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

Electrocardiographic approach strategies in patients with Parkinson disease treated with deep brain stimulation

Deep brain stimulation (DBS) is an interdisciplinary and reversible therapy that uses high-frequency electrical stimulation to correct aberrant neural pathways in motor and cognitive neurological disorders. However, the high frequency of the waves used in DBS can interfere with electrical recording devices (e.g., electrocardiogram, electroencephalogram, cardiac monitor), creating artifacts that hinder their interpretation. The compatibility of DBS with these devices varies and depends on factors such as the underlying disease and the configuration of the neurostimulator. In emergencies where obtaining an electrocardiogram is crucial, the need for more consensus on reducing electrical artifacts in patients with DBS becomes a significant challenge. Various strategies have been proposed to attenuate the artifact generated by DBS, such as changing the DBS configuration from monopolar to bipolar, temporarily deactivating DBS during electrocardiographic recording, applying frequency filters both lower and higher than those used by DBS, and using non-standard leads. However, the inexperience of medical personnel, variability in DBS models, or the lack of a controller at the time of approach limit the application of these strategies. Current evidence on their reproducibility and efficacy is limited. Due to the growing elderly population and the rising utilization of DBS, it is imperative to create electrocardiographic methods that are easily accessible and reproducible for general physicians and emergency services.

Effects of Blood Flow Restriction Resistance Training on Autonomic and Endothelial Function in Persons with Parkinson's Disease

Background

Autonomic dysfunction precedes endothelial dysfunction in Parkinson's disease (PD) and causes blood pressure and circulation abnormalities that are highly disruptive to one's quality of life. While exercise interventions have proven helpful for motor symptoms of PD, improving associated non-motor symptoms is limited. Low-intensity resistance training with blood flow restriction (LIRT-BFR) improves autonomic dysfunction in non-PD patients and high-intensity resistance training (HIRT) is recommended for motor symptom improvements for people with PD (PwPD).

Objective

To determine the effects of LIRT-BFR and HIRT on homocysteine and autonomic and endothelial function in PwPD and to determine the hemodynamic loads during LIRT-BFR and HIRT in PwPD using a novel exercise protocol.

Methods

Thirty-eight PwPD were assigned LIRT-BFR, HIRT or to a control (CNTRL) group. The LIRT-BFR and HIRT groups exercised three days per week for four weeks. The LIRT-BFR protocol used 60% limb occlusion pressure (LOP) and performed three sets of 20 repetitions at 20% of the one-repetition maximum (1RM). The HIRT group performed three sets of eight repetitions at 80% 1RM. The CNTRL group was asked to continue their normal daily routines.

Results

LIRT-BFR significantly improved orthostatic hypotension (p = 0.026), homocysteine levels (p < 0.001), peripheral circulation (p = 0.003), supine blood pressure (p = 0.028) and heart rate variability (p = 0.041); LIRT-BFR improved homocysteine levels (p < 0.018), peripheral circulation (p = 0.005), supine blood pressure (p = 0.007) and heart rate variability (p = 0.047) more than HIRT; and hemodynamic loads for LIRT-BFR and HIRT were similar.

Conclusions

LIRT-BFR may be more effective than HIRT for autonomic and endothelial function improvements in PwPD and hemodynamic loads may be lessened in LIRT-BFR protocols using single-joint exercises with intermittent blood flow restriction. Further research is needed to determine if non-motor symptoms improve over time and if results are sustainable.

Abnormally reduced frontal cortex activity during Trail-Making-Test in prodromal parkinson's disease-a fNIRS study

Parkinson's Disease (PD) is a neurodegenerative disorder leading to typical motor as well as a range of non-motor symptoms, including cognitive decline mainly characterized by executive deficits. The latter are known to appear years before the typical motor signs, thus representing the prodromal phase of PD. However, appropriate methods for measuring executive dysfunction in this context are not well established yet. Traditionally, executive performance is associated with frontal structures. Here, we investigated prodromal, early PD patients and healthy controls regarding their executive functioning on the behavioral and neural level, measured by the Trail-Making-Test (TMT) combined with functional near-infrared spectroscopy. We observed significantly reduced neural activity in the right dorsolateral prefrontal cortex within PD patients compared to controls completing the TMT-A and -B in contrast to the TMT-C, but no differences on a behavioral level. These promising results need to be confirmed and checked for reliability in future studies to extend the spectrum of markers applied in prodromal PD.

Evidence for Early and Regular Physical Therapy and Exercise in Parkinson's Disease

Advances in medical management of Parkinson's disease (PD) have resulted in living longer with disability. Although disability worsens over the course of the disease, there are signs of disability even in the early stages. Several studies reveal an early decline in gait and balance and a high prevalence of nonmotor signs in the prodromal period that contribute to early disability. There is a growing body of evidence revealing the benefits of physical therapy and exercise to mitigate motor and nonmotor signs while improving physical function and reducing disability. The presence of early disability coupled with the benefits of exercise suggests that physical therapy should be initiated earlier in the disease. In this review, we present the evidence revealing early disability in PD and the effectiveness of physical therapy and exercise, followed by a discussion of a secondary prevention model of rehabilitation to reduce early disability and optimize long-term outcomes.

Premotor Parkinson's disease: Overview of clinical symptoms and current diagnostic methods

Parkinson's disease (PD) is characterized by typical motor symptoms. However, recent studies show several non-motor features that may precede the development of the motor symptoms of PD. The best known premotor symptoms include hyposmia, REM sleep behavior disorder (RBD), constipation, and depression; other symptoms are excessive daytime somnolence, orthostatic hypotension and symptomatic hypotension, erectile or urinary dysfunction, musculoskeletal symptoms, pain, and global cognitive deficit. In this review, we summarize currently available diagnostic methods for these symptoms. We also briefly summarize neuroimaging, polyneuropathy, peripheral markers, and cerebrospinal fluid biomarkers that may be used in the early diagnosis of PD.

Parkinson-like early autonomic dysfunction induced by vagal application of DOPAL in rats

AIM

To understand why autonomic failures, a common non-motor symptom of Parkinson's disease (PD), occur earlier than typical motor disorders.

METHODS

Vagal application of DOPAL (3,4-dihydroxyphenylacetaldehyde) to simulate PD-like autonomic dysfunction and understand the connection between PD and cardiovascular dysfunction. Molecular and morphological approaches were employed to test the time-dependent alternation of α-synuclein aggregation and the ultrastructure changes in the heart and nodose (NG)/nucleus tractus solitarius (NTS).

RESULTS

Blood pressure (BP) and baroreflex sensitivity of DOPAL-treated rats were significantly reduced accompanied with a time-dependent change in orthostatic BP, consistent with altered echocardiography and cardiomyocyte mitochondrial ultrastructure. Notably, time-dependent and collaborated changes in Mon-/Tri-α-synuclein were paralleled with morphological alternation in the NG and NTS.

CONCLUSION

These all demonstrate that early autonomic dysfunction mediated by vagal application of DOPAL highly suggests the plausible etiology of PD initiated from peripheral, rather than central site. It will provide a scientific basis for the prevention and early diagnosis of PD.

Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis

BACKGROUND

Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups.

METHODS

Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale.

RESULTS

One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I2 = 99%) for 34 community cohorts, 19% (15-25%; I2 = 98%) for 23 primary care cohorts and 31% (15-50%; I2 = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16-23%; I2 = 98%) with hypertension (20 cohorts), 21% (16-26%; I2 = 92%) with diabetes (4 cohorts), 25% (18-33%; I2 = 88%) with Parkinson's disease (7 cohorts) and 29% (25-33%, I2 = 0%) with dementia (3 cohorts), compared to 14% (12-17%, I2 = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04).

CONCLUSIONS

PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH.

PROSPERO

CRD42017075423.

Acupuncture Treatment Reduces Incidence of Parkinson's Disease in Patients With Depression: A Population-Based Retrospective Cohort Study in Taiwan

Depression is a risk factor for subsequent Parkinson's disease (PD). Some patients with depression undergo acupuncture treatment because of other diseases in Taiwan. Therefore, the present study used data from Taiwan's National Health Insurance Research Database (NHIRD) to investigate the incidence of PD in patients having depression with and without acupuncture treatment. We conducted a retrospective study of a matched cohort of 48,981 patients with newly diagnosed depression between 2000 and 2012 who were selected from the NHIRD. The 1:1 propensity score method was utilized to match an equal number of patients (N = 9,189) in the acupuncture and non-acupuncture cohorts. We employed Cox proportional hazard models to evaluate the risk of PD. The cumulative incidence of PD in both cohorts was estimated using the Kaplan–Meier method, and the difference was examined through a log-rank test. Patients with depression who received acupuncture treatment demonstrated a lower risk of PD [adjusted hazard ratio (aHR) = 0.39, 95% confidence interval = 0.31–0.49] than those who did not undergo acupuncture treatment, after adjusting for age, sex, insurance amount, geographic region, urbanization levels, comorbidities, and drugs. The cumulative incidence of PD was significantly lower in the acupuncture cohort than in the non-acupuncture cohort (log-rank test, p < 0.001). The database did not indicate the severity of depression and acupoints. The results suggest that acupuncture treatment significantly reduced the development of PD in patients with depression; however, a future study should be conducted to provide more objective evidence.

Phenylalanine Effects on Brain Function in Adult Phenylketonuria

OBJECTIVE

To evaluate the relationship between circulating phenylalanine and brain function as well as neuropsychiatric symptoms in adults with phenylketonuria.

METHODS

In this prospective cross-sectional study, early-treated patients with phenylketonuria older than 30 years and age- and sex-matched controls were included. Extensive neurologic evaluation, neuropsychological and behavioral testing, sensory and motor evoked potentials, and MRI were performed. CSF concentrations of neurodegenerative markers were evaluated in addition in a subset of 10 patients.

RESULTS

Nineteen patients with phenylketonuria (median age 41 years) with different phenylalanine levels (median 873 μmol/L) entered the study. They showed higher prevalence of neurologic symptoms, cognitive and behavioral abnormalities, autonomic dysfunction, alterations in neurophysiologic measures, and atrophy in putamen and right thalamus compared to controls. In CSF, patients with phenylketonuria exhibited higher β-amyloid 1-42 (p = 0.003), total tau (p < 0.001), and phosphorylated tau (p = 0.032) levels compared to controls. Plasma phenylalanine levels highly correlated with the number of failed neuropsychological tests (r = 0.64, p = 0.003), neuropsychiatric symptoms (r = 0.73, p < 001), motor evoked potential latency (r = 0.48, p = 0.030), and parietal lobe atrophy.

CONCLUSIONS

Our study provides strong evidence for a correlation between phenylalanine levels and clinical, neuropsychological, neurophysiologic, biochemical, and imaging alterations in adult patients with phenylketonuria.

Detection of orthostatic hypotension with ambulatory blood pressure monitoring in parkinson's disease

We sought to test the accuracy of 24-hours ambulatory blood pressure (BP) monitoring (ABPM) for the detection of orthostatic hypotension (OH) in Parkinson's disease (PD). A total of 113 patients referred for autonomic testing between January 2015 and June 2017 underwent ABPM and office BP measurements in supine and standing positions. The study population consisted of 81 males and 32 females with PD duration of 6.5 ± 4.1 years and Hoehn and Yahr staging of 1 (13.3%), 1.5 (20.4%), 2 (27.4%), 2.5 (23.9%), 3 (13.3%), and 4 (1.8%). Motor fluctuations were present in 44% of patients. The data from office BP recordings were compared to selected ABPM parameters, and the results showed an association between OH and (a) ABPM-detected hypotensive episodes (Hypo-ep) and (b) ABPM-detected awakening hypotension (Hypo-aw). Having 2 or more Hypo-ep episodes ≤15 mmHg (systolic) compared to average 24-h systolic BP [Formula: see text] yielded 75% diagnostic accuracy for OH, while the presence of at least one [Formula: see text] within 90 min after getting up [Formula: see text] yielded 93% specificity for OH. A diagnostic accuracy of 87.6% was achieved when including daytime and nighttime ABPM values, weighted BP variability, systolic and diastolic BP loads, nocturnal dipping, and postprandial hypotension in a computerized prediction algorithm. In conclusion, our findings suggest that selected ABPM parameters, such as the number of hypotensive episodes and the presence of awakening hypotension, may be used to screen patients for OH, while using a computerized prediction algorithm that includes all ABPM parameters provides the greatest diagnostic accuracy.

The long-term direct and indirect economic burden among Parkinson's disease caregivers in the United States

BACKGROUND

Parkinson's disease is a progressive, disabling neurodegenerative disorder associated with significant economic burden for patients and caregivers. The objective of this study was to compare the direct and indirect economic burden of Parkinson's patients' caregivers with demographically matched controls in the United States, in the 5 years after first diagnosis of Parkinson's disease.

METHODS

Policyholders (18-64 years old) linked to a Parkinson's disease patient (≥2 diagnoses of Parkinson's disease; first diagnosis is the index date) from January 1, 1998 to March 31, 2014, were selected from a private-insurer claims database and categorized as Parkinson's caregivers. Eligible Parkinson's caregivers were matched 1:5 to policyholders with a non-Parkinson's dependent (controls). Multivariable regression adjusted for baseline characteristics estimated direct costs (all-cause insurer cost [medical and prescription] and comorbidity-related medical costs; patient out-of-pocket costs) and indirect costs (disability and medically related absenteeism costs). Income progression was also compared between cohorts.

RESULTS

A total of 1211 eligible Parkinson's caregivers (mean age, 56 years; 54% female) were matched to 6055 controls. In adjusted analyses, Parkinson's caregivers incurred significantly higher year 1 total all-cause insurer costs ($8999 vs $7117) and medical costs ($7081 vs $5568) (both P < 0.01) and higher prescription costs (range for years 1-5, $2506-2573 vs $1405-$1687) and total out-of-pocket costs ($1259-1585 vs $902-$1192) in years 1-5 (all P < 0.01). Parkinson's caregivers had significantly higher adjusted indirect costs in years 1-3 (range for years 1-3, $2054-$2464 vs $1681-$1857; all P < 0.05) and higher cumulative income loss over 5 years ($5967 vs $2634 by year 5; P for interaction = 0.03).

CONCLUSIONS

Parkinson's caregivers exhibited higher direct and indirect costs and greater income loss compared with matched controls. © 2018 International Parkinson and Movement Disorder Society © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Non-Motor Symptoms of Parkinson's Disease and Their Impact on Quality of Life in a Cohort of Moroccan Patients

Background

Non-motor symptoms (NMSs) are a real burden in Parkinson’s disease (PD). They may appear in early pre-symptomatic stage as well as throughout the disease course. However, their relationship with the deterioration of the patient’s quality of life (QoL) is still under debate. This study aimed to investigate the prevalence of NMSs and their impact on the QoL in a cohort of Moroccan patients.

Methods

We carried out a cross-transactional study, where a total of 117 patients were submitted to a structured clinical interview and examination investigating motor and NMSs based on common and conventional scales. Motor symptoms were assessed by the UPDRS I–VI during ON condition. The NMSs were evaluated with common scales and their relationship with the QoL was investigated.

Results

The mean patient’s age was 60.77 ± 11.36 years old, and the median disease duration was 6 years [2.5–9.5]. Motor’s phenotype subtypes were the mixed form in 40.2% of patients, akinetic-rigid in 20.5% and a tremor-dominant form in 39.3%. The median Hoehn and Yahr staging was 2 [1–2.5]. Regarding NMSs, the most common were urinary dysfunctions (82.6%), sleep (80.6%), and gastrointestinal (80%) disorders. Other autonomic dysfunctions were also frequent: thermoregulatory dysfunctions 58.6%, cardiovascular troubles 50.9%, and sexual dysfunctions 47.9%. Depression was present in 47.9% and fatigue symptoms in 23.1%. The median score of SCOPA-AUT was 14 [7.75–21.80]. The median PD questionnaire 39-score index (PDQ39-SI) was 23.22% and the most affected dimension was “mobility.” Univariate and multivariate analyses showed that the SCOPA-AUT score impacted the QoL (p = 0.001), especially the gastrointestinal (p = 0.007), and cardiovascular (p = 0.049) dimensions.

Conclusion

Our data show that all patients have presented at least one NMS. Autonomic and sleep disorders were the most frequent, and in contrast to other studies, digestive and cardiovascular disorders were rather the factors influencing negatively the QoL of patients. Understanding the pathophysiology of these NMSs should be placed at the forefront in order to develop new therapeutic approaches by improving the QoL of PD patients.

Effects of Exercise on Non-motor Symptoms in Parkinson's Disease

Patients with Parkinson's disease experience disabling non-motor symptoms, including autonomic dysfunction, cognitive decline, and sleep disorders. Pharmacologic treatments for these symptoms are often ineffective or have intolerable side effects. Therefore, non-pharmacologic interventions are an attractive alternative. Exercise in particular has the potential to alleviate the progressive impairment related to these non-motor symptoms. In this commentary, we explore available research that addresses the impact of exercise and physical activity on autonomic dysfunction, cognitive impairment, and sleep disorders in Parkinson's disease and suggest areas in need of further study. Many gaps remain in our understanding of the most effective exercise intervention for these symptoms, the mechanisms underlying exercise-induced changes, and the best way to monitor response to therapy. However, available research suggests that exercise is a promising approach to improve non-motor symptoms in patients with Parkinson's disease.

Impact of autonomic dysfunctions on the quality of life in Parkinson's disease patients

Autonomic dysfunctions are part of a spectrum of non-motor symptoms in Parkinson's disease (PD) patients. The aim of the study was to assess the prevalence of autonomic dysfunctions and their influence on the quality of life (QoL) in PD patients, adjusted for age, sex, disease duration and motor symptoms. Patients were evaluated for motor function (Unified Parkinson's Disease Rating Scale, UPDRS part III), disease stage (Hoehn and Yahr scale, H&Y scale), autonomic dysfunction (Scales for Outcomes in Parkinson's disease, Autonomic, SCOPA-AUT) and QoL (Parkinson's Disease Questionnaire-39, PDQ-39). Urinary, gastrointestinal and sexual autonomic dysfunctions were most frequently reported, while the most severe symptoms were reported for sexual and urinary systems. Age and motor symptoms did not correlate with autonomic dysfunction, while disease duration correlated with cardiovascular dysfunction. There were sex differences on the thermoregulation subscale. All types of autonomic dysfunction influenced QoL, mostly gastrointestinal and thermoregulatory dysfunctions, except for sexual one. Many aspects of QoL (activity of daily living, emotion, cognitive functions, communication and social support) except for stigma and mobility were affected by autonomic dysfunctions. Age, disease duration, sex and motor symptoms were not found to affect global QoL scores, but had detrimental effects on different PDQ-39 dimensions. Autonomic dysfunctions influence QoL in more aspects than motor symptoms, age, disease duration and sex. Patients tend to be more stigmatized with motor than non-motor symptoms.

Association between cognitive impairment and urinary dysfunction in Parkinson's disease

Urinary dysfunction (UD) is a common non-motor feature of Parkinson's disease (PD), and might be secondary to neurodegeneration involving cortical and subcortical brain areas. The possible link between UD and cognitive deficits has never been examined in frontal cortex impairment, and is still not completely understood in PD. In the present study, 94 PD patients underwent a comprehensive motor, cognitive and non-motor assessment. It was shown that 55.3% of patients reported UD, of which 17% needed specific urological treatment. Patients who reported UD performed worse on global cognition (PANDA, p = .05), visuo-constructive functions (CERAD/praxis, p = .03; and Figure Test, p = .03), and instrumental activities of daily living functions (IADL, p = .03), than patients without UD. The group with UD medication performed worse on global cognition (PANDA, p = .02) and visuo-constructive functions (CERAD/praxis, p = .05; CERAD/praxis recall, p = .05) than the UD group without medication, independent of anticholinergic treatment effect. Our findings suggest an association between cognitive impairment and UD in PD independent from symptomatic treatment.