The nondeclaration of nonmotor symptoms of Parkinson's disease to health care professionals: An international study using the nonmotor symptoms questionnaire

Managing sleep issues in Parkinson's disease: an up-to-date review

INTRODUCTION

In Parkinson's disease (PD), sleep-wake problems are disease-related symptoms that occur throughout the day and have a negative impact on patients' quality of life to an extent that is equal to or greater than that of typical motor symptoms.

AREAS COVERED

Insomnia due to fragmented sleep and excessive daytime sleepiness (EDS) worsen as PD progresses. Nighttime wearing-off and early morning-off should be considered first when fragmented sleep is reported in PD patients. If the main complaint of patients with insomnia is difficulty falling asleep, restless legs syndrome should be differentiated first. Obstructive sleep apnea causes sleep quality deterioration and fragmented sleep. For rapid eye movement sleep behavior disorder (RBD), preventative measures against sleep-related trauma are necessary. RBD has also attracted attention as a PD precursor state and as a disease progression marker that is associated with specific PD clinical subtypes. In PD patients, the sleep-wake phase may advance/delay or become irregular due to circadian dysfunction.

EXPERT OPINION

Importantly, sleep-wake problems are core symptoms related to the pathogenesis and progression of PD, and addressing a wide range of these symptoms will improve patients' quality of life.

Wearable devices may aid the recognition of fluctuation-related pain in Parkinson's disease-An exploratory, cross-sectional analysis of two prospective observational studies

Fluctuation-related pain (FRP) affects more than one third of people with Parkinson's disease (PwP, PD) and has a harmful effect on health-related quality of life (HRQoL), but often remains under-reported by patients and neglected by clinicians. The National Institute for Health and Care Excellence (NICE) recommends The Parkinson KinetiGraphTM (the PKGTM) for remote monitoring of motor symptoms. We investigated potential links between the PKGTM-obtained parameters and clinical rating scores for FRP in PwP in an exploratory, cross-sectional analysis of two prospective studies: "The Non-motor International Longitudinal, Real-Life Study in PD-NILS" and "An observational-based registry of baseline PKG™ in PD-PKGReg". 63 PwP (41.3% female; age: 64.24±9.88 years; disease duration, DD: 6.83±5.63 years; Hoehn and Yahr Stage, H&Y: 2 (1-4); Levodopa Equivalent Daily Dose 535 (0-3230) mg) were included. PwP with FRP (n = 23) had longer DD (8.88 (1.29-19.05) vs. 3.16 (0.34-28.92), p = 0.001), higher severity of motor symptoms (H&Y 3 (1-4) vs. 2 (1-4), p = 0.015; SCOPA Motor total score 21.35±10.19 vs. 13.65±8.99, p = 0.003), more dyskinesia (SCOPA Motor Item 18 ≥1 60.9% vs. 7.5%, p<0.001), and worse HRQoL (PDQ-8 Total Score 10.74±5.98 vs. 6.78±5.13, p = 0.007) then PwP without FRP (n = 40). In the multivariate logistic regression, after the adjustment for DD, H&Y and SCOPA-Motor total score, the presence of FRP was significantly associated with the PKGTM-derived Fluctuation-dyskinesia score (Exp (B) = 1.305, 95% CI for Exp (B) 1.012-1.683, p = 0.040) and the Bradykinesia score (Exp (B) = 0.917, 95% CI for Exp (B) 0.842-0.999, p = 0.048). The PKGTM system may potentially advance the way we screen for, assess, and treat FRP in clinical practice.

Pain beliefs and their relationship with pain, psychological distress and catastrophizing in individuals with Parkinson's disease

In Parkinson's disease (PD), a large number of individuals are confronted with pain. This issue has been receiving increasing attention in literature in recent years, as the complexity of pain in this disease makes its evaluation and treatment challenging. However, psychological variables related to the pain experience have received limited attention, especially when it comes to the exploration of beliefs regarding pain which, to our knowledge, remains unexplored in PD. Pain beliefs are defined as a subset of a patient's belief system which represents a personal understanding of the pain experience. Four dimensions of pain beliefs have been isolated in literature: mystery, pain permanence, pain constancy and self-blame. Thus, the goal of this study was first to describe pain beliefs in individuals with PD and second, to explore the relationships between pain beliefs and clinical and psychological variables. One hundred and sixty-nine international individuals with PD completed an online survey with socio-demographic and medical data. Participants completed self-report instruments to assess their pain (King's Parkinson's Disease Pain Questionnaire, McGill Pain Questionnaire and Brief Pain Inventory), psychological distress (Beck Depression Inventory, short-form and Parkinson Anxiety Scale), pain catastrophizing (Pain Catastrophizing Scale) and pain beliefs catastrophizing (Pain Beliefs and Perception Inventory). The study's findings revealed that most participants' beliefs are marked by the dimension of permanence, suggesting that individuals with PD perceive the pain experience as chronic and enduring. Meanwhile, pain is minimally perceived as constant, mysterious, or a source of guilt. Our finding concerning the permanence dimension deserves specific attention: even though this belief is prevalent in our population, it is not, or only weakly, associated with an impact on mood or pain catastrophizing. These results bring forth several hypotheses for understanding, highlighting the role of acceptance, and offer new perspectives toward improving clinical practices in terms of assessing and managing pain in PD.

The Effect of Dysautonomia on Motor, Behavioral, and Cognitive Fluctuations in Parkinson's Disease

BACKGROUND

Motor and nonmotor fluctuations adversely impact the quality of life in Parkinson's disease (PD). Dysautonomia, a feature frequently associated with PD and a possible adverse effect of dopaminergic therapy, may be comorbid with fluctuations.

OBJECTIVE

We sought to evaluate the effect of dysautonomia on motor and nonmotor fluctuations in PD.

METHODS

Two hundred subjects with PD were evaluated in both on and off dopamine states to assess changes in symptoms related to dopaminergic fluctuations. Multivariable logistic regression was performed to assess the association of dysautonomia with motor, cognitive, and psychiatric worsening from on to off states with adjustment for disease duration, levodopa equivalent daily dosage (LEDD), and dopamine-agonist LEDD.

RESULTS

Subjects with dysautonomia had greater odds of clinically meaningful change in motor features (odds ratio [OR]: 3.0), cognition (OR: 3.4), and anxiety (OR: 4.3) compared to those without dysautonomia.

CONCLUSIONS

Dysautonomia may be a contributory mechanism behind fluctuations in PD. The exact nature of this relationship deserves further evaluation. © 2024 International Parkinson and Movement Disorder Society.

Characterizing pain in Parkinson's disease: types, predictors, and management implications

Background

Pain impacts quality of life (QoL) in Parkinson's disease (PD) patients, yet it is often overlooked. This study aims to comprehensively evaluate pain in PD, particularly focusing on differences between neuropathic pain (NP) and other types.

Methods

We conducted a cross-sectional study involving PD patients, assessing the prevalence and characteristics of pain. Various scales were employed to evaluate anxiety, depression, and QoL. We investigated associations between pain, demographic, and clinical variables to determine predictors and pain-related factors. Additionally, factors related to NP were explored.

Results

During the study period, a total of 109 patients were examined. Sixteen patients were excluded due to various reasons. The final analysis included 93 patients (34 females and 59 males). Pain was reported by 80.6% of PD patients, with no significant demographic or clinical differences between those with and without pain. However, longer disease duration predicted NP, and musculoskeletal pain was more prevalent in females. Anxiety was common in patients with central parkinsonian pain (CPP). Patients taking amantadine reported less radicular/ neuropathic pain (RNP), suggesting a therapeutic role.

Conclusions

Our findings underscore the high prevalence of pain in PD and its impact on QoL. NP appears to be associated with disease progression, while sex-specific differences highlight the need for personalized pain management strategies. The association between anxiety and CPP emphasizes the importance of addressing psychological factors in PD pain management. Further research on amantadine's benefits in reducing RNP is warranted, emphasizing the importance of tailored pain management strategies for PD patients.

Efficacy of Oriental Exercises for Non-Motor Symptoms and Quality of Life in Parkinson's Disease: A Systematic Review and Meta-Analysis

Parkinson's disease (PD) is a progressive neurodegenerative disorder without a definitive cure. Oriental exercises (OEs) have emerged as a complementary and alternative therapy for PD, but their efficacy in ameliorating non-motor symptoms (NMS) and quality of life (QOL) remains uncertain. This systematic review and meta-analysis actively investigated the efficacy of OEs in addressing NMS and enhancing QOL and sought to offer recommendations for optimal OE regimens for PD patients. By analyzing 30 controlled trials involving 2029 participants, we found that OEs significantly improved cognitive function, neuropsychiatric symptoms, and QOL compared to control groups. Specifically, significant improvements were observed in several outcome measures: Parkinson's Disease Questionnaire (PDQ) [MD: [Formula: see text]3.67, 95% CI: [Formula: see text]5.72-[Formula: see text]1.63, [Formula: see text], [Formula: see text]%], Parkinson's Disease Non-Motor Symptom Questionnaire (NMSQ) [MD: [Formula: see text]2.34, 95% CI: [Formula: see text]4.67-[Formula: see text]0.01, [Formula: see text], [Formula: see text]%], Montreal Cognitive Assessment (MoCA) [MD: 1.75, 95% CI: 1.46-2.03, [Formula: see text], [Formula: see text]%], Stroop Color and Word Test (SCWT) [MD: 0.87, 95% CI: 0.49-1.24, [Formula: see text], [Formula: see text]%], Frontal Assessment Battery (FAB) [MD: 1.49, 95% CI: 1.16-1.81, [Formula: see text], [Formula: see text]%], Hamilton Depression Scale (HAMD) [MD: [Formula: see text]4.27, 95% CI: [Formula: see text]6.85-[Formula: see text]1.69, [Formula: see text], [Formula: see text]%], Hamilton Anxiety Scale (HAMA) [MD: [Formula: see text]0.24, 95% CI: [Formula: see text]0.32-[Formula: see text]0.16, [Formula: see text], [Formula: see text]%], and the Symptom Checklist-90 (SCL-90) [MD: [Formula: see text]0.37, 95% CI: [Formula: see text]0.48-[Formula: see text]0.25, [Formula: see text], [Formula: see text]%]. Our findings provide compelling evidence for the potential benefits of OEs in managing NMS and improving QOL in PD patients. To optimize outcomes, we recommend customizing OE regimens based on individual clinical phenotypes, and to validate these results we emphasize the need for rigorous, large-scale studies.

Importance of focusing on subjective symptoms to maintain quality of life in patients with Parkinson's disease for over 5 years

Parkinson's disease (PD) is a neurodegenerative disorder that causes a variety of motor and non-motor symptoms (NMS), which affect the patient's quality of life (QOL). This study aimed to compare QOL and background in patients with PD based on the disease duration and investigate the factors affecting QOL. Patients with PD were evaluated based on age, sex, disease duration (≤5 years and > 5 years groups), Mini Mental State Examination (MMSE), Japanese version of Montreal Cognitive Assessment (MoCA-J), Levodopa equivalent daily dose (LEDD), Hoehn and Yahr (HY) severity, movement disorder society-sponsored revision of the unified Parkinson's disease rating scale (MDS-UPDRS) parts I-IV, and QOL using the Parkinson's disease questionnaire (PDQ-8). Overall, 102 patients with PD (58 males; mean age = 70.0 years; mean disease duration = 7.3 years) were included in this study. QOL was significantly correlated (r > 0.30, p < 0.05) with disease duration and MDS-UPDRS parts I-IV total scores. When the PDQ-8 total score was compared with MDS-UPDRS parts I-IV total scores based on disease duration classification, it was positively correlated with the scores for parts I and II in the >5 years group. Moreover, MDS-UPDRS parts I and II total scores appeared to be the factors most significantly affecting QOL. The factors affecting QOL in patients with PD were subjective NMS and motor symptoms. Since, physician-rated motor symptoms were not associated with QOL in patients with >5 years PD, subjective symptoms should be evaluated and treated to maintain QOL.

Navigating the challenge of pain when diagnosed at an early age with Parkinson's disease: an interpretative phenomenological analysis

PURPOSE

Despite the substantial impact of pain in Parkinson's, little attention has been given to understanding how individuals, especially those diagnosed at a younger age, perceive and manage their pain. This research aims to fill this gap by exploring the subjective experiences of pain in this population which is at a higher risk of experiencing pain.

MATERIALS AND METHODS

Interpretative Phenomenological Analysis (IPA) was used as a methodological framework. Non-directive, in-depth interviews were conducted with four French-speaking participants with Parkinson's (diagnosed before 50 years old, with various pain profiles), and analyzed using IPA.

RESULTS

Four major themes emerged: (1) the history of the disease, (2) adaptation to the disease, (3) losses related to pain and (4) strategies deployed to regain control over pain. Results highlight the participants' processes of adaptation, despite the major identity disruption caused by the disease and pain. They also shed light on how the experience of pain is influenced by its relational dimension.

CONCLUSIONS

Our results offer an understanding of the complexity and diversity of the experience of pain in this population. This complexity contributes to challenges in patients' ability to articulate and represent their pain accurately, advocating personalized, multidisciplinary pain management approaches within this population.

Experimental models of Parkinson's disease: Challenges and Opportunities

Parkinson's disease (PD) is a widespread neurodegenerative disorder occurs due to the degradation of dopaminergic neurons present in the substantia nigra pars compacta (SNpc). Millions of people are affected by this devastating disorder globally, and the frequency of the condition increases with the increase in the elderly population. A significant amount of progress has been made in acquiring more knowledge about the etiology and the pathogenesis of PD over the past decades. Animal models have been regarded to be a vital tool for the exploration of complex molecular mechanisms involved in PD. Various animals used as models for disease monitoring include vertebrates (zebrafish, rats, mice, guinea pigs, rabbits and monkeys) and invertebrate models (Drosophila, Caenorhabditis elegans). The animal models most relevant for study of PD are neurotoxin induction-based models (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), 6-Hydroxydopamine (6-OHDA) and agricultural pesticides (rotenone, paraquat), pharmacological models (reserpine or haloperidol treated rats), genetic models (α-synuclein, Leucine-rich repeat kinase 2 (LRRK2), DJ-1, PINK-1 and Parkin). Several non-mammalian genetic models such as zebrafish, Drosophila and Caenorhabditis elegance have also gained popularity in recent years due to easy genetic manipulation, presence of genes homologous to human PD, and rapid screening of novel therapeutic molecules. In addition, in vitro models (SH-SY5Y, PC12, Lund human mesencephalic (LUHMES) cells, Human induced pluripotent stem cell (iPSC), Neural organoids, organ-on-chip) are also currently in trend providing edge in investigating molecular mechanisms involved in PD as they are derived from PD patients. In this review, we explain the current situation and merits and demerits of the various animal models.

Pain Characteristics of Parkinson's Disease Using Validated Arabic Versions of the King's Parkinson's Disease Pain Scale and Questionnaire: A Multicenter Egyptian Study

OBJECTIVE

Pain is one of the most common nonmotor symptoms in Parkinson's disease (PD), with variable characteristics among populations. This multicenter Egyptian study aimed to translate and validate the King's Parkinson's Disease Pain Scale (KPPS) and Questionnaire (KPPQ) into Arabic versions and to investigate the pain characteristics in Egyptian people with PD (PWP).

METHODS

A total of 192 PWP and 100 sex- and age-matched controls were evaluated by the KPPS-Arabic and KPPQ-Arabic. Both tools were assessed for test-retest reliability, floor or ceiling effects, construct validity and convert validity. PWP were also assessed by the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Hoehn and Yahr scale (H&Y), Non-Motor Symptom Scale (NMSS), PD Questionnaire-39, and Non-Motor Fluctuation Assessment (NoMoFA).

RESULTS

The KPPS-Arabic and KPPQ-Arabic showed inter- and intrarater consistency and high validity, with an acceptable ceiling effect. A total of 188 PWP (97.9%) reported at least 1 type of pain (p < 0.001). The severity and prevalence of all pain domains in the KPPS-Arabic were significantly higher among PWP than among controls (p < 0.001). Fluctuation-related and musculoskeletal pains were the most common (81.3% and 80.7%, respectively). In the PD group, the total and domains of KPPS-Arabic were significantly correlated to the MDS-UPDRS total score and the scores of Parts I, II, III, postural instability gait disorder, axial, and H&Y but not with age or age of onset. The predictors of KPPS-Arabic scores included the total MDS-UPDRS, the part III-OFF, disease duration, the total NMSS, and the NoMoFA scores.

CONCLUSION

The current multicenter study provided validated Arabic versions of the KPPS and KPPQ, which exhibited high reliability and validity, and demonstrated a high prevalence and severity of pain within Egyptian PWP and characterized its determinants.

Sleep disturbances and associated factors in patients with Parkinson's disease

AIMS

This study aimed to describe clinical characteristics and sleep quality of Parkinson's Diseases (PD) patients and identify associated factors with sleep quality.

METHODS

A cross-sectional study was conducted at the National Geriatric Hospital, Hanoi, Vietnam, from December 2022 to April 2023. A total of 130 Parkinson's disease patients undergoing treatment at the hospital were invited. Demographic and clinical characteristics were obtained. The diagnosis of sleep disorders was based on the standards outlined in the DSM-V. A multivariate logistic regression model was employed.

RESULTS

90.9 % experienced sleep disorder, with the significant types including insomnia (76.2 %) and restless legs syndrome (56.2 %). The majority of patients suffered two (33.1 %) and one kind of sleep disorder (32.3 %). Most patients experienced sleep disorders after diagnosis of PD (80.0 %). Only having shoulder and neck pain was positively associated with a likelihood of having sleep disturbances (OR=4.87, 95 %CI=1.18-20.15).

CONCLUSION

This study found a high rate of sleep disorders among PD patients in our sample. Shoulder and neck pain was found to be associated with a risk of sleep disorders. Pain management should be performed to improve the sleep quality of PD patients.

Vestibular Neurostimulation for Parkinson's Disease: A Novel Device-Aided Non-Invasive Therapeutic Option

Dopaminergic replacement therapy remains the mainstay of symptomatic treatment for Parkinson's disease (PD), but many unmet needs and gaps remain. Device-based treatments or device-aided non-oral therapies are typically used in the advanced stages of PD, ranging from stereotactic deep brain stimulation to levodopa or apomorphine infusion therapies. But there are concerns associated with these late-stage therapies due to a number of procedural, hardware, or long-term treatment-related side effects of these treatments, and their limited nonmotor benefit in PD. Therefore, there is an urgent unmet need for low-risk adjuvants or standalone therapies which can address the range of burdensome motor and nonmotor symptoms that occur in PD. Recent studies suggest that non-invasive neurostimulation of the vestibular system may be able to address these gaps through the stimulation of the vestibular brainstem sensory network which extensively innervates brain regions, regulating both motor and a range of nonmotor functions. Therapeutic non-invasive vestibular stimulation is a relatively modern concept that may potentially improve a broad range of motor and nonmotor symptoms of PD, even at early stages of the disease. Here, we review previous studies supporting the therapeutic potential of vestibular stimulation for the treatment of PD and discuss ongoing clinical trials and potential areas for future investigations.

The effect of dysautonomia on motor, behavioral and cognitive fluctuations in Parkinson's disease

Background

Motor and non-motor fluctuations adversely impact quality of life in Parkinson's disease (PD). Dysautonomia, a feature frequently associated with PD and a possible adverse effect of dopaminergic therapy, may be comorbid with fluctuations.

Objectives

We sought to evaluate the effect of dysautonomia on motor and non-motor fluctuations in PD.

Methods

Two hundred subjects with PD were evaluated in both "on" and "off" dopamine states to assess changes in symptoms related to dopaminergic fluctuations. Multivariable logistic regression was performed to assess the association of dysautonomia with motor, cognitive, and psychiatric worsening from ON to OFF states with adjustment for disease duration, levodopa equivalent daily dosage (LEDD), and dopamine agonist LEDD.

Results

Subjects with dysautonomia had greater odds of clinically meaningful change in motor features (OR 3.0), cognition (OR 3.4) and anxiety (OR 4.3) compared to those without dysautonomia.

Conclusions

Dysautonomia may be a contributory mechanism behind fluctuations in PD. The exact nature of this relationship deserves further evaluation.

Emerging perspectives on precision therapy for Parkinson's disease: multidimensional evidence leading to a new breakthrough in personalized medicine

PD is a prevalent and progressive neurodegenerative disorder characterized by both motor and non-motor symptoms. Genes play a significant role in the onset and progression of the disease. While the complexity and pleiotropy of gene expression networks have posed challenges for gene-targeted therapies, numerous pathways of gene variant expression show promise as therapeutic targets in preclinical studies, with some already in clinical trials. With the recognition of the numerous genes and complex pathways that can influence PD, it may be possible to take a novel approach to choose a treatment for the condition. This approach would be based on the symptoms, genomics, and underlying mechanisms of the disease. We discuss the utilization of emerging genetic and pathological knowledge of PD patients to categorize the disease into subgroups. Our long-term objective is to generate new insights for the therapeutic approach to the disease, aiming to delay and treat it more effectively, and ultimately reduce the burden on individuals and society.

Imbalance and Falls in Patients with Parkinson's Disease: Causes and Recent Developments in Training and Sensor-Based Assessment

Imbalance and falls in patients with Parkinson's disease (PD) do not only reduce their quality of life but also their life expectancy. Aging-related symptoms as well as disease-specific motor and non-motor symptoms contribute to these conditions and should be treated when appropriate. In addition to an active lifestyle, advanced exercise training is useful and effective, especially for less medically responsive symptoms such as freezing of gait and postural instability at advanced stages. As treadmill training in non-immersive virtual reality, including dual tasks, significantly reduced the number of falls in PD patients, the mechanism(s) explaining this effect should be further investigated. Such research could help to select the most suitable patients and develop the most effective training protocols based on this novel technology. Real-life digital surrogate markers of mobility, such as those describing aspects of endurance, performance, and the complexity of specific movements, can further improve the quality of mobility assessment using wearables.

Identification and optimization of nitrophenolic analogues as dopamine metabolic enzyme inhibitors for the treatment of Parkinson's disease

Progressive loss of dopaminergic neurons leads to the depletion of the striatal neurotransmitter dopamine, which is the main cause of Parkinson's disease (PD) motor symptoms. Simultaneous inhibition of the two key dopamine metabolic enzymes, catechol-O-methyltransferase (COMT) and monoamine oxidase B (MAO-B), could potentially be a breakthrough in achieving clinical efficacy. Representative compound C12 exhibits good COMT inhibitory activity (IC50 = 0.37 μM), metal chelation ability, and BBB permeability. Furthermore, results from in vivo biological activity evaluations indicate that C12 can improve dopamine levels and ameliorate MPTP-induced PD symptoms in mice. Preliminary in vivo and in vitro study results highlight the potential of compound C12 in PD treatment.

Machine learning for the detection and diagnosis of cognitive impairment in Parkinson's Disease: A systematic review

BACKGROUND

Parkinson's Disease is the second most common neurological disease in over 60s. Cognitive impairment is a major clinical symptom, with risk of severe dysfunction up to 20 years post-diagnosis. Processes for detection and diagnosis of cognitive impairments are not sufficient to predict decline at an early stage for significant impact. Ageing populations, neurologist shortages and subjective interpretations reduce the effectiveness of decisions and diagnoses. Researchers are now utilising machine learning for detection and diagnosis of cognitive impairment based on symptom presentation and clinical investigation. This work aims to provide an overview of published studies applying machine learning to detecting and diagnosing cognitive impairment, evaluate the feasibility of implemented methods, their impacts, and provide suitable recommendations for methods, modalities and outcomes.

METHODS

To provide an overview of the machine learning techniques, data sources and modalities used for detection and diagnosis of cognitive impairment in Parkinson's Disease, we conducted a review of studies published on the PubMed, IEEE Xplore, Scopus and ScienceDirect databases. 70 studies were included in this review, with the most relevant information extracted from each. From each study, strategy, modalities, sources, methods and outcomes were extracted.

RESULTS

Literatures demonstrate that machine learning techniques have potential to provide considerable insight into investigation of cognitive impairment in Parkinson's Disease. Our review demonstrates the versatility of machine learning in analysing a wide range of different modalities for the detection and diagnosis of cognitive impairment in Parkinson's Disease, including imaging, EEG, speech and more, yielding notable diagnostic accuracy.

CONCLUSIONS

Machine learning based interventions have the potential to glean meaningful insight from data, and may offer non-invasive means of enhancing cognitive impairment assessment, providing clear and formidable potential for implementation of machine learning into clinical practice.

Clinical and cost-effectiveness of 'Live Well with Parkinson's' self-management intervention versus treatment as usual for improving quality of life for people with Parkinson's: study protocol for a randomised controlled trial

BACKGROUND

The Live Well with Parkinson's Self-Management Toolkit is designed for use in the NHS to support people with Parkinson's, their carers and health professionals in managing motor and non-motor symptoms and promoting well-being. The Toolkit was developed based on theory-based behaviour change and self-management techniques in consultation with people living with Parkinson's and health and social care practitioners. There are digital (e-Toolkit) and paper (manual) versions.

METHODS

Single-blind two-arm randomised controlled trial RCT of clinical effectiveness and cost-effectiveness of the Toolkit, facilitated by up to six sessions with a trained non-specialist supporter, in improving quality of life. People with Parkinson's will be assessed at baseline, 6 and 12 months. Assessors will be blind to the treatment group. The primary outcome measure is the Parkinson's Disease Questionnaire (PDQ-39, Parkinson's related quality of life) score at 12 months. Secondary outcome measures include the MDS Unified Parkinson's Disease Rating Scale (Part I, II, III, IV), EQ-5D, and a Client Service Receipt Inventory shortened, adapted for Parkinson's. Carer outcomes include the Zarit Carer Burden Inventory and Carer Quality of Life Questionnaire for Parkinsonism. A total of 338 people with Parkinson's, and their carers if appropriate, will be recruited from diverse settings across England. Those with advanced dementia, at end-of-life or with atypical Parkinsonism will be excluded. A parallel mixed methods process evaluation will explore the factors promoting or inhibiting implementation, uptake, use, effectiveness and cost-effectiveness of the Toolkit and sessions.

DISCUSSION

If successful, the Live Well with Parkinson's Toolkit could be used as a model for other complex long-term disorders, including dementia. This would bridge existing gaps in the NHS (as shown by the national Parkinson's audit data), by enabling patients and carers to access personalised information, advice and support on symptom management and 'living well' with Parkinson's.

TRIAL REGISTRATION

ISRCTN92831552. Registered on 26th Oct 2021.

Setting the clinical context to non-motor symptoms reflected by Park-pain, Park-sleep, and Park-autonomic subtypes of Parkinson's disease

Non-motor symptoms (NMS) of Parkinson's disease (PD) are well described in both clinical practice and the literature, enabling their management and enhancing our understanding of PD. NMS can dominate the clinical pictures and NMS subtypes have recently been proposed, initially based on clinical observations, and later confirmed in data driven analyses of large datasets and in biomarker-based studies. In this chapter, we provide an update on what is known about three common subtypes of NMS in PD. The pain (Park-pain), sleep dysfunction (Park-sleep), and autonomic dysfunction (Park-autonomic), providing an overview of their individual classification, clinical manifestation, pathophysiology, diagnosis, and potential treatments.

Parkinson's Disease-related Pains are Not Equal: Clinical, Somatosensory and Cortical Excitability Findings in Individuals With Nociceptive Pain

Chronic pain is a frequent and burdensome nonmotor symptom of Parkinson's disease (PD). PD-related chronic pain can be classified as nociceptive, neuropathic, or nociplastic, the former being the most frequent subtype. However, differences in neurophysiologic profiles between these pain subtypes, and their potential prognostic and therapeutic implications have not been explored yet. This is a cross-sectional study on patients with PD (PwP)-related chronic pain (ie, started with or was aggravated by PD). Subjects were assessed for clinical and pain characteristics through questionnaires and underwent quantitative sensory tests and motor corticospinal excitability (CE) evaluations. Data were then compared between individuals with nociceptive and non-nociceptive (ie, neuropathic or nociplastic) pains. Thirty-five patients were included (51.4% male, 55.7 ± 11.0 years old), 20 of which had nociceptive pain. Patients with nociceptive PD-related pain had lower warm detection threshold (WDT, 33.34 ± 1.39 vs 34.34 ± 1.72, P = .019) and mechanical detection threshold (MDT, 2.55 ± 1.54 vs 3.86 ± .97, P = .007) compared to those with non-nociceptive pains. They also presented a higher proportion of low rest motor threshold values than the non-nociceptive pain ones (64.7% vs 26.6%, P = .048). In non-nociceptive pain patients, there was a negative correlation between WDT and non-motor symptoms scores (r = -.612, P = .045) and a positive correlation between MDT and average pain intensity (r = .629, P = .038), along with neuropathic pain symptom scores (r = .604, P = .049). It is possible to conclude that PD-related chronic pain subtypes have distinctive somatosensory and CE profiles. These preliminary data may help better frame previous contradictory findings in PwP and may have implications for future trial designs aiming at developing individually-tailored therapies. PERSPECTIVE: This work showed that PwP-related nociceptive chronic pain may have distinctive somatosensory and CE profiles than those with non-nociceptive pain subtypes. These data may help shed light on previous contradictory findings in PwP and guide future trials aiming at developing individually-tailored management strategies.

Educational disparities in Brazil may interfere with the cognitive performance of Parkinson's disease patients

The prevalence of cognitive impairment in Parkinson's disease (PD) is about 20% to 60%. The Mini-Mental Status Examination (MMSE) is the most used cognitive screening test.

Objective

To evaluate the influence of clinical and demographic characteristics, specifically the education level, on the MMSE score in PD patients of a northeast Brazilian sample.

Methods

We performed a cross-sectional study of 198 PD patients at a Movement Disorders outpatient clinic in Fortaleza, CE, Brazil. Participants were assessed by detailed clinical history, modified Hoehn and Yahr staging (HY), geriatric depression scale (GDS) and MMSE.

Results

We found that 68% of patients had MMSE scores below the Brazilian thresholds, which were based in Brucki et al. study (2003). There was a statistically significant difference in the bivariate analysis between educational level and cut-off classification for MMSE. More years of formal schooling were associated with more patients scoring below threshold. We found that 75%, 68.8%, and 79.7% of individuals with more than 11, 9 to 11, and 4 to 8 years of formal schooling, respectively, were below the suggested Brazilian Brucki's threshold. GDS and age were negatively correlated with total MMSE and all its domains. There was no correlation between disease duration and MMSE. Subjects with hallucinations had lower scores.

Conclusion

Most of the sample had lower performance according to Brazilian thresholds, but there was no control group and no neuropsychological test in this study. Further studies in northeast Brazil are needed to review MMSE cut-off values.

Evaluation of Long Non-coding RNA Expression Profiles in Peripheral Blood Mononuclear Cells of Patients with Parkinson's Disease

As in many biological processes, the long non-coding RNAs (lncRNA) are currently known to have important roles in Parkinson's disease (PD). The aim of the study is to evaluate differentiated expressions of lncRNAs and their target mRNAs in the peripheral blood cells of individuals with Parkinson's disease. The peripheral blood samples were taken from 10 Parkinson's diagnosed people aging 50 years and more and from 10 healthy people as for the control group. Total RNA was isolated from peripheral blood mononuclear cells (PBMC), and a total of 5 samples were selected and evaluated by microarray analysis. lncRNAs with high fold change (fc < 1.5/fc > 1.5) were determined as a result of the analysis. Following this, the expression changes of some lncRNAs and their target mRNAs were examined by quantitative simultaneous polymerase chain reaction (qRT-PCR) in all individuals in the patient and control groups. Also, in order to determine the molecular level basic activities of lncRNAs determined by microarray analysis and which biological process and biochemical pathway they were in, Gene Ontology (GO) analysis ( http://geneontology.org/ ) database was used. Thirteen upregulated and 31 downregulated lncRNAs whose expression changes were determined by microarray analysis and confirmed by qRT-PCR method were found in Parkinson's patients. As they were evaluated by GO analysis, lncRNAs were expressed differently in patient and control groups and they are found to be related with the processes such as macromolecule metabolic processes, immune system, gene expression, cell activation, ATPase activity, DNA packaging complex, signal receptor activity, immune receptor activity, and protein binding were found to be significant.

Associations between non-motor symptoms and patient characteristics in Parkinson's disease: a multicenter cross-sectional study

Objective

Parkinson's disease (PD) is characterized by various non-motor symptoms (NMS), such as constipation, olfactory disturbance, sleep disturbance, mental disorders, and motor symptoms. This study aimed to investigate factors associated with NMS in patients with PD.

Methods

Symptoms of PD were evaluated using the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Parts I-IV. NMS was assessed using the MDS-UPDRS Part I (self-assessment of NMS) and rapid eye movement sleep behavior disorder (RBD) questionnaires. Patients were categorized by age into <70 years and ≥ 70 years (older adults) groups, according to disease duration into early-stage and advanced-stage groups with a cut-off value of 5 years for motor symptoms, and by sex into male and female groups.

Results

A total of 431 patients with PD (202 males and 229 females) with a mean age of 67.7 years, a mean disease duration of 6.4 years, and a mean Part I total score of 9.9 participated in this study. The Part I total score was significantly positively correlated (p < 0.01) with disease duration and Part II, III, and IV scores. For Part I sub-item scores, the older group had significantly higher scores for cognitive impairment, hallucinations, sleep problems, urinary problems, and constipation than the <70 years group, whereas the advanced-stage group had significantly higher scores for hallucinations, sleep problems, daytime sleepiness, pain, urinary problems, and constipation (p < 0.05) than the early-stage group. Anxiety was higher in female patients than in male patients, whereas daytime sleepiness, urinary problems, and RBD were higher in male patients than in female patients (p < 0.05). Factors affecting Part I included disease duration, Part II total scores, Part IV total scores, and RBD.

Conclusion

According to the self-questionnaire assessment, NMS was highly severe in older adult patients, those with longer illness duration, subjective and objective motor function impairments, and RBD. Sex-based differences were also observed.

Autonomic function and motor subtypes in Parkinson's disease: a multicentre cross-sectional study

Autonomic symptoms (AS) are critical in Parkinson's disease (PD). We aimed to determine the relative significance of clinical factors allowing predictions about incidence of AS, and examine AS profiles among PD patients by motor subtype and its relation to AS. The cross-sectional data of a multicentre sample, including 714 PD patients and 194 healthy controls from Parkinson's Progression Marker Initiative study and Pingchan granule study were analyzed, stratified by PD subtypes [postural instability and gait disturbances (PIGD), tremor dominant (TD), and indeterminate] and domain autonomic dysfunction. Compared with healthy controls, PD patients scored higher in the total Scales for Outcomes in Parkinson's Disease-Autonomic dysfunction score and in several domain scores in particular, and there was a significant overlap in domain AS. Risk factors of individual domain autonomic dysfunction were heterogeneous. PIGD and indeterminate were the predominant subtypes in pupillomotor and thermoregulatory symptoms. TD and indeterminate were more likely to suffer from cardiovascular problem. The odd in sexual dysfunction was significant for PIGD. Gastrointestinal and urinary symptoms seemed not to be associated with a specific subtype. Our study demonstrated that AS were highly heterogeneous and 3 subtypes differed in autonomic performance, providing clues to understand mechanisms underlying AS in PD.

Adjusting for Underrepresentation Reveals Widespread Underestimation of Parkinson's Disease Symptom Burden

BACKGROUND

Clinical research is limited by underrepresentation, but the impact of underrepresentation on patient-reported outcomes in Parkinson's disease (PD) is unknown.

OBJECTIVES

To produce nationwide estimates of non-motor symptom (NMS) prevalence and PD-related quality of life (QOL) limitations while accounting for underrepresentation.

METHODS

We performed a cross-sectional analysis of data from the Fox Insight (FI) study, an ongoing prospective longitudinal study of persons with self-reported PD. Using epidemiologic literature and United States (US) Census Bureau, Medicare, and National Health and Aging Trends Study data, we simulated a "virtual census" of the PD population. To compare the PD census to the FI cohort, we used logistic regression to model the odds of study participation and calculate predicted probabilities of participation for inverse probability weighting.

RESULTS

There are an estimated 849,488 persons living with PD in the US. Compared to 22,465 eligible FI participants, non-participants are more likely to be older, female, and non-White; live in rural regions; have more severe PD; and have lower levels of education. When these predictors were incorporated into a multivariable regression model, predicted probability of participation was much higher for FI participants than non-participants, indicating a significant difference in the underlying populations (propensity score distance 2.62). Estimates of NMS prevalence and QOL limitation were greater when analyzed using inverse probability of participation weighting compared to unweighted means and frequencies.

CONCLUSIONS

PD-related morbidity may be underestimated because of underrepresentation, and inverse probability of participation weighting can be used to give greater weight to underrepresented groups and produce more generalizable estimates. © 2023 International Parkinson and Movement Disorder Society.

Starburst amacrine cells, involved in visual motion perception, loose their synaptic input from dopaminergic amacrine cells and degenerate in Parkinson's disease patients

BACKGROUND

The main clinical symptoms characteristic of Parkinson's disease (PD) are bradykinesia, tremor, and other motor deficits. However, non-motor symptoms, such as visual disturbances, can be identified at early stages of the disease. One of these symptoms is the impairment of visual motion perception. Hence, we sought to determine if the starburst amacrine cells, which are the main cellular type involved in motion direction selectivity, are degenerated in PD and if the dopaminergic system is related to this degeneration.

METHODS

Human eyes from control (n = 10) and PD (n = 9) donors were available for this study. Using immunohistochemistry and confocal microscopy, we quantified starburst amacrine cell density (choline acetyltransferase [ChAT]-positive cells) and the relationship between these cells and dopaminergic amacrine cells (tyrosine hydroxylase-positive cells and vesicular monoamine transporter-2-positive presynapses) in cross-sections and wholemount retinas.

RESULTS

First, we found two different ChAT amacrine populations in the human retina that presented different ChAT immunoreactivity intensity and different expression of calcium-binding proteins. Both populations are affected in PD and their density is reduced compared to controls. Also, we report, for the first time, synaptic contacts between dopaminergic amacrine cells and ChAT-positive cells in the human retina. We found that, in PD retinas, there is a reduction of the dopaminergic synaptic contacts into ChAT cells.

CONCLUSIONS

Taken together, this work indicates degeneration of starburst amacrine cells in PD related to dopaminergic degeneration and that dopaminergic amacrine cells could modulate the function of starburst amacrine cells. Since motion perception circuitries are affected in PD, their assessment using visual tests could provide new insights into the diagnosis of PD.

Sexual Dysfunction and Related Factors in Patients With Parkinson's Disease

The current cross-sectional study investigated sexual dysfunction and related factors in patients with Parkinson's disease (PD). The sample comprised 76 patients with PD in the neurology clinic of a training and research hospital. Data were collected using the Hospital Anxiety and Depression Scale and Arizona Sexual Experiences Scale. Approximately nine (88.2%) in 10 participants had sexual dysfunction. Sexual dysfunction depended on sex, educational background, employment status, side effects, body image, difficulty falling asleep, self-care, and walking dependence. Sexual dysfunction was positively correlated with age and symptoms of depression and anxiety. Sexual dysfunction was more prevalent in females than males. Advanced age and high risk of depression resulted in increased prevalence of sexual dysfunction. Health care professionals should evaluate the causes of sexual dysfunction and plan and implement appropriate interventions for patients with PD. [Journal of Psychosocial Nursing and Mental Health Services, 61(3), 45-55.].

Combined EEG and immersive virtual reality unveil dopaminergic modulation of error monitoring in Parkinson's Disease

Detecting errors in your own and others' actions is associated with discrepancies between intended and expected outcomes. The processing of salient events is associated with dopamine release, the balance of which is altered in Parkinson's disease (PD). Errors in observed actions trigger various electrocortical indices (e.g. mid-frontal theta, error-related delta, and error positivity [oPe]). However, the impact of dopamine depletion to observed errors in the same individual remains unclear. Healthy controls (HCs) and PD patients observed ecological reach-to-grasp-a-glass actions performed by a virtual arm from a first-person perspective. PD patients were tested under their dopaminergic medication (on-condition) and after dopaminergic withdrawal (off-condition). Analyses of oPe, delta, and theta-power increases indicate that while the formers were elicited after incorrect vs. correct actions in all groups, the latter were observed in on-condition but altered in off-condition PD. Therefore, different EEG error signatures may index the activity of distinct mechanisms, and error-related theta power is selectively modulated by dopamine depletion. Our findings may facilitate discovering dopamine-related biomarkers for error-monitoring dysfunctions that may have crucial theoretical and clinical implications.

Advances in the Pharmacological and Non-pharmacological Management of Non-motor Symptoms in Parkinson's Disease: An Update Since 2017

BACKGROUND

Non-motor symptoms (NMS) are an important and ubiquitous determinant of quality of life in Parkinson's disease (PD). However, robust evidence for their treatment is still a major unmet need.

OBJECTIVE

This study aimed to provide an updated review on advances in pharmacological, nonpharmacological, and exercise-based interventions for NMS in PD, covering the period since the publication of the MDS Task Force Recommendations.

METHODS

We performed a literature search to identify pharmacological, non-pharmacological, and exercise-based interventions for NMS in PD. As there are recent reviews on the subject, we have only included studies from the 1st of January 2017 to the 1st of December 2021 and limited our search to randomised and non-randomised (including open-label) clinical trials.

RESULTS

We discuss new strategies to manage NMS based on data that have become available since 2017, for instance, on the treatment of orthostatic hypotension with droxidopa, several dopaminergic treatment options for insomnia, and a range of non-pharmacological and exercise-based interventions for cognitive and neuropsychiatric symptoms, pain, and insomnia and excessive sleepiness.

CONCLUSION

Recent evidence suggests that targeted non-pharmacological treatments, as well as some other NMS management options, may have a significant beneficial effect on the quality of life and need to be considered in the pathways of treatment of PD.

Serum zinc deficiency could be associated with dementia conversion in Parkinson's disease

Background

Association between heavy metals and Parkinson's disease (PD) is well noted, but studies regarding heavy metal levels and non-motor symptoms of PD, such as PD's dementia (PD-D), are lacking.

Methods

In this retrospective cohort study, we compared five serum heavy metal levels (Zn, Cu, Pb, Hg, and Mn) of newly diagnosed PD patients (n = 124). Among 124 patients, 40 patients were later converted to Parkinson's disease dementia (PD-D), and 84 patients remained without dementia during the follow-up time. We collected clinical parameters of PD and conducted correlation analysis with heavy metal levels. PD-D conversion time was defined as the initiation time of cholinesterase inhibitors. Cox proportional hazard models were used to identify factors associated with dementia conversion in PD subjects.

Results

Zn deficiency was significant in the PD-D group than in the PD without dementia group (87.53 ± 13.20 vs. 74.91 ± 14.43, p < 0.01). Lower serum Zn level was significantly correlated with K-MMSE and LEDD at 3 months (r = -0.28, p < 0.01; r = 0.38, p < 0.01). Zn deficiency also contributed to a shorter time to dementia conversion (HR 0.953, 95% CI 0.919 to 0.988, p < 0.01).

Conclusion

This clinical study suggests that a low serum Zn level can be a risk factor for developing PD-D and could be used as a biological marker for PD-D conversion.

Therapeutic Approaches to Non-Motor Symptoms of Parkinson's Disease: A Current Update on Preclinical Evidence

Despite being classified as a movement disorder, Parkinson's disease (PD) is characterized by a wide range of non-motor symptoms that significantly affect the patients' quality of life. However, clear evidence-based therapy recommendations for non-motor symptoms of PD are uncommon. Animal models of PD have previously been shown to be useful for advancing the knowledge and treatment of motor symptoms. However, these models may provide insight into and assess therapies for non-motor symptoms in PD. This paper highlights non-motor symptoms in preclinical models of PD and the current position regarding preclinical therapeutic approaches for these non-motor symptoms. This information may be relevant for designing future preclinical investigations of therapies for nonmotor symptoms in PD.

Determination of the motor status of patients with advanced Parkinson’s disease under levodopa–carbidopa intestinal gel using a machine learning model

BACKGROUND

Despite the careful selection of candidate patients, the levodopa-carbidopa intestinal gel (LCIG) treatment of advanced Parkinson's disease (PD) remains challenging due to a complex interplay between motor and non-motor symptoms. We developed a random forest (RF) model to determine the postoperative motor outcome of patients with advanced PD at 2 years under the LCIG therapy by using motor and non-motor data from a Greek multicenter, observational registry (ForHealth S.A.).

METHODS

This was a prospective 24-month, observational study of 59 patients with advanced PD under LCIG treatment from September 2019 to September 2021. Motor status was assessed with the Unified Parkinson's Disease Rating Scale (UPDRS) parts III and IV. Non-motor symptoms (NMS) were assessed by the Non-Motor Symptoms Questionnaire (NMSQ) and the Geriatric Depression Scale (GDS).

RESULTS

We demonstrated that the proper combination of motor and non-motor measures significantly determines the motor outcome (UPDRS-III year 2: 23.57 ± 14.22 p < 0.001), reducing the RMSE (root-mean-square-error) from 3.487279 to 3.066292, suggesting that the optimized model performed well. Based on the "IncNodePurity," the major determinant factors of UPDRS-III (year 2) were, in descending order: UPDRS-III (year 0), disease duration, NMSQ (year 2), age, NMSQ (year 0), time off (hours) (year 2), time dyskinesia (year 0), quality of life (year 2) after the LCIG implementation.

CONCLUSIONS

The novelty of this model is the possibility to determine the motor outcome after two years of LCIG. This model could be also useful for not specialized Parkinson's neurologists, to improve patient counseling, expectation management, and patient satisfaction with LCIG therapy.

Hallucinations, Antipsychotic Use, and Mortality in Older Adults with Dementia: Retrospective Cohort Study of Two Medicare-Linked National Health Surveys

BACKGROUND

Hallucinations are associated with earlier death in older adults with dementia, but antipsychotic medications are also associated with mortality, and comparisons of their relative harms are lacking.

OBJECTIVE

To determine the individual and combined association between hallucinations, antipsychotic use, and mortality.

METHODS

We performed a retrospective cohort study using Medicare-linked survey data from two nationally representative studies (the National Health and Aging Trends Study and the Health and Retirement Study) containing validated dementia identification algorithms and a screening question for hallucinations. Using Medicare claims, we identified participants with dementia who had no history of antipsychotic use during the year of or prior to entry. We used extended Cox regression with time-varying covariates to analyze the association between hallucinations, antipsychotic use, and mortality adjusting for confounders.

RESULTS

We identified 1703 eligible subjects who contributed 4,819 person-years of follow-up. 555 (32.6%) had hallucinations at baseline, 705 (41.4%) reported hallucinations at least once during follow-up, and 284 (16.7%) received antipsychotics. Hallucinations were associated with an increased risk of death in unadjusted models (hazard ratio (HR) 1.36; 95% confidence interval (CI): 1.18-1.5), but antipsychotic use was not (HR 1.03; 95% CI 0.85-1.2). After adjusting for age, race, gender, dementia severity, and comorbidities, the HR for hallucinations attenuated and was no longer statistically significant (1.15, 95% CI 0.98-1.34). There was no significant interaction between hallucinations and antipsychotic use.

CONCLUSION

Hallucinations are associated with an increased risk of death that is greater than the risk associated with antipsychotic use, though this is partially confounded by dementia severity and comorbidities.

Should patients with Parkinson’s disease only visit a neurologist’s office? - a narrative review of neuropsychiatric disorders among people with Parkinson’s disease

Introduction: Parkinson’s disease is a neurodegenerative disease that is often accompanied by disorders such as depression, psychotic disorders, cognitive disorders, anxiety disorders, sleep disorders, impulse control disorders. The aim of the study was to review the literature and present the characteristics of neuropsychiatric disorders occurring in people suffering from Parkinson’s disease, with the specification of the above-mentioned disorders.

Material and method: The literature available on the PubMed platform from 1986 to 2022 was reviewed using the following keywords: Parkinson’s disease, depression, anxiety disorders, psychotic disorders, sleep disorders, cognitive disorders, impulse control disorders. Original studies, reviews, meta-analyzes and internet sources were analyzed.

Results: The above-mentioned neuropsychiatric disorders appear with different frequency among people suffering from Parkinson’s disease and occur at different times of its duration or even precede its onset for many years. The non-motor symptoms in the form of depressed mood, energy loss or changes in the rhythm of the day may result in a delay of appropriate therapy and thus in complications. Neuropathological changes in the course of Parkinson’s disease as well as dopaminergic drugs used in its therapy influence the development of neuropsychiatric disorders.

Conclusions: In order to avoid misdiagnosis, practitioners should use, e.g. scales intended for patients with Parkinson’s disease. To prevent the consequences of the aforementioned disease entities, methods of early diagnosis, determination of risk factors and standardization of the treatment process must be determined. Consistent care for patients with Parkinson’s disease is significant, not only in the neurological field, but also in the psychiatric one.

Correction of the wake-sleep cycle by intranasal administration of dopamine in modeling of the preclinical stage of Parkinson's disease in rats

Sleep disorders, which are among the earliest and most sensitive non-motor manifestations of Parkinson's disease (PD), are not diagnosed in 40–50 % of patients and are not subject to the necessary correction. In this regard, the ineffectiveness of a late start of treatment, when more than 50 % of dopamine-producing neurons are already affected, dictates the need to search for and develop approaches to the prevention and slowdown of neurodegenerative pathology at the preclinical stages of its development using adequate experimental models. Taking into account the low bioavailability of dopamine (DA) and data on the advantages of the intranasal route of administration in comparison with oral and parenteral methods of drug delivery to the CNS, the aim of the work was to study the neurophysiological features of the wake-sleep cycle as early manifestations of nigrostriatal insufficiency and the effect of intranasal administration of DA on the quality of sleep during the formation of the preclinical stage of PD in rats. It was shown that under the conditions of modeling PD, the cyclic organization of sleep with a predominance of incomplete cycles against the background of hyperproduction of slow-wave sleep and REM phases are early manifestations of nigrostriatal insufficiency. Course administration of DA at a dose of 3 mg/kg is accompanied by the normalization of sleep quality in the form of reduction (by 76 %) in the number of incomplete cycles. The preventive orientation of the obtained effects may indicate a certain therapeutic potential of intranasal delivery of DA to the brain, aimed at slowing down the processes of neurodegeneration and possibly delaying its clinical manifestation

[Characteristics and treatment of pain in Parkinson's disease]

Pain is a representative non-motor symptom in patients with Parkinson's disease (PD). Pain is one of the most common symptoms that plague patients with PD regardless of the stage of the disease, also it can exacerbate other symptoms, such as depression, anxiety or sleep disturbance, and lead to impaired quality of life. However, pain is often not adequately evaluated and treated. PD patients complain of a wide variety of pain, including both PD-related pain which caused by PD-specific symptoms, for example, rigidity, bradykinesia or motor fluctuation, and PD-unrelated pain, and it can be divided into central and peripheral depending on the site of the disorder. In the medical care of the pain, it is important to evaluate the type and severity of the pain using PD-specific assessment scales such as King's PD pain scale and to consider the evidence-based treatment methods according to the pathophysiology of the pain.

Prevalence and Incidence of Nonmotor Symptoms in Individuals with and Without Parkinson's Disease

Background

The prevalence ratio (PR) and incidence rate ratio (IRR) of nonmotor symptoms (NMS) were calculated for early Parkinson's disease (PD) versus non-PD from 2 observational studies.

Methods

NMS were assessed through the self-reported Non-Motor Symptom Questionnaire in the online Fox Insight study and through self- and clinician-rated scales in the Parkinson's Progression Marker Initiative (PPMI) study. Age- and sex-adjusted/matched PR and IRR were estimated for each NMS by PD status using Poisson regression.

Results

Most NMS occurred more frequently in PD. Among 15,194 Fox Insight participants, sexual dysfunction had the largest adjusted PR (12.4 [95% CI, 6.9-22.2]) and dysgeusia/hyposmia had the largest adjusted IRR over a 2-year median follow-up (17.0 [95% CI, 7.8-37.1]). Among 607 PPMI participants, anosmia had the largest PR (16.6 [95% CI, 6.1-44.8]). During the 7-year median follow-up, hallucinations had the largest IRR (13.5 [95% CI, 6.3-28.8]).

Conclusion

Although many NMS are more common in early PD than in non-PD, their occurrence may differ with time (hallucinations) or data collection methods (sexual dysfunction).

Self-management Interventions for People With Parkinson Disease: Scoping Review

BACKGROUND

Parkinson disease can impose substantial distress and costs on patients, their families and caregivers, and health care systems. To address these burdens for families and health care systems, there is a need to better support patient self-management. To achieve this, an overview of the current state of the literature on self-management is needed to identify what is being done, how well it is working, and what might be missing.

OBJECTIVE

The aim of this scoping review was to provide an overview of the current body of research on self-management interventions for people with Parkinson disease and identify any knowledge gaps.

METHODS

The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) and Population, Intervention, Comparator, Outcome, and Study type frameworks were used to structure the methodology of the review. Due to time and resource constraints, 1 reviewer systematically searched 4 databases (PubMed, Ovid, Scopus, and Web of Science) for the evaluations of self-management interventions for Parkinson disease published in English. The references were screened using the EndNote X9 citation management software, titles and abstracts were manually reviewed, and studies were selected for inclusion based on the eligibility criteria. Data were extracted into a pre-established form and synthesized in a descriptive analysis.

RESULTS

There was variation among the studies on study design, sample size, intervention type, and outcomes measured. The randomized controlled trials had the strongest evidence of effectiveness: 5 out of 8 randomized controlled trials found a significant difference between groups favoring the intervention on their primary outcome, and the remaining 3 had significant effects on at least some of the secondary outcomes. The 2 interventions included in the review that targeted mental health outcomes both found significant changes over time, and the 3 algorithms evaluated performed well. The remaining studies examined patient perceptions, acceptability, and cost-effectiveness and found generally positive results.

CONCLUSIONS

This scoping review identified a wide variety of interventions designed to support various aspects of self-management for people with Parkinson disease. The studies all generally reported positive results, and although the strength of the evidence varied, it suggests that self-management interventions are promising for improving the care and outcomes of people with Parkinson disease. However, the research tended to focus on the motor aspects of Parkinson disease, with few nonmotor or holistic interventions, and there was a lack of evaluation of cost-effectiveness. This research will be important to providing self-management interventions that meet the varied and diverse needs of people with Parkinson disease and determining which interventions are worth promoting for widespread adoption.

A systematic review on resting state functional connectivity in patients with neurodegenerative disease and hallucinations

Hallucinations are a complex and multidimensional phenomenon which can differ based on the involved pathology, typology and sensory modality. Hallucinations are common in patients with neurodegenerative diseases. Recent sparse evidence from resting state functional magnetic resonance imaging (rs-fMRI) studies has identified altered functional connectivity in those patients within several brain networks, such as the default mode, attentional and sensory ones, without, however, providing an organized picture of the mechanisms involved. This systematic review, following PRISMA guidelines, aims at critically analyzing the current literature on the brain networks associated with the phenomenon of hallucinations in patients with neurodegenerative diseases. Ten rs-fMRI studies fulfilled our selection criteria. All these studies focused on synucleinopathies, and most of them focused on visual hallucinations and were characterized by a heterogeneous methodology. Thus, instead of offering a definite picture of the mechanisms underlying hallucinations in neurodegeneration, this systematic review encourages further research especially concerning tauopathies. Notwithstanding, the findings overall suggest a disruption in the top-down (associated with memory intrusion and difficulty of inhibition) and in the bottom-up processes (associated with the sensory areas involved in the hallucinations). Further investigations are needed in order to disentangle the brain mechanisms involved in hallucinations and to overcome possible limitations characterizing the current literature.

The impact of a digital artificial intelligence system on the monitoring and self-management of non-motor symptoms in People with Parkinson’s: Proposal for a Phase 1 implementation study (Preprint)

Background

Nonmotor symptoms of Parkinson disease are a major factor of disease burden but are often underreported in clinical appointments. A digital tool has been developed to support the monitoring and management of nonmotor symptoms.

Objective

The aim of this study is to establish evidence of the impact of the system on patient confidence, knowledge, and skills for self-management of nonmotor symptoms, symptom burden, and quality of life of people with Parkinson and their care partners. It will also evaluate the usability, acceptability, and potential for adoption of the system for people with Parkinson, care partners, and health care professionals.

Methods

A mixed methods implementation and feasibility study based on the nonadoption, abandonment, scale-up, spread, and sustainability framework will be conducted with 60 person with Parkinson–care partner dyads and their associated health care professionals. Participants will be recruited from outpatient clinics at the University Hospitals Plymouth NHS Trust Parkinson service. The primary outcome, patient activation, will be measured over the 12-month intervention period; secondary outcomes include the system’s impact on health and well-being outcomes, safety, usability, acceptability, engagement, and costs. Semistructured interviews with a subset of participants will gather a more in-depth understanding of user perspectives and experiences with the system. Repeated measures analysis of variance will analyze change over time and thematic analysis will be conducted on qualitative data. The study was peer reviewed by the Parkinson’s UK Non-Drug Approaches grant board and is pending ethical approval.

Results

The study won funding in August 2021; data collection is expected to begin in December 2022.

Conclusions

The study’s success criteria will be affirming evidence regarding the system’s feasibility, usability and acceptability, no serious safety risks identified, and an observed positive impact on patient activation. Results will be disseminated in academic peer-reviewed journals and in platforms and formats that are accessible to the general public, guided by patient and public collaborators.

Trial Registration

ClinicalTrials.gov NCT05414071; https://clinicaltrials.gov/ct2/show/NCT05414071

International Registered Report Identifier (IRRID)

PRR1-10.2196/40317

Effects of dance therapy on non-motor symptoms in patients with Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

Parkinson's disease (PD) represents the second most common neurodegenerative disease.

OBJECTIVE

To evaluate the effects of dance therapy (DT) aimed at improving non-motor symptoms in PD.

METHODS

Studies were performed through PubMed, Web of Science, The Cochrane Library, Embase, and Science Direct from inception to October 27, 2021. The data were screened independently by two reviewers, and the quality of the papers was assessed using the Cochrane manual. The included studies were randomized controlled trials and quasi-randomized controlled trials, reporting random-effects standardized mean differences, and 95% confidence intervals as the effect size. I² statistics were used to assess heterogeneity. The main outcomes included the Montreal Cognitive Assessment Scale (MOCA), Baker Depression Scale (BDI), Parkinson's Fatigue Scale (FPS-16), and Apathy Scale (AS). RevMan 5.3 software was integrated for meta-analysis.

RESULTS

Nine literatures were analyzed for the meta-analysis with a total of 307 patients. Random effects showed that DT significantly improved cognitive of PD (MD = 1.50, 95% CI [0.52, 2.48], P = 0.0003; I² = 51%). However, this meta-analysis demonstrated that dance therapy had no significance for improving depression (MD = - 1.33, 95% CI [- 4.11, 1.45], P = 0.35; I² = 79%), fatigue (MD = 0.26, 95% CI [- 0.31, 0.83], P = 0.37; I² = 0%), and apathy (MD = 0.07, 95% CI [- 2.55, 2.69], P = 0.96; I² = 50%).

CONCLUSION

The meta-analysis suggests that dance can improve cognitive function in PD.

Assessment of myocardial sympathetic innervation with 18F-FDOPA-PET/CT in patients with autonomic dysfunction: feasibility study in IPD patients

BACKGROUND

Dysfunction and denervation of myocardial nor-adrenergic sympathetic neurons has been documented in IPD patients with dysautonomia. The aim of this study was to evaluate the feasibility of single tracer imaging of myocardial sympathetic and cerebral striatal involvement in these patients.

METHODS

Twenty-two controls (mean-age 59.09 ± 12.39 years, 15 men) with no clinical autonomic-dysfunction and normal striatal-uptake in 18F-FDOPA-PET/CT; and 28 patients (mean-age 58.18 ± 8.25 years, 18 men) with autonomic-dysfunction (in Autonomic Function Tests) and striatal dopaminergic-dysfunction were enrolled. Both cardiac-PET/CT (40 minutes post IV-injection of 185-259MBq 18F-FDOPA) and Brain-PET/CT (60 minutes post-IV) were acquired in same session. ROIs were drawn over the entire left ventricular myocardium, individual walls and mediastinum for quantification. Patients and controls were followed-up for 26.93 ± 5.43 months and 37.91 ± 8.63 months, respectively.

RESULTS

Striatal and myocardial-parameters were significantly lower in patients compared to controls; with Myocardium/mediastinal ratio (MwMR) yielding the area-under-the-curve of .941 (P < .001). MwMR correlated negatively with the drop in systolic blood pressure (SBP) during AFTs {Pearson-coefficient (-).565, P = .002}. Mean MwMR in patients with abnormal-AFTs was significantly lower than patients with borderline-AFTs (1.39 ± .12 vs 1.55 ± .10; P = .002). 9/20 patients with abnormal-AFTs showed functional worsening during follow-up, compared to 2/8 with borderline-AFTs.

CONCLUSION

Single tracer, single session imaging of striatal and cardiac sympathetic dysfunction in patients with advanced IPD is feasible with use of 18F-FDOPA. Significantly reduced 18F-FDOPA uptake is seen in the myocardium of the IPD patients with sympathetic dysfunction.

Social isolation, loneliness and mental health sequelae of the Covid-19 pandemic in Parkinson's disease

People living with Parkinson Disease (PwP) have been at risk for the negative effects of loneliness even before the Coronavirus Disease 2019 (Covid-19) pandemic. Despite some similarities with previous outbreaks, the Covid-19 pandemic is significantly more wide-spread, long-lasting, and deadly, which likely means demonstrably more negative mental health issues. Although PwP are not any more likely to contract Covid-19 than those without, the indirect negative sequelae of isolation, loneliness, mental health issues, and worsening motor and non-motor features remains to be fully realized. Loneliness is not an isolated problem; the preliminary evidence indicates that loneliness associated with the Covid-19 restrictions has dramatically increased in nearly all countries around the world.

Non-Motor Symptoms in PLA2G6-Associated Dystonia-Parkinsonism: A Case Report and Literature Review

PLA2G6-dystonia-parkinsonism (PLAN-DP) is characterized by levodopa responsive parkinsonism and dystonia. While neuropsychiatric symptoms and early cognitive decline are also common in this entity there is little information regarding other non-motor symptoms (NMS). Here, we describe a 26-year-old patient with PLAN-DP whose motor symptoms were preceded by mild cognitive impairment and anxiety, and who developed many other NMS as the disease evolved. Furthermore, we reviewed the NMS described in all the PLAN-DP patients published to date. A total of 50 patients with PLAN-DP were identified, 42 of whom developed NMS and in 23 of these cases, NMS preceded the motor symptoms of the disease. Neuropsychiatric symptoms dominated the premotor phase of this condition and cognitive impairment/dementia was the most prevalent NMS. Other NMS were reported infrequently like sleep disorders, autonomic symptoms, pain and hyposmia, and mostly as the disease evolved. NMS are very frequent in PLAN-DP and they may appear before diagnosis or during the course of the disease. Neuropsychiatric symptoms and cognitive decline are the most frequent NMS. The appearance of neuropsychiatric symptoms like depression, anxiety or personality changes prior to a diagnosis of parkinsonism in younger individuals might suggest the presence of PLA2G6 gene mutations.

Undetected ophthalmological disorders in Parkinson's disease

Background

Ophthalmological disorders are common and frequently disabling for people with Parkinson’s disease (PD). However, details on the prevalence, severity and impact of ophthalmological disorders thus far lacking. We aimed to identify PD patients with undetected ophthalmological disorders in a large cross-sectional, observational study.

Methods

We previously delivered a screening questionnaire to detect ophthalmological symptoms (Visual impairment in PD questionnaire; VIPD-Q) to 848 patients. Here, we report on a subgroup of 102 patients who received complete ophthalmological assessment aimed at identifying clinically relevant ophthalmological diseases, which were classified as either vison-threatening or not. Impact on daily life functioning was measured using the visual functioning-25 questionnaire (VFQ-25) and fall frequency.

Results

Almost all patients (92%) had one or more clinically relevant ophthalmological disorders. Of those, 77% had a potentially vision-threatening disease, while 34% had a potentially treatable ophthalmological disease which impacted on quality of life. The most prevalent ophthalmological disorders were dry eyes (86%), ocular misalignment (50%) and convergence insufficiency (41%). We found a weak but significant association between clinically relevant ophthalmological diseases and both fall frequency (R² = 0.15, p = 0.037) and VFQ-25 score (R² = 0.15, p = 0.02). The VIPD-Q could not correctly identify patients with relevant ophthalmological disorders.

Conclusions

Surprisingly, in our study sample, many participants manifested previously undetected ophthalmological diseases, most of which threatened vision, impacted on daily life functioning and were amenable to treatment. Screening for these ophthalmological disorders using a questionnaire asking about symptoms seems insufficient. Instead, episodic ophthalmological assessments should be considered for PD patients, aiming to identify vision-threatening yet treatable diseases.

Trial registration

Dutch Trial Registration, NL7421.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11014-0.

Medicare Claims Data Underestimate Hallucinations in Older Adults With Dementia

OBJECTIVE

Administrative claims data are used to study the incidence and outcomes of dementia-related hallucinations, but the validity of International Classification of Diseases (ICD) codes for identifying dementia-related hallucinations is unknown.

METHODS

We analyzed Medicare-linked survey data from 2 nationally representative studies of U.S. older adults (the National Health and Aging Trends Study and the Health and Retirement Study) which contain validated cognitive assessments and a screening question for hallucinations. We identified older adults who had dementia or were permanent nursing home residents, and we combined this with questionnaire responses to define dementia-related hallucinations. Using Medicare claims data, we calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ICD codes for dementia-related hallucinations overall and within prespecified strata of age, neurologic comorbidity, and health care utilization.

RESULTS

We included 2,337 older adults with dementia in our cohort. Among 3,789 person-years of data, 1,249 (33.0%) had hallucations, and of these 286 had a qualifying ICD code for dementia-related hallucinations or psychosis (sensitivity 22.9%). Of 2,540 person-years of dementia without hallucinations, 284 had a diagnosis code for hallucinations (specificity 88.8%). PPV was 50.2%, and NPV was 70.1%. Sensitivity was greatest (57.0%) among those seeing a psychiatrist. Otherwise, there were no significant differences in sensitivity, specificity, PPV, or NPV by age, neurologic diagnosis, or neurologist care.

CONCLUSION

Dementia-related hallucinations are poorly captured in administrative claims data, and estimates of their prevalence and outcomes using these data are likely to be biased.

Pingchan Granule for Motor Symptoms and Non-Motor Symptoms of Parkinson’s Disease: A Randomized, Double-Blind, Placebo-Controlled Study

Background: Pingchan granule (PCG) is a traditional Chinese medicine for treating Parkinson’s disease (PD).

Objective: This study aimed at evaluating the efficacy and safety of PCG for motor and non-motor symptoms of PD.

Methods: In this multicenter, randomized, double-blind, placebo-controlled trial, 292 participants with mild-to-moderate PD were included and followed for 36 weeks (24 week treatment, 12-week follow-up after intervention), randomly assigned at a 1:1 ratio to receive PCG or placebo. The primary outcomes included the severity of motor symptoms assessed by the Unified Parkinson’s disease Rating Scale (UPDRS) part 3 (UPDRS-III) score and the rate of disease progression assessed by the total UPDRS score. Secondary outcomes included non-motor symptoms assessed using the Scale for Outcomes in Parkinson’s Disease-Autonomic (SCOPA-AUT), Parkinson’s disease Sleep Scale (PDSS), 24-item Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating Scale for Anxiety (HAM-A), UPDRS part 2 (UPDRS-II), and 39-item Parkinson’s Disease Questionnaire (PDQ-39) scores. Assessments were done at baseline (T0), 12 weeks (T1), 24 weeks (T2), and 36 weeks (T3).

Results: Generalized estimating equation analyses revealed that the PCG group had significantly better improvement in UPDRS-III score at T1, T2, and T3 [time-by-group interaction, T1: β, −0.92 (95% CI, −1.59–−0.25; p = 0.01); T2: β, −2.08 (95% CI, −2.90–−1.27; p < 0.001); T3: β, −4.54 (95% CI, −5.37–−3.71; p < 0.001))]. The PCG group showed a greater decrease (rate of disease change) in the total UPDRS score between T0 and T2 [−2.23 (95% CI, −2.72–−1.73; p < 0.001) points per week vs. −0.21 (95% CI, −0.80–0.39; p = 0.50) points per week in the placebo group, p < 0.001]. Ameliorations of SCOPA-AUT, PDSS, HAM-D, HAM-A, UPDRS-II, and PDQ-39 scores were also observed.

Conclusion: PCG had a long-lasting and extensive symptomatic efficacy for both motor and non-motor symptoms of PD with good tolerance.

Trial registration: Chinese Clinical Trial Register, ChiCTR-INR-17011949.

Ethnic Disparities in Treatment of Chronic Pain in Individuals with Parkinson's Disease Living in the United Kingdom

Background

Over 80% people with Parkinson's disease (PD; PwP) live with chronic pain.

Objective

Whether ethnic disparities in receipt of appropriate analgesia exist among PwP with chronic pain living in the United Kingdom (UK).

Methods

A retrospective datamining of an existing King's PD Pain Questionnaire validation study dataset enrolling 300 PwP.

Results

69 PwP: 23 Black (57% female), 23 Asian (57% female) and 23 White (65% female) had similar pain burden on the King's PD Pain Scale. Significantly more White PwP (83%) received pain relief compared to Black (48%) and Asian (43%) PwP (p = 0.016). The difference was most evident for opioid analgesics (White 43% vs. Black 4% vs. Asian 4%, p ≤ 0.001).

Conclusions

Ethnic disparities in the analgesic use among PwP with chronic pain living in the UK are evident in this retrospective analysis, prompting large‐scale studies and reinforcement of interventions to tackle the impact ethnicity might have on the successful analgesia.

[The new Parkinson's disease pain classification system (PD-PCS)]

BACKGROUND

Chronic pain is a common non-motor symptom in patients with Parkinson's disease (PD).

AIM

To facilitate the diagnosis of pain in PD, we developed a new classification system the Parkinson's disease pain classification system (PD-PCS) and translated the corresponding validated questionnaire into German.

METHODS

A causal relationship of the respective pain syndrome with PD can be determined by four questions before assigning it hierarchically into one of three pain categories (neuropathic, nociceptive and nociplastic).

RESULTS

In the initial validation study 77% of the patients (122/159) had PD-associated pain comprising 87 (55%) with nociceptive, 36 (22%) with nociplastic and 24 (16%) with neuropathic pain. The study revealed a high validity of the questionnaire and a moderate intrarater and interrater reliability. The questionnaire has been adapted into German and employed in 30 patients.

DISCUSSION

The PD-PCS questionnaire is a valid and reliable tool to determine the relationship of a pain syndrome with PD before classifying it according to the underlying category, facilitating further diagnostics and treatment.