Drug prescribing patterns in Parkinson's disease: a pharmacoepidemiological survey in a cohort of ambulatory patients

Dealing with the diagnosis of Parkinson's disease and its implications for couple functioning in the early stage: An interpretative phenomenological analysis

BACKGROUND

For couples facing Parkinson's disease, marital relationships are significantly impacted, even at the early stages of the disease. However, very few studies have explicitly explored the functioning of the couple and how both partners deal with Parkinson's disease. The aim of this study was to explore the experiences and strategies of couples facing Parkinson's disease in the early stage using dyadic interpretative phenomenological analysis.

METHODS

Fifteen couples agreed to participate in the study. Semistructured interviews were conducted with each partner separately regarding his or her individual experience with Parkinson's disease, the couple's history, the impact of the diagnosis on the functioning of the couple, and his or her projections for the future.

RESULTS

Three higher-order themes emerged from the analyses. The first theme, "Being tested by the diagnosis", highlights 4 dyadic configurations according to the individual's and the couple's capacity for adjustment following the diagnosis: "noncongruent", "collapsed", "relieved" and "avoidant". The second theme, "Talking about everything except the disease", underlines that communication about the disease is often avoided both within the couple and with relatives to protect the persons with Parkinson's disease or respect their wishes. The third theme, "Supporting each other", describes the different levels of harmony between the two partners in the management of daily life and symptoms and their relational impacts.

CONCLUSION

These results allow us to better understand the experiences of both partners and to highlight the importance of promoting better acceptance of the diagnosis by persons with Parkinson's disease to allow better communication between partners and with relatives. Such support prevents disease-specific distress and facilitates better adjustment in the later stages of the disease.

Potentially inappropriate medications in older adults with Parkinson disease before and after hospitalization for injury

BACKGROUND

Parkinson disease (PD) patients are at increased risk of serious injury, such as fall-related fractures. Prescription medications are a modifiable factor for injury risk.

OBJECTIVES

To determine the extent to which a serious injury requiring hospitalization affects prescribing of potentially inappropriate medications (PIMs) among older adults with PD.

METHODS

We conducted a quasi-experimental difference-in-difference (DID) study using 2013-2017 Medicare data. The cohort consisted of beneficiaries with PD hospitalized for injury versus for other reasons. PIMs were classified into PD and injury-relevant categories (CNS-active PIMs, PD motor symptom PIMs, PD non-motor symptom PIMs, PIMs that reduce bone mineral density). We estimated mean standardized daily doses (SDDs) of medications within each PIM category before and at 3, 6, and 12 months after hospitalization. We used generalized linear regression models to compare changes in mean SDDs for each PIM category between the injury and non-injury group at each timepoint, adjusting for biological, clinical and social determinants of health variables.

RESULTS

Both groups discontinued PIMs and/or reduced PIM doses after hospitalization. There were no between-group differences in mean SDD changes, after covariate adjustment, for any PIM category, except for the CNS-active PIMs category at 3 months (DID p-value = 0.00) and for the category of PIMs that reduce bone mineral density at all timepoints (DID p-values = 0.02, 0.04, 0.02 at 3, 6, and 12 months).

CONCLUSIONS

Similar patterns of PIM among persons with PD after hospitalization for serious injury versus for other reasons may represent a missed opportunity to deprescribe high-risk medications during care transitions.

Comparative Effectiveness of Carbidopa-Levodopa Enteral Suspension and Deep Brain Stimulation on Parkinson's Disease-Related Pill Burden Reduction in Advanced Parkinson's Disease: A Retrospective Real-World Cohort Study

Introduction

In advanced Parkinson’s disease (PD), a high pill burden is associated with poor compliance, reduced control of symptoms, and decreased quality of life. We assessed the impact of carbidopa–levodopa enteral suspension (CLES) and deep brain stimulation (DBS) on PD-related pill burden.

Methods

A retrospective cohort analysis was conducted in the IBM MarketScan and Medicare Supplemental databases. Patients with advanced PD, taking only PD medications, and initiating CLES or DBS between 9 January 2015 and 31 July 2019 were identified. CLES patients were matched to DBS patients in a 1:3 ratio based on a propensity score to balance patient characteristics. Pill burden was measured as a 30-day average number of PD-related pills per day and was captured monthly. Pill-free status was evaluated as the percentage of patients receiving CLES or DBS monotherapy. Descriptive statistics were used to compare pill counts and assess the proportion of patients on monotherapy at 6 and 12 months after initiating CLES or DBS.

Results

The cohorts included 34 CLES patients matched to 97 DBS patients. A significant reduction in PD-related pill burden was observed at 6 months after initiation of CLES or DBS (∆CLES: −5.62, p < 0.0001; ∆DBS: −1.48, p = 0.0022). PD-related pill burden reduction in CLES patients was significantly greater than in matched DBS patients at 6 months (∆: −4.14, p < 0.0001), which was sustained at 12 months after initiation. At 12 months, nearly three times more CLES patients were pill free than DBS patients (29.41% and 10.31%, respectively, p = 0.0123).

Conclusions

Device-aided therapies such as CLES and DBS are effective in significantly reducing PD-related pill burden. Patients treated with CLES were more likely to achieve pill-free status than patients receiving DBS.

[Oral antiparkinsonian treatments, nursing practices in Ehpad]

Parkinson's disease is a complex, chronic and debilitating disease that requires a personalised treatment regimen, focusing on the regular administration of medication. The management of these treatments can be tricky in institutions for the dependent elderly, particularly when oral administration is difficult. A preliminary survey was carried out in order to establish the current state of nursing practices in these institutions.

Antimuscarinic Anticholinergic Medications in Parkinson Disease: To Prescribe or Deprescribe?

The relative importance of antimuscarinic anticholinergic medications for Parkinson's disease (PD) declined after the introduction of levodopa, such that anticholinergic medications are now much more likely to be prescribed for clinical indications other than parkinsonism. Recent studies have found an association between anticholinergic medication exposure and future risk of dementia in older individuals and those with PD. These findings provide a further reason to avoid the use of anticholinergic medications to treat motor symptoms of PD. More importantly, they raise the question of whether one of the goals of PD treatment should be to deprescribe all medications with anticholinergic properties, regardless of their indication, to reduce dementia risk. In this review, we discuss the use of anticholinergic medications in PD, the evidence supporting the association between anticholinergic medications and future dementia risk, and the potential implications of these findings for clinical care in PD.

Increased atrial fibrillation risk in Parkinson's disease: A nationwide population-based study

OBJECTIVE

Parkinson's disease (PD) is the second most common neurodegenerative disorder associated with various morbidities. Although the relationship between cardiovascular disease and PD has been studied, a paucity of information on PD and atrial fibrillation (AF) association exists. Thus, we aimed to investigate whether patients with PD have an increased risk of AF.

METHODS

This study included 57,585 patients with newly diagnosed PD (≥40-year-old, mean age 69.7 years, men 40.2%) and without a history of AF from the Korean National Health Insurance Service (NHIS) database between 2010 and 2015. Furthermore, an equal number of age- and sex-matched subjects without PD were selected for comparison. The primary outcome was new-onset AF.

RESULTS

During the mean follow-up period of 3.4 ± 1.8 years, AF was newly diagnosed in 3,665 patients. A significantly higher incidence rate of AF was noted among patients with PD than among patients without PD (10.75 and 7.86 per 1000 person-year, respectively). Multivariate Cox-regression analysis revealed that PD was an independent risk factor for AF (hazard ratio [HR]: 1.27, 95% confidence interval [CI]: 1.18-1.36). Furthermore, subgroup analyses revealed that AF risk was higher in the younger age subgroups, and compared with the non-PD group, the youngest PD group (age: 40-49 years) had a threefold increased risk of AF (HR: 3.06, 95% CI: 1.20-7.77).

INTERPRETATION

Patients with PD, especially the younger age subgroups, have an increased risk of AF. Active surveillance and management of AF should be considered to prevent further complications.

Medication Adherence and Coping with Disease in Patients from a Neurological Clinic: An Observational Study

PURPOSE

Medication non-adherence is a huge concern for the medical community. For chronic, especially neurological diseases, taking medication is a central pillar of treatment. To improve adherence to these oftentimes complex medication regimens, the construct needs to be understood in more depth. The aim of this study was to investigate associations between adherence with sociodemographics, clinical variables, and coping in neurological patients.

PATIENTS AND METHODS

The sample consisted of 545 patients from a German neurological clinic. Adherence was assessed with the Stendal Adherence to Medication Score (SAMS). Patients were grouped as completely adherent (SAMS = 0), non-adherent (upper 25% of the sample), and moderately adherent. Associations with coping were assessed using the Essen Coping Questionnaire.

RESULTS

Medication adherence was low compared to other non-neurological patient samples. Differences between adherence groups were found regarding gender and facets of coping, namely "trivialisation, wishful thinking and defence" and "finding of inner stability".

CONCLUSION

Interventions to improve medication adherence should focus on facets of coping with disease, increasing acceptance of disease, willpower, and confidence in treatment.

Frequency of and risk factors for potentially inappropriate medication use in Parkinson's disease

BACKGROUND

impairments in neurotransmitter pathways put Parkinson's disease (PD) patients at risk for drug-disease interactions and adverse medication events.

OBJECTIVE

to determine the prevalence and risk factors for potentially inappropriate medication (PIM) prescriptions, as defined by the 2015 Beers List, in PD.

METHODS

cross-sectional analysis was conducted on 2014 Medicare beneficiaries with PD who had parts A, B and D coverage. The prevalence of PIM prescriptions for older adults was determined overall, and specifically for medications that can exacerbate motor symptoms or cognitive impairment in PD. Logistic regression models were constructed to determine the association between age, sex, race, geography and poverty with PIM prescriptions.

RESULTS

the final sample included 458,086 beneficiaries. In 2014, 35.8% of beneficiaries with PD filled a prescription for at least one PIM for older adults. In total, 8.7% of beneficiaries received a PIM that could exacerbate motor symptoms and 29.0% received a PIM that could worsen cognitive impairment. After adjustment, in all models, beneficiaries who were younger, female, white, urban-dwelling and eligible for Medicaid benefits were more likely to receive a PIM.

CONCLUSION

PIM prescriptions are not uncommon in PD, particularly for medications that can exacerbate cognitive impairment. Future research will examine underlying drivers of sex and other disparities in PIM prescribing. Additional studies are needed to understand the impact of PIMs on disease symptoms, healthcare utilisation and patient outcomes.

Access and Use of Device-Aided Therapies for Parkinson's Disease in Denmark

Background

In Denmark's five regions, there is potential inequality in access to device-aided therapy (DAT) for Parkinson's disease (PD) based on structural or socioeconomic factors. It is unclear how long DAT is maintained and affects concomitant medication.

Objectives

To investigate access to DAT by comparing the proportion of patients with DBS, subcutaneous apomorphine infusion (SCAI), or levodopa/carbidopa intestinal gel (LCIG) in Danish regions 2008-2016 and describe demographics of patients, changes in use of comedication, and maintenance of DAT.

Methods

This work is a retrospective nationwide population-based registry analysis generated by combining various registries and statistics in Denmark.

Results

From 2008 to 2016, 612 patients started DAT. There were statistically significant differences in the number of patients starting DAT between the Capital Region (99.5 per 1,000) and both Central Jutland (66.6 per 1,000) and North Jutland (70.6 per 1,000; P < 0.05). Among DBS and LCIG patients, respectively, 4% and 42% were aged ≥70 years, 68% and 63% were men (vs. 59% in the general PD population; P < 0.05 for DBS), 73% and 63% had a partner (vs. 62% in the general PD population), and 73% and 71% had a qualifying education (vs. 63% in the general PD population; P < 0.05). Use of PD-related medication decreased significantly from 4 years before to 4 years after DAT. Eighty-one percent of the patients who started LCIG, alive 4 years later, had maintained this treatment.

Conclusions

There is unequal access to DAT in the Danish regions, and political and social considerations are warranted to address structural and socioeconomic causes.

Are Anticholinergic Medications Associated With Increased Risk of Dementia and Behavioral and Psychological Symptoms of Dementia? A Nationwide 15-Year Follow-Up Cohort Study in Taiwan

BACKGROUND/OBJECTIVE

In previous reports, the usage of anticholinergic medications has been associated with an increased risk of dementia with prolonged usage or with a high Anticholinergic Cognitive Burden (ACB). This study aimed to investigate the association between anticholinergic medications and the risk of dementia using data from Taiwan's National Health Research Database (NHIRD).

METHODS

A total of 790,240 patients, with 197,560 patients receiving anticholinergic medications and 592,680 control patients (1:3) matched for sex, age, and index-year, were enrolled from the two million Longitudinal Health Insurance Dataset, a subdataset of the NHIRD, between 2000 and 2015. The time-dependent Cox regression analysis was used to explore the hazard ratio (HR) with a 95% confidence interval for the association between anticholinergics and the risk of dementia during the 15-year follow-up. The behavioral and psychological symptoms of dementia (BPSD) were recognized by the usage of psychotropics. The ACB ranged from zero to three, divided as score <1, 1-1.9, 2-2.9, 3-4.9,and ≧5. The sensitivity analysis was done by excluding the diagnoses of dementia in the first 2 or 4 years after anticholinergic usage.

RESULTS

In the anticholinergic usage cohort, the HR was 1.043 (95% CI = 0.958-1.212, p = 0.139) without a significant difference. The sensitivity analysis revealed no association between the usage of anticholinergics and the risk of dementia. Anticholinergic usage was not associated with BPSD. Male sex, patients of ages of 60-64 and ≧80, usage of antiparkinsonian medications, a history of Parkinson's disease, epilepsy, urinary incontinence, depression, bipolar disorder, and psychotic disorder were independent risk factors of dementia. Increased HRs for dementia were associated with an ACB ≥ 5 and an anticholinergic usage period ≥ 1,460 days.

CONCLUSION

In this study, the usage of anticholinergics was not associated with the risk of dementia or BPSD in a 15-year follow-up study. However, patients with the male sex, patients with ages of 65-79 and ≧80, patients with some comorbidities, high ACB scores, and long anticholinergic treatment duration were associated with the risk of dementia.

Patterns and Determinants of Prescribing for Parkinson's Disease: A Systematic Literature Review

Since the discovery of levodopa (L-dopa) in 1967, the range of medications available to treat Parkinson's disease has increased significantly and guidance on the use, efficacy, and safety of these medications has evolved. To assess levels of adherence to national prescribing guidelines and awareness of changes in the efficacy and safety data published in the profiles of medications for the treatment of PD, we have reviewed studies on patterns and determinants of prescribing PD medications conducted in the last 50 years (since the discovery of L-dopa). A systematic literature review was conducted using EMBASE (1967 to March, 2018), Ovid MEDLINE(R) ALL (1967 to March 16, 2018), PsycINFO (1967 to the 2nd week of March, 2018), and PubMed to identify all studies measuring prescribing patterns of PD medication between 1967 and 2017. Study design, source of data, country, year of study, number of patients and/or prescriptions, unit of analysis, prescribing determinants, and percentage utilisation of PD medications were extracted where possible. 44 studies examining prescribing patterns and/or prescribing determinants across 17 countries were identified. Unsurprisingly, L-dopa was the most commonly prescribed medication in all studies, accounting for 46.50% to 100% of all prescriptions for PD. In several studies, the prescribing rate of ergot-derived dopamine agonists (DAs) decreased over time in concordance with guidance. In contrast, the prescribing rates of non-ergot DAs increased over the last ten years in most of the included studies. In examining prescribing factors, two major categories were exemplified, patients' factors and prescribers' factors, with patients' age being the most common factor that affected the prescription in most studies. In conclusion, L-dopa is now the most commonly prescribed medication for cases of PD but there is large variation in the prescribing rates of catechol-O-methyltransferase (COMT) inhibitors, monoamine oxidase B (MAO-B) inhibitors, amantadine, and anticholinergics between countries. New studies examining the effects of recent clinical trials and measuring the prescribing rates of newly approved medications are warranted.

Prescribing Pattern for Parkinson's Disease in Indian Community before Referral to Tertiary Center

BACKGROUND

Several factors determine the choice of medications in patients with Parkinson's disease (PD). We aimed to analyze the pattern of prescription of drugs in patients with PD before attending a tertiary-care center.

METHODS

The study included chart review of 800 PD patients attending the Department of Neurology of the National Institute of Mental Health and Neurosciences in Bangalore, India.

RESULTS

The mean age at onset was 51.1±11.8 years. The mean duration of illness was 41.7±43.6 months. At first visit, 79.4% (group 1, n=635) of patients were on medications, 10% (group 2, n=80) were on medications but later discontinued, and 10.6% (group 3, n=85) were drug-naïve. Overall, levodopa was prescribed in 94.8%, trihexyphenidyl in 40.4%, dopamine agonists in 23.2%, and amantadine in 17.2% either as monotherapy or in combination. In group 1, 37.8% were on monotherapy, with levodopa being the most commonly used agent (33.1%), followed by trihexyphenidyl (2.2%), dopamine agonists (1.6%), and amantadine (0.6%). Among those on polytherapy, levodopa plus trihexyphenidyl was the preferred combination (23.9%). In group 2, levodopa monotherapy was also most common (72.5%), followed by trihexyphenidyl monotherapy (7.5%).

CONCLUSIONS

Levodopa and trihexyphenidyl were the most commonly prescribed drugs in our patients. A higher use of trihexyphenidyl could be due to its easy availability, low cost, and better tolerability in our patients, who were relatively young at the time of onset of their disease. The choice of antiparkinsonian medications at the primary and secondary care levels in India may be inappropriate, and newer guidelines tailored to the Indian context are warranted.

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.

The effect of a structured medication review on quality of life in Parkinson's disease: The study protocol

BACKGROUND

Treatment of Parkinson's disease (PD) is symptomatic and frequently consists of complicated medication regimes. This negatively influences therapy adherence, resulting in lower benefit of treatment, drug related problems and decreased quality of life (QoL). A potential effective intervention strategy is a structured medication review, executed by community pharmacists. However, little is known about the effects on clinical endpoints like QoL, as well as on feasibility and cost-effectiveness in PD patients.

OBJECTIVES

To assess the effect of a structured medication review on QoL in PD patients. Secondary objectives are measurements of physical disability, activities in daily life, non-motor symptoms, health state, personal carers' QoL and cost-effectiveness. Furthermore, a better insight in the process of performing medication reviews will be obtained from the perspective of community pharmacists.

METHODS

In this multicenter randomized controlled trial we aim to enroll 200 PD patients from the outpatient clinic of three Dutch hospitals. Community pharmacists will perform a structured medication review in half of the assigned patients; the other half will receive usual care. Data obtained by use of six validated questionnaires will be collected at baseline and after 3 and 6 months of follow-up. Semi-structured interviews with community pharmacists will be conducted till data saturation has been reached.

DISCUSSION

This trial targets a high-risk patient group for whom optimizing therapy by a structured medication review might be of added value. If effectiveness is proven, this could further promote the implementation of pharmaceutical care in a primary care setting.

[Prescribing patterns of antiparkinson drugs in a group of Colombian patients, 2015]

INTRODUCTION

Parkinson's disease, whose prevalence in Colombia is 4.7 per 1,000 inhabitants, is a public health problem and a therapeutic challenge for health professionals.

OBJECTIVE

To determine the prescribing patterns of antiparkinson drugs and the variables associated with its use in a population from Colombia.

MATERIALS AND METHODS

We conducted a descriptive cross-sectional study. We selected patients who had been given antiparkinson drugs uninterruptedly between January 1st and March 31st, 2015 from a systematized database of approximately 3.5 million people affiliated to the Colombian health system. We included sociodemographic, pharmacologic and comedication variables. For the multivariate analysis, we used the IBM SPSS™-22 software.

RESULTS

A total of 2,898 patients was included; the mean age was 65.1years, and 50.7% were men; 69.4% (n=2010) of people received monotherapy and 30.6% combination therapy with two to five antiparkinson drugs. The most frequently prescribed drugs were: levodopa 45.5% (n=1,318 patients), biperiden 23.1% (670), amantadine 18.3% (531) and pramipexole 16.3% (471). The most commonly used association was levodopa/carbidopa + entacapone (n=311; 10.7%). Multivariate analysis showed that being male (OR=1.56; 95%CI: 1.321-1.837), over 60 years (OR=1.41; 95%CI 1.112-1.782) and receiving treatment in the city of Barranquilla (OR=2.23; 95%CI 1.675-2.975) were statistically associated with a greater risk of using combination therapy; 68.2% (n=1,977) patients were given concomitant treatment with other drugs.

CONCLUSIONS

Prescribing habits of drugs with high therapeutic value predominated, mainly in antiparkinson drugs monotherapy. Most were employed in the usual recommended doses. It is necessary to explore the clinical effectiveness of the medications studied and differentiate between disease and parkinsonian syndromes subtypes.

Prescription pattern and awareness of disease and treatment in patients of Parkinson's disease

AIM

This cross-sectional study aimed to evaluate the prescription pattern, awareness of disease and treatment in patients with Parkinson's disease (PD).

MATERIALS & METHODS

A total of 100 PD patients, attending a tertiary care hospital in Mumbai were included. Prescriptions were analyzed and awareness was evaluated using a questionnaire.

RESULTS

The mean number of anti-Parkinson agents (APA) prescribed was 1.52 ± 0.65. Number of APA strongly correlated with disease duration (ρ = 0.818; p < 0.001). Many APA were underutilized (prescribed daily dose/defined daily dose < 1). There was no awareness of all items on symptoms and alternative therapeutic options. Awareness of disease impairments (32%), long-term complications (28%), dosing regimen (46%) and follow-up (36%) was poor.

CONCLUSION

More than one APA is commonly prescribed in PD patients. Awareness of disease and treatment of PD is poor among the patients.

Comorbid conditions associated with Parkinson's disease: A longitudinal and comparative study with Alzheimer disease and control subjects

BACKGROUND AND OBJECTIVE

To study what comorbid conditions were present at baseline and 3years later in a cohort of Spanish Parkinson's disease (PD) patients, to compare comorbidity with both Alzheimer's disease (AD) and control groups and to analyze the role of comorbidity as predictor of mortality.

METHODS

One hundred and forty-seven non-demented PD patients (57.1% males; 70.9±8.6years old) were included in this 36months follow-up (2012-2015), monocenter, evaluation study. The International Classification of Diseases, Tenth Revision (ICD-10), Charlson Index (CI), Comorbidity-Polypharmacy Score (CPS) and Elixhauser Comorbidity Measure (ECM) were used to assess comorbidity at baseline and at 3years. Forty-four AD patients and 44 control subjects were included as comparator groups.

RESULTS

Total number of comorbidities (ICD-10) and polypharmacy at baseline were higher in PD and AD patients than controls (4.4±2.3 vs 5.2±2.4 vs 3.4±1.9 [p=0.001] and 81.6% vs 75% vs 56.8% [p=0.003], respectively). Diseases of the circulatory system (ICD-10/chapter-IX) and endocrine, nutritional and metabolic diseases (ICD-10/chapter-IV) were the most frequent in all groups. There was a significant increase in comorbidity (mean, +1.6±2.8) in all groups (p<0.0001) without differences between them. Seventeen patients died and 8 cases were did not follow-up. Comorbidity was a predictor of death in PD patients after adjust for other covariates (including age, sex, disease duration, disease stage, motor status and non-motor symptoms): ICD-10 (total number of comorbidities), hazard ratio 1.285 (95% confidence interval, 1.047-1.577; p=0.017); CI, hazard ratio 1.462 (95% confidence interval, 1.045-2.047; p=0.027).

CONCLUSIONS

Comorbidity is frequent in PD patients, increases significantly over time and predicts mortality.

Associations and implications of low health literacy in Parkinson's Disease

BACKGROUND

Low health literacy (HL) indicates a limited ability to understand and use basic information to make appropriate healthcare decisions. While low HL is associated with higher morbidity, mortality, and healthcare costs in multiple chronic conditions, little is known about HL and its associations in Parkinson's disease (PD).

METHODS

Cross-sectional study of non-demented adults with PD participating in the National Parkinson Foundation Parkinson's Outcomes Project at the University of Pennsylvania. Subjects were administered two brief HL assessments-the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF), a word-recognition test, and the Newest Vital Sign (NVS), a test of literacy, numeracy and understanding of health information-as well as demographic and clinical questionnaires. Adverse outcomes included falls in the 3 months preceding the study visit, and hospital admissions, emergency room visits, infections, or injuries in the preceding year. Caregiver burden was measured using the Multidimensional Caregiver Strain Index.

RESULTS

168 subjects completed both HL screens (mean 65.8 years, 65.5% male, 65.2% Hoehn & Yahr Stage 2). Using the REALM-SF, 97.6% of subjects had adequate HL. Using the NVS, however, 29.8% had low HL, which was associated with older age, lower education, male gender, greater disease severity, and poorer cognition. Low HL was associated with hospital admission and increased caregiver burden.

CONCLUSIONS

Low HL is common and associated with greater caregiver burden and a higher likelihood of hospitalization in patients with PD. Since HL is associated with both disease severity and adverse outcomes, it may be an important, modifiable contributor to morbidity.

Trends in inpatient antiparkinson drug use in the USA, 2001-2012

Purpose

Although therapeutic options and clinical guidelines for Parkinson’s disease (PD) have changed significantly in the past 15 years, prescribing trends in the USA remain unknown. The purpose of this population-based cohort study was to examine patterns of inpatient antiparkinson drug use between January 2001 and December 2012 in relation to clinical guideline publication, drug introduction/withdrawal, and emerging safety concerns.

Methods

A total of 16,785 inpatients receiving pharmacological treatment for PD were identified in the Cerner Health Facts database. Our primary outcome was standardized (age, sex, race, and census region) annual prevalence of antiparkinson drug use. We also examined antiparkinson medication trends and polypharmacy by age and sex.

Results

The most frequently prescribed antiparkinson drugs between 2001 and 2012 were levodopa (85 %) and dopamine agonists (28 %). Dopamine agonist use began declining in 2007, from 34 to 27 % in 2012. The decline followed publication of the American Academy of Neurology’s practice parameter refuting levodopa toxicity, pergolide withdrawal, and pramipexole label revisions. Despite safety concerns for cognitive impairment and falls, individuals ≥80 years of age demonstrated stable rates of dopamine agonist use from 2001 to 2012. Polypharmacy was most common in younger patients.

Conclusions

Dopamine agonist use declined from 2007 to 2012, suggesting that increased awareness of safety issues and practice guidelines influenced prescribing. These events appear to have minimally influenced treatment provided to older PD patients. Antiparkinson prescribing trends indicate that safety and best practice information may be communicated effectively.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-015-1881-4) contains supplementary material, which is available to authorized users.

Medication adherence in patients with Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder, after Alzheimer's disease, affecting the elderly worldwide. Current therapy for PD is largely based on prescription of drugs that act as either dopamine precursors, dopamine agonists or agents that inhibit key enzymes in the dopamine catabolic pathways. Most of these drugs are administered in tablet or capsule form and can involve multiple daily doses in complex dosing regimens, which contributes to sub-optimal compliance amongst patients. There is evidence to suggest that non-compliance with medications results in perceived poor response to therapy and may ultimately increase direct and indirect health care costs. Medication compliance in PD assumes a particularly important role, given that PD is a progressive, debilitating condition, and once medication is instituted for ameliorating the symptoms of PD, it is lifelong. We included nine research studies in our review of the medical literature, which report the prevalence of significant medication non-compliance in PD, using standard definitions, varies between 10 and 67%. This variation partly reflects differences in defining what clinically significant medication adherence is, the methods used to estimate the scale of the problem and the underlying population heterogeneity. Nevertheless, medication adherence is related to health costs and to the quality of life of patients affected by PD and, indirectly, their carers. Educating patients and their carers is one method of improving patient adherence to therapy. Simplifying drug regimens can also aid in this effort.

Prescribing pattern of anti-Parkinson drugs in Japan: a trend analysis from 2005 to 2010

Objective

Therapeutic options for Parkinson's disease mainly consist of L-dopa and dopamine agonists. However, in Japan, the product labeling of the ergot dopamine agonists, cabergoline and pergolide, was revised in April 2007 due to the risk of developing cardiac valvulopathy. Here, we describe the prescribing trends of anti-Parkinson drugs from 2005 through 2010 in Japan, and examined whether these trends changed after the drug safety measures in 2007.

Methods and Patients

We used medical claim data from January 2005 to December 2010 for Parkinson's disease patients older than 30 years who were prescribed anti-Parkinson drugs. We calculated the proportion of patients prescribed each drug for each year, and compared the proportions of first-line drugs prescribed before and after April 2007. We also examined the prescription variations of cabergoline/pergolide users one year before or after April 2007.

Results

L-dopa was the most frequently prescribed drug for Parkinson's disease (2005, 58%; 2010, 51%). The proportion of patients prescribed ergot dopamine agonists markedly decreased and non-ergot dopamine agonists increased after 2007. Among first-line drugs, the proportion of non-ergot agents increased after April 2007. Among 54 cabergoline/pergolide users, 24 (44%) discontinued these drugs, nine of whom switched to non-ergot agents.

Conclusion

L-dopa was the mainstay of Parkinson's disease treatment between 2005 and 2010 in Japan. There was a decrease in ergot agents and an increase in non-ergot agents prescribed after the regulatory actions in 2007.

Co-morbidities of persons dying of Parkinson's disease

Introduction

Disease interactions can alter functional decline near the end of life (EOL). Parkinson's disease (PD) is characterized by frequent occurrences of co-morbidities but data challenges have limited studies investigating co-morbidities across a broad range of diseases. The goal of this study was to describe disease associations with PD.

Methods

We conducted an analysis of death certificate data from 1998 to 2005 in Nova Scotia. All death causes were utilized to select individuals dying of PD and compare with the general population and an age–sex-matched sample without PD. We calculated the mean number of death causes and frequency of disease co-occurrence. To account for the chance occurrence of co-morbidities and measure the strength of association, observed to expected ratios were calculated.

Results

PD decedents had a higher mean number of death causes (3.37) than the general population (2.77) and age–sex-matched sample (2.88). Cancer was the most common cause in the population and matched sample but fifth for those with PD. Cancer was one of nine diseases that occurred less often than what would be expected by chance while four were not correlated with PD. Dementia and pneumonia occurred with PD 2.53 ([CI] 2.21–2.85) and 1.83 (CI 1.58–2.08) times more often than expected. The strength of association for both is reduced but remains statistically significant when controlling for age and sex.

Discussion

Those with PD have a higher number of co-morbidities even after controlling for age and sex. Individuals dying with PD are more likely to have dementia and pneumonia, which has implications for the provision of care at EOL.

Initiatives to improve prescribing efficiency for drugs to treat Parkinson's disease in Croatia: influence and future directions

Parkinson's disease (PD) is the second most common neurological disease affecting older adults. Consequently, this disease should be a focus among payers, with increasing utilization of newer premium-priced patent-protected add-on therapies to stabilize or even improve motor function over time. However, expenditure can be moderated by reforms. Consequently, there is a need to assess the influence of these reforms on the prescribing efficiency for drugs to treat PD in Croatia before proposing additional measures. Prescribing efficiency is defined as increasing the use of add-on therapies for similar expenditure. An observational retrospective study of the Croatian Institute for Health Insurance database of drugs to treat patients with PD in Croatia from 2000 to 2010 was carried out, with utilization measured in defined daily doses (defined as the average maintenance dose of a drug when used in its major indication in adults). The study years were chosen to reflect recent reforms. Only reimbursed expenditure is measured from a health insurance perspective. Utilization of drugs to treat PD increased by 218% between 2000 and 2010. Reimbursed expenditure increased by 360%, principally driven by increasing utilization of premium-priced patent-protected add-on therapies, including ropinirole and pramipexole. However, following recent reforms, reducing expenditure/defined daily dose for the different drugs, as well as overall expenditure, stabilized reimbursed expenditure between 2005 and 2010. Treatment of PD is complex, and add-on therapies are needed to improve care. Reimbursed expenditure should now fall following stabilization, despite increasing volumes, as successive add-on therapies lose their patents, further increasing prescribing efficiency.

The use of carer assisted adherence therapy for people with Parkinson's disease and their carers (CAAT-PARK): study protocol for a randomised controlled trial

BACKGROUND

Pharmacological intervention is essential for managing the symptoms of Parkinson's disease. Adherence to medication regimens however is a major problem. Poor adherence leads to significant motor deterioration and inadequate symptom control. This results in poor quality of life. Whilst interventions to improve medication adherence have shown considerable benefit in other chronic conditions, the efficacy of such treatments in Parkinson's disease is less well researched. Many people with Parkinson's disease require substantial support from spouse/caregivers. This often extends to medication taking. Consequently, spouse/caregiver's support for timely medication management is paramount. We aim to investigate the benefit of a novel intervention, Carer Assisted Adherence Therapy, for improving medication adherence and quality of life in people with Parkinson's disease. Adherence therapy may help to optimise the efficacy of anti-parkinsonian agents, subsequently improving clinical outcomes.

METHODS/DESIGN

A parallel, randomised controlled trial will be conducted to investigate whether carer assisted adherence therapy is effective for improving medication adherence and quality of life. We aim to recruit 40 patient/carer pairs into each group. Participants will be randomly assigned by the Clinical Research Trials Unit at the University of East Anglia. Adherence therapy is a brief cognitive-behavioural approach aimed at facilitating a process of shared decision making. The central theory is that when patients make shared choices with a professional they are more likely to continue with those choices because they are personally owned and meaningful. Outcomes will be rates of adherence and quality of life, determined by the Morisky Medication Adherence Scale-4 and the Parkinson's disease Questionnaire-39 respectively. Assessments will take place post randomisation, immediately post intervention and 12-weeks post randomisation. Primary outcomes are adherence and quality of life at 12-week follow-up. Efficacy will be determined using intention-to-treat analysis. Independent samples t-tests will compare mean changes between groups from baseline to follow-up. Per protocol analysis will be conducted based on individuals with no major protocol deviation. Where imbalances in baseline characteristics are identified, an adjusted analysis will be performed using a regression model. Analysis will be masked to treatment allocation.

TRIAL REGISTRATION

ISRCTN: ISRCTN07830951.

Drug safety monitoring in patients of movement disorders of a tertiary care hospital

Background:

Movement disorders (MD) are neurological conditions that affect the speed, fluency, quality, and ease of movement and commonly include Parkinson’s disease, tremor and dystonias. Drugs are important causes of MD, and the incidence and prevalence of such disorders are possibly underappreciated because of the lack of recognition.

Objectives:

To assess the incidence of all adverse drug reactions (ADRs) and estimate the prevalence of drug-induced MD among patients attending the clinic.

Materials and Methods:

This prospective observational study was conducted at an outpatient referral MD clinic of a tertiary care hospital for 1 year. The demographic data, drug intake, diagnosis, and ADRs experienced by the subjects were recorded. Causality assessment was done by Naranjo’s scale.

Results:

Incidence of ADR among patients who attended this clinic was 19.7% (151 out of 768 patients experienced at least one ADR). A total of 299 ADRs were detected out of which 30.8% were gastrointestinal, 28.4% psychiatric, and 26% MD effects. The commonly implicated suspect drugs were levodopa (37.8%) and trihexyphenidyl (25.1%). The prevalence of drug-induced MD was 10.15% and drug-induced dyskinesias and dystonias were the most common.

Conclusion:

MDs are clinically important neurological disorders which are often caused by drugs and interestingly drugs used for its management are also associated with high incidence of ADRs. Hence these ADRs should be carefully monitored.

Do neurologists in Germany adhere to the national Parkinson's disease guideline?

Implementation of guidelines can improve clinical practice. The aim in this study was to investigate whether neurologists in Germany adhered to the national Parkinson's disease guideline. Data were obtained from a cross-sectional survey of 60 neurologists. Analyses were performed on 320 patients with idiopathic Parkinson's disease with either low grades of functional impairment (Hoehn and Yahr stage I) or higher grades of functional impairment (stage II-V) but without motor complications. The sample was divided into four groups depending on age and grade of functional impairment. For each group, a biometric parameter on the use of dopamine agonists and L-dopa was defined based on the guideline. In patients aged <70 years, the recommendation to use dopamine agonists without L-dopa (parameter 1) was observed in 53% of patients with lower grades of functional impairment, whilst recommended use of dopamine agonists in more functionally impaired patients (parameter 2) was followed to a greater extent (84%). In patients aged ≥70 years, recommendations to use L-dopa without dopamine agonists were adhered to in only 50% of less functionally impaired (parameter 3) and 52% of more functionally impaired (parameter 4) patients. In conclusion, our results indicated there was moderate but not full adherence to the guideline.

Utilization of anti-Parkinson drugs in Australia: 1995-2009

PURPOSE

To examine trends in the prescribing of anti-Parkinsonian drugs (APD) in Australia from 1995 to 2009.

METHODS

We analyzed the Medicare Australia and Drug Utilisation Sub-Committee (DUSC) databases for prescription data for overall APD dispensed use from 1995. We were able to examine prescribing by gender, age, and type of prescriber between 2002 and 2009. Prescriptions were converted to defined daily doses (DDD)/1000 population/day using Australian Bureau of Statistics population data.

RESULTS

Dispensed use of levodopa + carbidopa remained steady from 1995 to 2009 (0.76-0.82 DDD/1000 population/day); levodopa + benserazide use increased from 0.34 to 0.55 DDD/1000 population/day. Since 2005 dispensed use of levodopa + carbidopa + entacapone has steadily increased, from 0.03 to 0.10 DDD/1000 population/day. In July 2009 levodopa + carbidopa was the most widely used agent, followed by levodopa + benserazide, then benztropine. Cabergoline increased from 1999, peaked in 2006, and thereafter declined. APD use peaked in males and females aged 60-69 years. Age-adjusted utilization was slightly higher in males than females.

CONCLUSIONS

The amount of levodopa dispensed has slowly increased with levodopa + benserazide increasing faster than levodopa + carbidopa. Use of cabergoline fell when pramipexole became available and the risk of ergot-related serosal adverse effects was more widely appreciated. Use of centrally acting anti-cholinergics decreased over a period of time when use of atypical anti-psychotic agents increased.

Drug therapies for Parkinson's disease: A database analysis of patient compliance and persistence

BACKGROUND

Evaluating medication adherence in Parkinson's disease (PD) is important to avoid erroneously attributing suboptimal patient outcomes from poor compliance to disease progression or adverse responses to medications.

OBJECTIVE

This study of patients with PD who were new to PD drug therapy examined patient compliance and persistence, by drug, to provide a comprehensive investigation of medication-taking behavior in PD.

METHODS

A retrospective analysis of patients receiving a new PD drug between March 1 and May 31, 2007, was conducted, using the IMS Health longitudinal prescription database, which contains ∼50% of all retail prescriptions and <150 million patients in the United States. Patients were considered to have received a new PD drug if they initiated PD therapy for the first time, added adjunctive PD therapy, or switched one PD drug for another. Patients were categorized as naive to PD therapy (NT) or having prior PD therapy (PT), which included adjunctive use and switches. The PD medications evaluated were rasagiline, levodopa/carbidopa, levodopa/carbidopa/entacapone, the catechol-O-methyltransferase (COMT) inhibitors (entacapone and tolcapone), pramipexole, ropinirole, and selegiline. The study consisted of a 12-month look-back period (during which patients were required to be active in the database), a 3-month selection period (during which patients received their first prescription), and a 12-month observation period. Compliance was measured using the medication possession ratio (MPR; defined as the number of days' supply of medication divided by the number of available days of therapy, from first dispense date in the selection period to last dispense date in the observation period); noncompliance was defined as an MPR ≤80%. Persistence was measured as the duration (days) of uninterrupted therapy.

RESULTS

A total of 29,682 patients with PD (19,673 NT, 10,009 PT) received a new PD drug and were analyzed. Of the 19,510 patients included in the compliance analysis, 10,438 (53.5%) had compliance rates >80% and 9072 (46.5%) were noncompliant. For all patients (NT and PT), compliance rates were significantly higher for patients taking rasagiline than for those taking other PD medications (all P < 0.001). For all patients, the highest mean number of persistent days of treatment (147.5) was reported for rasagiline, followed by levodopa/carbidopa/ entacapone (146.9); persistence for both of these drugs was significantly higher than that for the comparator medications (rasagiline vs levodopa/carbidopa, P = 0.002; rasagiline vs pramipexole, P = 0.003; rasagiline vs COMT inhibitors, ropinirole, and selegiline, all P < 0.001; levodopa/carbidopa/entacapone vs levodopa/carbidopa, P = 0.005; levodopa/carbidopa/entacapone vs pramipexole, P = 0.006; levodopa/carbidopa/entacapone vs COMT inhibitors, ropinirole, and selegiline, all P < 0.001). Almost half of the patients (13,103; 44.1%) remained on their PD medication ≥90 days.

CONCLUSIONS

This study found a differential compliance and persistence across PD drug therapies. The compliance rate for rasagiline was significantly higher than that for all of the other PD medications. In addition, rasagiline and levodopa/carbidopa/entacapone were associated with significantly higher persistence rates than were the other PD medications.

Prevalence and cost of medication nonadherence in Parkinson's disease: evidence from administrative claims data

We estimated the prevalence of medication nonadherence in Parkinson's disease (PD) and the association between treatment nonadherence and healthcare costs. Insurance claims from over 30 US health plans were analyzed. Inclusion criteria were as follows: PD diagnosis, >or=1 PD-related prescription between 1/1/1997 and 12/31/2004, continuous health plan enrollment for >or=6 months before and >or=12 months after first PD prescription. Adherence, all-cause healthcare utilization, and all-cause costs were evaluated over 12 months post-treatment initiation. Adherence was measured using the medication possession ratio (MPR), with MPR < 0.8 defining nonadherence. Among patients identified for inclusion (N = 3,119), 58% were male and mean age was 69 years. Mean MPR was 0.58 and 61% of patients were nonadherent. Unadjusted mean medical costs were significantly higher (P < 0.01) among nonadherers ($15,826) compared with adherers ($9,228), although nonadherers had lower prescription drug costs ($2,684 vs. $3,854; P < 0.05). After controlling for confounders in multivariable analyses, a large positive relationship between nonadherence and both medical and total healthcare costs remained (+$3,451, P < 0.0001 and +$2,383, P = 0.0053, respectively). Medication adherence in PD is suboptimal and nonadherence may be associated with increased healthcare costs despite offsets from reduced drug intake. Efforts to promote medication adherence in PD may lead to cost savings for managed care systems.

Patterns of initial pharmacotherapy for Parkinson's disease in the United States

Data from a mix of employer- and government-funded health plans were used to investigate actual treatment patterns for patients initiating pharmacotherapy for Parkinson's disease in the United States. Treatment patterns evaluated included type of initial therapy and rates and types of adjunctive and substitute therapies. The study confirms that levodopa remains the most often prescribed initial treatment for Parkinson's disease regardless of age or drug benefit coverage. The widespread use of levodopa in young Parkinson's patients (<65 years) with private insurance may indicate that physicians are not overly concerned about or are not fully aware of the association of levodopa with long-term motor complications. It may also indicate that currently available alternatives to levodopa are not sufficiently effective or well tolerated.

Cardiovascular dysautonomia as a cause of falls in Parkinson's disease

Parkinson's disease (PD) patients have a ninefold increased risk of recurring falls compared to healthy controls. The risk of falling due to cardiovascular dysautonomia (CVD) is not quantifiable. But, CVD is an integral part of the disease and at least 20% of PD patients suffer from orthostatic hypotension, an expression of CVD. One way to reduce falls due to CVD in PD patients could be to give adequate information on the relationship between falling risks and cardiovascular dysautonomia to patients and their caregivers. Moreover, drugs given for PD might contribute to OH and we propose that education and non-pharmacological strategies for its treatment might be preferable, especially because of the low efficacy of drugs available for the treatment of OH and the frailty of elderly PD patients.

Prescribing pattern in Parkinson's disease: are cost and efficacy overriding factors?

Information on prescribing pattern of antiparkinsonian medications and factors influencing neurologists' choice of such drugs are important considerations in evaluating healthcare cost of Parkinson's disease (PD). We surveyed neurologists' perceived factors influencing their choice of drugs and actual prescribing pattern in PD. Three hundred and six patients at a tertiary hospital, diagnosed with idiopathic PD and who were dispensed antiparkinsonian drugs during a 6-month period were randomly selected. Patient demographics, type and dose of medications were analysed. A questionnaire survey evaluating the factors influencing choice of medications was administered to neurologists who practiced at the institution. The study population had a mean age of 64.4 years (SD +/- 9.9 years), and more than 80% were at Hoehn & Yahr stage 2-3. 92.3% of the study population were receiving levodopa and monotherapy, with levodopa being the most common treatment regimen. Patients who were prescribed levodopa were significantly older and at a later stage of disease compared to those without levodopa (p < 0.05). Only 26.8% of patients were prescribed dopamine agonists. In the survey, the neurologists cited severity of symptoms, and patients' intolerance of side effects, and efficacy as the most important factors influencing their choice of drugs. However, the actual prescribing pattern revealed a strong positive correlation of drug usage with cost subsidy by the institution. While factors affecting drug usage in PD are well recognised, cost and efficacy of a drug appear to be overriding practical factors in influencing usage pattern in clinical practice.

Medical healthcare use in Parkinson's disease: survey in a cohort of ambulatory patients in Italy

BACKGROUND

Parkinson's disease (PD) is a chronic neurodegenerative disease which at present has no cure, and it usually results in severe disability. The burden of PD increases as the illness progresses, resulting in the extensive utilisation of both health and community services. Knowledge of healthcare use patterns and of their determinants may greatly contribute to improve patient care, however few studies have examined this issue in PD. The present study was devised to describe the type of and reasons for medical healthcare resource use in persons with PD attending a Centre for PD and Movement Disorders, and to examine drug prescriptions issued on such occasions.

METHODS

The study was a retrospective, cross-sectional survey in a cohort of ambulatory patients with PD, conducted by means of standard interviews.

RESULTS

In the year before the study, 92 (70.8%) of 130 patients used medical healthcare resources: 1/5 of the patients was admitted to hospital, 1/5 to emergency room, 2/5 were visited by a non-neurology specialist, and 1/4 by the GP. Reasons were: nearly 20% programmed hospital admissions and visits, and more than 25% injuries and musculo-skeletal diseases. Other conditions typically occurring in PD (e.g. dementia, diabetes and cardio- and cerebro-vascular disease) were less frequently involved. On such occasions, drugs for PD were occasionally changed, however drug prescriptions for other indications were issued to more than 66% of the patients.

CONCLUSION

Several physicians other than the neurologist may take care of PD patients on different occasions, thus emphasising the need for communication between the reference neurologist and other physicians who from time to time may visit the patient.

Pharmacotherapy of Parkinson’s disease in Germany

Treatment standards or guidelines have been developed for most features of Parkinson's disease (PD). However, data on the actual treatment that is put into practice are scarce. In 2000, a nationwide survey on the topic of sudden onset of sleep (SOS) in PD was initiated among the members of the German patient support group (deutsche Parkinson-Vereinigung, dPV). A part of this mailed questionnaire survey covering the antiparkinsonian and concomitant medication of the participants is presented here. This study analyses data sets from more than 6,500 PD patients. The mean dopaminergic dose was equivalent to 599 +/- 387 mg levodopa/die. The most frequently administered drugs were levodopa (94.2 %), dopamine agonists (DA) (71.7 %), amantadine (40.1 %), selegiline (27.6 %), entacapone (20.4 %), budipine (12.3 %), and anticholinergics (11.8 %). Costs of pharmacotherapy were estimated to be approximately <euro> 399 million/year in Germany. PD drug therapy in general strongly depended on age, disease duration, and the level of care. The treatment guidelines were apparently not consistently followed underlining the need for their continuous propagation throughout the medical community. In addition our data suggest that non-motor symptoms in PD are not adequately treated and that concomitant sedative medication contributes to the occurrence of SOS.