Failure of recognition of drug-induced parkinsonism in the elderly

Subcortical structure alteration in patients with drug-induced parkinsonism: Evidence from neuroimaging

Parkinson's Disease (PD) and Drug-induced parkinsonism (DIP) are the most common subtypes of parkinsonism, yet no studies have reported that the subcortical volume alterations in DIP patients. This study aimed to identify specific alterations of subcortical structures volume in DIP patients, and investigate association between the subcortical structure modifications and clinical symptoms. We recruited 27 PD patients, 25 DIP patients and 30 healthy controls (HCs). The clinical symptom-related parameters (Unified Parkinson's Disease Rating Scale, UPDRS) were evaluated. Structural imaging was performed on a 3.0 T scanner, and volumes of subcortical structures were obtained using FreeSurfer software. Analysis of covariance (ANCOVA) and partial correlation analysis were performed. DIP group had significantly smaller volume of the thalamus, pallidum, hippocampus and amygdala compared to HCs. ROC curve analysis demonstrated that the highest area under curve (AUC) value was in the right pallidum (AUC = 0.831) for evaluating the diagnostic efficacy in DIP from HCs. Moreover, the volumes of the putamen, hippocampus and amygdala were negatively correlated with UPDRSII in the DIP patients. The volume of the amygdala was negatively correlated with UPDRSIII. The present study provides novel information regarding neuroanatomical alteration of subcortical nuclei in DIP patients, suggesting that these methods might provide the basis for early diagnosis and differential diagnosis of DIP.

Effect of best practice advisory on the administration of contraindicated medications to hospitalized patients with Parkinson's disease and related disorders

Objective

To determine the effect of a Best Practice Advisory (BPA) on the ordering and administration of contraindicated dopamine blocking agents (DBA) to hospitalized patients with Parkinson's disease (PD) and related disorders.

Background

Patients with PD are more likely to require hospitalization and are at increased risk of complications. Administration of contraindicated DBA contributes to worsened outcomes in this patient population. Electronic medical record (EMR) warnings (also referred to as BPA) have been proposed as a way to prevent the administration of contraindicated medications.

Methods

A BPA was launched in January 2020 within the University of Rochester EMR system, which alerts the provider when a contraindicated DBA is ordered in hospitalized patients with PD and related disorders. Patients with PD and related disorders hospitalized at two hospitals affiliated to the University of Rochester during a time period before (t1: 1/1/2019-1/1/2020) and after (t2: 1/8/2020-1/8/2021) the implementation of the BPA were included in this study. Epic SliderDicer was used to collect the data from the University of Rochester EMR. The number of patients who had contraindicated DBA orders and administrations in both time periods, and the number of patients who had the BPA triggered during t2 were obtained. We compared the results before and after the implementation of the BPA.

Results

306 patients with PD and related disorders were hospitalized during t1 and 273 during t2. There was significantly less percentage of patients who had contraindicated DBA orders (41.5% in t1 vs. 17.6% in t2) and patients who had contraindicated DBA administrations (16% in t1 vs. 8.8% in t2) during t2 (p < 0.05 for both comparisons). There was no significant difference between the percentage of patients who had contraindicated DBA orders in t1 and patients with attempted orders (BPA triggered) in t2 (p = 0.27).

Conclusion

The results of this study increase the evidence of the potential benefit of EMR warnings for the optimization of inpatient medication management in patients with PD and related disorders. In particular, our results suggest that EMR warnings help reduce the administration of contraindicated medications, which is a known contributing factor for hospital complications in this patient population.

Neuroimaging Techniques in Differentiating Parkinson's Disease from Drug-Induced Parkinsonism: A Comprehensive Review

Neuroimaging can provide significant benefits in evaluating patients with movement disorders associated with drugs. This literature review describes neuroimaging techniques performed to distinguish Parkinson's disease from drug-induced parkinsonism. The dopaminergic radiotracers already reported to assess patients with drug-induced parkinsonism are [123I]-FP-CIT, [123I]-β-CIT, [99mTc]-TRODAT-1, [18F]-DOPA, [18F]-AV-133, and [18F]-FP-CIT. The most studied one and the one with the highest number of publications is [123I]-FP-CIT. Fludeoxyglucose (18F) revealed a specific pattern that could predict individuals susceptible to developing drug-induced parkinsonism. Another scintigraphy method is [123I]-MIBG cardiac imaging, in which a relationship between abnormal cardiac imaging and normal dopamine transporter imaging was associated with a progression to degenerative disease in individuals with drug-induced parkinsonism. Structural brain magnetic resonance imaging can be used to assess the striatal region. A transcranial ultrasound is a non-invasive method with significant benefits regarding costs and availability. Optic coherence tomography only showed abnormalities in the late phase of Parkinson's disease, so no benefit in distinguishing early-phase Parkinson's disease and drug-induced parkinsonism was found. Most methods demonstrated a high specificity in differentiating degenerative from non-degenerative conditions, but the sensitivity widely varied in the studies. An algorithm was designed based on clinical manifestations, neuroimaging, and drug dose adjustment to assist in the management of patients with drug-induced parkinsonism.

Treatment Changes and Prognoses in Patients with Incident Drug-Induced Parkinsonism Using a Korean Nationwide Healthcare Claims Database

This retrospective cohort study assessed treatment changes and prognoses after incident drug-induced parkinsonism (DIP). We used the National Health Insurance Service's National Sample Cohort database in South Korea. We selected patients diagnosed with incident DIP and given prescriptions to take offending drugs (antipsychotics, gastrointestinal (GI) motility drugs, or flunarizine) for a period of time that overlapped with the time of DIP diagnosis during 2004-2013. The proportion of patients experiencing each type of treatment change and prognosis was assessed for 2 years after DIP diagnosis. We identified 272 patients with incident DIP (51.9% of patients were aged ≥ 60 years and 62.5% of them were women). Switching (38.4%) and reinitiation (28.8%) were the most common modifications in GI motility drug users, whereas dose adjustment (39.8%) and switching (23.0%) were common in antipsychotic users. The proportion of persistent users was higher among antipsychotic users (7.1%) than that among GI motility drug users (2.1%). Regarding prognosis, 26.9% of patients experienced DIP recurrence or persistence, the rate being the highest in persistent users and the lowest in patients who discontinued the drug. Among patients with incident DIP diagnoses, the patterns of treatment change and prognosis differed across the types of offending drugs. Over 25% of patients experienced DIP recurrence or persistence, highlighting the need for an effective strategy to prevent DIP.

Adequate diagnosis of the cause of Parkinsonism and treatment in an elderly patient with schizophrenia: A case report

Background

Parkinsonism is frequently observed in patients with schizophrenia, and most patients are diagnosed with drug-induced parkinsonism. However, comorbidity with idiopathic Parkinson's disease or Parkinson-plus syndrome is also possible. The pathophysiology and treatment for each of these are entirely different, thus an appropriate diagnosis is required. However, distinguishing them based on clinical symptoms alone is often difficult, and many cases are misdiagnosed. Additionally, Parkinsonism is frequently mistaken for negative symptoms.

Case Description

We report a case of 68-year-old woman diagnosed with schizophrenia, who was admitted to a welfare center. At approximately age 60, the patient experienced motivation reduction, a loss of appetite, and pain in the extremities. In her mid-60s, tremor and muscle rigidity appeared; nuclear medicine testing was performed for a detailed examination, resulting in a diagnosis of levodopa-responsive Parkinson's syndrome. Notably, the patient's parkinsonism and emotional symptoms, which had been considered negative symptoms thus far, improved with levodopa treatment.

Conclusion

This case report illustrates the importance of properly diagnosing the cause of parkinsonism in patients with schizophrenia.

Risk of parkinsonism and related movement disorders with gabapentinoids or tramadol: A case-crossover study

INTRODUCTION

A safety signal concerning parkinsonism and related movement disorders with gabapentinoids (gabapentin and pregabalin) or tramadol was detected by reviewing individual case reports and data mining in spontaneous report databases. Well-designed pharmacoepidemiological studies are needed to assess the signal.

OBJECTIVE

This study aimed to investigate the association of exposure to gabapentinoids or tramadol with the risk of parkinsonism and related movement disorders.

METHODS

We conducted a case-crossover study using a Japanese electronic medical records database. Patients with newly diagnosed parkinsonism or related movement disorders between January 1, 2007, and April 14, 2019, were identified. The diagnosis date of outcomes was defined as the index date. We assessed the exposure of each patient to gabapentinoids or tramadol during a 90-day hazard period ending 1 day before the index date and in three 90-day reference periods. Multivariable conditional logistic regression models were employed to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). To confirm the robustness of the primary findings, we also performed sensitivity analyses using a case-case-time-control design, a different time window for hazard and reference periods, a different definition of outcome, and different number of reference periods.

RESULTS

A total of 28,972 eligible cases were included in the primary analysis. Exposure to gabapentinoids (aOR, 2.12; 95% CI, 1.73-2.61) and tramadol (aOR, 2.04; 95% CI, 1.57-2.64) was associated with increased risk. Results were consistent across sensitivity analyses.

CONCLUSION

Our findings serve as a caution to physicians who prescribe gabapentinoids or tramadol in routine clinical practice.

Updated Perspectives on the Management of Drug-Induced Parkinsonism (DIP): Insights from the Clinic

Parkinsonism refers to the clinical combination of bradykinesia, rigidity, tremor, and postural instability. Parkinsonism is often neurodegenerative, but it can be secondary or iatrogenic, as in drug-induced parkinsonism (DIP), which is the topic of this review. We review the pathophysiology of DIP, differentiate DIP and idiopathic Parkinson's disease (PD), list culprit medications in the development of DIP, discuss the diagnosis of DIP as well as the motor and nonmotor signs and symptoms that can help with differentiation of DIP and PD, and detail the management of DIP.

Phenytoin-associated movement disorder: A literature review

Phenytoin (PHT) was first synthesized as a barbiturate derivative and was approved in 1953 by the Food and Drug Administration. This work aimed to review the pathophysiology, epidemiology, clinical presentation, and treatment of PHT-associated movement disorders (MDs). Studies were searched in relevant databases (ScienceDirect, Google Scholar, Excerpta Medica, Latin American and Caribbean Health Sciences Literature, Medline, and Scientific Electronic Library Online) and were selected by two reviewers irrespective of language between 1963 and 2021. Papers of PHT-induced ataxia alone or tremor were excluded. In total, 127 reports with 219 individuals who developed MDs associated with PHT were encountered. MDs found: 126 dyskinesias, 49 myoclonus, 19 dystonia, 14 parkinsonism, 6 tics, 3 stuttering, and 2 restless legs syndrome. The mean age was 35 years (standard deviation [SD]: 23.5) and the predominant sex was male (53.4%). The mean PHT dose when the MD took place was 370.4 mg (SD: 117.5). A serum PHT concentration was reported in 103 cases, ranging from 4 to 110 μg/mL (median: 27.7 μg/mL). No significant relationship was found between PHT dose and age or PHT level. The mean onset time of PHT-associated MD was 23.4 months (SD: 4.4). The mean recovery time after MD management was 3.7 weeks (SD: 1.1). Regarding management, the most common form was PHT withdrawal in 90.4%. 86.3% of the individuals recovered fully. PHT-induced MD was extensively reported in the literature. Only general terms were used in the majority of the reports. The mechanisms underlying the adverse events caused by PHT probably depend on the presence of predisposing factors.

Pathophysiological Mechanisms of Antipsychotic-Induced Parkinsonism

Among neurological adverse reactions in patients with schizophrenia treated with antipsychotics (APs), drug-induced parkinsonism (DIP) is the most common motility disorder caused by drugs affecting dopamine receptors. One of the causes of DIP is the disruption of neurotransmitter interactions that regulate the signaling pathways of the dopaminergic, cholinergic, GABAergic, adenosinergic, endocannabinoid, and other neurotransmitter systems. Presently, the development mechanisms remain poorly understood despite the presence of the considered theories of DIP pathogenesis.

Clinical Aspects of the Differential Diagnosis of Parkinson's Disease and Parkinsonism

Parkinsonism is a clinical syndrome presenting with bradykinesia, tremor, rigidity, and postural instability. Nonmotor symptoms have recently been included in the parkinsonian syndrome, which was traditionally associated with motor symptoms only. Various pathologically distinct and unrelated diseases have the same clinical manifestations as parkinsonism or parkinsonian syndrome. The etiologies of parkinsonism are classified as neurodegenerative diseases related to the accumulation of toxic protein molecules or diseases that are not neurodegenerative. The former class includes Parkinson's disease (PD), multiple-system atrophy, progressive supranuclear palsy, and corticobasal degeneration. Over the past decade, clinical diagnostic criteria have been validated and updated to improve the accuracy of diagnosing these diseases. The latter class of disorders unrelated to neurodegenerative diseases are classified as secondary parkinsonism, and include drug-induced parkinsonism (DIP), vascular parkinsonism, and idiopathic normal-pressure hydrocephalus (iNPH). DIP and iNPH are regarded as reversible and treatable forms of parkinsonism. However, studies have suggested that the absence of protein accumulation in the nervous system as well as managing the underlying causes do not guarantee recovery. Here we review the differential diagnosis of PD and parkinsonism, mainly focusing on the clinical aspects. In addition, we describe recent updates to the clinical criteria of various disorders sharing clinical symptoms with parkinsonism.

Episodic Migraine and Older Adults

PURPOSE OF REVIEW

Migraine is and continues to be a significant medical issue in older adults. Migraine can have different characteristics in older adults and specific diagnostic and treatment considerations need to be applied when managing headache and migraine in this population, which is increasing in both size and diversity. Contrary to widely held beliefs, migraine may not improve in older women following menopause and can have new onset in older age. The purpose of this review is to give an update on the diagnosis and treatment of episodic migraine in older adults.

RECENT FINDINGS

As the population ages, migraine in older adults will become a more significant public health issue. Migraine in older adults can present with different clinical symptoms than in a younger population and is primarily a diagnosis of exclusion in older adults. Migraine treatment considerations for older adults should include comorbidities and medication interactions. Recent findings suggest there are medications that should be avoided when treating seniors with migraine. The purpose of this review is to give an update on the most important aspects regarding the diagnosis and treatment of headache and migraine in older adults. In addition, recommendations will be made concerning medications that need careful consideration when prescribing to seniors.

Use of antipsychotics and long-term risk of parkinsonism

INTRODUCTION

Few epidemiological studies have assessed the risk of parkinsonisms after prolonged use of neuroleptics. We aimed to examine the long-term risk of degenerative parkinsonisms (DP) associated with previous use of neuroleptics.

METHODS

All residents in Piedmont, Northern-west Italy, older than 39 years (2,526,319 subjects), were retrospectively followed up from 2013 to 2017. Exposure to neuroleptics was assessed through the regional archive of drug prescriptions. The development of DP was assessed using the regional archives of both drug prescriptions and hospital admissions. We excluded prevalent DP cases at baseline as well as those occurred in the first 18 months (short-term risk). The risk of DP associated with previous use of neuroleptics was examined through Cox regression, using a matched cohort design.

RESULTS

The risk of DP was compared between 63,356 exposed and 316,779 unexposed subjects. A more than threefold higher risk of DP was observed among subjects exposed to antipsychotics, compared to those unexposed (HR = 3.27, 95% CI 3.00-3.57), and was higher for exposure to atypical than typical antipsychotics. The risk decreased after 2 years from therapy cessation but remained significantly elevated (HR = 2.38, 95% CI 1.76-3.21).

CONCLUSIONS

These results indicate a high risk of developing DP long time from the start of use and from the cessation for both typical and atypical neuroleptics, suggesting the need of monitoring treated patients even after long-term use and cessation.

Iatrogenesis and neurological manifestations in the elderly

Older people are often exposed to polypharmacy in a multimorbidity context. Inappropriate polypharmacy is often harmful, increasing the risk of inappropriate prescriptions and therefore adverse drug events (ADEs). Five to 20% of all hospital admissions are related to ADE in older people, among which 40 to 70% could be prevented. However, identifying ADEs and drug-related admissions in the elderly is challenging because ADEs often present as common geriatric problems such as falls, delirium, which might be due to the aging process, underlying diseases, and/or medications. In the pharmacovigilance database of the World Health Organization, drug-related neurological manifestations are the third reported cause of ADEs in the elderly, and neurological drugs are the third leading class of medications involved in ADEs. We must therefore be particularly vigilant, both in our prescriptions but also in our diagnoses to avoid prescribing inappropriate treatments and detect ADEs. Even though multiple pharmacologic changes occur in the elderly (absorption, distribution, drug metabolism and excretion), most of medications are still often prescribed at the same daily dosage as in young adults. When prescribing any drug for old patients, we should remember that daily intake should be adapted to these specificities, keeping in mind the old well-known aphorism "start low, go slow". In this review, we describe the main drug-related neurological manifestations (drug-induced movement disorders, falls, seizures, delirium, hypoglycemia, stroke, hyponatremia, peripheral neuropathy and myopathy, and serotonin syndrome) and the main drugs associated with neurological manifestations (dopamine receptor blocking agents, antithrombotics, anticholinergics, beta-lactams, antidepressants, benzodiazepines, mood stabilizers).

Comparative risk of Parkinsonism associated with olanzapine, risperidone and quetiapine in older adults-a propensity score matched cohort study

PURPOSE

The purpose of this study was to examine the incidence of Parkinsonism in new users of second-generation antipsychotics (SGAs) in older adults (≥65 years). In the secondary analyses, we examined the risk of Parkinsonism by type and dose of SGA and conducted age-sex interactions.

METHOD

This population-based study included older adults who had a new-onset diagnosis of Parkinsonism and who started taking olanzapine, risperidone or quetiapine between 1 January 2005, and 30 December 2016. The Cox proportional hazard (COXPH) model with inverse probability treatment weighted (IPTW) covariates was used to evaluate the risk of new-onset Parkinsonism associated with SGAs, using quetiapine as the reference. We used the Generalized Propensity Score method to evaluate the dose-response risk of Parkinsonism associated with SGAs.

RESULTS

After IPTW adjustment for covariates, the COXPH model showed that compared to quetiapine, the use of olanzapine and risperidone were associated with an increased risk of Parkinsonism. The IPTW-hazard ratios are 1.76 (95% confidence interval 1.57-1.97) and 1.31 (95%CI 1.16-1.49), respectively. The dose-response risk of Parkinsonism was highest for olanzapine with a hazard ratio of 1.69 (95%CI 1.40-2.05) and the least for quetiapine with a hazard ratio of 1.22 (95%CI 1.14-1.31). The risk of Parkinsonism in the 65 to 74-year age group was higher for both sexes with risperidone compared to olanzapine, but the risk increased with olanzapine for both sexes in the 85+ age group.

CONCLUSION

The study found that the risk of new-onset Parkinsonism in older adults is 31% and 76% higher with risperidone and olanzapine respectively compared to quetiapine.

[Parkinson's syndromes in geriatric patients : Epidemiological, clinical and therapeutic characteristics]

Due to their high prevalence, Parkinson's syndromes are exemplary geriatric syndromes. In addition to idiopathic Parkinson's disease, drug-induced and vascular Parkinson's syndromes are especially relevant in older age. A comprehensive anamnesis, thorough clinical neurological examination and rational additional diagnostics ensure the correct differential diagnostic classification. The multidimensional geriatric assessment is used to quantify the syndrome-specific ability impairments. The primary therapeutic objective in old age is the preservation of everyday competences. Drug treatment is centered around L‑dopa because of its favorable effect-side effect ratio. In cases of motor fluctuations, entacapone, opicapone or safinamide can be added, whereas dopamine agonists are generally unsuitable. Rivastigmine is indicated in mild to moderate Parkinson's dementia and furthermore can possibly improve gait stability. Speech therapy, as well as physical and occupational therapy, including the Parkinson's disease-specific Lee Silverman voice treatment are indispensable components of the multiprofessional treatment concept.

"Pseudo-syndromes" associated with Parkinson disease, dementia, apathy, anxiety, and depression

PURPOSE OF REVIEW

Physicians treating patients with Parkinson disease must evaluate not only motor symptoms but also acquire expertise in assessing the complex behavioral features that often accompany the disease, such as dementia, apathy, anxiety, and depression.

RECENT FINDINGS

There is a risk of diagnostic confusion and error because many of the behavioral and motor symptoms accentuate, overlap, or mimic each other.

SUMMARY

Awareness of potential diagnostic pitfalls and "pseudo-syndromes" should lead to more accurate clinical assessment and better care for our patients.

Lurasidone-Induced Tardive Syndrome

Introduction

Tardive syndrome (TS) is an often irreversible movement disorder caused by dopamine receptor-blocking agents (DRBAs). Although TS are well recognized to occur with typical antipsychotics, less well appreciated is that atypical antipsychotics also carry a risk of TS.

Methods

Case series.

Results

We describe 4 patients who developed tardive dystonia, tardive akathisia, and drug-induced parkinsonism with the use of the atypical antipsychotic, lurasidone, which was U.S. Food and Drug Administration approved in 2013 for use in bipolar disorder and schizophrenia.

Conclusion

Movement disorders are reported as a rare side effect of lurasidone, and, as such, prescribers may perceive a false sense of security regarding this potential complication. Our cases indicate that this relatively new atypical antipsychotic may cause irreversible disabling TS as well as parkinsonism. Caution must be taken when prescribing lurasidone.

The Dopamine Receptor Antagonism of Opipramol: Relevance to Parkinsonism?

Drug-induced Parkinsonism (DIP) represents the second most-frequent etiology of Parkinson syndromes after neurodegenerative disorders. It has been described mainly for antipsychotics, Ca-channel blockers, antiemetics, and gastrointestinal prokinetics. In this article, we present a clinical case series of 10 patients, retrieved within our movement disorders hospital, with DIP under intake of opipramol. Symptoms completely resolved after drug withdrawal, and associated risk factors were old age, high doses, and presence of cortical atrophy. This frequently prescribed anxiolytic drug has so far not been associated with DIP. Our objective is to raise awareness of DIP as an adverse effect of opipramol.

Antipsychotic-Related Movement Disorders: Drug-Induced Parkinsonism vs. Tardive Dyskinesia-Key Differences in Pathophysiology and Clinical Management

Introduction

Drug-induced parkinsonism (DIP) and tardive dyskinesia (TD) are stigmatizing movement disorders associated with exposure to dopamine receptor blocking agents such as antipsychotics, but they differ in their pathophysiology and clinical management. Treatment for one may worsen the other, and there are important diagnostic clues that assist in making an accurate assessment and instituting a rational treatment plan.

Methods

A literature review was executed to identify articles relating to the presentation, pathophysiology, epidemiology, and management of DIP and TD.

Results

DIP and TD prevalence estimates range from approximately 20 to 35% among antipsychotic users, but may be higher in select populations. DIP often presents as bradykinesia and rigidity, as well as rhythmic tremor, and the majority of cases appear within hours to weeks of initiation of therapy with an antipsychotic, or if dosage of the antipsychotic is increased. TD onset is delayed, typically appearing after at least 3 months or longer of treatment, and patients will commonly present with involuntary, abnormal facial movements such as lip smacking, puckering, chewing, or tongue protrusion. DIP often resolves with discontinuation of the causative agent, but TD may be permanent. Broadly, proposed mechanisms underlying these adverse events include decreased dopamine concentrations in the nigrostriatal pathway of the striatum and dopamine hypersensitivity, for DIP and TD, respectively. Pharmacologic treatment approaches for DIP have commonly included anticholinergic agents such as benztropine; however, anticholinergic medications can make TD worse. Switching the antipsychotic medication to one with lower propensity for DIP is an option for some patients. Amantadine, a non-anticholinergic agent used for the treatment of DIP, may be preferred in patients with comorbid DIP and TD. In TD, treatment options include the new reversible vesicular monoamine 2 transporter inhibitors, valbenazine and deutetrabenazine.

Conclusions

It is important for clinicians to be able to recognize DIP and TD in patients using antipsychotics so that they can minimize the impact of these adverse events on their patients’ quality of life. Accurate diagnosis will drive the selection of the correct treatment.

Plain Language Summary

Plain language summary available for this article.

Factors that lead to hospitalisation in patients with Parkinson disease-A systematic review

OBJECTIVES

Parkinson disease (PD) frequently leads to acute hospitalisation resulting in increased cost to health care systems and reduced quality of life for patients. The objective of this review was to identify causes that lead to acute hospitalisation of patients with PD.

METHODS

A systematic review of English language literature from 1997 to present.

FINDINGS

The incidences of acute general medical or surgical problems that trigger acute hospitalisation in patients with PD are similar to those in the general population. However, falls, acute decompensation of PD symptoms and infections are far more common in PD patients and are responsible for more than 50% of the causes of hospitalisation in this patients' group.

IMPLICATIONS

Preventive strategies to avoid decompensation of PD symptoms and early detection and treatment of infections are needed to reduce hospitalisation in patients with PD.

Population Base Rates and Disease Course of Common Psychiatric and Neurodegenerative Disorders

Knowledge of population base rates of neurological and psychiatric disorders is fundamental for diagnostic decision making. Consideration of relevant probabilistic information can improve diagnostic efficiency and accuracy. However, such data continue to be misused or underutilized, which can lead to misdiagnoses and negative patient outcomes. The aim of the current review is to create an easily accessible and comprehensive reference of existing age of onset as well as prevalence and incidence data for common neurodegenerative and psychiatric disorders in adults. Relevant epidemiological data were compiled from well-respected and frequently-cited textbooks and scholarly studies. Reviews were collected from PubMed, and publicly-available sources were gathered from Google Scholar. Results are organized and presented in several tables and a figure, which can be used as a diagnostic guide for students and clinicians across healthcare disciplines.

Microstructural white matter alterations in patients with drug induced parkinsonism

Drug-induced parkinsonism (DIP) is the second most common etiology of parkinsonism. And yet, there is little information on structural imaging in DIP to elucidate the accurate underlying pathomechanisms. To investigate microstructural white matter (WM) in patients with DIP using diffusion tensor image and to determine its relationship to severity of parkinsonian motor symptoms and cognitive function. A total of 42 patients with DIP, 65 with Parkinson's disease, and 33 control subjects were recruited from a movement disorders outpatient clinic. We performed comparative analysis of fractional anisotropy (FA) and mean diffusivity (MD) values among groups using tract-based spatial statistics. Correlation analysis between WM integrity and parkinsonian motor symptoms and cognitive performance was also performed in DIP patients using voxel-wise statistical analysis. DIP patients had significantly lower FA and higher MD values over widespread WM areas than control subjects. The patients with DIP had poor cognitive performance relative to control subjects, which correlated well with WM properties. Additionally, the parkinsonian motor symptoms were negatively correlated with FA values. In contrast, exposure time to the offending drugs prior to the development of parkinsonism or duration of parkinsonism showed no significant association with FA or MD values. The present study demonstrates that disruption of the WM microstructure is extensive in patients with DIP, and it is correlated with clinical parameters of parkinsonism and cognitive performance. This suggests that DIP may be reflective of underlying abnormality of microstructural WM. Hum Brain Mapp 38:6043-6052, 2017. © 2017 Wiley Periodicals, Inc.

Drug-induced Parkinsonism versus Idiopathic Parkinson Disease: Utility of Nigrosome 1 with 3-T Imaging

Purpose To explore the utility of nigrosome 1 with 3-T magnetic resonance (MR) imaging to differentiate idiopathic Parkinson disease (IPD) from drug-induced parkinsonism (DIP). Materials and Methods The institutional review board approved this study, and participants gave informed consent. This study enrolled patients with DIP (n = 20) and IPD (n = 29) who underwent N-3-fluoropropyl-2-β-carbomethoxy-3-β-(4-iodophenyl)nortropane ((18)F-FP-CIT) positron emission tomography (PET) and healthy participants (n = 20). All participants underwent 0.5 × 0.5 × 1.0 mm(3) oblique axial three-dimensional multiecho-data image combination imaging to view the nigrosome 1 with 3-T imaging. Two reviewers independently assessed the nigrosome 1 without clinical information. DIP was diagnosed when no abnormality was seen at (18)F-FP-CIT PET. Diagnostic sensitivity, specificity, and accuracy of the nigrosome 1 imaging were evaluated between the IPD and DIP patients and between the IPD patients and healthy participants. Interrater agreement was assessed with Cohen κ. Results Both reviewers agreed in 63 of 69 participants (91.3%) for the presence of any abnormality on either side of the nigrosome 1 (κ = 0.825). Findings in all 29 IPD patients (100%) and three of 20 DIP patients (15%) were rated as abnormal and in 17 of 20 DIP patients (85%) they were interpreted as normal on the basis of imaging of the nitgrosome 1 (sensitivity, 100% (29 of 29); specificity, 85.0% (17 of 20); accuracy, 93.9% (46 of 49) between IPD and DIP patients). Findings in 3 of 20 healthy participants (15.0%) were interpreted as abnormal on the basis of imaging the nigrosome 1 while in the other 17 of 20 healthy participants (85.0%) they were rated as normal (sensitivity, 100% [29 of 29]; specificity, 85.0% [17 of 20]; accuracy, 93.9% [46 of 49] between IPD patients and healthy participants [κ = 0.831]). Conclusion The imaging of nigrosome 1 with 3-T imaging can differentiate DIP from IPD with high accuracy and may help to screen patients who need dopamine transporter imaging in those suspected of having DIP. (©) RSNA, 2015 Online supplemental material is available for this article.

Neuromotor Adverse Effects in 342 Youth During 12 Weeks of Naturalistic Treatment With 5 Second-Generation Antipsychotics

OBJECTIVE

Second-generation antipsychotic (SGA) effects in youth were monitored to quantify extrapyramidal side effects (EPS) and to identify risk profiles for treatment-emergent EPS.

METHOD

Data were analyzed for the nonrandomized, prospective Second-generation Antipsychotic Treatment Indications, Effectiveness and Tolerability in Youth (SATIETY) inception cohort study. EPS were assessed at baseline and 4, 8, and 12 weeks after naturalistic SGA initiation for schizophrenia, mood, disruptive behavior, and autism spectrum disorders using the Simpson-Angus Scale (SAS), Barnes Akathisia Scale, Abnormal Involuntary Movement Scale (AIMS), and Treatment Emergent Side Effect Scale. Drug-induced parkinsonism was defined by incident mean SAS score >0.33, anticholinergic initiation, or increasing total SAS score ≥2 in patients with baseline EPS.

RESULTS

In 342 youth aged 13.6 ± 3.5 years (male = 58.2%, antipsychotic-naive = 65.8%), 15.2% developed drug-induced parkinsonism. Raw SGA-grouped drug-induced parkinsonism rates were as follows: quetiapine = 1.5%, olanzapine = 13.8%, risperidone = 16.1%, ziprasidone = 20.0%, and aripiprazole = 27.3%. SGA type, dose, higher age, and lower baseline functioning were jointly associated with drug-induced parkinsonism (R(2) = 0.18; p < .0001). Controlling for these factors, drug-induced parkinsonism rates were significantly lower only for quetiapine and olanzapine. Subjectively reported EPS (5%), EPS-related treatment discontinuation (3.3%), and anticholinergic initiation (3%) were infrequent. Anticholinergic initiation was most frequent with risperidone (10.2%; p = .0004). Treatment-emergent dyskinesia ranged from 4.5% (aripiprazole) to 15.5% (olanzapine). SGA type, younger age, white race/ethnicity, and baseline AIMS were jointly associated with treatment-emergent dyskinesia (R(2) = 0.31; p < .0001). Controlling for these factors, treatment-emergent dyskinesia rates differed among SGA subgroups, with higher rates with olanzapine and ziprasidone. At baseline, psychostimulant use was associated with dyskinesia, and number of psychotropic comedications was associated with subjective EPS.

CONCLUSION

In youth, SGA-related EPS rates did not generally exceed those reported in adults, with particularly low rates with quetiapine and olanzapine.

High rates of parkinsonism in adults with autism

Background

While it is now recognized that autism spectrum disorder (ASD) is typically a life-long condition, there exist only a handful of systematic studies on middle-aged and older adults with this condition.

Methods

We first performed a structured examination of parkinsonian motor signs in a hypothesis-generating, pilot study (study I) of 19 adults with ASD over 49 years of age. Observing high rates of parkinsonism in those off atypical neuroleptics (2/12, 17 %) in comparison to published population rates for Parkinson’s disease and parkinsonism, we examined a second sample of 37 adults with ASD, over 39 years of age, using a structured neurological assessment for parkinsonism.

Results

Twelve of the 37 subjects (32 %) met the diagnostic criteria for parkinsonism; however, of these, 29 subjects were on atypical neuroleptics, complicating interpretation of the findings. Two of eight (25 %) subjects not taking atypical neuroleptic medications met the criteria for parkinsonism. Combining subjects who were not currently taking atypical neuroleptic medications, across both studies, we conservatively classified 4/20 (20 %) with parkinsonism.

Conclusions

We find a high frequency of parkinsonism among ASD individuals older than 39 years. If high rates of parkinsonism and potentially Parkinson’s disease are confirmed in subsequent studies of ASD, this observation has important implications for understanding the neurobiology of autism and treatment of manifestations in older adults. Given the prevalence of autism in school-age children, the recognition of its life-long natural history, and the recognition of the aging of western societies, these findings also support the importance of further systematic study of other aspects of older adults with autism.

Tardive Syndromes are Rarely Reversible after Discontinuing Dopamine Receptor Blocking Agents: Experience from a University-based Movement Disorder Clinic

BACKGROUND

Several studies have examined reversibility of tardive syndromes (TS), primarily in psychotic patients who are maintained on dopamine receptor blocking drugs. The results have varied widely. However, few have assessed remission rates after discontinuing the offending agents. This study evaluated reversibility of TS in patients who permanently withdrew the causative agent(s). We also examined for any possible clinical predictors of reversibility.

METHODS

A retrospective cohort of 108 TS patients was studied. Most of the patients were not psychotic; most patients were being treated either for a mood disorder with atypical antipsychotics or for a gastrointestinal disturbance with metoclopramide. Patients were stratified on the basis of reversibility, and statistical tests were used for subgroup comparisons of relevant clinical variables. Logistic regression was undertaken to identify clinical variables predictive of reversibility.

RESULTS

Only 13% of the cohort experienced reversibility of the TS, 2% without medical intervention. When stratified by reversibility, there were no significant differences in any study variables between subgroups. None of the study variables predicted reversibility in the logistic regression.

DISCUSSION

Our study demonstrated a low remission rate for TS in a cohort of psychiatric and non-psychiatric patients seen in a movement disorder clinic after the offending agents were completely withdrawn. Such a finding has significant prognostic implications. It is possible that limitations of the retrospective design may have resulted in an underestimation. There is a clear need for prospective, multicenter, clinical trials in populations that can be safely withdrawn from dopamine receptor blocking agents so that true remission rates can be measured.

Clinical features of drug-induced parkinsonism based on [18F] FP-CIT positron emission tomography

Drug-induced parkinsonism (DIP) is the common cause of parkinsonism. It is difficult to make a differentiation between DIP and Parkinson's disease (PD) because there are no notable differences in the clinical characteristics between the two entities. In this study, we examined the relationship between the characteristics of [(18)F] fluorinated-N-3-fluoropropyl-2-β-carboxymethoxy-3-β-(4-iodophenyl)nortropane (FP-CIT) positron emission tomography (PET) images and clinical features in DIP patients. We retrospectively studied 76 patients with DIP who underwent [(18)F] FP-CIT PET. We also enrolled 16 healthy controls who underwent it. We compared the clinical characteristics between the DIP patients with normal [(18)F] FP-CIT PET scans and those with abnormal ones. Symmetric parkinsonism was more frequent in the patients with normal [(18)F] FP-CIT PET scans as compared with those with abnormal ones. Interval from drug intake to onset of parkinsonism was longer in the patients with abnormal [(18)F] FP-CIT PET scans as compared with those with normal ones. A semi-quantitative analysis showed that specific to non-specific binding ratios in the putamen was lower in the patients with abnormal [(18)F] FP-CIT PET scans as compared with those with normal ones and the age-matched control group. Our results suggest that symmetric parkinsonism was more prevalent, and the duration of drug exposure before the onset of parkinsonism was shorter in the patients with normal [(18)F] FP-CIT PET scans as compared with those with abnormal ones.

A severe and irreversible case of tardive rigid-akinetic parkinsonian syndrome: the role of the DaTscan

In elderly patients, exposure to antipsychotic medication and subsequent withdrawal may lead to the development of persistent extrapyramidal symptoms, possibly including a syndrome suggested to be tardive parkinsonism. We describe a case in which withdrawal of antipsychotics was unexpectedly associated with progressive deterioration, rather than improvement, of extrapyramidal parkinsonian symptoms. Abnormal imaging of presynaptic dopamine transporters (DaTs) using single-photon emission computed tomography (SPECT) with ioflupane I 123 (DaTscan) substantially contributed to the differential diagnosis, suggesting it was likely that the patient had an underlying neurodegenerative disorder that preceded the onset of medicationinduced parkinsonian symptoms. Our report illustrates how novel findings from DaTscan may assist with diagnosing the cause of persistent parkinsonian symptoms after antipsychotic withdrawal and provide insight into the controversial concept of tardive parkinsonism.

Epidemiology and Clinical Diagnosis of Parkinson Disease

Parkinson disease (PD) is the second most common neurodegenerative disease, typically affecting elderly individuals and with a disproportionate male prevalence. Some genetic predispositions and environmental exposures are proposed risk factors for the development of PD. Cigarette smoking, caffeine intake, and increased serum uric acid have the strongest data supporting a reduced risk of PD. Mortality is slightly increased in most individuals with PD but certain clinical features and patient characteristics significantly increase mortality. Certain imaging modalities such as magnetic resonance imaging, transcranial ultrasound, and single-photon emission computed tomography can be useful in making diagnostic decisions in some cases of PD.

Movement disorders in elderly users of risperidone and first generation antipsychotic agents: a Canadian population-based study

Background

Despite concerns over the potential for severe adverse events, antipsychotic medications remain the mainstay of treatment of behaviour disorders and psychosis in elderly patients. Second-generation antipsychotic agents (SGAs; e.g., risperidone, olanzapine, quetiapine) have generally shown a better safety profile compared to the first-generation agents (FGAs; e.g., haloperidol and phenothiazines), particularly in terms of a lower potential for involuntary movement disorders. Risperidone, the only SGA with an official indication for the management of inappropriate behaviour in dementia, has emerged as the antipsychotic most commonly prescribed to older patients. Most clinical trials evaluating the risk of movement disorders in elderly patients receiving antipsychotic therapy have been of limited sample size and/or of relatively short duration. A few observational studies have produced inconsistent results.

Methods

A population-based retrospective cohort study of all residents of the Canadian province of Manitoba aged 65 and over, who were dispensed antipsychotic medications for the first time during the time period from April 1, 2000 to March 31, 2007, was conducted using Manitoba's Department of Health's administrative databases. Cox proportional hazards models were used to determine the risk of extrapyramidal symptoms (EPS) in new users of risperidone compared to new users of FGAs.

Results

After controlling for potential confounders (demographics, comorbidity and medication use), risperidone use was associated with a lower risk of EPS compared to FGAs at 30, 60, 90 and 180 days (adjusted hazard ratios [HR] 0.38, 95% CI: 0.22–0.67; 0.45, 95% CI: 0.28–0.73; 0.50, 95% CI: 0.33–0.77; 0.65, 95% CI: 0.45–0.94, respectively). At 360 days, the strength of the association weakened with an adjusted HR of 0.75, 95% CI: 0.54–1.05.

Conclusions

In a large population of elderly patients the use of risperidone was associated with a lower risk of EPS compared to FGAs.

Diagnostic accuracy of 123 I-FP-CIT SPECT in diagnosing drug-induced parkinsonism: a prospective study

INTRODUCTION

Drug-induced parkinsonism is a major type of parkinsonism in our setting. Symptoms usually disappear after discontinuation of the drug. However, they may persist in patients with a variant known as subclinical drug-exacerbated parkinsonism; early identification of this entity has important prognostic and therapeutic implications. The most widely used complementary test in this diagnosis is single-photon emission computed tomography with ioflupane ((123)I), also known as (123)I-FP-CIT SPECT. The aim of our study is to verify its diagnostic accuracy.

METHODS

We designed a prospective study of patients with drug-induced parkinsonism in which, after discontinuing the drug and undergoing a (123)I-FP-CIT SPECT scan, patients would be monitored for at least 6 months. Patients were categorised as having iatrogenic parkinsonism if symptoms disappeared, or as having subclinical drug-exacerbated parkinsonism if they persisted. Lastly, we verified concordance between the clinical diagnosis and results from the (123)I- FP-CIT SPECT scan.

RESULTS

The sample included 19 patients. The most commonly prescribed drug class was neuroleptic agents. For the diagnosis of both subgroups, (123)I-FP-CIT SPECT showed a sensitivity of 66.7%, specificity and positive predictive value of 100%, a negative predictive value of 86.7%, and a negative likelihood ratio of 0.33.

CONCLUSIONS

Although the study needs to be repeated in a larger sample of patients, (123)I-FP-CIT SPECT is useful in the diagnosis of drug-induced parkinsonism since it is a very precise tool for identifying patients with that illness.

Drug-induced parkinsonism

Drug-induced parkinsonism (DIP) is the second-most-common etiology of parkinsonism in the elderly after Parkinson's disease (PD). Many patients with DIP may be misdiagnosed with PD because the clinical features of these two conditions are indistinguishable. Moreover, neurological deficits in patients with DIP may be severe enough to affect daily activities and may persist for long periods of time after the cessation of drug taking. In addition to typical antipsychotics, DIP may be caused by gastrointestinal prokinetics, calcium channel blockers, atypical antipsychotics, and antiepileptic drugs. The clinical manifestations of DIP are classically described as bilateral and symmetric parkinsonism without tremor at rest. However, about half of DIP patients show asymmetrical parkinsonism and tremor at rest, making it difficult to differentiate DIP from PD. The pathophysiology of DIP is related to drug-induced changes in the basal ganglia motor circuit secondary to dopaminergic receptor blockade. Since these effects are limited to postsynaptic dopaminergic receptors, it is expected that presynaptic dopaminergic neurons in the striatum will be intact. Dopamine transporter (DAT) imaging is useful for diagnosing presynaptic parkinsonism. DAT uptake in the striatum is significantly decreased even in the early stage of PD, and this characteristic may help in differentiating PD from DIP. DIP may have a significant and longstanding effect on patients' daily lives, and so physicians should be cautious when prescribing dopaminergic receptor blockers and should monitor patients' neurological signs, especially for parkinsonism and other movement disorders.

Long-stay psychiatric patients: a prospective study revealing persistent antipsychotic-induced movement disorder

OBJECTIVE

The purpose of this study was to assess the frequency of persistent drug-induced movement disorders namely, tardive dyskinesia (TD), parkinsonism, akathisia and tardive dystonia in a representative sample of long-stay patients with chronic severe mental illness.

METHOD

Naturalistic study of 209, mainly white, antipsychotic-treated patients, mostly diagnosed with psychotic disorder. Of this group, the same rater examined 194 patients at least two times over a 4-year period, with a mean follow-up time of 1.1 years, with validated scales for TD, parkinsonism, akathisia, and tardive dystonia.

RESULTS

The frequencies of persistent movement disorders in the sample were 28.4% for TD, 56.2% for parkinsonism, 4.6% for akathisia and 5.7% for tardive dystonia. Two-thirds of the participants displayed at least one type of persistent movement disorder.

CONCLUSIONS

Persistent movement disorder continues to be the norm for long-stay patients with chronic mental illness and long-term antipsychotic treatment. Measures are required to remedy this situation.

The role of dopaminergic imaging in patients with symptoms of dopaminergic system neurodegeneration

Diagnosis of neurological and psychiatric conditions associated with disturbances of dopaminergic functioning can be challenging, especially in the early stages, and may be assisted with biomarkers such as dopamine system imaging. Distinguishing between Alzheimer's disease and dementia with Lewy bodies is a major diagnostic challenge. Clinical diagnosis of Parkinson's disease is straightforward with classic presentation, but accurate distinction among Parkinsonian variants may be difficult; non-Parkinson's disease conditions are commonly misdiagnosed as Parkinson's disease, and ~20% of patients with Parkinson's disease are not clinically diagnosed despite coming to medical attention. Early and accurate diagnosis is desirable to improve management. Imaging of the dopamine transporter using single-photon emission computed tomography may be of particular utility in this regard. Abnormal imaging indicates underlying nigrostriatal neurodegeneration, supportive of a diagnosis of Parkinson's disease, atypical parkinsonism or dementia with Lewy bodies, and identifies patient groups in whom dopaminergic therapy may be beneficial. Normal imaging supports diagnosis of a condition not involving nigrostriatal neurodegeneration such as Alzheimer's disease, essential tremor or drug-induced parkinsonism and hence a different therapeutic approach. In patients in whom there was diagnostic uncertainty between degenerative parkinsonism and non-degenerative tremor disorders, baseline imaging with the dopamine transporter ligand [(123)I]ioflupane (DaTscan™) has shown 78% sensitivity and 97% specificity with reference to clinical diagnosis at 3 years, versus 93% and 46%, respectively, for baseline clinical diagnosis. In a Phase III trial of [(123)I]ioflupane in patients with initial clinical diagnosis of probable or possible dementia with Lewy bodies or non-Lewy body dementia, mean specificity for excluding non-Lewy body dementia (predominantly Alzheimer's disease) was 90.4%. Using clinical diagnosis as a reference against which to assess sensitivity and specificity of dopamine transporter imaging is a limitation, but definitive diagnosis via pathological confirmation is generally not feasible. In a series of patients with post-mortem brain examination, imaging using [(123)I]ioflupane has demonstrated higher sensitivity (88%) and specificity (100%) for differentiating dementia with Lewy bodies from non-Lewy body dementia than clinical diagnosis (75% and 42%, respectively). Dopaminergic system imaging may be particularly valuable in patients with clinically inconclusive parkinsonism or a clinical diagnosis of possible dementia with Lewy bodies; it is not helpful in differentiating between Parkinson's disease and atypical parkinsonism, although postsynaptic dopaminergic imaging may be of utility. Other potential uses of dopamine transporter imaging include identification of patients with premotor Parkinson's disease, monitoring disease progression in testing novel therapeutics, and as an inclusion criterion for entry into clinical trials.

Hospitalization in Parkinson disease: a survey of National Parkinson Foundation Centers

OBJECTIVES

To explore current practices and opinions regarding hospital management of Parkinson disease (PD) patients in specialized PD Centers.

METHODS

Fifty-one out of 54 National Parkinson Foundation (NPF) Centers worldwide completed an online survey regarding hospitalization of PD patients.

RESULTS

Many Centers were concerned about the quality of PD-specific care provided to their patients when hospitalized. Primary concerns were adherence to the outpatient medication schedule and poor understanding by hospital staff of medications that worsen PD. Few Centers had a policy with their primary hospital that notified them when their patients were admitted. Rather, notification of hospitalization came often from the patient or a family member. Several Centers (29%) reported not finding out about a hospitalization until a routine clinic visit after discharge. Quick access to outpatient PD care following discharge was a problem in many Centers. Elective surgery, fall/fracture, infection, and mental status changes, were identified as common reasons for hospitalization.

CONCLUSIONS

There is a perceived need for PD specialists to be involved during hospitalization of their patients. Improvement in communication between hospitals and PD Centers is necessary so that hospital clinicians can take advantage of PD specialists' expertise. Education of hospital staff and clinicians regarding management of PD, complications of PD, and medications to avoid in PD is critical. Most importantly, outpatient access to PD specialists needs to be improved, which may prevent unnecessary hospitalizations in these patients.

Introduction to medication regimen review-part 2

Drug therapy is one of a variety of tools used by clinicians to manage symptoms and diseases in patients. To understand the medication regimen review process, it is important to understand the big picture of patient care and how medications fit into this overall scheme. The framework for patient management is known as "the care process."

Cognitive dysfunction in drug induced parkinsonism (DIP)

Several studies have suggested that the presence of dementia increases the risk of developing DIP. However, these prior studies exclusively focused on the underlying conditions before the development of DIP and there are no studies about the characteristics and prognosis of the cognitive status associated with DIP. We investigate the cognitive impairments associated with DIP by comparing neuro-psychological test results in patients with Parkinson's disease (PD) and normal controls and the longitudinal outcome of cognition in DIP. The cohort in this study included 13 consecutive patients with DIP and 91 patients with PD; all subjects completed a clinical assessment, neuropsychological investigation, and magnetic resonance imaging of brain. All patients with DIP were followed closely for more than six months after withdrawal of the offending drug. The cognitive function in DIP was significantly worse than in controls for most domains; however, there were no significant differences found in the comparisons with the PD patients. In addition, the severity of motor impairment was in part associated with cognitive function. Some patients had transient and reversible cognitive impairment, similar to other Parkinsonian motor features, and others experienced persistence and eventual worsening of their cognitive dysfunction after discontinuation of the offending drug. The results of this study suggest that cognitive impairment in patients with DIP reflects the toxic/metabolic symptoms associated with the offending drug in addition to being a risk factor for DIP.