The Neuropsychiatric Fluctuations Scale for Parkinson's Disease: A Pilot Study

Non-motor symptoms in PD evaluated during pharmacological ON state by a new tool: The NoMoS-ON scale. Is always the "ON" state beneficial?

OBJECTIVES

To evaluate non-motor symptoms (NMS) occurring during ON pharmacological state and validate a new questionnaire, the Non-motor symptoms-ON scale (NoMoS-ON), exploring ON NMS in Parkinson's disease (PD).

MATERIAL AND METHODS

Patients with PD were evaluated by a new questionnaire, the NoMoS-ON scale, evaluating 17 items related to the main symptoms experienced during the ON state. PD patients who experienced at least one symptom in ON were defined ON-NMS+. Internal consistency and test-retest reliability of NoMoS-ON scale were also assessed.

RESULTS

One-hundred and thirty-seven PD patients were consecutively enrolled (79 men and 58 women, age 69.4 ± 9.5 years (mean ± SD)). Seventy-seven patients were ON-NMS+ (56.6 %). PD patients with short disease duration (<7 years) showed the presence of unpleasant NMS: "sleepiness", "light-headedness", "nausea/vomiting". PD patients with longer disease duration experienced pleasant non-motor features including "feel lot of energy", "feel physical well-being". ON-NMS+ were also associated with female gender (OR 2.81, 95%CI 1.37-5.77, p-value 0.005) and with motor fluctuations (OR 2.41, 95%CI 1.20-4.83, p-value 0.013). Cronbach's alpha was 0.61 and 5 items had adequate item-to-total correlations (r ≥ 0.40). Test-retest reliability was acceptable (intraclass correlation coefficient, ICC = 0.77).

CONCLUSIONS

The NoMoS-ON scale is a valid, reproducible and reliable questionnaire capturing the ON NMS in PD. PD patients with disease duration shorter than 7 years showed the presence of unpleasant NMS whereas those with longer disease duration experienced pleasant non-motor features. This could help the physician in the therapy management of PD patients in different phases of their disease.

Subthalamic stimulation has acute psychotropic effects and improves neuropsychiatric fluctuations in Parkinson's disease

Background

Subthalamic nucleus deep brain stimulation (STN-DBS) is a well-established treatment for motor complications in Parkinson's disease (PD). However, its effects on neuropsychiatric symptoms remain disputed. The aim of this study was to evaluate the effects of STN-DBS on neuropsychiatric symptoms in PD.

Methods

We retrospectively assessed 26 patients with PD who underwent a preoperative levodopa challenge and postoperative levodopa and stimulation challenges 1 year after STN-DBS. Based on the Neuropsychiatric Fluctuations Scale, Neuropsychiatric State Scores and Neuropsychiatric Fluctuation Indices (NFIs) were calculated. Mixed-effects models with random effects for intercept were used to examine the association of Neuropsychiatric State Score and NFI with the different assessment conditions.

Results

In acute challenge conditions, there was an estimated increase of 15.9 points in the Neuropsychiatric State Score in stimulation ON conditions (95% CI 11.4 to 20.6, p<0.001) and 7.6 points in medication ON conditions (95% CI 3.3 to 11.9, p<0.001). Neuropsychiatric fluctuations induced by levodopa, quantified with NFI, decreased by 35.54% (95% CI 49.3 to 21.8, p<0.001) 1 year after STN-DBS.

Conclusions

Bilateral STN-DBS at therapeutic parameters has acute psychotropic effects similar to levodopa and can modulate and decrease levodopa-induced neuropsychiatric fluctuations.

Fluctuations in Parkinson's disease and personalized medicine: bridging the gap with the neuropsychiatric fluctuation scale

Background

Neuropsychiatric fluctuations (NpsyF) are frequent and disabling in people with Parkinson's disease (PD). In OFF-medication, NpsyF entail minus neuropsychiatric symptoms (NPS) like anxiety, apathy, sadness, and fatigue. In ON-medication, NpsyF consist in plus NPS, such as high mood, hypomania, and hyperactivity. Accurate identification of these NpsyF is essential to optimize the overall PD management. Due to lack of punctual scales, the neuropsychiatric fluctuation scale (NFS) has been recently designed to assess NpsyF in real time. The NFS comprises 20 items with two subscores for plus and minus NPS, and a total score.

Objective

To evaluate the psychometric properties of the NFS in PD.

Methods

PD patients with motor fluctuations and healthy controls (HC) were assessed. In PD patients, the NFS was administrated in both the ON-and OFF-medication conditions, together with the movement disorders society-unified Parkinson disease rating scale parts I-IV. Depression (Beck depression scale II), apathy (Starkstein apathy scale) and non-motor fluctuations items of the Ardouin scale of behaviour in PD (ASBPD OFF and ON items) were also assessed. NFS internal structure was evaluated with principal component analysis consistency (PCA) in both medication conditions in PD patients and before emotional induction in HC. NFS internal consistency was assessed using Cronbach's alpha coefficient. NFS convergent and divergent validity was measured through correlations with BDI-II, Starktein, and ASBPD OFF and ON non motor items. Specificity was assessed comparing NFS global score between the HC and PD populations. Sensitivity was evaluated with t-student test comparing the ON-and the OFF-medication conditions for NFS global score and for minus and plus subscores.

Results

In total, 101 consecutive PD patients and 181 HC were included. In PD patients and HC, PCA highlighted one component that explained 32-35 and 42% of the variance, respectively. Internal consistency was good for both the NFS-plus (alpha =0.88) and NFS-minus items (alpha =0.8). The NFS showed a good specifity for PD (p < 0.0001) and a good sensitivity to the medication condition (p < 0.0001).

Conclusion

The satisfactory properties of the NFS support its use to assess acute neuropsychiatric fluctuations in PD patients, adding to available tools.

Pharmacological management of Parkinson's disease motor symptoms: update and recommendations from an expert

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative multisystemic disorder that affects approximately 1% of the population over 55 years old, with the mean age of onset at 60 years old, and the prevalence of the disease constantly growing.

DEVELOPMENT

PD is a progressive disease characterized by motor and non-motor symptoms that compromise patients' daily activities. It has a variable profile of onset and clinical evolution. Although currently available treatments have failed to clinically demonstrate neuroprotective properties, most motor symptoms are acceptably managed with dopaminergic medication. More than 50 years after launching levodopa, it remains the most effective treatment of motor symptoms in PD, able to provide sustained benefit throughout the entire course of the disease. Nevertheless, after two to three years of treatment, certain fluctuations start to appear in motor and non-motor responses to different doses of levodopa. Early identification and treatment of these fluctuations have a strong positive impact on the quality of life of the patient. Frequently accompanied by involuntary movements, proper control of fluctuations requires periodical adjustments of the medication and expert supplementation with dopaminergic and non-dopaminergic adjuvants.

CONCLUSIONS

The main purpose of this work is to offer a practical, updated guideline for neurologists regarding the use of dopaminergic agents from the initial stages of PD. Special emphasis is placed on the critical period after the end of the 'honeymoon' phase when variations in the symptomatology presented by each patient appear, forcing re-adjustment of the medication to fit their individual needs.

Subclinical affective and cognitive fluctuations in Parkinson's disease: a randomized double-blind double-dummy study of Oral vs. Intrajejunal Levodopa

BACKGROUND

Chronic levodopa treatment in Parkinson's disease (PD) may promote undesirable motor and non-motor fluctuations. Compared to chronic oral levodopa treatment, continuous infusion of levodopa/carbidopa intestinal gel (LCIG) in advanced PD reduces motor fluctuations. However, differences in their effect on acute non-motor changes were not formally demonstrated.

OBJECTIVE

We performed a randomized, double-blind, double-dummy, crossover study to compare acute non-motor changes between intermittent oral immediate-release carbidopa/levodopa (LC-IR) and LCIG.

METHODS

After > 12-h OFF, thirteen PD patients chronically treated with LCIG and without history of non-motor swings, were allocated to receive first, LCIG infusion plus three oral doses of placebo, or placebo infusion plus three oral doses of LC-IR. Over-encapsulated oral medication (LC-IR or placebo) was administered every 2 h. We monitored plasmatic levels of levodopa, motor status (UPDRS-III), mood, anxiety, and frontal functions at baseline (0-h) and hourly after each oral challenge.

RESULTS

Repeated-measures ANOVAs showed significant group by treatment interaction indicating more fluctuations of levodopa plasma levels with LC-IR. No significant interactions were seen in the temporal profile of motor status, anxiety, mood and cognition. However, point-to-point parametric and nonparametric tests showed a significant more marked and more sustained improvement in anxiety scores under LCIG. A significant improvement of mood and verbal fluency was seen a + 3-h only under LCIG.

DISCUSSION

Our sample of advanced PD patients exhibited moderate but significant non-motor fluctuations. LCIG was associated with a more favorable profile of acute affective and cognitive fluctuations that was particularly expressed at the first part of the infusion curve.

Report from a multidisciplinary meeting on anxiety as a non-motor manifestation of Parkinson's disease

Anxiety is a severe problem for at least one-third of people living with Parkinson's disease (PD). Anxiety appears to have a greater adverse impact on quality of life than motor impairment. Despite its high prevalence and impact on daily life, anxiety is often undiagnosed and untreated. To better address anxiety in PD, future research must improve knowledge about the mechanism of anxiety in PD and address the lack of empirical evidence from clinical trials. In response to these challenges, the Parkinson's Foundation sponsored an expert meeting on anxiety on June 13th and 14th 2018. This paper summarizes the findings from that meeting informed by a review of the existing literature and discussions among patients, caregivers, and an international, clinician-scientist, expert panel working group. The goal is to provide recommendations to improve our understanding and treatment of anxiety in PD.

The movement disorder society nonmotor rating scale: Initial validation study

BACKGROUND

The Movement Disorder Society-sponsored Nonmotor Rating Scale is an update of the existing Parkinson's disease Nonmotor Symptoms Scale modified to address some limitations in Nonmotor Symptoms Scale scoring, structure, and symptom coverage.

METHODS

PD patients were recruited from movement disorder centers in an international, multicenter study. The Movement Disorder Society Nonmotor Rating Scale, consisting of 13 domains plus a subscale for nonmotor fluctuations, was rater administered, along with the Nonmotor Symptoms Scale and other clinical assessments. Standard reliability and validity testing were conducted.

RESULTS

Four hundred and two PD patients were recruited (mean age ± standard deviation, 67.42 ± 9.96 years; mean age at PD onset ± standard deviation, 59.27 ± 10.67 years; median Hoehn and Yahr stage 2 (interquartile range 2-3). Data quality was satisfactory for all Movement Disorder Society Nonmotor Rating Scale domains except sexual (6.7% missing data). There were no floor or ceiling effects for the Movement Disorder Society Nonmotor Rating Scale and nonmotor fluctuations total score; domains had no ceiling effects, but some floor effects (13.5%-83.5%). The Movement Disorder Society Nonmotor Rating Scale and nonmotor fluctuations total score internal consistency were acceptable (average Cronbach's alpha, 0.66 and 0.84, respectively); interrater reliability was excellent (intraclass correlation coefficient, >0.95); for test-retest reliability, the intraclass correlation coefficient was 0.84 for the Movement Disorder Society Nonmotor Rating Scale and 0.70 for Movement Disorder Society nonmotor fluctuations total score, and precision was excellent for the Movement Disorder Society Nonmotor Rating Scale (standard error of measurement, 25.30) and fair for nonmotor fluctuations (standard error of measurement, 7.06). Correlations between Movement Disorder Society Nonmotor Rating Scale score and the corresponding Nonmotor Symptoms Scale and Movement Disorder Society UPDRS scores were high. There were no significant sex or age effects. The Movement Disorder Society Nonmotor Rating Scale score increased with increasing PD duration, disease severity, and PD medication dose (all P < 0.001).

CONCLUSIONS

The Movement Disorder Society Nonmotor Rating Scale is a valid measure for measuring the burden of a wide range of Nonmotor Rating Scale scores, including nonmotor fluctuations, in PD patients. © 2019 International Parkinson and Movement Disorder Society.

The experience of off periods: Qualitative analysis of interviews with persons with Parkinson's and carepartners

Introduction

Off period research in Parkinson's disease commonly relies on questionnaires. We aimed to investigate the breadth of off period experiences by interviewing persons with Parkinson's disease (PwP) and carepartners.

Methods

Investigators performed PwP and carepartner dyad interviews using a semi-structured questionnaire to describe off period experiences. Investigators analyzed interview transcripts using a qualitative descriptive approach to identify and compare themes between groups.

Results

Twenty PwP and their carepartners participated in interviews. PwP were on average 65.1 years-old (SD 8.3) and 7.8 years (SD 4.7) after their Parkinson's disease diagnosis. PwP and carepartners identified 13 motor symptoms, 5 of which (immobility, gait changes, freezing, trouble swallowing, and having to concentrate on movements) were not in the wearing off questionnaires recommended by the International Parkinson and Movement Disorders Society. PwP and carepartners identified 15 non-motor symptoms, 8 of which (behavior changes, irritability, fatigue, language difficulties, dizziness, dry mouth, urinary symptoms, and swollen feet) were not in recommended questionnaires. Certain symptoms were reported only by PwP (e.g. dizziness, urinary symptoms) or carepartners (e.g. behavioral changes), or were reported by dyad members to different degrees (e.g. fatigue, anxiety).

Conclusion

Wearing off questionnaires capture the presence of fluctuations and can facilitate patient-physician communication regarding off periods. However, they may miss the breadth of individual PwP experiences. PwP and carepartners also report different PwP experiences during off periods. To fully appreciate an individual's off experiences, clinicians likely need to use multiple approaches to gathering information including questionnaires and both PwP and carepartner report.

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Wearing off questionnaires may capture fluctuation presence but not all experiences.

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Persons with Parkinson's identified some motor off symptoms not in questionnaires.

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Six of the described non-motor wearing off symptoms were absent from questionnaires.

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Certain off symptoms (e.g. dizziness, urinary symptoms) were reported only by PwPs.

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Certain off symptoms (e.g. behavioral symptoms) were reported only by carepartners.

Neurobiology and clinical features of impulse control failure in Parkinson's disease

Impulse control disorders (ICDs) and other impulsive-compulsive related behaviours are frequent and still under recognized non-motor complications of Parkinson's disease (PD). They result from sensitization of the mesocorticolimbic pathway that arose in predisposed PD patients concomitantly with spreading of PD pathology, non-physiological dopaminergic and pulsatile administration of dopamine replacement therapy (DRT). Neuropsychiatric fluctuations (NPF) reflect the psychotropic effects of dopaminergic drugs and play a crucial role in the emergence of ICDs and behavioral addictions. Dopamine agonists (DA) which selectively target D2 and D3 receptors mostly expressed within the mesocorticolimbic pathway, are the main risk factor to develop ICDs. Neuroimaging studies suggest that dopamine agonists lead to a blunted response of the brain's reward system both during reward delivery and anticipation. Genetic predispositions are crucial for the responsiveness of the mesolimbic system and the development of ICDs with several genes having been identified. Early screening for neuropsychiatric fluctuations, reduction of DA, fractionating levodopa dosage, education of patients and their relatives, are the key strategies for diagnosis and management of ICDs and related disorders.