Orthostatic hypotension and attention in Parkinson's disease with and without dementia

Hypotension with neurovascular changes and cognitive dysfunction: An epidemiological, pathobiological, and treatment review

ABSTRACT

Hypotension is a leading cause of age-related cognitive impairment. The available literature evidences that vascular factors are associated with dementia and that hypotension alters cerebral perfusion flow and can aggravate the neurodegeneration of Alzheimer's disease (AD). Despite the discovery of biomarkers and the recent progress made in neurovascular biology, epidemiology, and brain imaging, some key issues remain largely unresolved: the potential mechanisms underlying the neural deterioration observed in AD, the effect of cerebrovascular alterations on cognitive deficits, and the positive effects of hypotension treatment on cognition. Therefore, further well-designed studies are needed to unravel the potential association between hypotension and cognitive dysfunction and reveal the potential benefits of hypotension treatment for AD patients. Here, we review the current epidemiological, pathobiological, and treatment-related literature on neurovascular changes and hypotension-related cognitive dysfunction and highlight the unsettled but imminent issues that warrant future research endeavors.

Cardiovascular dysautonomia and cognitive impairment in Parkinson's disease (Review)

Cognitive impairment is a prevalent non-motor symptom of Parkinson's disease (PD), which can result in significant disability and distress for patients and caregivers. There is a marked variation in the timing, characteristics and rate at which cognitive decline occurs in patients with PD. This decline can vary from normal cognition to mild cognitive impairment and dementia. Cognitive impairment is associated with several pathophysiological mechanisms, including the accumulation of β-amyloid and tau in the brain, oxidative stress and neuroinflammation. Cardiovascular autonomic dysfunctions are commonly observed in patients with PD. These dysfunctions play a role in the progression of cognitive impairment, the incidents of falls and even in mortality. The majority of symptoms of dysautonomia arise from changes in the peripheral autonomic nervous system, including both the sympathetic and parasympathetic nervous systems. Cardiovascular changes, including orthostatic hypotension, supine hypertension and abnormal nocturnal blood pressure (BP), can occur in both the early and advanced stages of PD. These changes tend to increase as the disease advances. The present review aimed to describe the cognitive changes in the setting of cardiovascular dysautonomia and to discuss strategies through which these changes can be modified and managed. It is a multifactorial process usually involving decreased blood flow to the brain, resulting in the development of cerebral ischemic lesions, an increased presence of abnormal white matter signals in the brain, and a potential influence on the process of neurodegeneration in PD. Another possible explanation is this association being independent observations of PD progression. Patients with clinical symptoms of dysautonomia should undergo 24-h ambulatory BP monitoring, as they are frequently subtle and underdiagnosed.

The mechanism of impaired delayed recall verbal memory function in Parkinson's disease with orthostatic hypotension: a multiple imaging study

Introduction

Orthostatic hypotension (OH) frequently accompanies autonomic dysfunction and is an important risk factor for cognitive impairment in Parkinson's disease (PD). However, the association between different cognitive functions and OH in PD patients is not yet fully understood.

Methods

This study aimed to evaluate the scores of different cognitive domains and multiple parameters using different imaging techniques on PD patients with or without OH. A total number of 31 PD patients with OH (n = 20) and without OH (n = 11) were recruited from the Department of Neurology, Beijing Xuanwu Hospital for this study. All patients underwent beat-to-beat non-invasive blood pressure recordings and an active standing test to evaluate neurogenic OH and a global neuropsychological test to assess cognitive function. All patients underwent dynamic cerebral autoregulation (dCA) measurement, brain magnetic resonance imaging (MRI), and brain 18fluorine-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT).

Results

The results showed that OH patients had poor delayed recall verbal memory when compared with the PD patients without OH (1.75 ± 1.59 vs. 3.10 ± 1.73, p = 0.042). The dCA test indicated a significant difference in the right very low-frequency (VLF) gain between two groups (1.27 ± 0.17 vs. 1.10 ± 0.26, p = 0.045) and the brain 18F-FDG PET/CT indicated a significant difference in the SUV (right medial temporal lobe) to SUV (occipital lobe) ratio (0.60 ± 0.08 vs. 0.67 ± 0.11, p = 0.049). Meanwhile, these two imaging parameters were negatively correlated (p < 0.001). Furthermore, the score of a delayed recall verbal memory in the OH group was positively correlated with the right medial temporal lobe to occipital lobe ratio (p < 0.001) and was negatively correlated with the right VLF gain (p = 0.023).

Discussion

PD with OH patients had poor delayed recall memory, which might have been caused by the decreased metabolic dysfunction of specific medial temporal lobe due to the impaired dCA ability.

Effects of different levodopa doses on blood pressure in older patients with early and middle stages of Parkinson's disease

Objective

Levodopa is the first-line treatment for patients with Parkinson's disease (PD). However, only a few studies have focused on the tolerance of this drug in older patients with PD in the early and middle stages. Therefore, this study aimed to explore the effects of different levodopa doses on blood pressure (BP) in this subpopulation.

Methods

This cohort analysis enrolled 83 patients. The levodopa challenge test was used to evaluate drug responsiveness. After at least 12 h following anti-PD drug discontinuation, patients' BPs were measured in a lying position, after 1 min standing, and after 3 min standing, in "off state" and best "on state."

Results

BP in the 250 mg and 375 mg levodopa/benserazide groups decreased significantly in the lying and standing positions. The 3-min standing-position systolic BP was significantly influenced by the dose of levodopa/benserazide. However, no statistical change was observed in the 125 mg group. The postural-mediated systolic BP disparity was significant at 3 min in the upright position. Nineteen (incidence, 22.9%) and Twenty-five patients (incidence, 30.1%) developed complications of orthostatic hypotension (OH) in the "off state" and best "on state," respectively. Mild cognitive impairment was a risk factor for OH occurrence in the "off state." The OH occurrence in the best "on state" was associated with OH in the "off state" and urinary incontinence.

Conclusion

Our findings suggest that 250 mg or more of levodopa/benserazide could significantly reduce BP and orthostatic effect in older patients with PD in the early and middle stages. Therefore, they should routinely monitor their BP.

Trial registration number

ChiCTR2200055707.

A systematic review and meta-analysis on the association between orthostatic hypotension and mild cognitive impairment and dementia in Parkinson's disease

BACKGROUND

Cognitive impairment is a frequent disabling feature of Parkinson's disease (PD). Orthostatic hypotension (OH) is treatable and may be a risk factor for cognitive impairment.

OBJECTIVE

We conducted a systematic review and meta-analysis to examine the relationship between OH with PD-associated minimal cognitive impairment (PD-MCI) and dementia (PDD) and assess the mitigating effects of potential confounding factors.

METHODS

Observational studies published in English, Spanish, French, or Portuguese up to January 2022 were searched for in PubMed, EBSCO, and SciELO databases. The primary aim of this study was to revise the association between OH with PD-MCI and PDD. Alongside, we assessed OH as related to cognitive rating scales. Fixed and random models were fitted. Meta-regression was used to assess the mitigating effects of confounding variables.

RESULTS

We identified 18 studies that reported OH association with PDD or PD-MCI, 15 of them reporting OH association with cognitive rating scales. OH was significantly associated with PDD/PD-MCI (OR, 95% CI: 3.31, 2.16-5.08; k = 18, n = 2251; p < 0.01). OH association with PDD (4.64, 2.68-8.02; k = 13, n = 1194; p < 0.01) was stronger than with PD-MCI (1.82, 0.92-3.58; k = 5, n = 1056; p = NS). The association between OH and PD-MCI/PDD was stronger in studies with a higher proportion of women and in those with a lower frequency of supine hypertension. Global cognition rating scale scores were lower in patients with OH (SMD, 95% CI: - 0.55, - 0.83/ - 0.26; k = 12, n = 1427; p < 0.01).

CONCLUSIONS

Orthostatic hypotension shows as a significant risk factor for cognitive impairment in PD, especially in women and patients not suffering from hypertension.

Impaired Cerebral Autoregulation in Parkinson's Disease: An Orthostatic Hypotension Analysis

Orthostatic hypotension (OH) is an early non-motor manifestation of Parkinson's disease (PD). However, the underlying mechanism of hemodynamic changes in patients with PD and OH remains unclear. This study aimed to investigate the dynamic cerebral autoregulation changes in patients with PD with OH. Ninety patients with PD and 20 age- and sex-matched healthy controls (HCs) were recruited. The patients' non-invasive blood pressure (BP) and cerebral blood flow velocity were simultaneously recorded at supine and orthostatic positions during the active standing test (AST). Transfer function analysis was used to determine autoregulatory parameters including gain [i.e., damping effect of dynamic cerebral autoregulation (dCA) on the magnitude of BP oscillation] and phase difference (i.e., the time delay of the cerebral blood flow response to BP). Sixteen patients (17.8%) in the PD population were diagnosed with OH (PD-OH). The AST results were normal for 74 patients (82.2%) (PD-NOR). In the supine position, the PD-OH group had a lower phase degree than the PD-NOR group (50.3 ± 23.4 vs. 72.6 ± 32.2 vs. 68.9 ± 12.1, p = 0.020); however, no significant difference was found upon comparing with the HC group. In the orthostatic position, the normalized gain was significantly higher for the symptomatic OH group than for the asymptomatic OH group and HC group (1.50 ± 0.58 vs. 0.97 ± 0.29 vs. 1.10 ± 0.31, p = 0.019). A symptomatic OH in the PD population indicates an impaired cerebral autoregulation ability in the orthostatic position. Cerebral autoregulation tends to be impaired in the supine position in the OH population.

Rivastigmine in Parkinson's Disease Dementia with Orthostatic Hypotension

OBJECTIVE

The purpose of this study was to evaluate if the cognitive benefit of rivastigmine is affected by the presence of orthostatic hypotension (OH) in patients with Parkinson's disease dementia (PDD).

METHODS

We conducted a post hoc analysis on 1,047 patients with PDD from 2 randomized controlled trials comparing rivastigmine versus placebo at week 24 (n = 501) and rivastigmine patch versus capsule at week 76 (n = 546). A drop ≥ 20 mm Hg in systolic blood pressure (SBP) or ≥ 10 in diastolic blood pressure (DBP) upon standing classified subjects as OH positive (OH+); otherwise, OH negative (OH-). The primary end point was the Alzheimer's Disease Assessment Scale - Cognitive subscale (ADAS-Cog) at week 24 and the Mattis Dementia Rating Scale (MDRS) at week 76, using intention-to-treat with retrieved dropout at week 24 and observed cases at week 76, consistent with the original analyses.

RESULTS

Overall safety was comparable between OH+ (n = 288, 27.5%) and OH- (n = 730, 69.7%), except for higher frequency of syncope (9.2%) in the OH+ placebo arm. The placebo-adjusted effect of rivastigmine on ADAS-Cog at week 24 was 5.6 ± 1.2 for OH+ and 1.9 ± 0.9 in OH- (p = 0.0165). Among subjects with OH, the MDRS change from baseline at week 76 was higher for rivastigmine capsules versus patch (10.6 ± 2.9 vs -1.5 ± 3.0, p = 0.031). The overall prevalence of OH was lower for rivastigmine than placebo at week 24 (28.3% vs 44.6%, p = 0.0476).

INTERPRETATION

The cognitive benefit from rivastigmine is larger in patients with PDD with OH, possibly mediated by a direct antihypotensive effect. ANN NEUROL 2021;89:91-98.

Early autonomic and cognitive dysfunction in PD, DLB and MSA: blurring the boundaries between α-synucleinopathies

Differential diagnosis between Parkinson's disease, dementia with Lewy bodies and multiple system atrophy can be difficult, especially because in early phase they might present with overlapping clinical features. Notably, orthostatic hypotension and cognitive dysfunction are common nonmotor aspects of parkinsonian syndromes and can be both present from the earliest stages of all α-synucleinopathies, indicating a common neurobiological basis in their strong relationship. In view of the increasing awareness about the prevalence of mild cognitive dysfunction in multiple system atrophy, the relevance of autonomic dysfunction in demented parkinsonian patients, the critical role of non-motor symptoms in clustering Parkinson's disease patients and the shift to studying patients in the prodromal phase, we will discuss some intrinsic limitations of current clinical diagnostic criteria, even when applied by movement disorder specialists. In particular, we will focus on the early coexistence of autonomic and cognitive dysfunction in the setting of overt or latent parkinsonism as pitfalls in the differential diagnosis of α-synucleinopathies. As early and accurate diagnosis remains of outmost importance for counselling of patients and timely enrolment into disease-modifying clinical trials, a continuous effort of research community is ongoing to further improve the clinical diagnostic accuracy of α-synucleinopathies.

Fluctuating cognition in the Lewy body dementias

Fluctuating cognition is a core diagnostic feature of dementia with Lewy bodies and is also a key clinical feature of Parkinson's disease dementia. These dementias share common pathological features and are referred to as Lewy body dementias. Whilst highly prevalent in Lewy body dementia, with up to 90% of patients experiencing the symptom at some point in the disease trajectory, clinical identification of fluctuating cognition is often challenging. Furthermore, its underlying pathophysiological processes remain unclear. However, neuroimaging and neurophysiological techniques have recently provided insight into potential drivers of the phenomenon. In this update, we review data pertaining to clinical features and underlying mechanisms of fluctuating cognition in Lewy body dementia. We collate evidence for different proposed aetiologies: fluctuating cognition as an attentional disorder, as a consequence of loss of cholinergic drive, as a manifestation of failure in neuronal efficiency and synchrony, and as a disorder of sleep/arousal. We also review data relating to putative mechanisms that have received less attention to date. Increased understanding of fluctuating cognition may help to illuminate pathophysiological mechanisms in cognitive processing in Lewy body dementia, guide future research, and facilitate the design of targeted therapeutic approaches.

Autonomic dysfunction is associated with neuropsychological impairment in Lewy body disease

OBJECTIVE

This study aimed to analyze the association of autonomic dysfunction with cognition, depression, apathy, and fatigue in Lewy body disease (LBD).

METHODS

We included 61 patients [49 with idiopathic Parkinson's disease, 7 with dementia with Lewy bodies, and 5 E46K-SNCA mutation carriers] and 22 healthy controls. All participants underwent a comprehensive battery of neuropsychological and clinical measures, autonomic symptom assessment with the SCOPA-AUT, analysis of non-invasive hemodynamic parameters during deep breathing, the Valsalva maneuver, and a 20-min tilt test, and electrochemical skin conductance measurement at rest (Sudoscan). Student's t tests were used to assess group differences, and bivariate correlations and stepwise linear regressions to explore associations between autonomic function, cognition, depression, apathy, and fatigue.

RESULTS

Compared to controls, patients who had significant impairment (p < 0.05) in cognition, higher depression, apathy, and fatigue, more autonomic symptoms and objective autonomic dysfunction, reduced deep breathing heart rate variability [expiratory-to-inspiratory (E/I) ratio], prolonged pressure recovery time, and lower blood pressure in Valsalva late phase II and phase IV, while 24.1% had orthostatic hypotension in the tilt test. Autonomic parameters significantly correlated with cognitive and neuropsychiatric outcomes, systolic blood pressure during the Valsalva maneuver predicting apathy and depression. The E/I ratio was the main predictor of cognitive performance (17.6% for verbal fluency to 32.8% for visual memory).

CONCLUSION

Cardiovascular autonomic dysfunction is associated with cognitive and neuropsychiatric impairment in LBD, heart rate variability during deep breathing and systolic blood pressure changes during the Valsalva procedure are the main predictors of neuropsychological performance and depression/apathy symptoms, respectively.

Cognition in multiple system atrophy: a single-center cohort study

OBJECTIVE

Cognitive impairment in multiple system atrophy (MSA) is common, but remain poorly characterized. We evaluated cognitive and behavioral features in MSA patients and assessed between-group differences for MSA subtypes and the effect of orthostatic hypotension (OH) on cognition.

METHODS

This retrospective study included 54 patients with clinical diagnosis of possible and probable MSA referred to the Department of Neurology at Medical University of Innsbruck between 2000 and 2018. Neurological work-up included comprehensive neuropsychological testing including Consortium to Establish a Registry for Alzheimer's Disease (CERAD-plus) test battery, Frontal Assessment Battery (FAB), digit span test (DST), clock drawing task (CLOX1), and Hospital Anxiety and Depression Scale (HADS-D).

RESULTS

The mean MMSE score was 27.6 points. Overall, slight to moderate cognitive impairment was noted in up to 40% of patients, with predominant impairment of executive function and verbal memory. Patients with the cerebellar variant performed significantly worse than patients with the parkinsonian type (P < 0.05) in a screening of executive functions (FAB) and in phonemic verbal fluency. Depression and anxiety scores were elevated in 28% and 22% of MSA patients, respectively. Cognitive profile, depression, and anxiety levels were comparable between patients with and without OH.

INTERPRETATION

Cognitive deficits are relatively frequent in MSA and primarily affect executive functions and verbal memory. Future comparative studies including Parkinson dementia, Lewy body disease, and MSA cases with and without OH are required to elucidate disease-specific cognitive profiles in these synucleinopathies and to examine the influence of cardiovascular autonomic dysfunction on cognitive function in MSA.

Trouble Concentrating is an Easily Overlooked Symptom of Orthostatic Hypotension in Early Parkinson's Disease

BACKGROUND

Trouble concentrating during orthostasis is one symptom of orthostatic hypotension (OH), but it is often ignored in clinical practice because OH incorporates many nonspecific symptoms. Blunted cognition during orthostasis may affect various aspects of the clinical status of patients with Parkinson's disease (PD), but its impact on drug-naïve, early PD patients is not clear.

OBJECTIVE

This study investigated the association between trouble concentrating during orthostasis and orthostatic blood pressure changes and the influence of trouble concentrating during orthostasis on other non-motor symptoms and health-related quality of life in de novo PD.

METHODS

A total of 124 patients with early PD were enrolled and received a structured clinical interview, physical examination, and validated questionnaires to evaluate motor and non-motor symptoms and quality of life. Disturbed concentration was evaluated with question 5 of the Orthostatic Hypotension Questionnaire system assessment (part I). Supine blood pressure and blood pressure change during tilt table testing were recorded, and any association was analyzed.

RESULTS

Among the study population, 76 (61.3%) patients had trouble concentrating. Patients with blunted concentration had a steeper decrease in blood pressure during orthostasis. The score for trouble concentrating was positively associated with non-motor symptoms and quality of life scores.

CONCLUSIONS

Trouble concentrating when standing was a frequent finding in early, drug-naïve PD patients. It was positively associated with non-motor burden, mood and quality of life in patients with PD. OH was correlated with the incidence of trouble concentrating. Such findings complicate treatment but provide valuable information for managing early PD.

Orthostatic hypotension and cognition in older adults: A systematic review and meta-analysis

BACKGROUND

Orthostatic hypotension (OH) is common in older adults with reported prevalence rates of 5-40%. A direct link between OH and cognitive performance has been proposed due to impaired vascular autoregulation.

AIM

To systematically assess the literature of the association between OH and cognitive performance in older adults.

METHODS

Literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials and PsycINFO from inception to May 2017. Studies were included if OH and cognition were assessed in subjects of mean or median age ≥65 years. Risk of bias was assessed with the Newcastle Ottawa Scale.

RESULTS

Of 3266 studies screened, 32 studies (22 cross-sectional; 10 longitudinal) reporting data of 28,980 individuals were included. OH prevalence ranged from 3.3% to 58%. Of the 32 studies, 18 reported an association between OH and worse cognitive performance and 14 reported no association. Mini Mental State Examination (MMSE) was the most commonly used cognitive assessment tool. Studies using more than one cognitive assessment tool were more likely to find an association between OH and worse cognition. OH was significantly associated with a lower MMSE mean score (mean difference - 0.51 (95% CI: -0.85, -0.17, p = 0.003)) and an increased risk of cognitive impairment (OR 1.19 (95% CI, 1.00-1.42, p = 0.048)).

CONCLUSIONS

OH is common in older populations and is associated with worse cognition expressed as lower MMSE scores. Use of MMSE alone as a cognitive assessment tool may underestimate the association. It is yet unclear whether the association between OH and worse cognitive performance is causative.

Orthostatic hypotension and dementia incidence: links and implications

Orthostatic hypotension (OH) is a common condition, particularly in patients with α-synucleinopathies such as Parkinson's disease, and has a significant impact on activities of daily living and quality of life. Recent data suggest an association with cognitive impairment. Herein, we review the evidence that OH increases the odds of incident mild cognitive impairment and dementia. Potential mechanisms underlying the putative relationship are discussed, including cerebral hypoperfusion, supine hypertension, white matter hyperintensities, and neurodegeneration. Finally, we highlight the challenges with respect to treatment and the negative impact on the quality of life and long-term prognosis presented by the coexistence of OH and dementia. Large population-based studies have reported that OH is associated with about a 20% increased risk of dementia in the general population, while smaller cohort studies suggest an even greater effect in patients with α-synucleinopathies (3- to 7-fold higher than controls). Ultimately, OH exposure is difficult to quantify, predominantly limited to pressure regulation during a one-time orthostatic challenge, and the causative association with dementia may turn out to be bidirectional, especially in α-synucleinopathies. Early diagnosis and treatment of OH may improve long-term prognosis.

Consensus statement on the definition of neurogenic supine hypertension in cardiovascular autonomic failure by the American Autonomic Society (AAS) and the European Federation of Autonomic Societies (EFAS) : Endorsed by the European Academy of Neurology (EAN) and the European Society of Hypertension (ESH)

PURPOSE

Patients suffering from cardiovascular autonomic failure often develop neurogenic supine hypertension (nSH), i.e., high blood pressure (BP) in the supine position, which falls in the upright position owing to impaired autonomic regulation. A committee was formed to reach consensus among experts on the definition and diagnosis of nSH in the context of cardiovascular autonomic failure.

METHODS

As a first and preparatory step, a systematic search of PubMed-indexed literature on nSH up to January 2017 was performed. Available evidence derived from this search was discussed in a consensus expert round table meeting in Innsbruck on February 16, 2017. Statements originating from this meeting were further discussed by representatives of the American Autonomic Society and the European Federation of Autonomic Societies and are summarized in the document presented here. The final version received the endorsement of the European Academy of Neurology and the European Society of Hypertension.

RESULTS

In patients with neurogenic orthostatic hypotension, nSH is defined as systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, measured after at least 5 min of rest in the supine position. Three severity degrees are recommended: mild, moderate and severe. nSH may also be present during nocturnal sleep, with reduced-dipping, non-dipping or rising nocturnal BP profiles with respect to mean daytime BP values. Home BP monitoring and 24-h-ambulatory BP monitoring provide relevant information for a customized clinical management.

CONCLUSIONS

The establishment of expert-based criteria to define nSH should standardize diagnosis and allow a better understanding of its epidemiology, prognosis and, ultimately, treatment.

Cognitive fluctuations in Parkinson's disease dementia: blood pressure lability as an underlying mechanism

Background

Cognitive fluctuations refer to alterations in cognition, attention, or arousal occurring over minutes to hours, most commonly in patients with dementias associated with advanced Lewy body pathology. Their pathophysiologic underpinning remains undetermined.

Case presentation

We documented serial blood pressure (BP) measurements in an 86-year-old man with Parkinson’s disease dementia experiencing cognitive fluctuations during an office visit. This patient’s associated dysautonomia included labile BP with orthostatic hypotension and nocturnal hypertension. A spontaneous episode of unresponsiveness occurred while his BP was 72/48. His mental status began to recover immediately as his BP increased to 84/56 when he was placed in a recumbent position; it fully returned to baseline when it reached 124/66 within 1 min. His heart rate remained in the mid-to-high 60s throughout. Subsequent treatment with midodrine markedly reduced the frequency of cognitive fluctuations.

Conclusions

Paroxysmal hypotension may represent an explanatory mechanism for cognitive fluctuations, a common clinical feature in patients with Parkinson’s disease dementia and dementia with Lewy bodies.

Autonomic Dysfunction in Early Parkinson's Disease: Results from the United Kingdom Tracking Parkinson's Study

BACKGROUND

Autonomic dysfunction is common in the later stages of Parkinson's disease (PD), but less is known about its presence and severity in early disease.

OBJECTIVE

To analyze features of autonomic dysfunction in recent onset PD cases, and their relationship to motor severity, medication use, other nonmotor symptoms (NMS), and quality-of-life scores.

METHODS

Detailed patient-reported symptoms of autonomic dysfunction were assessed in a multicenter cohort study in PD cases that had been diagnosed within the preceding 3.5 years.

RESULTS

There were 1746 patients (1132 males, 65.2%), mean age 67.6 years (SD 9.3), mean disease duration 1.3 years (SD 0.9), mean Movement Disorder Society Unified Parkinson's Disease Rating Scale motor score 22.5 (SD 12.1). Orthostatic symptoms were reported by 39.6%, male erectile dysfunction by 56.1%, and female anorgasmia by 57.4%. Sialorrhea was an issue in 51.4% of patients, constipation in 43.6%, and dysphagia in 20.1%. Autonomic features increased with higher modified Hoehn and Yahr stages (P < 0.001). The severity of autonomic dysfunction was associated with the postural instability gait difficulty motor phenotype [β-coefficient 1.7, 95% confidence interval (CI) 0.7, 2.6, P < 0.001], depression (β-coefficient 4.1, CI 3.0, 5.2, P < 0.001), and excess daytime sleepiness (β-coefficient 3.1, CI 1.9, 4.2, P < 0.001). Dopamine agonists were the only drug class associated with greater autonomic dysfunction (P = 0.019). The severity of autonomic dysfunction strongly correlated with the presence of other NMS (ρ = 0.717, P < 0.001), and with poorer quality-of-life scores (ρ = 0.483, P < 0.001).

CONCLUSIONS

Autonomic dysfunction is common in early PD. Autonomic dysfunction correlates with the presence of other NMS, and with worse quality of life.

Different Clinical and Neuroimaging Characteristics in Early Stage Parkinson's Disease with Dementia and Dementia with Lewy Bodies

Parkinson’s disease with dementia (PDD) and dementia with Lewy bodies (DLB) both commonly exhibit brain Lewy body pathology and similar end-stage symptoms, but early symptoms differ. To clarify these differences, we compared the demographic characteristics, symptoms, cognitive and affective functioning, activities of daily life, and neuroimaging results between PDD (n = 52) and DLB (n = 46) patients. In measures of cognitive functioning, PDD patients had worse Hasegawa dementia scale-revised (HDS-R) scores (11.2±4.8) and better frontal assessment battery (FAB) scores (11.3±4.1) compared with DLB (17.0±6.4, p = 0.013 and 8.6±4.7, p = 0.039, respectively). DLB patients performed worse than PDD patients in “orientation to place” tasks. In affective functions, DLB patients had worse GDS (7.6±3.4) and ABS (9.9±5.3) scores than PDD patients (5.1±4.1 and 4.8±3.0, respectively). ^99mTc-ECD images showed greater CBF in the whole cingulate gyrus and a lower CBF in the precuneus area in DLB than in PDD. These results suggest that PDD patients’ lower average scores for “repetition” (MMSE), “recent memory” (HDS-R), and “lexical fluency” (FAB) were related to lower CBF in the cingulate gyrus than in DLB. Furthermore, DLB patients’ poorer average subscale scores of “orientation to place” (MMSE) and “similarities”, “conflicting instructions”, and “go-no go” (FAB) tasks may be related to the lower CBF in the precuneus area in DLB than PDD.

The association between orthostatic hypotension and cognitive state among adults 65 years and older who underwent a comprehensive geriatric assessment

The prevalence of cognitive impairment and orthostatic hypotension (OH) increases with age, but the results of studies that assessed possible associations between them are inconsistent.The aim of this study is to assess possible associations between cognitive impairment and OH in patients ≥65 years of age who underwent a comprehensive geriatric assessment.A retrospective analysis was conducted of the computerized medical records of the study population from 2005 to 2013. Data collected included blood pressure measurements that enabled the calculation of OH, results of the mini-mental state examination (MMSE), results of the Montreal cognitive assessment (MoCA) test, and cognitive diagnoses that were determined over the course of the assessment.The rate of OH in the study population of 571 adults was 32.1%. The mean MMSE score was 22.5 ± 5.2 among participants with OH and 21.6 ± 5.8 among those without OH (P = 0.09). The absence of a significant association between OH and MMSE remained after adjusting the MMSE score for age and education level. The mean MoCA score was 16.4 ± 5.0 among participants with OH and 16.4 ± 4.8 among those without (P = 0.33). The prevalence of OH was 39% among participants without cognitive impairment, 28.9% among those with mild cognitive impairment (MCI), and 30.6% among those with dementia (P = 0.13).There was no association between OH and cognitive impairment in adults who underwent a comprehensive geriatric assessment.

Clinical Relevance of Orthostatic Hypotension in Neurodegenerative Disease

The autonomic nervous system appears to be uniquely susceptible to degeneration in disorders of α-synuclein pathology. Clinically, autonomic dysfunction in these disorders manifests as neurogenic orthostatic hypotension (nOH), a condition that results in substantial morbidity and mortality. nOH results from pathology affecting either the central autonomic pathways or peripheral autonomic nerve fibers. Determining the localization and pathophysiology of nOH is critical in effectively managing this disorder and selecting appropriate treatment options. In this review, we discuss the pathophysiology of nOH with respect to the various α-synuclein-related neurodegenerative conditions. We highlight the associated clinical features, including gait instability, rapid eye movement behavior disorder, and hyposmia. We also review the current pharmacologic treatment options for nOH. Overall, the goals of therapy are to improve symptoms and prevent syncope and falls. Non-pharmacologic interventions should be introduced first, followed by carefully selected pharmacologic therapies. Treatment decisions should be directed by an understanding of the underlying pathophysiology, as well as the comorbidities and potential contributing factors present in each individual patient.

Supine hypertension in Parkinson's disease and multiple system atrophy

OBJECTIVE

Supine hypertension (SH) is a feature of cardiovascular autonomic failure that often accompanies orthostatic hypotension and may represent a negative prognostic factor in parkinsonian syndromes. Here we investigated the frequency rate as well as the clinical and tilt test correlates of SH in Parkinson's disease (PD) and multiple system atrophy (MSA).

METHODS

197 PD (33 demented) and 78 MSA (24 MSA-Cerebellar, 54 MSA-Parkinsonian) patients who had undergone a tilt test examination were retrospectively included. Clinical-demographic characteristics were collected from clinical records at the time of the tilt test examination.

RESULTS

SH (>140 mmHg systolic, >90 mmHg diastolic) occurred in 34 % of PD patients (n = 66, mild in 71 % of patients, moderate in 27 %, severe in 2 %) and 37 % of MSA ones (n = 29, mild in 55 % of patients, moderate in 17 %, severe in 28 %). No difference was observed in SH frequency between demented versus gender-, age- and disease duration-matched non-demented PD patients, or between patients with the parkinsonian (MSA-P) versus the cerebellar (MSA-C) variant of MSA. In PD, SH was associated with presence of cardiovascular comorbidities (p = 0.002) and greater systolic (p = 0.007) and diastolic (p = 0.002) orthostatic blood pressure fall. Orthostatic hypotension (p = 0.002), and to a lesser degree, lower daily dopaminergic intake (p = 0.01) and use of anti-hypertensive medications (p = 0.04) were associated with SH in MSA.

INTERPRETATION

One-third of PD and MSA patients suffer from mild to severe SH, independently of age, disease duration or stage. In PD, cardiovascular comorbidities significantly contribute to the development of SH, while in MSA, SH appears to reflect cardiovascular autonomic failure.

Cognitive and sleep features of multiple system atrophy: review and prospective study

BACKGROUND

The profile and degree of cognitive impairment in Multiple System Atrophy (MSA) and the impact of sleep disorders, REM sleep behavior disorder (RBD) in particular, in parkinsonism-related cognitive deficits are currently being debated.

SUMMARY

We reviewed the cognitive, affective and sleep findings in MSA and also carried out a longitudinal investigation of 10 MSA patients. At the first evaluation, 3 patients showed isolated cognitive deficits. After a mean of 16 months, these patients remained unchanged, while 1 patient worsened from a normal condition. No significant differences emerged when the cognitive, affective and video-polysomnographic findings of MSA-P and MSA-C were compared. Depression was present in half of the patients, although it did not influence their cognitive performance. Comparisons between the first and second evaluation data showed significant worsening in visual attention and in ADL/IADL and UMSARS.

KEY MESSAGES

Isolated cognitive deficits are evidenced in a minority of MSA patients with the absence of a clear-cut diagnosis of dementia in the early stages of the disease. Attention and executive functions are often impaired. This study with a short follow-up period showed that RBD, although present in almost all patients affected by MSA, does not appear a clear early marker of cognitive impairment. Future longer-term studies with a larger patient sample are thus encouraged.

Predictors of dementia in Parkinson disease: a prospective cohort study

OBJECTIVE

We investigated an array of possible markers of early dementia in Parkinson disease.

METHODS

We performed a comprehensive assessment of autonomic, sleep, psychiatric, visual, olfactory, and motor manifestations in 80 patients with Parkinson disease who were dementia-free at baseline. After 4.4 years' follow-up, patients were evaluated for dementia. Predictive variables were assessed using logistic regression adjusting for disease duration, follow-up duration, age, and sex.

RESULTS

Of 80 patients, 27 (34%) developed dementia. Patients destined to develop dementia were older and more often male (odds ratio [OR] = 3.64, p = 0.023). Those with baseline mild cognitive impairment had increased dementia risk (OR = 22.5, p < 0.001). REM sleep behavior disorder at baseline dramatically increased dementia risk (OR = 49.7, p = 0.001); however, neither daytime sleepiness nor insomnia predicted dementia. Higher baseline blood pressure increased dementia risk (OR = 1.37 per 10 mm Hg, p = 0.032). Orthostatic blood pressure drop was strongly associated with dementia risk (OR = 1.84 per 10 mm Hg, p < 0.001); having a systolic drop of >10 mm Hg increased dementia odds 7-fold (OR = 7.3, p = 0.002). Abnormal color vision increased dementia risk (OR = 3.3, p = 0.014), but olfactory dysfunction did not. Among baseline motor variables, proportion of gait involvement (OR = 1.12, p = 0.023), falls (OR = 3.02, p = 0.042), and freezing (OR = 2.63, p = 0.013), as well as the Purdue Pegboard Test (OR = 0.67, p = 0.049) and alternate tap test (OR = 0.97, p = 0.033) predicted dementia.

CONCLUSION

Cardiovascular autonomic dysfunction, REM sleep behavior disorder, color discrimination ability, and gait dysfunction strongly predict development of dementia in Parkinson disease.

Orthostatic hypotension in patients with Parkinson's disease and atypical parkinsonism

Orthostatic hypotension (OH) is one of the commonly occurring nonmotor symptoms in patients with idiopathic Parkinson's disease (IPD) and atypical parkinsonism (AP). We aimed to review current evidences on epidemiology, diagnosis, treatment, and prognosis of OH in patients with IPD and AP. Major electronic medical databases were assessed including PubMed/MEDLINE and Embase up to February 2013. English-written original or review articles with keywords such as "Parkinson's disease," "atypical parkinsonism," and "orthostatic hypotension" were searched for relevant evidences. We addressed different issues such as OH definition, epidemiologic characteristics, pathophysiology, testing and diagnosis, risk factors for symptomatic OH, OH as an early sign of IPD, prognosis, and treatment options of OH in parkinsonian syndromes. Symptomatic OH is present in up to 30% of IPD, 80% of multiple system atrophy (MSA), and 27% of other AP patients. OH may herald the onset of PD before cardinal motor symptoms and our review emphasises the importance of its timely diagnosis (even as one preclinical marker) and multifactorial treatment, starting with patient education and lifestyle approach. Advancing age, male sex, disease severity, and duration and subtype of motor symptoms are predisposing factors. OH increases the risk of falls, which affects the quality of life in PD patients.

Association of cognitive dysfunction with neurocirculatory abnormalities in early Parkinson disease

OBJECTIVE

Cognitive impairment and neurocirculatory abnormalities such as orthostatic hypotension (OH), supine hypertension (SH), and failure to decrease blood pressure at night (nondipping) occur relatively commonly in Parkinson disease (PD); however, whether cognitive dysfunction in early PD is related to neurocirculatory abnormalities has not been established. Cognitive dysfunction in PD is associated with white matter hyperintensities on MRI. We report results of an analysis of neuropsychological and hemodynamic parameters in patients with early PD.

METHODS

Among 87 patients, 25 had normal cognition, 48 had mild cognitive impairment, and 14 had dementia, based on comprehensive neuropsychological tests. Orthostatic vital signs and ambulatory 24-hour blood pressure monitoring were recorded, and brain magnetic resonance scans were obtained for all patients.

RESULTS

Cognitive impairment was associated with OH, SH, and white matter hyperintensities but not with nondipping. Dementia and white matter hyperintensities were common in SH. Of 13 patients with OH + SH, every one had mild cognitive impairment or dementia.

CONCLUSIONS

Cognitive dysfunction is related to neurocirculatory abnormalities, especially OH + SH, in early PD, raising the possibility that early detection and effective treatment of those abnormalities might slow the rate of cognitive decline.

The potential prognostic role of cardiovascular autonomic failure in α-synucleinopathies

Cardiovascular autonomic failure is the second most common dysautonomic feature of α-synucleinopathies and has significant impact on daily activities and quality of life. Here we provide a systematic review of cardiovascular autonomic failure in α-synucleinopathies, emphasizing its impact on cognitive functions and disease outcomes. Articles spanning the period between January 1985 and April 2012 were identified from the PubMed database using a keyword-based search. Epidemiological studies highlight the negative prognostic effect of cardiovascular autonomic failure on cardiovascular and cerebrovascular outcomes and overall mortality in all α-synucleinopathies. Altered cerebral perfusion, vascular pressure stress, and related disruption of the blood-brain barrier may also contribute to the white matter hyperintensities and cognitive dysfunction frequently found in patients affected by neurocardiovascular instability. These findings support the hypothesis that cardiovascular autonomic failure may play a negative prognostic role in α-synucleinopathies and suggest that precocious screening and therapeutic management of cardiovascular autonomic failure may positively impact disease course.

Diagnostic criteria for mild cognitive impairment in Parkinson's disease: Movement Disorder Society Task Force guidelines

Mild cognitive impairment is common in nondemented Parkinson's disease (PD) patients and may be a harbinger of dementia. In view of its importance, the Movement Disorder Society commissioned a task force to delineate diagnostic criteria for mild cognitive impairment in PD. The proposed diagnostic criteria are based on a literature review and expert consensus. This article provides guidelines to characterize the clinical syndrome and methods for its diagnosis. The criteria will require validation, and possibly refinement, as additional research improves our understanding of the epidemiology, presentation, neurobiology, assessment, and long-term course of this clinical syndrome. These diagnostic criteria will support future research efforts to identify at the earliest stage those PD patients at increased risk of progressive cognitive decline and dementia who may benefit from clinical interventions at a predementia stage.

Differences in motor and cognitive function in patients with Parkinson's disease with and without orthostatic hypotension

Patients with Parkinson's disease (PD) often present with orthostatic hypotension (OH) as a result of the dysautonomia associated with the disease or as a side effect of the dopaminergic medications used to treat the disease. The purpose of this study was to investigate differences in motor and cognitive function in patients with PD with and without OH. Forty-four patients with a diagnosis of PD were evaluated and stratified by the presence of OH based on orthostatic blood pressure recordings. Both groups underwent assessments of motor and cognitive function. OH was present in 17 of 44 patients (39%) with PD. These patients with OH had significantly lower scores in gross motor, balance, and cognitive function (p < .05). No significant difference between groups was found in the finger tapping scores. These results suggest that patients with PD should be routinely screened for OH as it commonly occurs and may negatively impact gross motor, balance, and cognitive function.

A review of orthostatic blood pressure regulation and its association with mood and cognition

AIMS

This paper will review literature that examines the psychological and neuropsychological correlates of orthostatic blood pressure regulation.

RESULTS

The pattern of change in systolic blood pressure in response to the shift from supine to upright posture reflects the adequacy of orthostatic regulation. Orthostatic integrity involves the skeletal muscle pump, neurovascular compensation, neurohumoral effects and cerebral flow regulation. Various physiological states and disease conditions may disrupt these mechanisms. Clinical and subclinical orthostatic hypotension has been associated with impaired cognitive function, decreased effort, reduced motivation and increased hopelessness as well as dementia, diabetes mellitus, and Parkinson's disease. Furthermore, inadequate blood pressure regulation in response to orthostasis has been linked to increased depression and anxiety as well as to intergenerational behavioral sequalae.

CONCLUSIONS

Identifying possible causes and consequences of subclinical and clinical OH are critical in improving quality of life for both children and older adults.

Cardiovascular autonomic testing in extrapyramidal disorders

Various diagnostic tests are available to demonstrate autonomic failure in extrapyramidal disease. Autonomic function tests can identify parasympathetic and sympathetic dysfunction. While specialized tests are only available in autonomic labs, routine tests such as 24h ambulatory blood pressure measurements can be broadly used in clinical practice eg. as screening tests. In this review, we briefly introduce functional cardiovascular autonomic testing and propose a workup plan for patients with extrapyramidal disease. In all patients with extrapyramidal disease, screening for autonomic dysfunction should be performed. In the case of pathological findings, detailed autonomic testing should be considered with repeated measurements at follow up visits.

Prevalence of orthostatic hypotension in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

Although orthostatic hypotension (OH) is recognized as one of the main non-motor symptoms of Parkinson's disease (PD), there is inconsistent evidence about the prevalence of OH in PD. To estimate the prevalence of OH in PD more precisely we conducted a systematic review of the literature.

METHODS

From PubMed and Embase searches with predefined inclusion criteria, we identified studies published up till December 2009. Prevalence numbers from studies were pooled using a non-linear random-effects meta-analysis.

RESULTS

We found 25 studies from which the prevalence of OH could be calculated. The pooled estimate of the point prevalence of OH in PD was 30.1% (95% CI: 22.9% to 38.4%). We found a large statistical heterogeneity between studies which could not be reduced by several subgroup analyses.

CONCLUSIONS

The estimated prevalence of OH in PD is 30%. However, due to the large heterogeneity between studies this pooled estimate should be interpreted with caution. More data from unselected population-based cohorts are needed.

Treatment of dysautonomia in extrapyramidal disorders

Although extrapyramidal diseases are commonly thought to solely affect the extrapyramidal motor system, nonmotor symptoms such as behavioural abnormalities, dysautonomia, sleep disturbances and sensory dysfunctions are also frequently observed. Autonomic dysfunction as an important clinical component of extrapyramidal disease (idiopathic Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, dementia with Lewy bodies) is often not formally assessed and thus frequently misdiagnosed. Symptoms of autonomic dysfunction in general impact more on quality of life than motor symptoms. Appropriate symptom-oriented diagnosis and symptomatic treatment as part of an interdisciplinary approach can greatly benefit the patient. Unfortunately, double-blind, randomized, controlled studies are scarce with the consequence that most recommendations are not based on the highest level of evidence. This review elaborates a limited overview on the treatment of cardiovascular, gastrointestinal, urogenital and sudomotor autonomic dysfunction in various extrapyramidal syndromes.

Ventilatory response to hypercapnia in C(5-8) chronic tetraplegia: the effect of posture

OBJECTIVE

To study the effect of posture on the hypercapnic ventilatory responses (HCVR).

DESIGN

Nonrandomized controlled study.

SETTING

Rehabilitation hospital and a pulmonary institute.

PARTICIPANTS

Patients with neurologically stable C(5-8) tetraplegia (n=12) and healthy control subjects (n=7).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Supine and seated forced vital capacity (FVC) and HCVR, and supine and erect blood pressure.

RESULTS

FVC in the sitting position was reduced in patients with tetraplegia (52+/-13% predicted); supine FVC was 21% higher (P=.0005). In the sitting position, HCVR was lower in patients than in controls (0.8+/-0.4 vs 2.46+/-0.3 L/min/mmHg, P<.001). Supine HCVR was not significantly different between the groups. When HCVR was normalized to FVC, there was still a significant difference between patients and controls in the sitting position. Patients with tetraplegia were orthostatic (mean supine blood pressure 91+/-13 mmHg vs mean erect blood pressure 61+/-13 mmHg, respectively, P<.0001). The magnitude of the orthostatism correlated with that of the postural change in HCVR (r=.93, P<.0001).

CONCLUSIONS

Respiratory muscle weakness may contribute to the attenuated HCVR in tetraplegia. However, the observation that supine HCVR is still low even when normalized to FVC suggests a central posture-dependent effect on the HCVR, which may be linked to the postural effect on arterial blood pressure.

Cardiovascular autonomic dysfunction in Parkinson's disease

Symptoms of cardiovascular dysautonomia are a common occurrence in Parkinson's disease (PD). In addition to this dysautonomia as part of PD itself, dysfunction of the autonomic nervous system (ANS) can be triggered as a side-effect of drug treatment interacting with the ANS or - if prominent and early - an indication of a different disease such as multiple system atrophy (MSA). Various diagnostic tests are available to demonstrate autonomic failure. While autonomic function tests can differentiate parasympathetic from sympathetic dysfunction, cardiac imaging can define the pathophysiologically involved site of a lesion. Standard tests such as 24-h ambulatory blood pressure measurements can identify significant autonomic failure which needs treatment. The most frequent and disturbing symptom of cardiovascular autonomic dysfunction is orthostatic hypotension. Symptoms include generalized weakness, light-headiness, mental "clouding" up to syncope. Factors like heat, food, alcohol, exercise, activities which increase intrathoraric pressure (e.g. defecation, coughing) and certain drugs (e.g. vasodilators) can worsen a probably asymptomatic orthostatic hypotension. Non-medical and medical therapies can help the patient to cope with a disabling symptomatic orthostatic hypotension. Supine hypertension is often associated with orthostatic hypotension. The prognostic role of cardiovagal and baroreflex dysfunction is still not yet known.