One common thread in PD is the presence of intracytoplasmic inclusions that contain the protein, α-synuclein. The presence of toxic aggregated forms of α-synuclein (e.g., amyloid structures) are purported to be a harbinger of subsequent pathology. In fact, PD is both a cerebral amyloid disease and the most common synucleinopathy, that is, diseases that display accumulations of α-synuclein. Here we present our current understanding of PD etiology, pathology, clinical symptoms and therapeutic approaches with an emphasis on misfolded α-synuclein.

The possible clinical predictors of fatigue in Parkinson's disease: a study of 135 patients as part of international nonmotor scale validation project

Fatigue is a common yet poorly understood and underresearched nonmotor symptom in Parkinson's disease. Although fatigue is recognized to significantly affect health-related quality of life, it remains underrecognised and empirically treated. In this paper, the prevalence of fatigue as measured by a validated visual analogue scale and the Parkinson's disease nonmotor symptoms scale (PDNMSS) was correlated with other motor and nonmotor comorbidities. In a cohort of patients from a range of disease stages, occurrence of fatigue correlated closely with more advanced Parkinson's disease, as well as with depression, anxiety, and sleep disorders, hinting at a common underlying basis.

Strategies for Parkinson’s disease care: prevention and management of motor fluctuations

SUMMARY Parkinson’s disease (PD) is characterized clinically by the hallmark motor signs of bradykinesia, rest tremor and rigidity. Current pharmacological management goals include control of motor symptoms as well as prevention and management of motor complications including motor fluctuations and dyskinesias. While the use of levodopa revolutionized the pharmacological management of PD, multiple other agents and strategies have emerged with many demonstrable, albeit sometimes controversial, advantages to a ‘levodopa’ only approach. Despite these developments, the progressive nature of PD requires vigilance and creativity from clinicians as both motor and nonmotor complications grow in number and severity over time.

Polypharmacy increases the risk of Parkinson's disease in older people in Taiwan: a population-based study

BACKGROUND

Little is known about the relationship between polypharmacy and Parkinson's disease (PD). In the present study, we tested the hypothesis that polypharmacy increases the risk of PD in older people in Taiwan.

METHODS

From a randomly sampled cohort of one million health insurance enrollees, we identified 2827 new cases of PD over the period 2000-2008 aged ≥ 65 years and selected 11 308 age-matched controls without PD. Medication history and baseline comorbidities were compared between the two groups. We defined 'polypharmacy' as an average daily use of five or more prescribed drugs.

RESULTS

Compared with patients using between none and one drug, the odds ratios (ORs) for PD increased to 1.53, 2.08, 2.64, and 2.95 for patients using two to four, five to seven, eight to nine, and ≥ 10 drugs, respectively. The other conditions associated with PD were dementia (OR 3.43), stroke (OR 2.30), depression (OR 2.15), and alcoholism (OR 2.11). Hyperlipidemia (OR 0.90) was inversely associated with PD.

CONCLUSIONS

Polypharmacy was shown to increase the risk of PD in older people in Taiwan, with risk increasing with the number of medications taken daily. Dementia, stroke, depression, and alcoholism were also associated with an increased risk of PD, whereas there was an inverse correlation between PD and hyperlipidemia.

Impact of ω-3 fatty acids in Parkinson's disease

Current epidemiological, preclinical and clinical data suggest that omega-3 polyunsaturated fatty acids (n-3 PUFAs) may constitute therapeutic strategy for several disorders of the central nervous system, including Parkinson's disease (PD). PD is a neurodegenerative disorder primarily characterized by motor symptoms but which also includes several other pathological features such as autonomic system failures, mood disorders, and cognitive deficits. Current pharmacological options for the disease are limited to symptom management and their long-term use leads to important side effects. In this review, we discuss the evidence for the effects of n-3 PUFAs in PD both from an epidemiological perspective as well as in light of data gathered on various pathological features of the disease. Effects of n-3 PUFAs on the dopaminergic system, α-synucleinopathy, their possible mechanisms of action as well as their therapeutic potential for PD patients are also reviewed. n-3 PUFAs are inexpensive, readily transferable to the clinical setting and their use could represent a neuroprotective strategy or a disease-modifying option to delay the appearance of symptoms. It could also be beneficial as a symptomatologic treatment or serve as an add-on therapy to current pharmacological approaches. Review of the current literature as well as the undertaking of future clinical trials will shed light on these possibilities.

Relation of Parkinson's disease subtypes to visual activities of daily living

Visual perceptual problems are common in Parkinson's disease (PD) and often affect activities of daily living (ADLs). PD patients with non-tremor symptoms at disease onset (i.e., rigidity, bradykinesia, gait disturbance or postural instability) have more diffuse neurobiological abnormalities and report worse non-motor symptoms and functional changes than patients whose initial symptom is tremor, but the relation of motor symptom subtype to perceptual deficits remains unstudied. We assessed visual ADLs with the Visual Activities Questionnaire in 25 non-demented patients with PD, 13 with tremor as the initial symptom and 12 with an initial symptom other than tremor, as well as in 23 healthy control participants (NC). As expected, the non-tremor patients, but not the tremor patients, reported more impairment in visual ADLs than the NC group, including in light/dark adaptation, acuity/spatial vision, depth perception, peripheral vision and visual processing speed. Non-tremor patients were significantly worse than tremor patients overall and on light/dark adaptation and depth perception. Environmental enhancements especially targeted to patients with the non-tremor PD subtype may help to ameliorate their functional disability.

The development and testing of an instrument for perceived self-efficacy for fatigue self-management

BACKGROUND

Persons with chronic illness commonly report fatigue. Measurement of perceived self-efficacy for fatigue self-management (PSEFSM) is essential if fatigue is to be monitored and enhanced to improve physical functional status.

OBJECTIVE

The objective of the study was to describe the development and testing of the PSEFSM instrument.

METHODS

The PSEFSM instrument was incorporated into 2 randomized controlled trials for secondary analysis (N=298): 63 persons with lung cancer and 235 persons with other cancer diagnoses undergoing a course of chemotherapy.

RESULT

: Evidence for construct validity and generalizability was supported through hypotheses testing of the mediation pathway from fatigue to physical functional status through PSEFSM, with results indicating support for partial mediation. Structural modeling indicated a good model fit that further supported the construct validity of the PSEFSM instrument.

CONCLUSIONS

The instrument provides a reliable and valid measure of PSEFSM that could be used in research to facilitate the development of interventions to increase perceived self-efficacy to achieve optimal symptom self-management.

IMPLICATIONS FOR PRACTICE

The PSEFSM instrument is brief and easy to complete, which results in a low response burden for persons who are already fatigued, providing for regular use in transdisciplinary research and practice settings. This is important because the use of this instrument can impact how we partner with our patients to better understand how to manage this troublesome symptom, fatigue.

Mechanisms of antidepressant action: an integrated dopaminergic perspective

The molecular mechanisms that cause and maintain the major depressive disorder (MDD) are currently unknown. Consistently, antidepressant treatments are characterized by insufficient success rates. This causes high social costs and severe personal sufferings. In the present review we analyze some of the paradigms that are used to explain MDD, particularly from the perspective of the dopaminergic (DA) system. DA has been more classically associated with psychosis and substance abuse disorders, even though a role of DA in MDD has been proposed as well and some antidepressants with DA profile exist. In the present work, we review some of the molecular mechanisms that underpin MDD from the perspective of the dopaminergic system, in the hope of unifying some of the major theories of MDD - the monoaminergic, inflammatory, epigenetics, neurotrophin and anti-apoptotic theories. Several shared components of these theories are highlighted, partially accounted by the functions of the DA system (see supplementary video).

Dopamine receptors and Parkinson's disease

Parkinson's disease (PD) is a progressive extrapyramidal motor disorder. Pathologically, this disease is characterized by the selective dopaminergic (DAergic) neuronal degeneration in the substantia nigra. Correcting the DA deficiency in PD with levodopa (L-dopa) significantly attenuates the motor symptoms; however, its effectiveness often declines, and L-dopa-related adverse effects emerge after long-term treatment. Nowadays, DA receptor agonists are useful medication even regarded as first choice to delay the starting of L-dopa therapy. In advanced stage of PD, they are also used as adjunct therapy together with L-dopa. DA receptor agonists act by stimulation of presynaptic and postsynaptic DA receptors. Despite the usefulness, they could be causative drugs for valvulopathy and nonmotor complication such as DA dysregulation syndrome (DDS). In this paper, physiological characteristics of DA receptor familyare discussed. We also discuss the validity, benefits, and specific adverse effects of pharmaceutical DA receptor agonist.

In vivo effect of 5-HT₇ receptor agonist on pyramidal neurons in medial frontal cortex of normal and 6-hydroxydopamine-lesioned rats: an electrophysiological study

The 5-hydroxytryptamine (5-HT)-7 receptor began to be cloned and pharmacologically characterized close to 20 years ago. It couples positively via G-proteins to adenylyl cyclase and activation of this receptor increases neuronal excitability, and several studies have shown that degeneration of the nigrostriatal pathway leads to an impairment of 5-HT system. Here we reported that systemic and local administration of 5-HT₇ receptor agonist AS 19 produced excitation, inhibition and no change in the firing rate of pyramidal neurons in medial prefrontal cortex (mPFC) of normal and 6-hydroxydopamine-lesioned rats. In normal rats, the mean response of the pyramidal neurons to AS 19 by systemic and local administration in mPFC was excitatory. The inhibitory effect by systemic administration of AS 19 was reversed by GABA(A) receptor antagonist picrotoxinin. Systemic administration of picrotoxinin excited all the neurons examined in normal rats, and after treatment with picrotoxinin, the local administration of AS 19 further increased the firing rate of the neurons. In the lesioned rats, systemic administration of AS 19, at the same doses, also increased the mean firing rate of the pyramidal neurons. However, cumulative dose producing excitation in the lesioned rats was higher than that of normal rats. Systemic administration of AS 19 produced inhibitory effect in the lesioned rats, which was partially reversed by picrotoxinin. The local administration of AS 19, at the same dose, did not change the firing rate of the neurons in the lesioned rats. Systemic administration of picrotoxinin and the local administration of AS 19 did not affect the firing rate of the neurons in the lesioned rats. These results indicate that activity of mPFC pyramidal neurons is regulated through activation of 5-HT₇ receptor by direct or indirect action, and degeneration of the nigrostriatal pathway leads to decreased response of these neurons to AS 19, suggesting dysfunction and/or down-regulation of 5-HT₇ receptor on the pyramidal neurons and GABA interneurons in the lesioned rats.

Fatigue in spinocerebellar ataxia: patient self-assessment of an early and disabling symptom

OBJECTIVE

To identify the prevalence and severity of fatigue and predicting factors for severe fatigue in autosomal dominant spinocerebellar ataxia (SCA).

METHODS

We studied a cross-section of 123 patients with SCA. Six functional scales were used in a self-assessment: the Fatigue Severity Scale (FSS); the Beck Depression Inventory (BDI); the Rotterdam Handicap Scale (RHS); the Short Form-36 health survey, distinguishing a norm-based physical and mental component score (Nb-PCS and Nb-MCS); the Pittsburgh Sleep Quality Index (PSQI); and the Epworth Sleepiness Scale (ESS). A subset of 58 patients was clinically evaluated, measuring severity of ataxia with the Scale for the Assessment and Rating of Ataxia and cognitive functioning with the Mini-Mental State Examination.

RESULTS

Severe fatigue (FSS ≥5) was present in 69% of patients and FSS value correlated with the scores on RHS, Nb-PCS, Nb-MCS, BDI, PSQI, and ESS. There was no relation with disease duration, gender, or medication use. Multivariate analysis revealed that Nb-PCS and BDI were the best independent predictors for severe fatigue. Interestingly, the presence of visual symptoms was related to FSS value in the clinically evaluated subgroup.

CONCLUSION

Fatigue is a severe and disabling symptom in adult patients with SCA, even early in the course of disease. Physical functioning and depression are the strongest predictors of fatigue. In treatment strategies, all treatable factors for fatigue should be addressed, especially depression, visual symptoms, and sleeping disorders.

Nonmotor symptoms are independently associated with impaired health-related quality of life in Chinese patients with Parkinson's disease

We performed a cross-sectional study of 82 Chinese patients with Parkinson's disease (PD) enrolled during an 18-month period using a clinical interview to assess the prevalence of nonmotor symptoms (NMS), the association with disease severity and motor status, and the impact on patients' health-related quality of life (Hr-QoL). The patients' NMS, Hr-QoL, disease severity, and motor status were assessed by the Nonmotor Symptoms Scale (NMSS), the 39-item Parkinson's Disease Questionnaire (PDQ-39), the modified Hoehn and Yahr staging scale (H&Y) and the Unified Parkinson's Disease Rating Scale part III (UPDRS III), respectively. We found that 100% of patients with PD presented with NMS. The NMSS significantly correlated with disease duration (Spearman's r(S) = 0.276, P = 0.012), H&Y (r(S) = 0.230, P = 0.038), and UPDRS III (r(S) = 0.350, P = 0.001). Similarly, the PDQ-39 SI significantly associated with the disease duration (r(S) = 0.258, P = 0.019), H&Y (r(S) = 0.340, P = 0.002), and UPDRS III (r(S) = 0.453, P < 0.001). NMS domains that influenced the PDQ-39 SI were sleep/fatigue, mood, gastrointestinal, urinary, and miscellaneous symptoms. This strongly suggested that the five domains played a key role in the manifestation of Hr-QoL. NMSS explains more of the variability in Hr-QoL than UPDRS III, when both are the model (stepwise multiple linear regression analysis R² change, 47.8% vs. 5.87%, respectively). Therefore, these findings demonstrate that NMS are independently and negatively associated with Hr-QoL in PD and that improving NMS should be viewed as an important part in the management of PD.

Anxiety and depression severity are related to right but not left onset Parkinson's disease duration

Depression and anxiety have both been associated with relative left frontal hypoactivation and the motor symptoms of Parkinson's disease typically begin in a lateral or asymmetrical fashion. Hence, PD patients with right hemibody onset may experience heightened depression and anxiety. However, research is mixed regarding whether right or left hemibody onset PD is associated with elevated levels of depression and anxiety. This literature, though, has not considered the potential moderating variable of disease duration. We hypothesized that disease duration would be positively correlated with measures of depression and anxiety in right but not left hemibody onset PD patients. The results indicated that scores on the Geriatric Depression Scale, Beck Depression Inventory-II, and the State Trait Anxiety Scale - State correlated positively with disease duration, but only in the right hemibody onset group of PD patients. Thus, right hemibody onset PD is associated with more severe depressive and anxiety symptoms, but only when disease duration is considered.

Fatigue in Parkinson's disease: a short update

This article provides a short update on fatigue in Parkinson's disease (PD), focusing on measurements, prevalence, associated factors, pathophysiology and treatment. As long as there is no universally accepted definition of fatigue the definition used has to be stated. Different aspects of fatigue, namely physical-, mental- and chronic fatigue will be discussed. The many questionnaires used to assess fatigue measure different aspects of fatigue, making comparisons between studies difficult. Examples of uni- and multidimensional self-report questionnaires are given. In PD patients, the wide range of prevalence of fatigue (37-56%) is largely because of varying definitions of fatigue and populations tested. Without understanding the pathophysiology of subjective fatigue, the development of effective therapies is a challenge.

Anxiety and self-perceived health status in Parkinson's disease

Both anxiety and depression are associated with lower self-perceived health status (HS) in persons with Parkinson's disease (PD). Given the high co-morbidity with depression and other non-motor symptoms, it is unclear whether anxiety disorders, in general, versus specific anxiety subtypes have an independent effect on HS in PD. To examine this question, comprehensive assessments of motor and non-motor symptoms from 249 subjects with idiopathic PD followed in three community-based movement disorders neurology practices were analyzed. HS was measured using the 8-item PD Questionnaire (PDQ-8). Psychiatric diagnoses were established by consensus using a panel of six psychiatrists with expertise in geriatric psychiatry and movement disorders. Stepwise multiple regression analyses were used, with the PDQ-8 score as the dependent variable, to identify independent predictors of HS among motor, psychiatric, and other non-motor variables. Among the anxiety disorders, only anxiety associated with motor fluctuations was an independent predictor of HS after accounting for co-morbid depression and other clinical features. In addition, depressive disorders were also an independent predictor of lower HS. Prevention or treatment of state-dependent anxiety may improve HS in persons with PD.

Evaluation of fatigue in Parkinson's disease using the Brazilian version of Parkinson's Fatigue Scale

OBJECTIVE

Fatigue is common in Parkinson's disease (PD). However, factors associated with fatigue in PD are still controversial. This study aimed to translate the Parkinson's Fatigue Scale (PFS) into Brazilian-Portuguese, to test its psychometric properties, and to assess the severity of fatigue in PD as well as its relation to demographic and clinical features, depression, anxiety, excessive daytime sleepiness and cognitive performance.

METHODS

We translated and assessed the internal consistency of the Brazilian version of the PFS. After, we assessed 87 PD patients with several neurological and psychopathological instruments.

RESULTS

The Brazilian version of PFS had good internal consistency (Cronbach's alpha = 0.939). Clinical significant fatigue was present in 36 patients (41.4%). A logistic regression analysis showed that fatigue was better explained by dysthymia (P = 0.006), more severe symptoms of depression as assessed by the Hamilton Depression Rating Scale (P = 0.027), daytime sleepiness (P = 0.022) and female gender (P = 0.031).

CONCLUSIONS

Fatigue is a common non-motor symptom in PD and seems to be associated with female gender, dysthymia, severity of depression and daily somnolence.

The pyramidal neurons in the medial prefrontal cortex show decreased response to 5-hydroxytryptamine-3 receptor stimulation in a rodent model of Parkinson's disease

In the present study, effect of SR 57227A, a selective 5-hydroxytryptamine-3 (5-HT(3)) receptor agonist, on the firing activity of pyramidal neurons in the medial prefrontal cortex (mPFC) was studied in normal rats and rats with 6-hydroxydopamine lesions of the substantia nigra pars compacta by using extracellular recording. Systemic administration of SR 57227A (40-640 μg/kg, i.v.) decreased the mean firing rate of pyramidal neurons in normal and the lesioned rats. This inhibition was significant only at doses higher than 320 μg/kg and 640 μg/kg in normal and the lesioned rats, respectively, and was reversed by i.v. administration of 5-HT(3) receptor antagonist tropisetron or GABA(A) receptor antagonist bicuculline. Furthermore, local application of SR 57227A (0.01 μg) in the mPFC inhibited the firing rate of pyramidal neurons in normal rats while having no effect on firing rate in the lesioned rats. The i.v. administration of bicuculline excited the pyramidal neurons in normal rats, and then local application of SR 57227A did not alter the mean firing rate of these neurons. However, these two drugs did not affect the activity of the pyramidal neurons in the lesioned rats. We conclude that activation of 5-HT(3) receptors inhibited pyramidal neurons in the mPFC of normal rats via GABAergic interneurons, and degeneration of the nigrostriatal pathway decreased response of the pyramidal neurons to SR 57227A, suggesting the dysfunction of 5-HT(3) receptors and/or down-regulation of the expression on GABAergic interneurons in the lesioned rats.

Fatigue in patients with Parkinson's disease: impact on quality of life

OBJECTIVE

To determine the prevalence of fatigue and factors associated with fatigue in patients with Parkinson's disease (PD).

METHODS

Fatigue was evaluated using the PD Fatigue Scale, a self-report questionnaire consisting of 16 statements describing the severity of fatigue symptoms. Patients were also evaluated using the Unified PD Rating Scale, Zung Depression Scale, the Epworth Sleepiness Scale, the PD Questionnaire-39 (PDQ-39) for assessing quality of life (QOL), and the Apathy Scale.

PATIENTS

We examined 46 consecutive outpatients clinically diagnosed with PD, excluding patients with cognitive impairment.

RESULTS

Fatigue was present in 22 (48%) patients. Multiple logistic regression analysis indicated that only QOL-scores and Apathy Scale scores were significant independent variables related to the presence of fatigue.

CONCLUSION

Fatigue is a common symptom in patients with PD, and it is a symptom closely related to impaired QOL.

Clinical, laboratory, and neuroimaging characteristics of fatigue in HIV-infected individuals

Fatigue is among the most common symptoms reported by HIV-infected individuals. Previous reports suggest that the prevalence of fatigue varies by disease status with rates close to 80% in patients with AIDS. However, most studies have not been conducted in the setting of a controlled trial and have not assessed the association of fatigue with cellular markers of brain activity. Data for this study were derived from baseline and longitudinal evaluations in ACTG A5090, a randomized, double-blind, placebo-controlled trial of the Selegiline Transdermal System for the treatment of HIV-associated cognitive impairment. Fatigue was assessed using the Fatigue Severity Scale with scores of >4 considered "fatigued". Participants in a substudy underwent brain magnetic resonance spectroscopy (MRS) imaging, an in vivo method for assessing brain metabolites associated with neuronal and glia activity. Differences between fatigued and non-fatigued participants were evaluated with respect to demographics and clinical characteristics, plasma and CSF HIV-1 RNA concentration, CD4 counts, and brain metabolites. One hundred and twenty-eight participants were enrolled (88% male, median age = 45 years) and 82 participants (64%, 95% confidence interval 55%, 72%) were fatigued at baseline. MRS was conducted in 62 of the 128 participants. Fatigued participants were significantly younger (p = 0.011), had lower Karnofsky scores (p = 0.032), and had higher levels of depressive symptoms on the Center for Epidemiologic Studies Depression (CES-D) scale (p < 0.001) than non-fatigued participants. Statistically significant differences between fatigued and non-fatigued groups were not detected for plasma and CSF HIV-1RNA concentration, CD4 counts, or on neuropsychological tests. MRS revealed significantly lower levels of the cellular energy marker total creatine (p = 0.002) in the basal ganglia of fatigued participants. Statistically significant differences in other brain metabolites were not detected. Longitudinal data showed that fatigue persisted and worse fatigue at baseline was predictor of future fatigue. Among the cognitive tests, baseline Stroop score was associated with future fatigue. Fatigue was present in 64% of A5090 study participants and persisted during the 24 weeks of follow-up. Fatigue was associated with worse functional performance and depressive mood. Lower cellular energy levels in the basal ganglia, as measured by MRS total creatine concentration, suggest energy dysmetabolism in this brain region. This observation, taken together with the association between fatigue and neuropsychological tests of frontal lobe performance is consistent with the hypothesis of a striatal-cortical circuitry involvement in the symptoms of fatigue.

Clinical predictors of frequent patient telephone calls in Parkinson's disease

BACKGROUND

Patient telephone calls are a major form of unreimbursed healthcare utilization in Parkinson's disease (PD), yet little is known about potential risk factors for frequent calling behavior.

METHODS

Prospective cohort study of 175 non-demented outpatients with PD. Our primary outcome measure was the frequency of patient telephone calls over a three-month period relative to baseline demographics, State-Trait Anxiety Index (STAI) and Beck Anxiety Inventory (BAI) scores, Unified Parkinson's Disease Rating Scale (UPDRS) motor scores, and medication use. Based on the median call rate (1 call/3 months), subjects were dichotomized into frequent (≥2 calls) and infrequent (≤1 call) caller groups.

RESULTS

A total of 297 calls were received, of which 264 (89%) were from the frequent caller group (n = 63 subjects), and only 33 (11%) were from the infrequent caller group (n = 112 subjects). Compared with calls from infrequent callers, those from frequent callers more commonly related to somatic symptoms of PD (46.8% vs. 19.4%, p = 0.007). In multivariate logistic regression analysis, independent predictors of frequent calling were: anxiety (STAI ≥55; adjusted OR = 2.62, p = 0.02), sleep disorders (adjusted OR = 2.36, p = 0.02), dyskinesias (adjusted OR = 3.07, p = 0.03), and dopamine agonist use (adjusted OR = 2.27, p = 0.03). Baseline demographics, UPDRS motor scores, and levodopa use were similar in both groups.

CONCLUSIONS

Frequent patient telephone calls in PD are independently associated with anxiety, sleep disorders, dyskinesias, and dopamine agonist use, with a minority of patients accounting for the majority of calls. Aggressive treatment of these non-motor symptoms and motor complications might potentially reduce the burden of patient telephone calls in PD.

Dopamine receptor agonists and depression in Parkinson's disease

Depression is one of the most common non-motor symptoms in Parkinson's disease (PD). It is associated with a more rapid progression of physical symptoms, greater decline in cognitive skills, and a poorer quality of life. Despite the high prevalence of depression and antidepressant use in PD, validated guidelines for the treatment of PD-associated depression (dPD) are lacking. Several methodological limitations have been recognized in the available studies examining the treatment of dPD. Some studies support a relevant role of the catecholaminergic systems in the pathogenesis of dPD. In open-label studies, the dopamine receptor agonists pramipexole and pergolide have shown antidepressant effects in PD patients. A placebo-controlled study of pramipexole in dPD is ongoing. The combined results of data from animal models and evidence in human studies support the strategy of dopaminergic stimulation as a treatment of depression. Treatment strategies for depressive symptoms in PD should include optimization of dopaminergic treatment prior to the addition of classic antidepressant drugs, thus reducing the risk of side-effects associated with multi-drug therapies.

White matter microstructure changes in the thalamus in Parkinson disease with depression: A diffusion tensor MR imaging study

BACKGROUND AND PURPOSE

Depression occurs frequently in PD; however the neural basis of depression in PD remains unclear. The aim of this study was to characterize possible depression-related white matter microstructural changes in the thalamus of patients with DPD compared with those with NDPD.

MATERIALS AND METHODS

FA and MD maps from DTI were obtained in 14 patients with DPD and 18 patients with NDPD. Region-of-interest-guided VBA was conducted on the FA maps to detect possible microstructural differences in the thalamus between these 2 patient groups. Moreover, mean FA and MD in regions with a detected difference were compared between DPD and NDPD groups, and correlations between diffusion quantities and the severity of depression were analyzed.

RESULTS

White matter microstructure differences were found between the patients with DPD and NDPD in the bilateral mediodorsal thalamic regions. In these regions, patients with DPD showed significantly decreased FA values (P < .005) compared with patients with NDPD, and the mean values of FA were negatively correlated with the scores of depression severity (P < .05) for patients with PD. No significant differences of MD were found in the mediodorsal thalamus between these 2 groups.

CONCLUSIONS

Our results provide preliminary evidence that the mediodorsal thalamus may play an important role in depression in PD and suggest a relationship between FA in the mediodorsal thalamus and the presence of depressive symptoms in patients with DPD. These findings may be helpful for further understanding the potential mechanisms of depression in PD.

Anxiety affects working memory only in left hemibody onset Parkinson disease patients

OBJECTIVE

This investigation sought to examine the potential moderating influence of heightened anxiety on working memory in Parkinson disease (PD) patients. Further, we wanted to determine whether this moderating influence of anxiety differentially affects PD patients with left hemibody (LBH) versus right hemibody (RHB) onset of motor symptoms.

BACKGROUND

Research has examined the neurocognitive effects of depression in PD. However, a paucity of research has examined the effects of heightened anxiety in PD. We predicted that LHB PD patients with heightened anxiety would perform worse on a measure of working memory than RHB PD patients.

METHOD

A total of 59 PD patients completed the state-trait anxiety inventory and were also administered the digit span subtest of the Wechsler Memory Scale-III.

RESULTS

The results supported the hypotheses, indicating that the LHB PD patients with heightened anxiety performed significantly worse than the RHB PD patients with heightened anxiety and the LHB PD patients with low anxiety.

CONCLUSIONS

These findings suggest that left hemibody onset PD patients may experience more disability in their activities of daily living. Future research should explore whether differences also exist between PD patients with and without the diagnosed anxiety disorders.

Anxious and depressive symptoms in Parkinson's disease: the French cross-sectionnal DoPaMiP study

Anxiety has been less extensively studied than depression in Parkinson's disease (PD). The DoPaMiP survey allowed assessing simultaneously anxiety and depressive symptoms in PD and comparing correlations of both symptoms with clinical and therapeutic features of the disease. Cross sectional survey conducted prospectively in 450 ambulatory nondemented PD patients and 98 patients with other disorders than PD. Anxiety and depressive symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS), parkinsonism using the Unified Parkinson's Disease Rating Scale (UPDRS). Other clinical factors were measured using a structured standardized examination/questionnaire. The mean HADS-A (anxiety) subscore was higher in PD patients than in the others (8.2 +/- 3.9 vs. 6.5 +/- 3.2, P < 10(-4)) as was the HADS-D (depressive) subscore (6.6 +/- 3.8 vs. 3.9 +/- 3.2, P < 10(-4)). Patients with possible/probable anxious signs (HADS-A >or= 8) were more prevalent in PD (51% vs. 29%, P < 10(-4)) as were those with depressive symptoms (40% vs. 10%, P < 10(-4)). Conversely, anxiolytic and antidepressant medications consumption was not different between the 2 groups. Patients with anxious symptoms were more frequently female and younger than those without such symptoms, while those with depressive symptoms had more severe indices of parkinsonism, more comorbidities and lower cognitive function (Mini Mental State Exam). The logistic regression model revealed that patients with depressive symptoms received more frequently levodopa and less frequently a dopamine agonist. Anxiety and depressive symptoms were more frequent in PD patients than in medical control group. Both symptoms were commonly associated in the same PD patients, but were correlated with different clinical/therapeutic features, suggesting different underlying pathophysiological mechanisms.

Effectiveness of an online fatigue self-management programme for people with chronic neurological conditions: a randomized controlled trial

OBJECTIVE

To evaluate an online fatigue self-management programme in a sample of adults with chronic neurological conditions.

DESIGN

Randomized controlled trial.

SETTING

Online fatigue self-management programme delivered across Australia.

PARTICIPANTS

Ninety-five people with fatigue secondary to multiple sclerosis, Parkinson's disease or post-polio syndrome.

INTERVENTIONS

An online fatigue self-management programme, an information-only fatigue self-management programme and a control group.

MAIN MEASURES

Groups were compared at pre test, post test and at three months on primary outcomes using the Fatigue Impact Scale, Activity Card Sort and Personal Wellbeing Index.

RESULTS

With the exception of the Personal Wellbeing Index at post test (F = 3.519; P =0.034) and the Physical Subscale of the Fatigue Impact Scale at follow-up (F = 3.473; P =0.035) there were no significant differences between the three groups on primary outcomes. Post-hoc testing showed the differences to be between the information-only and control groups (P = 0.036 and P = 0.030 respectively). Improvement in the information-only group was unexpected but appears to be similar to results of other online interventions. The fatigue self-management and information-only groups performed better than the control on some secondary outcome measures. Low power in the analysis may have contributed to the findings. Repeated-measures ANCOVA showed that the fatigue self-management and the information-only groups improved over time on the Fatigue Impact Scale and the Activity Card Sort (P<0.05). The control group showed no improvements over time.

CONCLUSIONS

Although the fatigue self-management group improved over time, results did not demonstrate additional benefit in most outcome measures when compared with the control group.

Parkinson's disease in women: a call for improved clinical studies and for comparative effectiveness research

The incidence and prevalence of Parkinson's disease (PD) is expected to rise precipitously over the next several decades, as will the associated healthcare related costs. The epidemiology and disease manifestations of PD may differ when comparing women to men. Women are for example less likely to acquire PD, and in several studies have demonstrated a delayed onset of motor symptoms. Women, however, are more likely to experience PD-related complications that may lead to disability (e.g. depression and medication-associated dyskinesia). Further, there are purported differences in the treatment and treatment outcomes in PD men compared to women. Whether estrogen, other hormonal activity, or whether multiple factors underpin these findings remains unknown. Also unknown is whether estrogen itself may represent a therapeutic option for symptomatic PD treatment. This review summarizes what is known about gender differences in epidemiology, clinical features, treatment outcomes (medical and surgical/deep brain stimulation), and social impact among all available PD studies. We offer expert opinion regarding the shortcomings of the current evidence, and we propose a detailed list of studies that will help to clarify important gender related PD questions. Our hope is that this review will spark comparative effectiveness research into improving care and outcomes in women with PD.

Influence of left versus right hemibody onset Parkinson's disease on cardiovascular control

Whereas the left hemisphere is involved in regulating the parasympathetic nervous system, the right hemisphere regulates the sympathetic. Given the asymmetrical onset of motor symptoms and neuropathology in PD, differences in cardiovascular functions might be expected between PD patients with left hemibody onset (LHO) versus right hemibody onset (RHO). A total of 66 PD patients served as participants, including 31 LHO patients and 35 RHO PD patients. All participants had their resting heart rate (HR) and blood pressure (BP) recorded. Although the LHO group had lower systolic BP, it had higher resting HR than did the RHO group. The reason for this dissociation is not known but might be related to asymmetrical vagus nerve control of the heart (SA node). Future researchers might want to use additional indices of cardiovascular functioning that are more precise measures of parasympathetic and sympathetic functioning, as well as learn the influence of dopaminergic medications.

Behavioral phenotyping of mouse models of Parkinson's disease

Parkinson's disease (PD) is a common neurodegenerative movement disorder afflicting millions of people in the United States. The advent of transgenic technologies has contributed to the development of several new mouse models, many of which recapitulate some aspects of the disease; however, no model has been demonstrated to faithfully reproduce the full constellation of symptoms seen in human PD. This may be due in part to the narrow focus on the dopamine-mediated motor deficits. As current research continues to unmask PD as a multi-system disorder, animal models should similarly evolve to include the non-motor features of the disease. This requires that typically cited behavioral test batteries be expanded. The major non-motor symptoms observed in PD patients include hyposmia, sleep disturbances, gastrointestinal dysfunction, autonomic dysfunction, anxiety, depression, and cognitive decline. Mouse behavioral tests exist for all of these symptoms and while some models have begun to be reassessed for the prevalence of this broader behavioral phenotype, the majority has not. Moreover, all behavioral paradigms should be tested for their responsiveness to L-DOPA so these data can be compared to patient response and help elucidate which symptoms are likely not dopamine-mediated. Here, we suggest an extensive, yet feasible, battery of behavioral tests for mouse models of PD aimed to better assess both non-motor and motor deficits associated with the disease.

Apathy and depression in Parkinson disease

The purpose of this study was to investigate the prevalence and clinical correlates of apathy and depression in Parkinson disease (PD), and to clarify whether apathy can be dissociated from depression. One hundred fifty patients with PD completed the Beck Depression Inventory Second Edition (BDI-II), Starkstein's Apathy Scale (AS), and a quality of life (QOL) battery. Hoehn and Yahr (HY) staging, the Unified Parkinson's Disease Rating Scale (UPDRS), and the Mini-Mental State Examination (MMSE) were performed on the same day. Apathy (AS score > or = 16) was diagnosed in 60% of patients and depression (BDI-II score > or = 14) in 56%. Apathy coexisted with depression in 43% of patients, compared with depression without apathy in 13% and apathy without depression in 17%. Apathy scale score was significantly correlated with UPDRS scores, HY stage, and age, whereas BDI-II score was correlated only with UPDRS scores. Both AS and BDI-II scores were negatively correlated with QOL. However, multiple regression analysis revealed that depression was strongly and negatively associated with emotional well-being and communication, whereas apathy was mainly associated with cognition and stigma. These findings suggest that apathy and depression may be separable in PD, although both are common in patients with PD and are associated with QOL.

Laryngeal somatosensory deficits in Parkinson's disease: implications for speech respiratory and phonatory control

Parkinson's disease (PD) is often associated with substantial impairment of speech respiratory and phonatory control. However, the degree to which these impairments are related to abnormal laryngeal sensory function is unknown. This study examined whether individuals with PD exhibited abnormal and more asymmetric laryngeal somatosensory function compared with healthy controls, and whether these deficits were associated with disease and voice severity. Nineteen PD participants were tested and compared with 18 healthy controls. Testing included endoscopic assessment of laryngeal somatosensory function, with aerodynamic and acoustic assessment of respiratory and phonatory control, and clinical ratings of voice and disease severity. PD participants exhibited significantly abnormal and asymmetric laryngeal somatosensory function compared with healthy controls. Sensory deficits were significantly associated with timing of phonatory onset, voice intensity, respiratory driving pressure, laryngeal resistance, lung volume expended per syllable, disease severity, and voice severity. These results suggest that respiratory and phonatory control are influenced by laryngeal somatosensory function, that speech-related deficits in PD are related to abnormal laryngeal somatosensory function, and that this function may degrade as a function of disease severity. Thus, PD may represent a model of airway sensorimotor disintegration, highlighting the important role of the basal ganglia and related neural networks in the integration of laryngeal sensory input for speech-related motor control.

Fatigue in Japanese patients with Parkinson's disease: a study using Parkinson fatigue scale

The objective of this multicenter cross-sectional study was to determine the prevalence of fatigue and factors contributing to it in a large sample of Japanese patients with Parkinson's disease (PD). We used the 16-item Parkinson Fatigue Scale (PFS-16), which was designed to assess fatigue exclusively associated with PD. We carried out this study using PFS-16, the Unified Parkinson's Disease Rating Scale, Zung's Self-Rating Depression Scale, Parkinson's Disease Sleep Scale (PDSS), and the PD quality of life (QOL) scale (PDQ-39) by interview using questionnaires and physical examination by neurologists in 361 nondemented PD patients. Fatigue (an average PFS score of 3.3 or greater) was revealed in 151 patients (41.8%). Multiple logistic regression analysis indicated that the significant independent variables related to the presence of fatigue were the scores of PDSS and PDQ-39. Depression score was not a significant contributing factor. Our study revealed that the prevalence of fatigue in Japanese PD patients is as high as that in Western countries, and that fatigue is a relatively independent symptom, although sleep disturbance may be associated with fatigue. Since fatigue is significantly related to QOL reduction, therapeutic interventions including treatment of sleep disturbance are important.

Quality of sleep in primary focal dystonia: a case-control study

BACKGROUND

Sleep disturbances are common in patients with movement disorders. Evaluating quality of sleep is of primary importance because of the effect that nocturnal and daytime sleep abnormalities exert on general health status. However, quality of sleep has never been addressed in detail in patients with dystonia. The aim of this case-control study was to analyse quality of sleep in patients with the two most common forms of primary focal dystonia, blepharospasm (BSP) and cervical dystonia (CD).

METHODS

We evaluated quality of sleep (Pittsburgh Sleep Quality Index, PSQI) and excessive daytime sleepiness (Epworth Sleepiness Scale, ESS) in 98 patients with focal adult-onset dystonia (52 with BSP; 46 with CD) and in a group of 56 age-and gender-matched healthy subjects. The Beck Depression Inventory (BDI) was used for the evaluation of depressive symptomatology.

RESULTS

Quality of sleep was impaired (significantly higher PSQI scores) in both groups of patients. However, differences in PSQI scores between patients with CD and control subjects were partly confounded by BDI scores, whereas differences in PSQI scores between patients with BSP and control subjects were not influenced by BDI. Excessive daytime sleepiness was not significantly more frequent than in control subjects in either patients with BSP or patients with CD.

CONCLUSIONS

This study suggests that the assessment and treatment of insomnia-related complaints should be considered in global management plans of patients with focal dystonia, particularly in those affected by BSP.