Autonomic and sensory symptoms and signs in incident, untreated Parkinson's disease: Frequent but mild

Association between autonomic dysfunction with motor and non-motor symptoms in patients with Parkinson's disease

To investigate the association between autonomic dysfunction (AutD) and motor as well as non-motor symptoms (NMS) in patients with Parkinson's disease (PD). Fifty-three PD patients were divided into two groups based on the number of domains affected by AutD: a multi-domain AutD group (AutD-M) and a single-domain AutD group (AutD-S), as evaluated using the Scale for Outcomes in Parkinson's disease-Autonomic (SCOPA-AUT), which assesses autonomic symptoms, one of the NMS. A comprehensive comparison was conducted between the two groups, including clinical measures such as clinical scales, quantitative evaluations of motor function and exercise capacity. Spearman correlation analysis was employed to investigate the relationship between AutD severity and PD symptoms. Additionally, we performed multiple linear regression model analysis to determine whether associations between SCOPA-AUT scores and clinical assessments remained significant after adjusting for Hoehn and Yahr stage, sex, and age. PD patients in the AutD-M group exhibited significantly more severe NMS and motor symptoms compared to those in the AutD-S group. In correlation analysis, SCOPA-AUT scores showed significant correlations with multiple clinical symptoms, such as most of the NMS, 10-MWT and CPET parameters. Furthermore, regression analysis also revealed that more pronounced fatigue, anxiety, depressive symptoms, worse walking speed and impaired exercise capacity were associated with higher SCOPA-AUT scores. The presence of AutD is correlated with emotional disturbances, decreased exercise endurance, and impaired gait function in patients with PD. Early management of AutD may prove beneficial in alleviating some NMS and motor symptoms in PD.

Obstructive sleep apnea in Parkinson's disease: A prevalent, clinically relevant and treatable feature

Parkinson's disease (PD) is a chronic neurodegenerative disease characterized by motor and non-motor symptoms, including obstructive sleep apnea (OSA), a common comorbid sleep disorder. The prevalence of OSA in PD is high, and its impact on quality of life, accident risk, and limited treatment options underscores the need for vigilant monitoring and effective interventions. OSA is observed in 20-70% of PD patients, whereas the general population exhibits a lower prevalence ranging from 2 to 14%. These discrepancies in prevalence may be attributed to differences in demographic characteristics, sample sizes with selection bias, and variations in scoring systems for apnea and hypopnea events used across different studies. This review highlights the potential pathogenesis of comorbid OSA in PD and provides an overview of ongoing clinical trials investigating interventions for this condition. Several mechanisms have been implicated in the development of OSA in PD, including intermittent hypoxemia, sleep fragmentation, alterations in the glymphatic system homeostasis, upper airway obstruction, and inflammation. Given the adverse effects of PD comorbid OSA, early intervention measures are crucial. It is imperative to conduct longitudinal studies and clinical trials to elucidate the pathogenesis and develop novel and effective interventions for OSA in PD patients. These efforts aim to delay the progression of PD, enhance patients' quality of life, and alleviate the burden on society and families.

Prevalence and Factors Associated with Drooling in Parkinson’s Disease: Results from a Longitudinal Prospective Cohort and Comparison with a Control Group

Introduction. Drooling in Parkinson’s disease (PD) is frequent but often goes underrecognized. Our aim was to examine the prevalence of drooling in a PD cohort and compare it with a control group. Specifically, we identified factors associated with drooling and conducted subanalyses in a subgroup of very early PD patients. Patients and Methods. PD patients who were recruited from January 2016 to November 2017 (baseline visit; V0) and evaluated again at a 2-year ± 30-day follow-up (V2) from 35 centers in Spain from the COPPADIS cohort were included in this longitudinal prospective study. Subjects were classified as with or without drooling according to item 19 of the NMSS (Nonmotor Symptoms Scale) at V0, V1 (1-year ± 15 days), and V2 for patients and at V0 and V2 for controls. Results. The frequency of drooling in PD patients was 40.1% (277/691) at V0 (2.4% (5/201) in controls; $p$  < 0.0001), 43.7% (264/604) at V1, and 48.2% (242/502) at V2 (3.2% (4/124) in controls; $p$  < 0.0001), with a period prevalence of 63.6% (306/481). Being older (OR = 1.032; $p$  = 0.012), being male (OR = 2.333; $p$  < 0.0001), having greater nonmotor symptom (NMS) burden at the baseline (NMSS total score at V0; OR = 1.020; $p$  < 0.0001), and having a greater increase in the NMS burden from V0 to V2 (change in the NMSS total score from V0 to V2; OR = 1.012; $p$  < 0.0001) were identified as independent predictors of drooling after the 2-year follow-up. Similar results were observed in the group of patients with ≤2 years since symptom onset, with a cumulative prevalence of 64.6% and a higher score on the UPDRS-III at V0 (OR = 1.121; $p$  = 0.007) as a predictor of drooling at V2. Conclusion. Drooling is frequent in PD patients even at the initial onset of the disease and is associated with a greater motor severity and NMS burden.

Salivation in Parkinson's disease: A scoping review

OBJECTIVES

We aimed to provide an overview of the available literature that includes both objective assessments (namely hypersalivation and hyposalivation) and the subjective experience (namely xerostomia and drooling) of salivary problems in patients with Parkinson's disease.

BACKGROUND

In patients with Parkinson's disease, there may be complaints of salivary problems such as xerostomia or drooling. This can have consequences for their oral health and quality of life. To date, systematic reviews have focused on drooling only.

MATERIALS AND METHODS

A literature search in 4 databases was performed up to 12 February 2021. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 63 studies were included. The prevalence of self-reported xerostomia ranged from 49% to 77%, and that of self-reported drooling ranged from 5% to 80%. Ten articles reported a significantly lower mean salivary flow in patients with Parkinson's disease than in controls. None of the articles with both a control group and a patient group reported a significantly higher salivary flow in patients with Parkinson's disease. When questioned about subjective salivary problems, a significantly higher prevalence of both xerostomia (7 studies) and drooling (14 studies) was found in patients with Parkinson's disease than in controls. Patients with Parkinson's disease have a lower salivary flow rate and higher prevalence of both xerostomia and drooling than controls.

CONCLUSION

The complexity of salivary problems present in patients with Parkinson's disease necessitates a multidisciplinary approach in order to avoid mutually counteracting treatments from different healthcare professionals.

Prevalence and characteristics of dry eye disease in Parkinson's disease: a systematic review and meta-analysis

We investigated and characterized the prevalence of dry eye disease (DED) in Parkinson's disease (PD). PubMed and EMBASE databases were searched for relevant studies between January 1, 1979 and March 10, 2022. Quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Study-specific estimates were combined using the DerSimonian-Laird random-effects model. Prevalence of subjective DED symptoms in patients with PD and mean differences in blink rate, corneal thickness, tear film breakup time, and tear secretion volume on Schirmer test I were compared to those in controls. Of 383 studies, 13 (1519 patients with PD) and 12 were included in qualitative and quantitative syntheses, respectively. Meta-analysis revealed a 61.1% prevalence of subjective DED symptoms in PD and that, compared with controls, patients with PD had significantly lower blink rate, thinner corneal thickness, shorter tear film breakup time, and lower tear secretion volumes on Schirmer test I, without and with anesthesia.

Motor and non-motor circuit disturbances in early Parkinson disease: which happens first?

For the last two decades, pathogenic concepts in Parkinson disease (PD) have revolved around the toxicity and spread of α-synuclein. Thus, α-synuclein would follow caudo-rostral propagation from the periphery to the central nervous system, first producing non-motor manifestations (such as constipation, sleep disorders and hyposmia), and subsequently impinging upon the mesencephalon to account for the cardinal motor features before reaching the neocortex as the disease evolves towards dementia. This model is the prevailing theory of the principal neurobiological mechanism of disease. Here, we scrutinize the temporal evolution of motor and non-motor manifestations in PD and suggest that, even though the postulated bottom-up mechanisms are likely to be involved, early involvement of the nigrostriatal system is a key and prominent pathophysiological mechanism. Upcoming studies of detailed clinical manifestations with newer neuroimaging techniques will allow us to more closely define, in vivo, the role of α-synuclein aggregates with respect to neuronal loss during the onset and progression of PD.

24-hour ambulatory blood pressure alterations in patients with Parkinson's disease

OBJECTS

Abnormal blood pressure (BP) regulation is a feature of autonomic dysfunction in Parkinson's disease (PD) patients. The present study was to analyze the BP alterations by 24-h ambulatory BP monitoring in PD patients with different disease stages and subtypes.

METHODS

32 consecutive patients PD patients and 43 control patients in our hospital from 2017 to 2020 were included. The circadian BP rhythm was divided into three types according to the 24-h ambulatory BP monitoring. Dipping was defined as an average systolic BP (SBP) reduction during night-time of 10%-19%. Reverse dipping was defined as an average increase in night-time SBP values. The differences of the circadian BP rhythm and BP variability (BPV) were analyzed between PD group and the control group, the early PD group and the advanced PD group, as well as the tremor-dominant group and the nontremor-dominant group.

RESULTS

There was statistical difference in circadian BP rhythm between PD group and control group (p < .05). There were statistical differences in circadian BP rhythm between the early PD group and the advanced PD group (p < .05). The mean values of night-time SBP and diastolic BP (DBP) in the advanced PD group were higher than those in the control group and the early PD group (p < .05). The DBP CV in the advanced PD group was higher than that in the control group and the early PD group (p < .05). There was no significant difference of circadian BP rhythm, mean BP, and BPV between the tremor-dominant and the nontremor-dominant PD group after matching the disease duration.

CONCLUSIONS

Reverse dipping was more common in PD patients in this study, especially in the advanced PD patients. 24-h ambulatory BP monitoring is an important method to evaluate the BP alterations in PD patients. Clinicians should be alert to reverse dipping in PD patients and intervene to prevent serious clinical events.

Correlation of Dopaminergic Denervation and the Progression of Autonomic Dysfunctions in Different Clinical Subtypes of Parkinson's Disease

BACKGROUND

Autonomic dysfunctions occur in the early stage of Parkinson's disease (PD) and impact the quality of life during the progression of the disease. In this study, we evaluated the serial progression of autonomic dysfunctions between different subtypes of a prospective PD cohort.

MATERIALS AND METHODS

From the Parkinson's Progression Markers Initiative (PPMI) database, 325 PD patients (age: 61.2 ± 9.7, M : F = 215 : 110) were enrolled. Patients were subgrouped into tremor-dominant (TD), indeterminate, and postural instability and gait disorder (PIGD) subtypes. The progression of autonomic dysfunctions and dopaminergic denervation from I-123 FP-CIT SPECT images of each group were analyzed and compared at baseline, 12 months, 24 months, and 48 months of follow-up periods.

RESULTS

The SCOPA-AUT score of the indeterminate subtype was significantly higher than that of the TD subtype (P < 0.05) at baseline and was significantly higher than that of both TD and PIGD subtypes (P < 0.05) at 48 months. The indeterminate subtype had the most significant correlation between the aggravation of dopaminergic denervation in I-123 FP-CIT SPECT images and the increase of SCOPA-AUT scores during 48 months of follow-up (r = 0.56, P < 0.01).

CONCLUSIONS

Autonomic dysfunctions were most severe in the indeterminate subtype throughout the 48 months of the follow-up period, with a significant correlation with dopaminergic denervation. We suggest a positive relationship between dopaminergic denervation and autonomic dysfunctions of the indeterminate subtype, beginning from the early stage of PD.

Nonmotor symptoms and quality of life in Parkinson's disease with different motor subtypes

OBJECTIVE

To explore the differences in the features and impact on quality of life (QOL) of nonmotor symptoms (NMS) of the tremor dominant (TD) and non-tremor dominant (NTD) subtypes of Parkinson's disease (PD) and elucidate the characteristic NMS and determinants of QOL for the subtypes.

METHODS

This cross-sectional study included 77 patients with PD. The NMS questionnaire was used to assess the range and prevalence of NMS. The modified Hoehn and Yahr staging and the unified PD rating scale (UPDRS) were used to assess symptom severity. Cognitive abilities were investigated using the mini-mental status examination (MMSE). Emotional state was assessed using the Hamilton depression scale (HAMD) and the Hamilton anxiety scale (HAMA) and QOL was evaluated using the Parkinson's disease questionnaire-39 (PDQ-39).

RESULTS

Overall, 39 (50.65%) patients were classified as the TD subtype, and 38 (49.35%) were classified as the NTD subtype. Patients with NTD subtype presented a significantly higher number of NMS total scores (P = 0.007) and significantly higher score in the cognition domain of PDQ-39 (P = 0.021) than patients with TD subtype. Patients with NTD subtype had significantly higher NMS prevalence than patients with TD subtype with constipation (P = 0.021), incomplete bowel emptying (P = 0.050), anxiety (P = 0.030), daytime sleepiness (P = 0.017) and intense vivid dreams (P = 0.016). The predictors for the NTD subtype were intense vivid dreams (P = 0.012), anxiety (P = 0.030) and constipation (P = 0.044). The UPDRS, NMS total, and MMSE scores were the determinants of QOL in patients with PD (P < 0.05).

CONCLUSION

The NMS is a prominent manifestation of PD. Patients with the NTD subtype had a higher prevalence of NMS than those with the TD subtype and intense vivid dreams, anxiety and constipation were characteristic of the NTD subtype. NMS is one of the important factors that determine the QOL of patients with PD especially those with the NTD subtype.

Impact of Progression of Parkinson's Disease on Swallowing Ability and Oral Environment

This study investigated the impact of the severity and treatment of Parkinson's disease (PD) on the swallowing ability and oral environment of patients. Swallowing dysfunction increases the aspiration risk and may lead to poor oral health among patients with PD. We investigated the influences of PD progression and drug treatment on the swallowing ability and oral environment using simple noninvasive screening measurements. We recruited 87 patients with PD (mean age, 71.9 ± 8.0 years; mean Hoehn and Yahr score, 2.9 ± 0.9). The PD condition was assessed in each patient using the unified Parkinson's disease rating scale (UPDRS) part III, diet type and oropharyngeal function using the swallowing disturbances questionnaire (SDQ), maximum bite force (MBF), tongue pressure (TP), and oral bacterial count (OBC). Levodopa equivalent daily dose (LEDD) was also calculated for 56 participants. Based on an SDQ score of ≥11, 29.5% of patients were dysphagic, but almost all were still on a regular diet. The SDQ score was positively correlated with disease duration (rho = 0.228, p=0.047) and UPDRS part III score (rho = 0.307, p=0.007) but was negatively correlated with OBC (rho = -0.289, p=0.012). OBC was significantly higher among patients with an SDQ score of <11 (nondysphagic) (p=0.01), and the SDQ score was lower in patients with higher OBC requiring professional oral care (p=0.03). However, OBC was also negatively correlated with LEDD (rho = -0.411, p=0.004). These results indicated low self-awareness of dysphagia among the participants and an association between dysphagia and PD progression. Moreover, the oral environment could have deteriorated with swallowing dysfunction. Patients and clinicians should be aware that higher LEDD can increase xerostomia and associated deficits in oral health.

Ethnic Variation in the Manifestation of Parkinson's Disease: A Narrative Review

The global prevalence of Parkinson's disease is increasing, yet the characteristics, risk factors and genetics of PD in Black, Asian and Hispanic populations is little understood. In this paper we review the published literature on clinical variation in the symptoms and signs of Parkinson's disease in different ethnic groups and responses to treatment. We included any study that sampled patients with Parkinson's disease from distinct ethnic backgrounds. We conclude that whilst there is little published evidence for ethnic variation in the clinical features of Parkinson's disease, there are substantial limitations and gaps in the current literature, which mean that the evidence does necessarily not fit with clinical observation. Possible explanations for expected differences in manifestation include genetic determinants, the co-existence of cerebrovascular disease and/or Alzheimer's disease pathology, healthcare inequalities and socio-cultural factors.

Pain Assessment in Indian Parkinson's Disease Patients Using King's Parkinson's Disease Pain Scale

Background:

Pain is a common symptom in Parkinson's disease (PD) patients. Scales to rate pain in PD are marred by several flaws, either not being available in other languages or not specific for PD.

Objectives:

To assess the frequency of pain among bilingual Indian PD patients using “King's Parkinson's disease pain scale” (KPPS) and to validate it.

Methods:

We randomly administered KPPS in Hindi/English to all consecutive bilingual persons with PD. The results were appropriately analyzed.

Results:

A total of 119 PD patients were enrolled with a mean age of 64.34 (± 9.57) years. Median Hoehn and Yahr stage was 2 (42.85%). Pain was present in 62 (52.1%) PD patients. The most common type was musculoskeletal (74.19%). The mean total KPPS score was 16.02 ± 10.57. KPPS score was significantly higher in women and correlated positively with unified Parkinson's disease rating scale (UPDRS) part 2 and 4 scores (r = 0.27 and r = 0.25). Risk factors for pain were female gender, higher H and Y stage, total UPDRS score, and individual UPDRS part 3 and 4 scores. Difficulty falling asleep (P = 0.01), frequent awakenings (P = 0.01), diminished smell sensation (P = 0.003), diminished speech volume (P = 0.02), gait freezing (P = 0.03), and falls (P = 0.001) correlated with the presence of pain. The interclass correlation coefficient between the Hindi and English versions of KPPS was 0.835, while Bland–Altman analysis showed 96.7% agreement suggesting excellent correlation and validation.

Conclusions:

KPPS is an easy tool for characterization, scoring, and follow-up of pain in PD patients. The Hindi version has good agreement with the original English version.

Autonomic Dysfunctions in Parkinson's Disease: Prevalence, Clinical Characteristics, Potential Diagnostic Markers, and Treatment

Parkinson's disease (PD) is a common neurodegenerative disease in the middle-aged and the elderly. Symptoms of autonomic dysfunctions are frequently seen in PD patients, severely affecting the quality of life. This review summarizes the epidemiology, clinical manifestations, and treatment options of autonomic dysfunctions. The clinical significance of autonomic dysfunctions in PD early diagnosis and differential diagnosis is also discussed.

Clinical and Epidemiological Aspects of Parkinson's Disease in the South of Western Siberia

Background: The article is devoted to one of the most common neurodegenerative diseases in the world—Parkinson's disease (PD), the prevalence of which in Russia reaches 140–150 people per 100,000 people. The clinical and anamnestic profile of a patient with PD is presented, the prevalence of motor and non-motor symptoms is reflected, and a comparative characteristic of the neurological deficit in the Siberian population of patients with other cohorts of patients with Parkinson's disease in different countries and ethnic groups is presented.

Methods: We studied 140 patients with Parkinson's disease. A comprehensive assessment of neurological status was performed using the “Unified Parkinson's Disease Rating Scale (UPDRS).” In addition, we used the Beck Depression and MoCA scale test. Assessment of the presence and severity of olfactory dysfunction was performed using the Sniffin Stick odor identification test. The stage of PD was evaluated according to the classification of M. M. Hoehn and M. D. Yahr.

Results: The cohort of the study was dominated by overweight patients with a higher level of education, with concomitant arterial hypertension, coronary heart disease, and dyslipidemia. The severity of motor and most non-motor symptoms directly correlates with the duration of PD and the stage of the disease. The predominant form of the disease was a mixed form, which was also noted in research cohorts in Canada and the UK. The Siberian cohort tends to be more prevalent in hyposmia, daytime sleepiness, orthostatic hypotension, and depressive and REM disorders.

Conclusion: Our data show the importance of a comprehensive assessment of both motor and non-motor neurological deficits as well as the analysis of comorbid disorders and risk factors for the occurrence and progression of Parkinson's disease. They also show the prevalence of certain motor and non-motor symptoms in the Siberian cohort of patients with Parkinson's disease.

Cross-cultural adaptation and validation of the Swallowing Disturbance Questionnaire and the Sialorrhea Clinical Scale in Portuguese patients with Parkinson's disease

INTRODUCTION

To date, no valid outcome measure has been developed in European Portuguese (EP) to evaluate the Parkinsons' Disease (PD) patients' (PwP) reports regarding their swallowing disturbances.

OBJECTIVES

The aim of this study was to translate and cross-culturally adapt the Swallowing Disturbance Questionnaire (SDQ) and the Sialorrhea Clinical Scale for PD (SCS-PD) into EP and to determine its clinimetric properties in PwP.

MATERIALS AND METHODS

The original English SDQ and SCS-PD versions were cross-culturally adapted following recommendations established in international guidelines. The validation process involved 75 PwP and 65 healthy sex- and age-matched participants.

RESULTS

The EP versions of the SDQ and SCS-PD are equivalent to the original versions (content, depth, and scoring). Statistical analyses for the SDQ tool revealed good feasibility (missing data <5%), acceptability (no floor or ceiling effects), excellent internal consistency (Cronbach´s α = 0.95), good construct validity (78.5% revealed large to moderate loadings), moderate convergent validity (r = 0.60), good divergent validity (r = 0.40), good known-groups validity (p-value < .05) and a fair sensitivity and specificity (AUC = 0.700). Statistical analyses for the SCS-PD tool shows good feasibility, reasonable acceptability (floor effect), good internal consistency (Cronbach´s α = 0.85), good construct validity (85.7% showed between large to moderate loadings), good convergent validity (r = 0.78), good divergent validity (r = 0.39), good known groups validity (p-value < .05) and a fair sensitivity and specificity (AUC = 0.704).

CONCLUSIONS

The EP versions of the SDQ and SCS-PD maintained the characteristics of the original versions and therefore consistent tools to be used in PwP.

Pathological Influences on Clinical Heterogeneity in Lewy Body Diseases

PD, PD with dementia, and dementia with Lewy bodies are clinical syndromes characterized by the neuropathological accumulation of alpha-synuclein in the CNS that represent a clinicopathological spectrum known as Lewy body disorders. These clinical entities have marked heterogeneity of motor and nonmotor symptoms with highly variable disease progression. The biological basis for this clinical heterogeneity remains poorly understood. Previous attempts to subtype patients within the spectrum of Lewy body disorders have centered on clinical features, but converging evidence from studies of neuropathology and ante mortem biomarkers, including CSF, neuroimaging, and genetic studies, suggest that Alzheimer's disease beta-amyloid and tau copathology strongly influence clinical heterogeneity and prognosis in Lewy body disorders. Here, we review previous clinical biomarker and autopsy studies of Lewy body disorders and propose that Alzheimer's disease copathology is one of several likely pathological contributors to clinical heterogeneity of Lewy body disorders, and that such pathology can be assessed in vivo. Future work integrating harmonized assessments and genetics in PD, PD with dementia, and dementia with Lewy bodies patients followed to autopsy will be critical to further refine the classification of Lewy body disorders into biologically distinct endophenotypes. This approach will help facilitate clinical trial design for both symptomatic and disease-modifying therapies to target more homogenous subsets of Lewy body disorders patients with similar prognosis and underlying biology. © 2019 International Parkinson and Movement Disorder Society.

Frequency and Dynamics of Non-motor Symptoms Presentation in Hispanic Patients With Parkinson Disease

The clinical phenotype of Parkinson's disease (PD) encompasses a wide range of non-motor symptoms (NMS) compromising the quality of life of affected patients. Currently, information about NMS in PD is scarce among Hispanic populations. Furthermore, few studies have reported the temporal pattern of NMS presentation. We conducted a cross-sectional study aimed to describe the frequency and time of NMS occurrence in Hispanic patients with PD using the self-completed NMS questionnaire (NMSQuest). Participants were interrogated about the time of each NMS presentation respect to the onset of motor symptoms. The frequency of NMS was described according to gender, age at disease onset, disease duration and Hoehn and Yahr (H&Y) stage. We enrolled 120 patients, 73.33% males and 26.66% females, with a mean age of 63.33 ± 8.60 years. All the participants presented at least 1 NMS. The median number of NMS per patient was 12. The most frequent NMS domains were miscellaneous, urinary tract, sleep/fatigue, and gastrointestinal tract symptoms, with no significant gender differences. The most frequent individual NMS were nocturia, urinary urgency, feeling sadness, and constipation. Any patient reported NMS before the onset of motor manifestations. The pattern of occurrence of NMS domains in our population was as follows: attention/memory, cardiovascular, gastrointestinal tract, perceptual problems/hallucinations, mood/cognition, urinary, miscellaneous, sleep/fatigue, and sexual function. Nausea/vomiting was the earliest symptom observed in all patients, whereas sexual dysfunction and changes in interest for sex were the last symptoms to occur. We found no differences in the total number and frequency of NMS between participants grouped according to their age at disease onset. Conversely, patients with a duration of disease >10 years reported a higher frequency of NMS compared to participants with a duration of disease < 10 years. The total number of NMS per patient increased as the HY stage progressed. The proportion of patients presenting symptoms of the gastrointestinal tract, urinary tract, mood/cognition, cardiovascular, and sexual function domains was higher in the HY 4–5 group. Our study provides relevant data to improve our understanding of NMS in PD, which may contribute to anticipate and plan diagnostic and therapeutic strategies among Hispanic PD patients.

Longitudinal assessment of autonomic dysfunction in early Parkinson's disease

INTRODUCTION

Clinical correlates of autonomic nervous system (ANS) dysfunction in early Parkinson's disease (PD) have been addressed mainly in a cross-sectional way.

METHODS

This is a combined cross-sectional and longitudinal prospective study of ANS dysfunction using the SCOPA-AUT in PD patients at the Hoehn and Yahr stage 1 with disease duration <2 years. PD patients (n = 107) were compared to healthy controls (HC, n = 79), and then followed-up for over 3 years. The severity of PD, depression, anxiety, apathy and cognitive impairment were evaluated using rating scales.

RESULTS

At least one symptom of ANS dysfunction was present in 71% of PD patients in comparison to 30.4% of HC, and in all PD patients after three years. The overall severity of dysautonomia symptoms was mild (SCOPA-AUT mean ± SD; 4.16 ± 5.0), but worsened by 23%, 86% and 0.3% during the 1st, 2nd and 3rd year respectively. Nighttime voiding (38.3%), constipation (30.8%) and straining for defecation (29%) were the most common symptoms. Prevalence and severity of urinary, gastrointestinal, and orthostatic symptoms increased, in contrast to thermoregulatory and pupillomotor symptoms. Frequency of symptoms suggestive of multi-domain ANS dysfunction rose from 49% to 79%. Psychiatric symptoms and age, but not motor impairment, were associated with dysautonomia symptoms.

CONCLUSION

Symptoms of ANS dysfunction were frequent in the initial motor stage of PD and progressed, yet remaining mild, within 3 years. An independent progression of dysautonomia symptoms from motor disability and its associations with non-motor, mainly psychiatric symptoms and age support the non-motor clustering in PD.

Central Nervous System-Derived Exosomal Alpha-Synuclein in Serum May Be a Biomarker in Parkinson's Disease

Parkinson's disease (PD) is a common movement disorder. Alpha-synuclein (α-synuclein) plays a critical role in PD. In this study, we evaluated the level of central nervous system (CNS)-derived exosomal α-synuclein in serum, which may be regarded as a specific peripheral biomarker for PD. We recruited patients with PD in the early stage along with essential tremor (ET), and we recruited age- and gender-matched healthy subjects as healthy controls (HC). We divided patients with PD into the tremor-dominant (TD) group and the non-tremor-dominant (NTD) group. We evaluated the levels of α-synuclein in CNS-derived exosomes in serum samples. As a result, there was a significant difference between four groups (p<0.05). This level was lower in the PD group than in the ET and HC groups (p<0.05). Among the PD group, this level was lower in the NTD group than in the TD group (p<0.05). Furthermore, the performance of serum CNS-derived exosomal α-synuclein was found to moderately aid in PD diagnosis (AUC=0.675, p<0.05) and had a potential to diagnose NTD (AUC=0.761, p<0.05). Therefore, CNS-derived exosomal α-synuclein in the serum may be regarded as a biomarker to identify PD from ET and HC in the early stage. It may also be used to identify different motor types in PD. The pathogenesis of PD in different motor types may be different, which needs further research.

Real-world pharmacological treatment patterns of patients with young-onset Parkinson's disease in Japan: a medical claims database analysis

INTRODUCTION

Young-onset Parkinson's disease is reported to comprise 5-10% of all Parkinson's disease cases; however, as physicians encounter a limited number of these patients, their treatment patterns are still unclear.

METHODS

We performed a descriptive study using the large Japanese medical claims database to describe the epidemiology and real-world pharmacological treatment patterns of newly diagnosed patients with young-onset Parkinson's disease. Patients aged 21-50 years in whom Parkinson's disease was newly diagnosed between January 1, 2005 and March 31, 2016 were included. We excluded individuals with Parkinson's-related diseases and those using antipsychotics to eliminate the possibility of drug-induced parkinsonism. The patients' demographics, comorbidities, prescribing patterns, and changes in levodopa equivalent daily dose were analyzed.

RESULTS

We identified 131 newly diagnosed young-onset Parkinson's disease patients (median age, 44.2 years). The most common comorbidities were depression (23.7%), hypertension (23.7%), and insomnia (22.9%). Of these patients, 122 were prescribed antiparkinson drugs. During the study period, the proportion of patients who were prescribed dopamine agonists, levodopa, and anticholinergics were 77.1%, 44.3%, and 27.5%, respectively. Dopamine agonists (49.2%) were most commonly prescribed initially, followed by anticholinergics (23.8%), levodopa (19.7%), and others (4.1%). The levodopa equivalent daily dose increased steadily with longer disease duration.

CONCLUSIONS

Dopamine agonists were most frequently prescribed during the study period and were the initial treatment of choice. We also observed a change in levodopa equivalent daily dose over the disease course. This study provides a descriptive overview of real-world prescribing patterns in young-onset Parkinson's disease patients.

Association of autonomic symptoms with presynaptic striatal dopamine depletion in drug-naive Parkinson's disease: An analysis of the PPMI data

While the involvement of the central and peripheral autonomic networks is thought to play an integral role in the development of autonomic symptoms in Parkinson's disease (PD), there is little evidence for an association between autonomic symptoms and striatal dopaminergic depletion. We compared dopamine transporter activity in striatal subregions with various autonomic symptoms covered by the SCOPA-AUT domains including gastrointestinal, urinary, cardiovascular, thermoregulatory, pupillomotor, and sexual symptoms in 418 untreated patients with PD. We found evidence for a dopaminergic association with only urinary symptoms. Moreover, dopaminergic denervation in the putamen but not in the caudate may underlie these symptoms.

Intercepting Parkinson disease non-motor subtypes: A proof-of-principle study in a clinical setting

The construct of non-motor symptoms (NMS) subtyping in Parkinson Disease (PD) is emerging as a line of research in the light of its potential role in etiopathological interpretation of PD heterogeneity. Different approaches of NMS subtyping have been proposed: an anatomical model suggests that NMS aggregate according to the underpinning pathology; other researchers find aggregation of NMS according to the motor phenotype; the contribution of genetic background to NMS has also been assessed, primarily focusing on cognitive impairment. We have analyzed NMS burden assessed through an extensive clinical and neuropsychological battery in 137 consecutive non-demented PD patients genotyped for MAPT haplotypes (H1/H1 vs H2 carriers) in order to explore the applicability of the "anatomo-clinical", "motor" or "genetic" models for subtyping PD in a clinical setting; a subsequent independent analysis was conducted to verify a possible cluster distribution of NMS. No clear-cut NMS profiles according to the previously described models emerged: in our population, the autonomic dysfunctions and depressive symptoms represent the leading determinant of NMS clusters, which seems to better fit with the hypothesis of a "neurotransmitter-based" model. Selective preferential neurotransmitter network dysfunctions may account for heterogeneity of PD and could address translational research.

Constipation is not associated with dopamine transporter pathology in early drug-naïve patients with Parkinson's disease

BACKGROUND AND PURPOSE

Constipation is a common non-motor symptom of Parkinson's disease (PD). Deposition of α-synuclein inclusions that spread from the gut to the substantia nigra through the vagus nerve has recently been speculated to be a pre-motor and early stage of PD. The aim of the study was to investigate whether constipation is associated with dopaminergic pathology on dopamine transporter (DAT) single-photon emission computed tomography in early drug-naïve patients with PD. Our hypothesis was that constipation is associated with other signs of pre-motor PD and is independent of DAT pathology. We then investigated for associations with motor and non-motor symptoms, and with cerebrospinal fluid biomarkers of PD pathology.

METHODS

Using the Parkinson's Progression Markers Initiative database, we investigated the prevalence of constipation and the association between constipation and clinical features, striatal [¹²³ I]Ioflupane uptake and non-imaging (cerebrospinal fluid and serum) biomarkers. Constipation was evaluated using Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Part I item 1.11.

RESULTS

One third (132/398) of de-novo patients with PD had constipation. Higher severity of constipation correlated with older age (r = 0.728, P < 0.001), higher MDS-UPDRS total score (r = 0.285, P < 0.001), worse postural instability (r = 0.190, P = 0.012), rapid eye movement sleep behaviour disorder (r = 0.228, P < 0.0001) and depression (r = 0.187, P = 0.024). No correlation was found with cerebrospinal fluid, serum and imaging markers of PD pathology.

CONCLUSIONS

Constipation was not associated with DAT pathology but with rapid eye movement sleep behaviour disorder and depression, which are speculated to be pre-motor symptoms of PD. This confirms the hypothesis that constipation may be a pre-motor sign of PD due to an impairment of non-dopaminergic pathways.

Algorithms for the treatment of motor problems in Parkinson's disease

Several different strategies are effective for medical treatment of motor problems in Parkinson's disease (PD). Many guidelines and evidence-based reviews are available, but there is no documentation or consensus in favor of just one treatment strategy. This review presents two algorithms that may be helpful when deciding how to treat a PD patient at various stages of the disease. The first algorithm suggests one way to treat PD from the first onset of motor symptoms. It is largely based on treatment recommendations from the Scandinavian countries and Germany. The other algorithm is meant as assistance for choosing among the different device-aided treatments for advanced PD. There is not sufficient comparative data to recommend one particular line of treatment, neither in early PD nor in advanced disease with motor complications. Individualized treatment is needed for each patient. The current algorithms only represent an alternative for aiding treatment decisions.

Association of Autonomic Dysfunction With Disease Progression and Survival in Parkinson Disease

Importance

Evidence suggests that development of autonomic dysfunction (AutD) may negatively affect disease course and survival in patients with synucleinopathies. However, the few available studies on Parkinson disease (PD) have conflicting results, comprise a small number of patients, have short follow-up periods, and lack pathologic confirmation of the diagnosis.

Objective

To examine the association of time of onset of AutD with disease progression and survival in PD.

Design, Setting, and Participants

This retrospective review of clinical data from 100 consecutive patients with an autopsy-confirmed diagnosis of PD from the archives of the Queen Square Brain Bank in London, United Kingdom, from January 1, 2006, to June 3, 2016, included patients with PD regularly seen by hospital specialists (neurologists or geriatricians) in the United Kingdom throughout their disease until death. Patients with dementia before or within 1 year after onset of motor symptoms, monogenic forms of PD, comorbidities that affect autonomic function, a coexisting neuropathologic diagnosis, or insufficient clinical information were excluded.

Main Outcomes and Measures

Survival and time from diagnosis to specific disease milestones were calculated to assess disease progression. Autonomic dysfunction was defined as autonomic failure at autonomic function testing or 2 of the following symptoms: urinary symptoms, constipation, upper gastrointestinal tract dysfunction, orthostatic hypotension, sweating abnormalities, or erectile dysfunction. Multivariable Cox proportional hazards regression models on the risk of a disease milestone and death were used.

Results

A total of 100 patients (60 [60.0%] male; mean [SD] age at diagnosis, 63.9 [10.3] years; mean [SD] disease duration, 14.6 [7.7] years) were studied. Autonomic dysfunction developed in 85 patients (mean [SD] time from diagnosis, 6.7 [7.7] years) and was associated with older age at diagnosis, male sex, poor initial levodopa treatment response, and postural instability and gait difficulty motor PD subtype in linear regression analysis, but staging of α-synuclein pathologic changes was unrelated. Earlier AutD increased the risk of reaching the first milestone (hazard ratio, 0.86; 95% CI, 0.83-0.89; P < .001) and shortened survival (hazard ratio, 0.92; 95% CI, 0.88-0.96; P < .001). Older age at diagnosis and poorer levodopa treatment response were the other factors associated with shorter survival in adjusted multivariate analysis.

Conclusions and Relevance

Earlier AutD is associated with a more rapid development of disease milestones and shorter survival in patients with PD.

The Epidemiology of Nonmotor Symptoms in Parkinson's Disease (Cohort and Other Studies)

Nonmotor symptoms (NMS) of Parkinson's disease (PD) were recognized by James Parkinson himself and are now considered to be an integral part of PD. While clinical assessment had focused on prevalence and severity of individual NMS such as dementia and depression, work in the last decade has concentrated on global or holistic assessment of NMS using validated tools such as the NMS questionnaire and NMS scale. These studies from cohorts of varying sizes have allowed comparison of NMS across different disease stages, duration, age, and ethnicity in PD. The data also allow exploration of the concept of the nonlinear relationship of NMS to disease duration of PD and motor stages as well as nonmotor subtypes of PD. In this chapter, these aspects of epidemiological studies of NMS in PD cohorts are described.

[No motor signs in Parkinson's disease]

In Parkinson's disease, motor signs have long been the main targets of the management of the disease. In recent years, non-motor disorders have elicited increasing interest. These disorders are under diagnosed and managed more difficultly than motor signs and are sometimes perceived as more disturbing by the patients. These signs are polymorphous, sometimes occurring before the motor symptoms but increase with the disease duration and complicating always the late stages. They may fluctuate as the motor signs, while being under the control of dopaminergic pathways, or be linked to the degeneration of other neuronal circuits. These clinical manifestations, whether or not fluctuating are classified into three major categories: psycho-cognitive including sleep disorders, autonomic and sensory.

Re-emergent tremor in Parkinson's disease

INTRODUCTION

Re-emergent tremor (RET) is a postural tremor that appears after a variable delay in patients with Parkinson's disease (PD). The aim of the present study was to evaluate the occurrence and the clinical characteristics of RET in a population of patients with PD.

METHODS

We consecutively assessed 210 patients with PD. We collected the patients' demographic and clinical data. RET was clinically characterized in terms of latency, severity and body side affected. We also investigated a possible relationship with motor and non-motor symptoms and differences in the clinical features in patients with and without RET.

RESULTS

RET was present in 42/210 patients. The mean latency of RET was 9.20 ± 6.8 seconds. Mean severity was 2.4 ± 1.9. RET was unilateral in 21 patients. Patients with RET had less severe speech, posture and gait disorders and upper limb and global bradykinesia than patients without RET. Similar findings were observed when we compared patients with RET with patients with tremor at rest associated with action tremor, patients with isolated action tremor and patients with no tremor. By contrast, patients with RET tremor did not clinically differ from those with isolated tremor at rest.

CONCLUSION

Our results suggest that patients with RET and patients with isolated tremor at rest represent the same clinical subtype, whereas patients with action tremor (whether isolated or associated with tremor at rest) might belong to a distinct subtype that is clinically worse. Patients with RET represents a benign subtype of PD, even within the tremor-dominant phenotype.

Gastrointestinal Dysfunctions in Parkinson's Disease: Symptoms and Treatments

A diagnosis of Parkinson's disease is classically established after the manifestation of motor symptoms such as rigidity, bradykinesia, and tremor. However, a growing body of evidence supports the hypothesis that nonmotor symptoms, especially gastrointestinal dysfunctions, could be considered as early biomarkers since they are ubiquitously found among confirmed patients and occur much earlier than their motor manifestations. According to Braak's hypothesis, the disease is postulated to originate in the intestine and then spread to the brain via the vagus nerve, a phenomenon that would involve other neuronal types than the well-established dopaminergic population. It has therefore been proposed that peripheral nondopaminergic impairments might precede the alteration of dopaminergic neurons in the central nervous system and, ultimately, the emergence of motor symptoms. Considering the growing interest in the gut-brain axis in Parkinson's disease, this review aims at providing a comprehensive picture of the multiple gastrointestinal features of the disease, along with the therapeutic approaches used to reduce their burden. Moreover, we highlight the importance of gastrointestinal symptoms with respect to the patients' responses towards medical treatments and discuss the various possible adverse interactions that can potentially occur, which are still poorly understood.

Motor and Non-Motor Symptoms in Parkinson's Disease: Effects on Quality of Life

INTRODUCTION

This study aimed to evaluate motor and non-motor symptoms in idiopathic Parkinson's disease (IPD) patients and to determine the self-reported influence of all existing symptoms on their quality of life (QoL).

METHODS

The sociodemographic and clinical characteristics, medical treatments, and Modified Hoehn and Yahr (mH&Y) scores of IPD patients without cognitive impairment were recorded. A survey questioning different motor and non-motor symptoms was administered to the patients. The patients were asked to rate their symptoms by number from the greatest influence to the least influence on their QoL. Subjects were divided into two groups: those suffering from IPD for ≤5 years (Group 1) and those suffering from IPD for >5 years (Group 2). These groups were compared in terms of sociodemographic and clinical characteristics, existing symptoms, and influences of these symptoms on their QoL.

RESULTS

There were 63 patients in Group 1 and 37 patients in Group 2. No statistically significant differences were detected between the groups with respect to sociodemographic characteristics or mH&Y scores. The most common motor symptoms in both of these groups were tremor and bradykinesia; meanwhile, the non-motor symptoms most frequently encountered in these groups were pain-cramps, constipation, and excessive daytime sleepiness (EDS). Again, while the symptoms that most greatly disturbed QoL in all patients were reported to be tremor and bradykinesia, the most disturbing non-motor symptom was frequent voiding/incontinence, which was a less common symptom. Pain-cramp, constipation, and EDS, which were the most frequent non-motor symptoms, were the symptoms that least disturbed QoL.

CONCLUSION

It is widely accepted that motor symptoms determine QoL in IPD. However, non-motor symptoms are seen during all phases of the disease. The impact of non-motor symptoms on the QoL of IPD patients remains substantial. Therefore, in addition to the well-known motor symptoms, non-motor symptoms, which may be overlooked during physical examination yet may profoundly impact QoL, should be questioned and treated appropriately to improve QoL in PD patients as much as possible.

Constipation: an emerging risk factor for Parkinson's disease?

Constipation is the most prominent and disabling manifestation of lower gastrointestinal (GI) dysfunction in Parkinson's disease (PD). The prevalence of constipation in PD patients ranges from 24.6% to 63%; this variability is due to the different criteria used to define constipation and to the type of population enrolled in the studies. In addition, constipation may play an active role in the pathophysiological changes that underlie motor fluctuations in advanced PD through its negative effects on absorption of levodopa. Several clinical studies now consistently suggest that constipation may precede the first occurrence of classical motor features in PD. Studies in vivo, using biopsies of the GI tract and more recently functional imaging investigations, showed the presence of α-synuclein (α-SYN) aggregates and neurotransmitter alterations in enteric tissues. All these findings support the Braak proposed model for the pathophysiology of α-SYN aggregates in PD, with early pathological involvement of the enteric nervous system and dorsal motor nucleus of the vagus. Therefore, constipation could have the potential sensitivity to be used as a clinical biomarker of the prodromal phase of the disease. The use of colonic biopsies to look at α-SYN pathology, once confirmed by larger prospective studies, might eventually represent a feasible, albeit partially invasive, new diagnostic biomarker for PD.

Non-motor symptoms and quality of life in tremor dominant vs postural instability gait disorder Parkinson's disease patients

OBJECTIVES

To explore the differences in the features and impact on quality of life (QOL) of non-motor symptoms (NMS) of tremor dominant (TD) and postural instability gait disorder (PIGD) phenotypes early Parkinson's disease (PD), as well as the determinants of poor QOL for TD and PIGD phenotypes.

METHODS

This cross-sectional study recruited 301 patients with early PD and 101 healthy controls. Specific assessments used for NMS included NMS scale (NMSS), the Hamilton Rating Scale for Depression (HRSD-24), the Hamilton Anxiety Scale (HAMA), the Mini-Mental state examination (MMSE), and Addenbrooke's Cognitive Exam-Revised (ACE-R). QOL was evaluated with the PD Quality of Life Questionnaire (PDQ-39).

RESULTS

Tremor dominant phenotype patients were 117 (38.9%), and PIGD were 155 (51.5%). Compared with TD patients, patients with PIGD had higher frequency of NMS (9.0 ± 5.3 vs 6.7 ± 4.6, P < 0.001), NMSS total scores (39.6 ± 34.5 vs 24.4 ± 22.7, P < 0.001) and more poorly for PDQ-39 summary index (19.2 ± 14.0 vs 13.8 ± 11.5, P = 0.001). There was no difference in the impact of NMS measured with NMSS on QOL between PIGD and TD phenotypes. PIGD phenotype had little impact on poor QOL once the effect of depression was taken into account. Depression was a primary negative predictor for QOL in both TD and PIGD patients (Beta: 0.697 and 0.619, respectively, P < 0.001).

CONCLUSIONS

PIGD phenotype had a higher prevalence of NMS and worse QOL than TD phenotype. Depression is related to a dramatic decline in QOL in both TD and PIGD phenotype patients with PD.

Nonmotor Features in Parkinson's Disease: What Are the Most Important Associated Factors?

Introduction. The purpose of this study was to demonstrate the frequency and severity of nonmotor symptoms and their correlations with a wide range of demographic and clinical factors in a large cohort of patients with Parkinson's disease (PD). Methods. 268 PD patients were assessed using the validated Movement Disorders Society's Unified Parkinson's Disease Rating Scale (MDS-UPDRS), the Beck Depression Inventory (BDI), Parkinson's Disease Questionnaire (PDQ-39), the Hoehn and Yahr scale (HY), the Schwab and England Activities of Daily Living (SE-ADL) Scale, and the Minimental State Examination (MMSE). Results. Nonmotor symptoms had a strong positive relationship with depression and lower quality of life. Also, age, duration and severity of PD, cognitive impairment, daily dose, and duration of levodopa treatment correlated with the burden of nonmotor symptoms. Patients with postural instability and gait disorder (PIGD) dominance or with the presence of motor complications had higher MDS-UPDRS Part I scores expressing the load of nonmotor features, compared to participants with other disease subtypes or without motor complications. Conclusions. Though the severity of individual nonmotor symptoms was generally rated by PD patients as “mild” or less, we found a significant cumulative effect of nonmotor symptoms on patients' mood, daily activities, and quality of life.

Nonmotor features of Parkinson's disease subtypes

Parkinson's disease is highly heterogeneous in early clinical features and later outcomes. This makes classifying subgroups of PD relevant to clinical research and practice, particularly if they are prognostically relevant. Subgroups have been defined both on the basis of motor and nonmotor features, and subgroups have been determined either empirically, based on clinical observation, or using data-driven analytic techniques. Previous studies have examined both the overall number and the nature of nonmotor symptoms and signs in tremor-dominant compared with non-tremor-dominant subtypes, and longitudinal studies identify nonmotor symptoms as important markers of prognosis and important defining features of PD subtypes. Autonomic features seem to preferentially affect individuals with non-tremor-dominant PD subtype early in the disease. Later in the disease cognitive disturbance distinguishes this phenotype. Pathological and neuroimaging studies provide substantial evidence for fundamental biological differences between tremor-dominant and postural instability gait disorder/akinetic-rigid subtypes. Biomarker studies point toward non-tremor-dominant PD as representing more advanced and diffuse neurodegeneration than tremor-dominant PD, encompassing dopaminergic and nondopaminergic as well as synuclein and nonsynuclein (Abeta) pathologies. This aligns with clinical studies that find a higher burden of nonmotor symptoms in non-tremor-dominant PD. The mounting evidence for the relevance of nonmotor features in PD subtypes behooves us to begin to investigate the biological underpinnings of subtypes defined by both motor and nonmotor features. This may be challenging, as PD subtypes are unlikely to be distinct nonoverlapping entities but are more likely to represent typical phenotypes within a multidimensional spectrum resulting from variable contributions of a number of simultaneous pathological processes. © 2016 International Parkinson and Movement Disorder Society.

Autonomic dysfunction in subjects at high risk for Parkinson's disease

Aim of this project was to evaluate autonomic dysfunction in subjects proposed to be at high risk to develop Parkinson's disease (PD) compared to control subjects and PD patients at different disease stages. Combinations of substantia nigra hyperechogenicity (SN+) assessed by transcranial ultrasound (TCS), hyposmia, lifetime prevalence of depression and mild PD-specific motor signs were used to identify subjects at high risk for motor Parkinson's disease (HR-PD). Supine and standing blood pressure (BP), hearth rate (HR), orthostatic, urinary, sexual and bowel symptoms were evaluated in HR-PD, healthy control subjects and PD patients, divided into mild and advanced stages. The study group consisted of 113 PD patients (mild PD n = 71, advanced PD, n = 42), 40 HR-PD individuals and 50 controls. Compared to controls, HR-PD subjects complained more often about urinary (p = 0.002) and bowel dysfunction (p = 0.001) and had a higher diastolic BP drop after standing (p = 0.01). The cumulative number of autonomic symptoms differentiated PD as well as HR-PD significantly from controls (p < 0.001). Advanced PD patients presented often and severe orthostatic symptoms, not significantly different from mild PD after concomitant medication correction. Our results support the presence of urinary and bowel dysfunction in subjects at high risk for motor PD. Presence and severity of orthostatic symptoms was higher during stages and increase in advanced stages, at least partly due to increase in dopaminergic and conflicting medication. Understanding the progression of non-motor aspects in PD might offer the possibility to use them as targets for disease-modifying therapies.

Delineating nonmotor symptoms in early Parkinson's disease and first-degree relatives

Nonmotor symptoms (NMS) are an important prodromal feature of Parkinson's disease (PD). However, their frequency, treatment rates, and impact on health‐related quality of life (HRQoL) in the early motor phase is unclear. Rates of NMS in enriched at‐risk populations, such as first‐degree PD relatives, have not been delineated. We assessed NMS in an early cohort of PD, first‐degree PD relatives and control subjects to address these questions. In total, 769 population‐ascertained PD subjects within 3.5 years of diagnosis, 98 first‐degree PD relatives, and 287 control subjects were assessed at baseline across the following NMS domains: (1) neuropsychiatric; (2) gastrointestinal; (3) sleep; (4) sensory; (5) autonomic; and (6) sexual. NMS were much more common in PD, compared to control subjects. More than half of the PD cases had hyposmia, pain, fatigue, sleep disturbance, or urinary dysfunction. NMS were more frequent in those with the postural instability gait difficulty phenotype, compared to the tremor dominant (mean total number of NMS 7.8 vs. 6.2; P < 0.001). PD cases had worse HRQoL scores than controls (odds ratio: 4.1; P < 0.001), with depression, anxiety, and pain being stronger drivers than motor scores. NMS were rarely treated in routine clinical practice. First‐degree PD relatives did not significantly differ in NMS, compared to controls, in this baseline study. NMS are common in early PD and more common in those with postural instability gait difficulty phenotype or on treatment. Despite their major impact on quality of life, NMS are usually under‐recognized and untreated. © 2015 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

The range and nature of non-motor symptoms in drug-naive Parkinson's disease patients: a state-of-the-art systematic review

Non-motor symptoms (NMS) are a key component of Parkinson’s disease (PD). A range of NMS, most notably impaired sense of smell, sleep dysfunction, and dysautonomia are present from the ‘pre-motor’ phase to the final palliative stage. Theories as to the pathogenesis of PD such as those proposed by Braak and others also support the occurrence of NMS in PD years before motor symptoms start. However, research addressing the range and nature of NMS in PD has been confounded by the fact that many NMS arise as part of drug-related side effects. Thus, drug-naive PD (DNPD) patients provide an ideal population to study the differences in the presentation of NMS. The aim of this paper is therefore to systematically review all the available studies of NMS in DNPD patients. We believe this is the first review of its kind. The current review confirms the increasing research being conducted into NMS in DNPD patients as well as the necessity for further investigation into less-studied NMS, such as pain. Moreover, the data confirms non-motor heterogeneity among PD patients, and, therefore, further research into the concept of non-motor subtyping is encouraged. The review suggests that the clinical assessment of NMS should be integral to any assessment of PD in clinical and research settings.

Premotor and nonmotor features of Parkinson's disease

PURPOSE OF REVIEW

This review highlights recent advances in premotor and nonmotor features in Parkinson's disease, focusing on these issues in the context of prodromal and early-stage Parkinson's disease.

RECENT FINDINGS

Although Parkinson's disease patients experience a wide range of nonmotor symptoms throughout the disease course, studies demonstrate that nonmotor features are not solely a late manifestation. Indeed, disturbances of smell, sleep, mood, and gastrointestinal function may herald Parkinson's disease or related synucleinopathies and precede these neurodegenerative conditions by 5 or more years. In addition, other nonmotor symptoms such as cognitive impairment are now recognized in incident or de-novo Parkinson's disease cohorts. Many of these nonmotor features reflect disturbances in nondopaminergic systems and early involvement of peripheral and central nervous systems, including olfactory, enteric, and brainstem neurons as in Braak's proposed pathological staging of Parkinson's disease. Current research focuses on identifying potential biomarkers that may detect persons at risk for Parkinson's disease and permit early intervention with neuroprotective or disease-modifying therapeutics.

SUMMARY

Recent studies provide new insights into the frequency, pathophysiology, and importance of nonmotor features in Parkinson's disease as well as the recognition that these nonmotor symptoms occur in premotor, early, and later phases of Parkinson's disease.