Assessing comorbidity in patients with Parkinson's disease

Exercise-Induced Functional Changes in People with Parkinson's Disease following External Cueing and Task-Based Intervention

Introduction

The purpose of this study was to evaluate change in motor function, gait speed, dynamic balance, balance confidence, and quality of life (QoL) in nine participants with Parkinson's disease (PwPD) completing Lee Silverman Voice Treatment BIG (LSVT-BIG), an external cueing and task-based intervention. Although supported as an efficacious treatment in PwPD, there is limited research examining clinically meaningful change in outcome measures related to external cueing and task-based interventions.

Materials and Methods

This was a case series of nine PwPD (age range 64-76 years, 55% male) who completed the LSVT-BIG protocol. Disease duration ranged from 1 to 17 years and was classified as moderate in all participants (Hoehn and Yahr = 2 or 3). Outcome measures included motor function (MDS-UPDRS Part III Motor), gait speed, dynamic balance (MiniBEST), Activities-specific Balance Confidence (ABC), and Summary Index for PD Quality of Life 39 (PDQ-SI). Assessments were completed at baseline (BASE), end of treatment (EOT), and 4 weeks after EOT (EOT+4).

Results

Minimal detectable change (MDC) or minimal clinical important difference (MCID) was observed in one or more outcome measures in 8 of 9 participants at EOT and EOT+4 across domains of motor function (67%, 78%), gait speed (78%, 67%), balance confidence (44%, 33%), quality of life (44%, 78%), and dynamic balance (22%, 22%). Discussion. In this case series, 8 of 9 participants showed MDC or MCID changes across multiple functional domains. Improvements were observed immediately post (EOT) and 4-week post-treatment (EOT+4) suggesting a temporal component of the LSVT-BIG impact on functional change. Future research should include clinical trials to examine additional external cueing and task-based intervention efficacy with consideration of intensity, frequency, and mode of delivery across disease severity.

Emergency department visits in Parkinson's disease: The impact of comorbid conditions

INTRODUCTION

Older adults have complex, often overlapping, medical conditions requiring careful management that may lead to increased emergency department usage compared to younger adults. Parkinson's disease (PD), a progressive neurodegenerative disorder characterized by distinct motor and nonmotor features, frequently occurs with additional comorbid disease. Classifying comorbid conditions into clinical subgroups allows for further understanding of the heterogeneity in outcomes in patients with PD. The current study examines the reasons for emergency department (ED) visits in a cohort of patients with PD and identifies comorbidities that are potential risk factors for specific ED presenting conditions.

METHODS

Using data from Optum's de-identified Integrated Claims-Clinical dataset years 2010-2018, patients with PD were identified based on ICD-9/10 diagnosis codes. We identified all ED visits occurring after the first observed diagnosis code for PD. Comorbid conditions were classified using the AHRQ Clinical Classification Software (CCS). We classified patients using Latent Class Analysis (LCA) and conducted multiple logistic regression models with the outcome of reason-for-visit to examine the associations with comorbidity-profile class, patient demographics, and socio-economic characteristics.

RESULTS

The most common reasons for ED admission were injuries such as fractures and contusions, diseases of the circulatory system, and general signs and symptoms, including abdominal pain, malaise, and fatigue. Comorbid medical conditions often observed in this patient population include depression, diabetes mellitus, and chronic pulmonary disease. Patients in the "Poorest Health" classification of the LCA had greater odds for ED admission for diseases related to the gastrointestinal system, musculoskeletal system, and injury/poisoning categories and reduced odds for admission for diseases of the circulatory system.

DISCUSSION

Patients with PD who present to the emergency department with injuries are more likely to be in poor health overall with a high comorbidity burden. Clarifying the complex medical needs of patients with PD is the first step to further individualize care, which may reduce ED visits in this population, improve quality of life, and lessen the footprint on the healthcare system.

The effects of medical comorbidity, cognition, and age on patient-reported outcomes in Parkinson's disease

OBJECTIVE

The purpose of this cross-sectional study was to compare the independent contributions of medical comorbidity, cognition, and age on patient-reported outcomes in Parkinson's disease (PD).

METHODS

572 PD patients completed the Patient-Reported Outcome Measurement Information System (PROMIS®)-29 v2.0 Profile (physical function, anxiety, depression, fatigue, sleep disturbance, satisfaction with participation in social roles, pain interference) and PROMIS Global Health (mental health and physical health) scales. Comorbidity was measured with the Cumulative Illness Rating Scale-Geriatric (CIRS-G) and cognition with the Montreal Cognitive Assessment (MoCA). Multiple regression models examined the 9 PROMIS measures as predicted by comorbidity, cognition, and age, adjusting for demographic and clinical characteristics (UPDRS and disease duration).

RESULTS

Comorbidity was associated with poorer outcomes in all nine PROMIS domains. Cognition was associated with two of nine domains: physical function and anxiety. Age was associated with five domains: anxiety, depression, sleep disturbance, satisfaction with participation in social roles, and global mental health. Comorbidity showed greater effects on all nine domains than cognition or age (higher standardized beta coefficients).

CONCLUSION

Medical comorbidity, cognition, and age have different impacts on patient-reported outcomes in PD. Medical comorbidity has a greater impact than either cognition or age on a range of patient-reported physical and mental health domains. Medical comorbidity is an important contributor to the patient's perspective of their physical and mental health.

Accumulation of Chronic Disease Among Survivors of Childhood Cancer Predicts Early Mortality

PURPOSE

Cancer survivors develop cancer and treatment-related morbidities at younger than normal ages and are at risk for early mortality, suggestive of an aging phenotype. The Cumulative Illness Rating Scale for Geriatrics (CIRS-G) is specifically designed to describe the accumulation of comorbidities over time with estimates of severity such as total score (TS) which is a sum of possible conditions weighted by severity. These severity scores can then be used to predict future mortality.

METHODS

CIRS-G scores were calculated in cancer survivors and their siblings from Childhood Cancer Survivor Study cohort members from two time points 19 years apart and members of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2004. CIRS-G metrics were analyzed using Cox proportional hazards regression to determine subsequent mortality risk.

RESULTS

In total, 14,355 survivors with a median age of 24 (IQR, 18-30) years and 4,022 siblings with a median age of 26 (IQR, 19-33) years provided baseline data; 6,138 survivors and 1,801 siblings provided follow-up data. Cancer survivors had higher median baseline TS than siblings at baseline (5.75 v 3.44) and follow-up (7.76 v 4.79), all P < .01. The mean increase in TS from baseline to follow-up was significantly steeper in cancer survivors (2.89 males and 3.18 females) vs. siblings (1.79 males and 1.69 females) and NHANES population (2.0 males and 1.94 females), all P < .01. Every point increase in baseline TS increased hazard for death by 9% (95% CI, 8 to 10) among survivors.

CONCLUSION

Application of a geriatric rating scale to characterize disease supports the hypothesis that morbidity accumulation is accelerated in young adult survivors of childhood cancer when compared with siblings and the general population.

High rates of blood transfusion associated with Parkinson’s disease

Background

As evidence continues to accumulate regarding the multi-organ dysfunction associated with Parkinson’s disease (PD), it is still unclear as to whether PD increases the risk of hematological pathology. In this study, the authors investigate the association between PD and hematological pathology risk factors.

Methods

This retrospective cohort analysis was conducted using 8 years of the National Readmission Database. All individuals diagnosed with PD were queried at the time of primary admission. Readmissions, complications, and risk factors were analyzed at 30-, 90-, 180-, and 300-day intervals. Statistical analysis included multivariate Gaussian-fitted modeling using age, sex, comorbidities, and discharge weights as covariates. Coefficients of model variables were exponentiated and interpreted as odds ratios.

Results

The database query yielded 1,765,800 PD patients (mean age: 76.3 ± 10.4; 44.1% female). Rates of percutaneous blood transfusion in readmitted patients at 30, 90, 180, and 300 days were found to be 8.7%, 8.6%, 8.3%, and 8.3% respectively. Those with anti-parkinsonism medication side effects at the primary admission had increased rates of gastrointestinal (GI) hemorrhage (OR: 1.02; 95%CI: 1.01–1.03, p < 0.0001) and blood transfusion (OR: 1.06; 95%CI: 1.05–1.08, p < 0.0001) at all timepoints after readmission. PD patients who experienced GI hemorrhage of any etiology, including as a side effect of anti-parkinsonism medication, were found to have significantly higher rates of blood transfusion at all timepoints (OR: 1.14; 95%CI: 1.13–1.16, p < 0.0001).

Conclusions

Blood transfusions were found to be significantly associated with anti-parkinsonism drug side effects and GI hemorrhage of any etiology.

Experienced Respiratory Symptoms and the Impact on Daily Life from the Perspective of People with Parkinson's Disease: A Grounded Theory

BACKGROUND

Abnormal respiratory function tests can be observed early in the course of Parkinson's disease (PD). A better understanding of the impact of respiratory dysfunction on daily life in PD is needed to prevent later occurring complications as a (aspiration) pneumonia.

OBJECTIVE

To explain which respiratory symptoms people with PD or a form of atypical parkinsonism experience and how these symptoms impact on their daily lives.

METHODS

This qualitative study used a grounded theory approach. A purposeful sample strategy was used to capture information-rich cases. Data were collected in semi-structured interviews with participants diagnosed with either PD (n = 11) or atypical parkinsonism (n = 3), all of whom had confirmed respiratory symptoms. Data were analyzed using grounded theory analysis by creating codes, categories, theoretical themes, and, ultimately, a conceptual model.

RESULTS

Four respiratory profiles emerged, describing different types of respiratory dysfunction, with various positive and negative influencing factors. First, a loss of breathing automatism was experienced. Second, episodes of breathlessness or a rapid, shallow breathing pattern were triggered by either physical exertion, fatigue, or postural deformities. Third, stress and anxiety also triggered episodes of breathlessness. Fourth, a decreased cough strength and frequent coughing. Based on these findings, we constructed a conceptual model that visualizes the relations between these four types of respiratory dysfunction and their impact on daily life, with 'discomfort' and 'avoidance of social activities' as crucial elements.

CONCLUSION

A tailored approach for each profile of respiratory dysfunction is recommended to improve respiratory dysfunction and to reduce its social impact in people with PD.

Adopting a multidisciplinary telemedicine intervention for fall prevention in Parkinson's disease. Protocol for a longitudinal, randomized clinical trial

Background

Approximately 40–70% of people with Parkinson’s disease (PD) fall each year, causing decreased activity levels and quality of life. Current fall-prevention strategies include the use of pharmacological and non-pharmacological therapies. To increase the accessibility of this vulnerable population, we developed a multidisciplinary telemedicine program using an Information and Communication Technology (ICT) platform. We hypothesized that the risk for falling in PD would decrease among participants receiving a multidisciplinary telemedicine intervention program added to standard office-based neurological care.

Objective

To determine the feasibility and cost-effectiveness of a multidisciplinary telemedicine intervention to decrease the incidence of falls in patients with PD.

Methods

Ongoing, longitudinal, randomized, single-blinded, case-control, clinical trial. We will include 76 non-demented patients with idiopathic PD with a high risk of falling and limited access to multidisciplinary care. The intervention group (n = 38) will receive multidisciplinary remote care in addition to standard medical care, and the control group (n = 38) standard medical care only. Nutrition, sarcopenia and frailty status, motor, non-motor symptoms, health-related quality of life, caregiver burden, falls, balance and gait disturbances, direct and non-medical costs will be assessed using validated rating scales.

Results

This study will provide a cost-effectiveness assessment of multidisciplinary telemedicine intervention for fall reduction in PD, in addition to standard neurological medical care.

Conclusion

In this challenging initiative, we will determine whether a multidisciplinary telemedicine intervention program can reduce falls, as an alternative intervention option for PD patients with restricted access to multidisciplinary care.

Trial registration

ClinicalTrials.gov Identifier: NCT04694443.

Prospective study on cost-effectiveness of home-based motor assessment in Parkinson's disease

Introduction Treatment adjustments in Parkinson's disease (PD) are in part dependent on motor assessments. The aim of this study was to evaluate the cost-effectiveness of home-based motor monitoring plus standard in-office visits versus in-office visits alone in patients with advanced PD. Methods The procedures consisted of a prospective, one-year follow-up, randomized, case-control study. A total of 40 patients with advanced PD were randomized into two groups: 20 patients underwent home-based motor monitoring by using wireless motion sensor technology, while the other 20 patients had in-office visits. Motor and non-motor symptom severities, quality of life, neuropsychiatric symptoms, and comorbidities were assessed every four months. Direct costs were assessed using a standardized questionnaire. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER). Results Both groups of PD patients were largely comparable in their clinical and demographic variables at baseline; however, there were more participants using levodopa-carbidopa intestinal gel in the home-based motor monitoring group. There was a trend for lower Unified Parkinson's Disease Rating Scale functional status (UPDRS II) scores in the patients monitored at home compared to the standard clinical follow-up ( p = 0.06). However, UPDRS parts I, III, IV and quality-adjusted life-years scores were similar between both groups. Home-based motor monitoring was cost-effective in terms of improvement of functional status, motor severity, and motor complications (UPDRS II, III; IV subscales), with an ICER/UPDRS ranging from €126.72 to €701.31, respectively. Discussion Home-based motor monitoring is a tool which collects cost-effective clinical information and helps augment health care for patients with advanced PD.

Chronic Frequent Headache in the General Population: Comorbidity and Quality of Life

We studied the nature and extent of comorbidity of chronic frequent headache (CFH) in the general population and the influence of CFH and comorbidity on quality of life. Subjects with CFH (headache on >14 days/month) were identified in a general health survey. We sent a second questionnaire including questions on comorbidity and quality of life to subjects with CFH and subjects with infrequent headache (IH) (1-4 days/month). We recoded comorbidity by using the Cumulative Illness Rating Scale (CIRS) and measured quality of life with the RAND-36, a Dutch version of Short Form-36. CFH subjects ( n = 176) had higher comorbidity scores than the IH subjects ( n = 141). Mean CIRS scores were 2.94 for CFH and 1.55 for IH [mean difference 1.40, 95% confidence interval (CI) 0.91, 1.89]. The mean number of categories selected was 1.92 in CFH and 1.10 in IH (mean difference 0.82, 95% CI 0.54, 1.11). Fifty percent of CFH subjects had a comorbidity severity level of at least 2, indicating disorders requiring daily medication, compared with 28% of IH subjects (mean difference 22%, 95% CI 12, 33). CFH subjects had more musculoskeletal, gastrointestinal, psychiatric and endocrine/breast pathology than IH subjects. Quality of life in CFH subjects was lower than that of IH subjects in all domains of the RAND-36. Both headache frequency and CIRS score had a negative influence on all domains. We conclude that patients with CFH have more comorbid disorders than patients with infrequent headaches. Many CFH patients have a comorbid chronic condition requiring daily medication. Both high headache frequency and comorbidity contribute to the low quality of life in these patients.

Factors associated with Mediterranean diet adherence in Huntington's disease

BACKGROUND & AIMS

Little is known about the importance of the Mediterranean Diet (MeDi) and dietary intake as environmental neuroprotective factors in Huntington's disease (HD); so, we evaluated and analyzed the prevalence and factors associated with MeDi adherence, and dietary intake in HD.

METHODS

Spanish participants of the European Huntington Disease Network (EHDN) Registry study diagnosed with HD or premanifest HD gene carriers were included from June 2012 to August 2013. Self-reported dietary intake was collected by 3-day dietary record, MeDi adherence was assessed by 0-9 range (proposed by Trichopoulou et al.) and, other contributing factors related to nutrition were collected by telephone. Demographics and clinical variables were obtained from the EHDN Registry study database. Association of HD with MeDi adherence and nutritional characteristics were performed using logistic regression models.

RESULTS

Ninety eight participants were included in the study, median age of 48 years (38-60 range), and median total functional capacity (TFC) 9 (5-13 range). HD severity was similar between participants with low vs moderate/high MeDi; however, quality of life (P = 0.009) was significantly higher among participants with moderate/high MeDi adherence. In terms of nutrients, higher MUFA/SFA intake was moderately correlated with better TFC and Unified HD Rating Scale (UHDRS) cognitive. Better TFC was associated with having a caregiver (OR = 11.86, P < 0.001), and non-smoking (OR = 0.21, P = 0.013). Moderate adherence to MeDi, was associated with older participants (OR = 1.19, P = 0.031), lower comorbidity (OR = 0.18, P = 0.018), lower UHDRS motor (OR = 0.90, P = 0.041), and lower risk for abdominal obesity (OR = 0.02, P = 0.011).

CONCLUSIONS

In HD the moderate MeDi adherence is associated with better quality of life, lower comorbidity, lower motor impairment and lower risk for abdominal obesity compared to those participants with low MeDi adherence.

Factors Associated with Low Body Mass Index in Huntington's Disease: A Spanish Multicenter Study of the European Huntington's Disease Registry

Background

Patients with Huntington's disease (HD) are at risk for body weight loss and increased risk for institutionalization, morbidity, and mortality. The aim of this study was to determine the factors associated with low body mass index (BMI) in patients with HD.

Methods

In this national, observational, cross-sectional study of the European Huntington's Disease Network, the frequency of food consumption, calories, and nutrient intake in patients with HD was assessed using questionnaires validated for the Spanish population and were calculated using the software package Alimentación and Salud (Diet and Health), version 2.0. Nutritional status was estimated using the BMI, and disease severity was assessed using the Unified Huntington's Disease Rating Scale and a total functional capacity (TFC) score. Linear regression models were performed using BMI as the dependent variable and using energy balance (energy caloric intake - energy expenditure); the TFC score; the presence of a caregiver; dysphagia; cytosine, adenine, guanine (CAG) repeats; comorbidities; intake of supplements; pharmacologic treatments; age; gender; education; and physical activity as the independent variables.

Results

Two hundred twenty-four patients with HD were included (59% women), and their mean age was 47.41 ± 14.26 years, a median TFC score of 9 (range, 3-13), normal BMI in 124 patients (55.4%), and low BMI in 13 patients (6.7%). In the linear regression model, older age (β = 0.003; P = 0.01), male gender (β = 0.13; P = 0.003), and lower energy balance (β = -0.0001; P = 0.0003) were associated with a higher log-transformed BMI.

Conclusions

Younger female HD patients are at risk for low BMI. To counteract the influence of the HD gene mutation on decreased BMI, an increase in kilocalories per day should be encouraged.

Effects of Group, Individual, and Home Exercise in Persons With Parkinson Disease: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Comparative studies of exercise interventions for people with Parkinson disease (PD) rarely considered how one should deliver the intervention. The objective of this study was to compare the success of exercise when administered by (1) home exercise program, (2) individualized physical therapy, or (3) a group class. We examined if common comorbidities associated with PD impacted success of each intervention.

METHODS

Fifty-eight people (age = 63.9 ± 8 years) with PD participated. People were randomized into (1) home exercise program, (2) individual physical therapy, or (3) group class intervention. All arms were standardized and based on the Agility Boot Camp exercise program for PD, 3 times per week for 4 weeks. The primary outcome measure was the 7-item Physical Performance Test. Other measures of balance, gait, mobility, quality of life, balance confidence, depressions, apathy, self-efficacy and UPDRS-Motor, and activity of daily living scores were included.

RESULTS

Only the individual group significantly improved in the Physical Performance Test. The individual exercise showed the most improvements in functional and balance measures, whereas the group class showed the most improvements in gait. The home exercise program improved the least across all outcomes. Several factors effected success, particularly for the home group.

DISCUSSION AND CONCLUSIONS

An unsupervised, home exercise program is the least effective way to deliver exercise to people with PD, and individual and group exercises have differing benefits. Furthermore, people with PD who also have other comorbidities did better in a program directly supervised by a physical therapist.Video Abstract available for additional insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A112).

Comorbidity and functional mobility in persons with Parkinson disease

OBJECTIVES

To report the frequency, severity, and types of comorbidities in people with Parkinson disease (PD) using a validated self-report comorbidity screening tool, and to determine the relationship between comorbidity and functional mobility.

DESIGN

A secondary analysis and cross-sectional observational study design.

SETTING

University hospital; outpatient balance disorders laboratory.

PARTICIPANTS

Persons with mild to moderate idiopathic PD (N=76).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The Cumulative Illness Rating Scale-Geriatric (CIRS-G) and a comprehensive mobility assessment including gait (distance walked in 3 min), balance (mini-Balance Evaluation Systems Test), and physical function (Physical Performance Test).

RESULTS

All participants reported comorbidities in addition to their diagnosed PD. The average ± SD number of comorbidities was 6.96 ± 2.0 (range, 2-11), and the total CIRS-G score ± SD was 12.7 ± 4.8. The most commonly reported organ systems with comorbidity were eyes and ears (89%), psychiatric (68%), musculoskeletal (64%), lower gastrointestinal (62%), respiratory (60.5%), upper gastrointestinal (59.2%), and genitourinary (53.9%). The total CIRS-G score was significantly related to functional mobility: gait (r=-.53, P=.0001), balance (r=-.43, P=.0003), and physical performance (r=-.36, P=.0041). Of the original 14 organ systems measured, there were 7 systems that, when combined, best predicted gait performance, 6 systems combined that best predicted balance performance, and 4 systems combined that predicted functional performance.

CONCLUSIONS

This study reports a high frequency of multiple medical system comorbidity in people with mild to moderate PD. Furthermore, comorbidity scores were associated with mobility disability: gait, balance, and physical function. Early intervention is important to delay mobility disability in PD, and we recommend that people with PD found to have comorbidities should be screened for balance and gait deficits.

The impact of occupational therapy in Parkinson's disease: a randomized controlled feasibility study

AIM

To evaluate the feasibility of a randomized controlled trial including process and potential impact of occupational therapy in Parkinson's disease.

DESIGN

Process and outcome were quantitatively and qualitatively evaluated in an exploratory multicentre, two-armed randomized controlled trial at three months.

PARTICIPANTS

Forty-three community-dwelling patients with Parkinson's disease and difficulties in daily activities, their primary caregivers and seven occupational therapists.

INTERVENTION

Ten weeks of home-based occupational therapy according to the Dutch guidelines of occupational therapy in Parkinson's disease versus no occupational therapy in the control group.

MAIN MEASURES

Process evaluation measured accrual, drop-out, intervention delivery and protocol adherence. Primary outcome measures of patients assessed daily functioning: Canadian Occupational Performance Measure (COPM) and Assessment of Motor and Process Skills. Primary outcome for caregivers was caregiver burden: Zarit Burden Inventory. Participants' perspectives of the intervention were explored using questionnaires and in-depth interviews.

RESULTS

Inclusion was 23% (43/189), drop-out 7% (3/43) and unblinding of assessors 33% (13/40). Full intervention protocol adherence was 74% (20/27), but only 60% (71/119) of baseline Canadian Occupational Performance Measure priorities were addressed in the intervention. The outcome measures revealed negligible to small effects in favour of the intervention group. Almost all patients and caregivers of the intervention group were satisfied with the results. They perceived: 'more grip on the situation' and used 'practical advices that make life easier'. Therapists were satisfied, but wished for a longer intervention period.

CONCLUSIONS

The positive perceived impact of occupational therapy warrants a large-scale trial. Adaptations in instructions and training are needed to use the Canadian Occupational Performance Measure as primary outcome measure.

Clinical correlates of apathy in patients recently diagnosed with Parkinson's disease: the ANIMO study

OBJECTIVE

Little is known about apathy in the early stages of Parkinson's disease (PD). We determined the clinical correlates of apathy in a large representative sample of patients recently diagnosed with PD (ANIMO study).

METHODS

PD patients, diagnosed within 2 years of inclusion, were recruited in 102 outpatient clinics situated in 82 populations throughout Spain. Apathy was quantified using the Lille Apathy Rating Scale (LARS). Clinical comparisons and correlations were performed using nonparametric tests. Regression analyses were used to test the association of clinical variables with apathy.

RESULTS

We recruited 557 PD patients (60.3% men) with a mean age of 68.8 ± 9.7 years, and UPDRS motor score of 21.1 ± 10.8. Apathy only was diagnosed in 186 (33.4%), and apathy and depression in 215 patients (38.6%). Patients with higher comorbidity (OR = 1.10, 95% CI 1.01-1.20, p = 0.001), motor impairment (OR = 1.07, 95% CI 1.03-1.10, p < 0.0001), and lower education (OR = 2.16, 95% CI 1.21-3.85, p = 0.009) had higher odds of having apathy, in contrast to patients living in a rural environment (OR = 0.35, 95% CI 0.32-0.85, p = 0.01), and left predominant PD motor laterality (OR = 0.34, 95% CI 0.13-0.88, p = 0.01). LARS scores were significantly correlated with UPDRS motor scores (r(s) = 0.44, p < 0.001), predominantly with axial score (r(s) = 0.43, p < 0.001).

CONCLUSIONS

In PD, apathy is a very common and disabling nonmotor symptom separable from depression. Patients living in a rural environment, with lower comorbidity and motor impairment, higher education background, and left predominant PD motor laterality are at lower risk of suffering from apathy.

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.

Efficacy of community-based physiotherapy networks for patients with Parkinson's disease: a cluster-randomised trial

BACKGROUND

Many patients with Parkinson's disease are treated with physiotherapy. We have developed a community-based professional network (ParkinsonNet) that involves training of a selected number of expert physiotherapists to work according to evidence-based recommendations, and structured referrals to these trained physiotherapists to increase the numbers of patients they treat. We aimed to assess the efficacy of this approach for improving health-care outcomes.

METHODS

Between February, 2005, and August, 2007, we did a cluster-randomised trial with 16 clusters (defined as community hospitals and their catchment area). Clusters were randomly allocated by use of a variance minimisation algorithm to ParkinsonNet care (n=8) or usual care (n=8). Patients were assessed at baseline and at 8, 16, and 24 weeks of follow-up. The primary outcome was a patient preference disability score, the patient-specific index score, at 16 weeks. Health secondary outcomes were functional mobility, mobility-related quality of life, and total societal costs over 24 weeks. Analysis was by intention to treat. This trial is registered, number NCT00330694.

FINDINGS

We included 699 patients. Baseline characteristics of the patients were comparable between the ParkinsonNet clusters (n=358) and usual-care clusters (n=341). The primary endpoint was similar for patients within the ParkinsonNet clusters (mean 47.7, SD 21.9) and control clusters (48.3, 22.4). Health secondary endpoints were also similar for patients in both study groups. Total costs over 24 weeks were lower in ParkinsonNet clusters compared with usual-care clusters (difference euro727; 95% CI 56-1399).

INTERPRETATION

Implementation of ParkinsonNet networks did not change health outcomes for patients living in ParkinsonNet clusters. However, health-care costs were reduced in ParkinsonNet clusters compared with usual-care clusters.

FUNDING

ZonMw; Netherlands Organisation for Scientific Research; Dutch Parkinson's Disease Society; National Parkinson Foundation; Stichting Robuust.

Potential influences of complementary therapy on motor and non-motor complications in Parkinson's disease

Nearly two-thirds of patients with Parkinson's disease (PD) use vitamins or nutritional supplements, and many more may use other complementary therapies, yet <50% of patients have discussed the use of these complementary therapies with a healthcare professional. Physicians should be aware of the complementary therapies their patients with PD are using, and the possible effects of these therapies on motor and non-motor symptoms. Complementary therapies, such as altered diet, dietary supplements, vitamin therapy, herbal supplements, caffeine, nicotine, exercise, physical therapy, massage therapy, melatonin, bright-light therapy and acupuncture, may all influence the symptoms of PD and/or the effectiveness of dopaminergic therapy. Preliminary evidence suggests complementary therapy also may influence non-motor symptoms of PD, such as respiratory disorders, gastrointestinal disorders, mood disorders, sleep and orthostatic hypotension. Whenever possible, clinicians should ensure that complementary therapy is used appropriately in PD patients without reducing the benefits of dopaminergic therapy.

Parkinson disease and comorbid cerebrovascular disease

Optimal management of chronic diseases not only requires tackling of the primary disease processes, but also necessitates timely recognition and treatment of comorbid conditions. In this article, we illustrate this two-pronged approach for two common age-related disorders: Parkinson disease (PD) and cerebrovascular disease (CVD). We first discuss the pathophysiological mechanisms that could provide a link between PD and CVD. Patients with PD have a series of risk factors that could promote development of CVD, but also have several protective factors. We then review the available clinical, radiological and neuropathological evidence to support an association between these two conditions. We conclude by discussing the potential implications for clinical practice, highlighting how comorbid CVD could alter the clinical presentation of PD and reviewing the possibilities for prevention and secondary prophylaxis. Additional research will be needed to fully evaluate the prevalence and clinical relevance of comorbid CVD in PD. Pending further evidence, we recommend that cerebral neuroimaging should be considered if patients with initially uncomplicated PD develop-either acutely or chronically-prominent and/or treatment-resistant gait impairment, postural instability, depression, cognitive decline, or urinary incontinence. Finding comorbid CVD in such patients could have prognostic implications, and could necessitate treatment to arrest further progression of CVD.

Psychometric attributes of the Hospital Anxiety and Depression Scale in Parkinson's disease

The Hospital Anxiety and Depression Scale (HADS) has been used in Parkinson's disease (PD) but information about its psychometric properties in this context is limited. The aim of this study is to assess the psychometric properties of the HADS in PD. In an observational, cross-sectional analysis, HADS data quality, acceptability, scaling assumptions, internal consistency, construct validity, and precision were explored. From a sample of 387 PD patients, 22% and 14% scored > or =11 points (definite case) on the HADS anxiety and depression subscales, respectively. Cronbach's alpha was 0.81 and 0.83 for these subscales. Factor analysis revealed two factors (49.8% of the variance) representing anxiety and depression. The HADS closely correlated with health-related quality of life (HRQL) measures and displayed satisfactory discriminative validity for patients grouped by severity level, disease duration, HRQL status, and treatment. The SEM was 1.84 for HADS-Anxiety and 1.72 for HADS-Depression. The HADS is an acceptable, consistent, valid, precise, and potentially responsive scale for use in PD.

Cross-cultural validation of the Scales for Outcomes in Parkinson's Disease-Psychosocial questionnaire (SCOPA-PS) in four Latin American countries

OBJECTIVE

To conduct a cross-national validation of the Scales for Outcomes in Parkinson's Disease-PsychoSocial questionnaire (SCOPA-PS) in four Latin American Countries.

METHODS

Data quality (missing items), scale assumptions (item-test correlation), internal consistency (Cronbach's alpha, item homogeneity), factor structure, content validity, and precision (standard error of measurement, SEM) of the scale were explored, as was convergent validity with motor symptoms (Clinical Impression of Severity Index [CISI-PD], Scales for Outcomes in Parkinson's Disease-Motor Scale), emotional status (Hospital Anxiety and Depression Scale) and health-related quality of life (Parkinson Disease Questionnaire-39). Known-groups validity was studied by category of severity, based on Hoehn and Yahr staging (HY), CISI-PD, and disease duration.

RESULTS

Three hundred thirty-one Parkinson's disease (PD) patients with usable data participated (mean age 64.7 years; 42.3% female; mean PD duration 8.5 years; HY, 1 to 5). Data quality (missing items <10%), scale assumptions (item-total correlation = 0.43 - 0.71) and internal consistency of SCOPA-PS (Cronbach's alpha = 0.87; item homogeneity = 0.38) were satisfactory. Factor analysis suggested a unifactorial structure. High convergent validity was found for depression (r(S) = 0.61), anxiety (r(S) = 0.62), and health-related quality of life (r(S) = 0.82). Known-groups validity analyses indicated a gradual influence of severity category and disease duration on SCOPA-PS scores (P < 0.0001). SEM value was 8.24 (7 to 12 in previous studies). These magnitudes may be indicative of the threshold for a real change and a minimum important difference.

CONCLUSIONS

The Latin American versions of the SCOPA-PS displayed appropriate psychometric attributes.

Clinical and psychosocial factors associated with fatigue in patients with Parkinson's disease

Fatigue is an important contributor to poor quality of life. The aim of our research was to identify factors associated with fatigue among patients with Parkinson's disease (PD). The sample consisted of 150 patients. The Multidimensional Fatigue Inventory (MFI), Unified Parkinson's Disease Rating Scale (UPDRS), Hospital Anxiety and Depression Scale (HADS) and Charlson co-morbidity index were used for analysis. Demographic data were obtained in a structured interview. T-test, chi(2)-test and general linear regression were used. Fatigue was reported in 81% of the patients, with the worst scores in physical fatigue. Mood disorders and worse UPDRS scores were associated with fatigue.

The metric properties of a novel non-motor symptoms scale for Parkinson's disease: Results from an international pilot study

Non-motor symptoms (NMS) in Parkinson's disease (PD) are common, significantly reduce quality of life and at present there is no validated clinical tool to assess the progress or potential response to treatment of NMS. A new 30-item scale for the assessment of NMS in PD (NMSS) was developed. NMSS contains nine dimensions: cardiovascular, sleep/fatigue, mood/cognition, perceptual problems, attention/memory, gastrointestinal, urinary, sexual function, and miscellany. The metric attributes of this instrument were analyzed. Data from 242 patients mean age 67.2 +/- 11 years, duration of disease 6.4 +/- 6 years, and 57.3% male across all stages of PD were collected from the centers in Europe, USA, and Japan. The mean NMSS score was 56.5 +/- 40.7, (range: 0-243) and only one declared no NMS. The scale provided 99.2% complete data for the analysis with the total score being free of floor and ceiling effect. Satisfactory scaling assumptions (multitrait scaling success rate >95% for all domains except miscellany) and internal consistency were reported for most of the domains (mean alpha, 0.61). Factor analysis supported the a prori nine domain structure (63% of the variance) while a small test-retest study showed satisfactory reproducibility (ICC > 0.80) for all domains except cardiovascular (ICC = 0.45). In terms of validity, the scale showed modest association with indicators of motor symptom severity and disease progression but a high correlation with other measures of NMS (NMSQuest) and health-related quality of life measure (PDQ-8) (both, rS = 0.70). In conclusion, NMSS can be used to assess the frequency and severity of NMS in PD patients across all stages in conjunction with the recently validated non-motor questionnaire.

Anxiety and depression: main determinants of health-related quality of life in Brazilian patients with Parkinson's disease

Determinants of health-related quality of life (HRQoL) were assessed in 115 Brazilian patients (56.5% males; mean age 62.5 years) with Parkinson's disease (PD). Hoehn and Yahr (H&Y) staging, Scales for Outcomes in Parkinson's Disease-Motor Scale (SCOPA-MS), Cumulative Illness Rating Scale-Geriatrics, Hospital Anxiety and Depression Scale (HADS), Parkinson's Disease Questionnaire (PDQ-39), and SCOPA-Psychosocial Questionnaire (SCOPA-PS) were applied. Median H&Y was 3 and the SCOPA-MS score was 25.6+/-13.1. The proportion of patients who scored > or =11 points in the HADS-Depression and HADS-Anxiety subscales were 47% and 30.4%, respectively. In the multivariate model, HADS-Anxiety or HADS-Depression (p<0.0001), disability (SCOPA-MS II) (p=0.0001) and comorbidity (p=0.0005) were independently associated to PDQ-39 and SCOPA-PS. Mood disturbances were the main determinants of HRQoL.