Characterisation of non‐motor fluctuations using the Movement Disorder Society Non‐Motor Rating Scale

Early-morning OFF in Parkinson's disease: A systematic literature review and current therapeutics

OBJECTIVE

Early morning OFF (EMO) is one of the first motor complications to manifest and frequently signals the onset of additional motor complications in Parkinson's Disease (PD). Although EOM are frequently observed in patients with PD and many caregivers must help with their motor inability, the treatment is still unsatisfactory. The majority of research that has been conducted on the wearing-off state of patients with PD has focused on daytime symptoms; evening and early morning symptoms have received much less attention.This study aimed to review the clinical perspectives of current therapies for EMO.

MATERIALS AND METHODS

We reviewed the searching relevant publications from the key words such as morning off. A total of 456 publications were identified and we reviewed 21 clinical trials as well as other relevant clinical studies and reviews.

RESULTS

EMO are frequently disregarded or undervalued, which could have resulted in unintentional risks, inadequate management, and an increased burden of care. Oral medication is still the primary medical intervention for EMO. However, new developments in non-oral medications and advanced formulations aim to reduce the delay in experiencing the benefits of oral levodopa due to gastrointestinal problems.

CONCLUSIONS

The current therapies for EMO could be helpful in selecting a limited practical treatment. Advancements in non-oral medications and oral formulations hold promise for improving efficacy in EMO.

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.

Digital biomarkers in Parkinson's disease

Digital biomarker (DB) assessments provide objective measures of daily life tasks and thus hold promise to improve diagnosis and monitoring of Parkinson's disease (PD) patients especially those with advanced stages. Data from DB studies can be used in advanced analytics such as Artificial Intelligence and Machine Learning to improve monitoring, treatment and outcomes. Although early development of inertial sensors as accelerometers and gyroscopes in smartphones provided encouraging results, the use of DB remains limited due to lack of standards, harmonization and consensus for analytical as well as clinical validation. Accordingly, a number of clinical trials have been developed to evaluate the performance of DB vs traditional assessment tools with the goal of monitoring disease progression, improving quality of life and outcomes. Herein, we update current evidence on the use of DB in PD and highlight potential benefits and limitations and provide suggestions for future research study.

Cognitive disorders in advanced Parkinson's disease: challenges in the diagnosis of delirium

Parkinson's disease (PD) is a neurodegenerative condition that is frequently associated with cognitive disorders. These can arise directly from the primary disease, or be triggered by external factors in susceptible individuals due to PD or other predisposing factors. The cognitive disorders encompass PD-associated cognitive impairment (PD-CI), delirium, PD treatment-associated cognitive side effects, cognitive non-motor fluctuations, and PD-associated psychosis. Accurate diagnosis of delirium is crucial because it often stems from an underlying disease that may be severe and require specific treatment. However, overlapping molecular mechanisms are thought to be involved in both delirium and PD, leading to similar clinical symptoms. Additionally, there is a bidirectional interaction between delirium and PD-CI, resulting in frequent concurrent processes that further complicate diagnosis. No reliable biomarker is currently available for delirium, and the diagnosis is primarily based on clinical criteria. However, the screening tools validated for diagnosing delirium in the general population have not been specifically validated for PD. Our review addresses the current challenges in the diagnosis of these cognitive disorders and highlights existing gaps within this field.

Medical, surgical, and physical treatments for Parkinson's disease

Although dopamine replacement therapy remains a core component of Parkinson's disease treatment, the onset of motor fluctuations and dyskinetic movements might require a range of medical and surgical approaches from a multidisciplinary team, and important new approaches in the delivery of dopamine replacement are becoming available. The more challenging, wide range of non-motor symptoms can also have a major impact on the quality of life of a patient with Parkinson's disease, and requires careful multidisciplinary management using evidence-based knowledge, as well as appropriately tailored strategies according to the individual patient's needs. Disease-modifying therapies are urgently needed to prevent the development of the most disabling refractory symptoms, including gait and balance difficulties, cognitive impairment and dementia, and speech and swallowing impairments. In the third paper in this Series, we present the latest evidence supporting the optimal treatment of Parkinson's disease, and describe an expert approach to many aspects of treatment choice where an evidence base is insufficient.

Gender differences in non-motor fluctuations in Parkinson's disease

Non-motor symptoms (NMS) and Non-motor fluctuations (NMF) in Parkinson's Disease (PD) are common, involving several domains and affecting quality of life. Aim of the study is to estimate the burden of NMF in PD patients and to evaluate the possible gender effect. PD patients fulfilling the MDS-PD diagnostic criteria attending the "Parkinson's Disease and Movement Disorders Centre" of the University of Catania were evaluated using the Non-Motor Fluctuations Assessment (NoMoFA) Questionnaire. NoMoFA items were also grouped into the following domains: cognitive, mood, sleep/fatigue, dysautonomia, hallucination/perception and miscellaneous domains were identified. One-hundred and twenty-one patients with PD (67 men, 55.4%; mean age 70.2 ± 8.9 years, disease duration 8.3 ± 4.6 years) were evaluated. All PD patients reported at least one NMS, whereas 87 (71.9%) also reported NMF. "Feel sluggish or had low energy levels" (47.2%) along with "Feel excessively sleepy during the day" (40.0%) were the most common NMF reported in the whole sample. The majority of PD patients reported the presence of NMF during the OFF state (79, 65.3%). At multivariate analysis, NMF were positively associated with the female gender (adjusted OR 3.13; 95%CI 1.21-8.11 p-value 0.01). Women with PD had higher NMF scores especially in depression/anxiety, sleep/fatigue and dysautonomia domains. Our study reported the presence of a gender-related pattern in the frequency of NMS and NMF in PD patients, with female gender associated with a higher risk of developing NMF, highlighting the need for personalized treatment strategies when addressing NMF.

Impact of non-motor fluctuations on QOL in patients with Parkinson's disease

Introduction

Long-term levodopa treatment in patients with Parkinson's disease (PwPD) often causes motor fluctuations, which are known to affect their quality of life (QOL). These motor fluctuations may be accompanied by fluctuations in non-motor symptoms. There is no consensus on how non-motor fluctuations affect QOL.

Methods

This was a single-center, retrospective study and included 375 patients with Parkinson's disease (PwPD) who visited the neurology outpatient department of Fukuoka University Hospital between July 2015 and June 2018. All patients were evaluated for age, sex, disease duration, body weight, and motor symptoms by the Movement Disorder Society-Unified Parkinson's Disease Rating Scale part III, depression scale by the Zung self-rating depression scale, apathy scale, and cognitive function by the Japanese version of The Montreal Cognitive Assessment. A nine-item wearing-off questionnaire (WOQ-9) was used to assess the motor and non-motor fluctuations. QOL in PwPD was investigated using the eight-item Parkinson's Disease Questionnaire (PDQ-8).

Results

In total, 375 PwPD were enrolled and classified into three groups according to the presence or absence of motor and non-motor fluctuations. The first group included 98 (26.1%) patients with non-motor fluctuations (NFL group), the second group included 128 (34.1%) patients who presented with only motor fluctuations (MFL group), and the third group included 149 (39.7%) patients without fluctuations in motor or non-motor symptoms (NoFL group). Among them, the PDQ-8 SUM and SI were significantly higher in the NFL group than in the other groups (p < 0.005), implying that the NFL group had the poorest QOL among groups. Next, multivariable analysis showed that even one non-motor fluctuation was an independent factor that worsened QOL (p < 0.001).

Conclusion

This study showed that PwPD with non-motor fluctuation had a lower QOL than those with no or only motor fluctuation. Moreover, the data showed that PDQ-8 scores were significantly reduced even with only one non-motor fluctuation.