Clinical review of treatment options for select nonmotor symptoms of Parkinson's disease

The effects of physiotherapy treatments on dysphagia in Parkinson's disease: a systematic review of randomized controlled trials

BACKGROUND

The prevalence of swallowing disorders in Parkinson's disease (PD) is relatively high. Different physiotherapy interventions for swallowing disorders are available but there is a lack of evidence-based medicine for their effectiveness in PD.

OBJECTIVE

The purpose of this systematic review was to investigate the effects of different physiotherapy interventions on dysphagia in PD.

METHODS

This systematic review was conducted according to PRISMA guidelines. We methodically searched databases including PubMed, PEDro, Cochrane Library, Embase, and Web of Science. Studies of any language published up to March 2022 were searched. Randomized controlled trials (RCTs) of non-pharmacological treatment for dysphagia in PD were selected in strict accordance with our exclusion and inclusion criteria.

RESULTS

In total, we identified and included 10 RCTs in patients with PD undergoing dysphagia. This review involved seven rehabilitation treatments, including acupuncture, expiratory muscle strength training (EMST), repetitive transcranial magnetic stimulation (rTMS), video-assisted swallowing therapy (VAST), electrical stimulation, and speech and language therapy (SLT).

CONCLUSION

For physiotherapy treatments, including acupuncture, EMST, high-frequency rTMS and VAST may be effective treatments for dysphagia in patients with PD. However, there was not enough evidence that electrical stimulation has therapeutic effects on dysphagia in patients with PD.

MALAT1 lncRNA and Parkinson's Disease: The role in the Pathophysiology and Significance for Diagnostic and Therapeutic Approaches

Parkinson's disease (PD) is the second most common age-related neurodegenerative disorder. PD is characterized by progressive loss of dopamine-producing neurons in the substantia nigra (SN) region of brain tissue followed by the α-synuclein-based Lewy bodies' formation. These conditions are manifested by various motor and non-motor symptoms such as resting tremor, limb rigidity, bradykinesia and posture instability, cognitive impairment, sleep disorders, and emotional and memory dysfunctions. Long non-coding RNAs (lncRNAs) are closely related to protein-coding genes and are involved in various biological processes. Metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) lncRNA is involved in different pathways, including alternative splicing, transcriptional regulation, and post-transcriptional regulation, and also interacts with RNAs as a miRNA sponge. MALAT1 is highly expressed in brain tissues and several lines of evidence suggested it is probably involved in synapse generation and other neurophysiological pathways. This narrative review discussed all aspects of MALAT1-associated mechanisms involved in the PD pathogenesis, i.e., perturbed α-synuclein homeostasis, apoptosis and autophagy, and neuro-inflammation. Lastly, the possible applications of MALAT1 as a diagnostic biomarker and its importance to developing therapeutic strategies were highlighted. The literature search was conducted using neurodegeneration, neurodegenerative disorders, Parkinson's disease, lncRNA, and MALAT1 as search items in Google Scholar, Web of Knowledge, PubMed, and Scopus up to December 2021.

A Transcriptome Analysis of mRNAs and Long Non-Coding RNAs in Patients with Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder. The number of cases of PD is expected to double by 2030, representing a heavy burden on the healthcare system. Clinical symptoms include the progressive loss of dopaminergic neurons in the substantia nigra of the midbrain, which leads to striatal dopamine deficiency and, subsequently, causes motor dysfunction. Certainly, the study of the transcriptome of the various RNAs plays a crucial role in the study of this neurodegenerative disease. In fact, the aim of this study was to evaluate the transcriptome in a cohort of subjects with PD compared with a control cohort. In particular we focused on mRNAs and long non-coding RNAs (lncRNA), using the Illumina NextSeq 550 DX System. Differential expression analysis revealed 716 transcripts with padj ≤ 0.05; among these, 630 were mRNA (coding protein), lncRNA, and MT_tRNA. Ingenuity pathway analysis (IPA, Qiagen) was used to perform the functional and pathway analysis. The highest statistically significant pathways were: IL-15 signaling, B cell receptor signaling, systemic lupus erythematosus in B cell signaling pathway, communication between innate and adaptive immune cells, and melatonin degradation II. Our findings further reinforce the important roles of mitochondria and lncRNA in PD and, in parallel, further support the concept of inverse comorbidity between PD and some cancers.

A Transcriptome Analysis of mRNAs and Long Non-Coding RNAs in Patients with Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder. The number of cases of PD is expected to double by 2030, representing a heavy burden on the healthcare system. Clinical symptoms include the progressive loss of dopaminergic neurons in the substantia nigra of the midbrain, which leads to striatal dopamine deficiency and, subsequently, causes motor dysfunction. Certainly, the study of the transcriptome of the various RNAs plays a crucial role in the study of this neurodegenerative disease. In fact, the aim of this study was to evaluate the transcriptome in a cohort of subjects with PD compared with a control cohort. In particular we focused on mRNAs and long non-coding RNAs (lncRNA), using the Illumina NextSeq 550 DX System. Differential expression analysis revealed 716 transcripts with padj ≤ 0.05; among these, 630 were mRNA (coding protein), lncRNA, and MT_tRNA. Ingenuity pathway analysis (IPA, Qiagen) was used to perform the functional and pathway analysis. The highest statistically significant pathways were: IL-15 signaling, B cell receptor signaling, systemic lupus erythematosus in B cell signaling pathway, communication between innate and adaptive immune cells, and melatonin degradation II. Our findings further reinforce the important roles of mitochondria and lncRNA in PD and, in parallel, further support the concept of inverse comorbidity between PD and some cancers.

Safety and Efficacy of Intermittent Colonic Exoperistalsis Device to Treat Chronic Constipation: A Prospective Multicentric Clinical Trial

Chronic constipation is associated with various comorbidities and reduced quality of life. Current solutions, either pharmacological or invasive, show limited efficacy. Manual colon-specific massage is a well-established intervention to treat chronic constipation, but it should be applied daily. MOWOOT automatically provides intermittent colonic exo-peristalsis (ICE) treatment like that in manual massage.

Long Non-coding RNAs in Parkinson's Disease

Parkinson's disease (PD) is the second most prevalent neurodegenerative disorder and is associated with a range of motor and non-motor clinical symptoms. The underlying molecular pathogenesis of PD involves a variety of pathways and mechanisms, including α-synuclein proteostasis, mitochondrial dysfunction, oxidative stress, autophagy and apoptosis, neuroinflammation, and epigenetic regulation. Long non-coding RNAs (lncRNAs) are involved in the regulation of multiple pathological processes of PD. In this review, we provide an overview of large-scale studies on lncRNA expression profiling in PD patients and models, as well as highlight the impacts of lncRNAs on the pathogenesis of PD, which could provide basic information regarding the putative lncRNA-based biomarkers and therapeutic targets for the early diagnosis and treatment strategies for PD.

Psychiatric Manifestation in Patients with Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder. Although its major manifestation is motor symptoms, resulting from the loss of dopaminergic neurons in the substantia nigra, psychiatric symptoms, such as depression, anxiety, hallucination, delusion, apathy and anhedonia, impulsive and compulsive behaviors, and cognitive dysfunction, may also manifest in most patients with PD. Given that the quality of life - and the need for institutionalization - is so highly dependent on the psychiatric well-being of patients with PD, psychiatric symptoms are of high clinical significance. We reviewed the prevalence, risk factors, pathophysiology, and treatment of psychiatric symptoms to get a better understanding of PD for improved management.

Enriched environment elevates expression of growth associated protein-43 in the substantia nigra of SAMP8 mice

An enriched environment protects dopaminergic neurons from 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced neuronal injury, but the underlying mechanism for this is not clear. Growth associated protein-43 (GAP-43) is closely associated with neurite outgrowth and axon regeneration during neural development. We speculate that an enriched environment can reduce damage to dopaminergic neurons by affecting the expression of GAP-43. This study is designed to test this hypothesis. Three-month-old female senescence-accelerated mouse prone 8 (SAMP8) mice were housed for 3 months in an enriched environment or a standard environment. These mice were then subcutaneously injected in the abdomen with 14 mg/kg MPTP four times at 2-hour intervals. Morris water maze testing demonstrated that learning and memory abilities were better in the enriched environment group than in the standard environment group. Reverse-transcription polymerase chain reaction, immunohistochemistry and western blot assays showed that mRNA and protein levels of GAP-43 in the substantia nigra were higher after MPTP application in the enriched environment group compared with the standard environment group. These findings indicate that an enriched environment can increase GAP-43 expression in SAMP8 mice. The upregulation of GAP-43 may be a mechanism by which an enriched environment protects against MPTP-induced neuronal damage.

Physical Exercise Modulates L-DOPA-Regulated Molecular Pathways in the MPTP Mouse Model of Parkinson's Disease

Parkinson's disease (PD) is characterized by the degeneration of dopaminergic (DA) neurons in the substantia nigra pars compacta (SNpc), resulting in motor and non-motor dysfunction. Physical exercise improves these symptoms in PD patients. To explore the molecular mechanisms underlying the beneficial effects of physical exercise, we exposed 1-methyl-4-phenyl-1,2,3,6-tetrahydropyrimidine (MPTP)-treated mice to a four-week physical exercise regimen, and subsequently explored their motor performance and the transcriptome of multiple PD-linked brain areas. MPTP reduced the number of DA neurons in the SNpc, whereas physical exercise improved beam walking, rotarod performance, and motor behavior in the open field. Further, enrichment analyses of the RNA-sequencing data revealed that in the MPTP-treated mice physical exercise predominantly modulated signaling cascades that are regulated by the top upstream regulators L-DOPA, RICTOR, CREB1, or bicuculline/dalfampridine, associated with movement disorders, mitochondrial dysfunction, and epilepsy-related processes. To elucidate the molecular pathways underlying these cascades, we integrated the proteins encoded by the exercise-induced differentially expressed mRNAs for each of the upstream regulators into a molecular landscape, for multiple key brain areas. Most notable was the opposite effect of physical exercise compared to previously reported effects of L-DOPA on the expression of mRNAs in the SN and the ventromedial striatum that are involved in-among other processes-circadian rhythm and signaling involving DA, neuropeptides, and endocannabinoids. Altogether, our findings suggest that physical exercise can improve motor function in PD and may, at the same time, counteract L-DOPA-mediated molecular mechanisms. Further, we hypothesize that physical exercise has the potential to improve non-motor symptoms of PD, some of which may be the result of (chronic) L-DOPA use.

A Survey of Application of Complementary and Alternative Medicine in Chinese Patients with Parkinson's Disease: A Pilot Study

OBJECTIVE

To investigate the prevalence and spectrum of complementary and alternative medicine (CAM) application and its related-factors in Parkinson's disease (PD) patients in China.

METHODS

A structured questionnaire regarding the use of CAMs was administered to PD patients by face-to-face interview. Demographic and social variables, clinical characteristics and treatments, and the related factors of PD were also surveyed.

RESULTS

Ninety out of 113 patients (79.6%) reported that they had received CAMs treatment, of which 48.6% (55/113) patients had received CAMs treatment for PD. The top 3 kinds of CAMs for PD were Chinese materia medica, rehabilitation exercise, and acupuncture ordinally. The source of information regarding CAMs treatment mainly came from relatives and friends (51.8%, 73 cases), followed by physicians (31.9%, 45 cases), and medias such as television, newspapers or the internet (16.3%, 28 cases). Fifty percent of CAM users reported a good therapeutic efficacy, whereas 39% patients reported that they felt neither better nor worse after the treatment, while 11% patients claimed worsening of symptoms. Multiple correspondence analyses survey found the main factors affecting the selectivity of CAMs ranked in the following order: income, education, occupation, habitation, age at onset, Hoehn and Yahr staging, PD duration, and gender.

CONCLUSION

CAMs, especially Chinese materia medica, rehabilitation exercise, and acupuncture, are widely used for PD patients in China.

The effect of light exposure on insomnia and nocturnal movement in Parkinson's disease: an open label, retrospective, longitudinal study

Insomnia, hypersomnia and REM Sleep Behavior Disorder (RSBD) during sleep are major problems for patients suffering from Parkinson's disease (PD) but they are also used to predict its onset. While these secondary symptoms detract from the quality of life in PD patients, few treatment options are available due to limited efficacy or risk of complicating the treatment regimen. Light therapy (LT) has been suggested as a strategy for sleep disorders but it has only been implemented recently for use in PD. An open label, retrospective study was undertaken where PD patients had been undergoing LT, using polychromatic light, for four months to 15 years prior. It was found that 1 h exposure to light, just prior to retiring, significantly improved insomnia and reduced RSBD in as little as one month after commencing LT. In addition, the improvement was maintained as long as LT was continued over a four to six year period. The efficacy of LT in alleviating these sleep related conditions was not compromised by time since diagnosis or age of the patient. These results intimate the value of long term application of non-invasive techniques such as LT for treating sleep disorders in PD and justify further controlled trials on the long term efficacy of LT.

Neuroprotective and Therapeutic Strategies against Parkinson's Disease: Recent Perspectives

Parkinsonism is a progressive motor disease that affects 1.5 million Americans and is the second most common neurodegenerative disease after Alzheimer’s. Typical neuropathological features of Parkinson’s disease (PD) include degeneration of dopaminergic neurons located in the pars compacta of the substantia nigra that project to the striatum (nigro-striatal pathway) and depositions of cytoplasmic fibrillary inclusions (Lewy bodies) which contain ubiquitin and α-synuclein. The cardinal motor signs of PD are tremors, rigidity, slow movement (bradykinesia), poor balance, and difficulty in walking (Parkinsonian gait). In addition to motor symptoms, non-motor symptoms that include autonomic and psychiatric as well as cognitive impairments are pressing issues that need to be addressed. Several different mechanisms play an important role in generation of Lewy bodies; endoplasmic reticulum (ER) stress induced unfolded proteins, neuroinflammation and eventual loss of dopaminergic neurons in the substantia nigra of mid brain in PD. Moreover, these diverse processes that result in PD make modeling of the disease and evaluation of therapeutics against this devastating disease difficult. Here, we will discuss diverse mechanisms that are involved in PD, neuroprotective and therapeutic strategies currently in clinical trial or in preclinical stages, and impart views about strategies that are promising to mitigate PD pathology.

Dementia With Lew Body: Impacts of Surgery

Patients who have dementia with Lewy bodies (DLB) and undergo surgery may develop aggravated postoperative cognitive dysfunction or postoperative delirium. Many patients with DLB respond poorly to surgery and anesthesia, and their conditions may worsen if they have other medical complications along with dementia. They may also face high risk of prolonged hospital stay, increased medical problems and/or mortality, causing significant physical, psychosocial, and financial burdens on individuals, family members, and society. Anesthesia, pain medications, old age, and surgery-related stresses are usually held responsible for the complications; however, the exact causes are still not fully understood. Literature on surgery-related complications for patients with DLB appears to be inadequate, and hence the topic merits detailed and systematic research. This article reviews postoperative complications and various surgery-related risk factors for DLB in light of other dementias such as Alzheimer's disease, as their neuropathologic features overlap with those of DLB.

Anticholinergic burden in Parkinson's disease inpatients

PURPOSE

Anticholinergic toxicity can arise as a result of the cumulative burden of multiple medications and metabolites rather than be caused by a single compound. In this sense, prescribing drugs with anticholinergic properties to Parkinson's disease (PD) patients could contribute to aggravate some frequent problems of the disease, like dementia, urinary retention, falls, or constipation, among others. The main purpose of this article is to measure the total anticholinergic burden in a group of PD inpatients.

METHOD

We analyzed information from different administrative Basque Country's healthcare databases using encrypted unique identifiers in order to detect PD patients admitted to public acute care hospital during 2011-2012. Subsequently, anticholinergic burden was measured using Duran et al.'s list. Secondarily, total anticholinergic load was assessed with the Anticholinergic Drug Scale, the Anticholinergic Risk Score, and the Anticholinergic Burden Scale. A logistic regression model was performed to study association of predictive variables with anticholinergic use.

RESULTS

A high proportion of PD patients were prescribed anticholinergic drugs, with 53.6% of admissions receiving at least one drug from Duran et al.'s "low-risk" and 10% at least "high-risk" drug. Drugs used for non-motor symptoms and other comorbidities other than PD itself contributed significantly to anticholinergic burden, namely antidepressants, antipsychotics, urological drugs, analgesics, and antihistamines, among others. The total number of drugs and cholinesterase inhibitors were independently associated with anticholinergic drug use.

CONCLUSIONS

Anticholinergic burden in PD patients is significant, and is caused mostly by drugs not used for PD motor symptoms. Polypharmacy and cholinesterase inhibitors were independently associated with anticholinergic drug prescriptions.

Psychosis

PURPOSE OF REVIEW

Psychosis is a common and functionally disruptive symptom of many psychiatric, neurodevelopmental, neurologic, and medical conditions and an important target of evaluation and treatment in neurologic and psychiatric practice. The purpose of this review is to define psychosis, communicate recent changes to the classification of and criteria for primary psychotic disorders described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and summarize current evidence-based approaches to the evaluation and management of primary and secondary psychoses.

RECENT FINDINGS

The DSM-5 classification of and criteria for primary psychotic disorders emphasize that these conditions occur along a spectrum, with schizoid (personality) disorder and schizophrenia defining its mild and severe ends, respectively. Psychosis is also identified as only one of several dimensions of neuropsychiatric disturbance in these disorders, with others encompassing abnormal psychomotor behaviors, negative symptoms, cognitive impairments, and emotional disturbances. This dimensional approach regards hallucinations and delusions as arising from neural systems subserving perception and information processing, thereby aligning the neurobiological framework used to describe and study such symptoms in primary psychotic disorders with those used to study psychosis associated with other neurologic conditions.

SUMMARY

This article provides practicing neurologists with updates on current approaches to the diagnosis, evaluation, and treatment of primary and secondary psychoses.

Comprehensive treatment of dementia with Lewy bodies

Dementia with Lewy bodies is an under-recognized disease; it is responsible for up to 20 % of all dementia cases. Accurate diagnosis is essential because the management of dementia with Lewy bodies is more complex than many neurodegenerative diseases. This is because alpha-synuclein, the pathological protein responsible for dementia with Lewy bodies (and Parkinson's disease), produces symptoms in multiple domains. By dividing the symptoms into cognitive, neuropsychiatric, movement, autonomic, and sleep categories, a comprehensive treatment strategy can be achieved. Management decisions are complex, since the treatment of one set of symptoms can cause complications in other symptom domains. Nevertheless, a comprehensive treatment program can greatly improve the patient's quality of life, but does not alter the progression of disease. Cholinesterase inhibitors are effective for cognitive and neuropsychiatric symptoms; rivastigmine has the widest evidence base. Special care needs to be taken to avoid potentially fatal idiopathic reactions to neuroleptic medications; these should be used for short periods only when absolutely necessary and when alternative treatments have failed. Pimavanserin, a selective serotonin 5-HT2A inverse agonist, holds promise as an alternative therapy for synuclein-associated psychosis. Levodopa/carbidopa treatment of parkinsonism is often limited by dopa-induced exacerbations of neuropsychiatric and cognitive symptoms. Autonomic symptoms are under-recognized complications of synucleinopathy. Constipation, urinary symptoms and postural hypotension respond to standard medications. Rapid eye movement sleep behavior disorder is highly specific (98 %) to the synucleinopathies. Nonpharmacological treatments, melatonin and clonazepam are all effective.

A systematic review of treatments for Impulse Control Disorders and related behaviours in Parkinson's disease

Impulse Control Disorders (ICDs) are a set of behaviours characterised by impulsivity despite known harm. Related to ICDs is the dopamine dysregulation syndrome (DDS), which is characterised by an addiction-like consumption of dopaminergic medication and punding. These behaviours all have an increased prevalence in Parkinson׳s disease (PD). The aim of this review is to identify treatments available for patients suffering from ICDs, DDS and punding in PD. Searches of The Cochrane Controlled Trials Register, Embase, Medline and PsychInfo were conducted, using the entire timescale available. Seven out of the 688 papers retrieved met the inclusion criteria and were considered in this systematic review. One class I study, one class II study, and five class IV studies were identified. All studies demonstrated a positive effect on ICDs in PD. Research in this field is still in its early stages. At present, there is insufficient evidence to recommend any treatment over another. There is a need for more methodologically robust research, using larger, more generalisable samples, randomisation and meaningful follow-up periods. In addition, the use of a validated outcome measures should be implemented in future research efforts.

Therapeutic strategies in Parkinson's disease: what we have learned from animal models

Parkinson's disease (PD), the second most common neurodegenerative disorder, is characterized by a loss of dopaminergic neurons in the substantia nigra, as well as in other brain areas. The currently available dopamine replacement therapy provides merely symptomatic benefit and is ineffective because habituation and side effects arise relatively quickly. Studying the genetic forms of PD in animal models provides novel insight that allows targeting of specific aspects of this heterogenic disease more specifically. Among others, two important cellular deficits are associated with PD; these deficits relate to (1) synaptic transmission and vesicle trafficking, and (2) mitochondrial function, relating respectively to the dominant and recessive mutations in PD-causing genes. With increased knowledge of PD, the possibility of identifying an efficient, long-lasting treatment is becoming more conceivable, but this can only be done with an increased knowledge of the specific affected cellular mechanisms. This review discusses how discoveries in animal models of PD have clarified the therapeutic potential of pathways disrupted in PD, with a specific focus on synaptic transmission, vesicle trafficking, and mitochondrial function.

Mixed effects of deep brain stimulation on depressive symptomatology in Parkinson's disease: a review of randomized clinical trials

Although ~50% of patients with Parkinson’s disease (PD) experience depression, treatment for this important and debilitating comorbidity is relatively understudied. Deep brain stimulation (DBS) has been increasingly utilized for the management of tremors in progressive PD. Several preliminary studies have shown the potential benefit of DBS for non-motor PD symptoms such as depression. Here, we critically evaluate seven recent randomized clinical trials of the effectiveness of DBS in reducing depressive symptomatology among individuals with PD. Findings are mixed for the effectiveness of DBS as a treatment for depression in PD. Our review suggests that this is due, in large part, to the anatomical and methodological variation across the DBS studies. We provide a comprehensive discussion of these variations and highlight the need to conduct larger, more controlled studies aimed specifically at evaluating the treatment of depression in PD patients.

Emerging therapies for Parkinson's disease: from bench to bedside

The prevalence of Parkinson's disease (PD) increases with age and is projected to increase in parallel to the rising average age of the population. The disease can have significant health-related, social, and financial implications not only for the patient and the caregiver, but for the health care system as well. While the neuropathology of this neurodegenerative disorder is fairly well understood, its etiology remains a mystery, making it difficult to target therapy. The currently available drugs for treatment provide only symptomatic relief and do not control or prevent disease progression, and as a result patient compliance and satisfaction are low. Several emerging pharmacotherapies for PD are in different stages of clinical development. These therapies include adenosine A2A receptor antagonists, glutamate receptor antagonists, monoamine oxidase inhibitors, anti-apoptotic agents, and antioxidants such as coenzyme Q10, N-acetyl cysteine, and edaravone. Other emerging non-pharmacotherapies include viral vector gene therapy, microRNAs, transglutaminases, RTP801, stem cells and glial derived neurotrophic factor (GDNF). In addition, surgical procedures including deep brain stimulation, pallidotomy, thalamotomy and gamma knife surgery have emerged as alternative interventions for advanced PD patients who have completely utilized standard treatments and still suffer from persistent motor fluctuations. While several of these therapies hold much promise in delaying the onset of the disease and slowing its progression, more pharmacotherapies and surgical interventions need to be investigated in different stages of PD. It is hoped that these emerging therapies and surgical procedures will strengthen our clinical armamentarium for improved treatment of PD.

Treatment effects for dysphagia in Parkinson's disease: a systematic review

BACKGROUND

Dysphagia remains a common problem in Parkinson's disease (PD). Previous systematic reviews on therapy effects for oropharyngeal dysphagia in PD have shown a lack of evidence. In the past 5 years several placebo or sham-controlled trials with varying results have been published.

OBJECTIVE

The aim of this systematic literature review is to summarize and qualitatively analyze the published studies on this matter.

METHOD(S)

Studies published up to December 2013 were found via a systematic comprehensive electronic database search using PubMed, Embase, and The Cochrane Library. Two reviewers independently assessed the studies using strict inclusion criteria.

RESULT(S)

Twelve studies were included and qualitatively analyzed using critical appraisal items. The review includes rehabilitative (exercises, electrical stimulation, bolus modification etc.) and pharmacologic treatment. Some well-designed controlled trials were included. However, none of the included studies fulfilled all criteria for external and internal validity. A meta-analysis was not carried out as most of the studies were not of sufficient quality to warrant doing so.

CONCLUSION

Expiratory Muscle Strength Training (EMST) and Video-Assisted Swallowing Therapy (VAST) may be effective dysphagia treatments solely or in addition to dopaminergic therapy for PD. However, these preliminary results warrant further investigation concerning their clinical applicability, and further research should be based on randomized sham-controlled trials to determine the effectiveness and long-term effects of different therapies for dysphagia in PD.

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.

Treatment of dementia with lewy bodies

OPINION STATEMENT

Dementia with Lewy bodies (DLB) is a multisystem disorder with diverse disease expression. A treatment regime restricted to the cognitive aspects of the disease does no favor to patients. Instead, patients should be educated to recognize the symptoms of this multisystem involvement. There are no treatments that slow the progression of disease, but symptomatic treatments can be effective. When thinking about treatment, we find it useful to divide the symptoms and signs into five categories: (a) cognitive features, (b) neuropsychiatric features, (c) motor dysfunction, (d) autonomic dysfunction, and (e) sleep dysfunction. Clinicians, funding bodies and industry are increasingly recognizing the importance of this common and debilitating disease.

Adding to the burden: gastrointestinal symptoms and syndromes in multiple sclerosis

Background. Multiple sclerosis (MS) patients often suffer from gastrointestinal (GI) symptoms. However, the full extent and prevalence of such symptoms are not clearly established. Thus, we sought to define the prevalence of GI symptoms and syndromes in those with MS. Methods. 218 MS patients completed self-reported demographic and clinical data questionnaires as well as several standardized surveys probing MS severity and GI health. Results. Nearly two thirds (65.6%) of patients endorsed at least one persistent GI symptom. Constipation (36.6%), dysphagia (21.1%), and fecal incontinence (15.1%) were common. Surprisingly, nearly 30% (28.4%) of the patients reported dyspeptic symptoms. Using validated diagnostic algorithms, patients met criteria for functional dysphagia (14.7%), functional dyspepsia (16.5%), functional constipation (31.7%), and IBS (19.3%), among others. Functional dysphagia, functional dyspepsia, and IBS were significantly more common in those with self-identified mood disorders. Conclusions. Constipation, fecal incontinence, and dysphagia are indeed frequent symptoms seen in MS patients. We also noted a ~30% prevalence of dyspepsia in this population. The mechanisms driving this association are not clear and require further study. However, due to this high prevalence, dyspeptic symptoms should be incorporated into the routine assessment of MS patients and, if found, may warrant collaborative referral with a GI specialist.

Nonmotor symptoms in Parkinson's disease: expanding the view of Parkinson's disease beyond a pure motor, pure dopaminergic problem

Nonmotor symptoms (NMS) of Parkinson's disease (PD) are critical to identify and treat because of their impact on quality of life. Despite growing evidence of the importance of NMS on patients' quality of life, gaps remain in their recognition and treatment. The result is a need for increased information and understanding of specific NMS and the clinical approaches for their assessment and management in the context of PD as a whole. This article discusses the NMS of PD, their relationship to the pathologic basis of PD, and how NMS can be best managed.

Psychiatric care in Parkinson's disease

OBJECTIVE

Parkinson's disease (PD) is a degenerative and disabling disease in which medical providers focus mainly on ameliorating problems in day-to-day functioning. This review summarizes current knowledge about the efficacy and tolerability of psychopharmacological agents in the treatment of depression, anxiety, psychosis, and insomnia in patients with PD. Recommended or promising nonpharmacological interventions are also reviewed.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULT

Findings in the research literature provide growing evidence concerning the antidepressant treatment of patients with PD. Psychoeducational interventions for managing depression and anxiety symptoms also appear promising. Music therapy has proven to be particularly effective for patients with PD. Psychosis is common in patients with PD. When psychosis is induced by antiparkinson drugs, a dose reduction can be considered, but it is seldom successful. Patients with PD do not generally tolerate conventional antipsychotic medications, justifying evaluation of newer atypical agents in this population. Cholinesterase inhibitors have also become increasingly important in the treatment of PD in recent years. Finally, insomnia is a very frequent complaint in patients with PD and may also contribute to the development of depression. Patients should be encouraged to improve sleep hygiene and use behavioral interventions. Definitive trials of treatments for sleep disorders in this population are also warranted.

CONCLUSION

Therapeutic approaches to the treatment of PD and its associated psychiatric symptoms must be individualized and may involve a combination of antiparkinson drugs, psychopharmacological treatment, and/or psychotherapeutic interventions.

New MRI Biomarkers Advance the Characterization of Parkinson Disease

The pathophysiology of idiopathic Parkinson disease (PD) is traditionally characterized as substantia nigra degeneration, but careful examination of the widespread neuropathological changes suggests individual differences in neuronal vulnerability. A major limitation to studies of disease progression in PD has been that conventional MRI techniques provide relatively poor contrast for the structures that are affected by the disease, and thus are not typically used in experimental or clinical studies. Here, we review the current state of structural MRI as applied to the analysis of the PD brain. We also describe a new multispectral MRI method that provides improved contrast for the substantia nigra and basal forebrain, which we recently used to show that these structures display different trajectories of volume loss early in the disease.

Behavioral disturbance in dementia

Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.

Psychosocial interventions for depression and anxiety in Parkinson's disease

BACKGROUND

Depression has been estimated to affect 1 in 3 individuals with Parkinson's disease (PD) and can lead to worse health outcomes and decreased quality of life. Anxiety further complicates PD outcomes. Pharmacologic treatments of depression and anxiety can have negative side effects in patients with PD, including exacerbation of PD symptoms. There is a critical need for alternative treatment approaches that address depression and anxiety among patients with PD. Psychosocial or behavioral approaches are known to be effective for depression generally, but only a handful of studies have examined the role of psychosocial treatments of patients with depression in PD.

OBJECTIVE

The aim of this article was to review published psychosocial treatment studies of depression and anxiety in patients with PD.

METHODS

The PubMed database was searched for articles published in English before April 2011 using the terms Parkinson's disease, depression, anxiety, psychotherapy, cognitive therapy, behavioral treatment, behavioral therapy, nonpharmacologic treatment, psychoeducation, education, psychosocial treatment, and stress management. Articles included were prospective clinical trials utilizing specific depression or anxiety assessments as primary or secondary outcomes in patients with PD.

RESULTS

Nine reports derived from 8 separate studies fit the inclusion criteria and were included in this review. All studies were published between 1997 and 2011, and all but 3 had small sample sizes (<40 patients). Interventions included cognitive behavioral therapy (CBT), psychodrama, education, and behavior therapy as well as multidisciplinary rehabilitation. Cognitive behavioral therapy was the most studied and was shown to decrease depressive and anxiety symptoms in patients with PD. Other individual and group therapies may improve depression and anxiety in patients with PD, but the general paucity of studies and study methods limit the interpretation of these results.

CONCLUSIONS

There have been few studies on psychosocial treatments that specifically assess change in depression and anxiety among patients with PD. While results for CBT and other modes of therapy are promising for acute management of depression and anxiety, longer term effects after treatment have been variable. There is a need for additional studies on psychosocial interventions in people with PD.

A pharmacist's contribution to an ambulatory neurology clinic

OBJECTIVE

Identify and categorize recommendations made by a consultant pharmacist in a neurology clinic, and document patient satisfaction with consultations provided by the pharmacist.

DESIGN

Prospective, case series.

SETTING

Ambulatory neurology clinic located in eastern Washington state.

PATIENTS

Participants were referred to the consultant pharmacist by the neurologist or neurology nurse practitioner or self-referral. The pharmacist saw 56 patients, for a total of 66 encounters.

INTERVENTIONS

A medication review was completed, and the patient and pharmacist met for consultation, assessment, and patient counseling. The pharmacist made pharmacotherapeutic recommendations and referrals to other health care providers. Printed surveys were distributed to patients regarding their satisfaction with the pharmacy consultation.

MAIN OUTCOME MEASURE(S)

The number and types of recommendations made by the pharmacist. Patient satisfaction with the pharmacist and pharmacy consultation, reported in a written survey provided after the consultation.

RESULTS

The pharmacist spent an average of 38 minutes with each patient. A total of 192 pharmacotherapeutic recommendations were made: 55 (29%) to discontinue a medication, 46 (24%) to add a medication, 45 (23%) to change a dose, 39 (20%) therapeutic substitutions, and 7 (4%) for therapeutic monitoring. Survey respondents indicated they were very satisfied (97%), and all (100%) had a better understanding of how to take their medications after meeting with the pharmacist.

CONCLUSION

Pharmacist involvement in a neurology clinic increases patient-pharmacist contact time and patient understanding regarding medications. The pharmacist offers numerous recommendations to health care providers, potentially improving the patient's pharmacotherapy.

Parkinson's disease therapeutics: new developments and challenges since the introduction of levodopa

The demonstration that dopamine loss is the key pathological feature of Parkinson's disease (PD), and the subsequent introduction of levodopa have revolutionalized the field of PD therapeutics. This review will discuss the significant progress that has been made in the development of new pharmacological and surgical tools to treat PD motor symptoms since this major breakthrough in the 1960s. However, we will also highlight some of the challenges the field of PD therapeutics has been struggling with during the past decades. The lack of neuroprotective therapies and the limited treatment strategies for the nonmotor symptoms of the disease (ie, cognitive impairments, autonomic dysfunctions, psychiatric disorders, etc.) are among the most pressing issues to be addressed in the years to come. It appears that the combination of early PD nonmotor symptoms with imaging of the nigrostriatal dopaminergic system offers a promising path toward the identification of PD biomarkers, which, once characterized, will set the stage for efficient use of neuroprotective agents that could slow down and alter the course of the disease.

In vivo imaging of the integration and function of nigral grafts in clinical trials

In vivo functional imaging has provided objective evidence for the integration and function of nigral grafts in the brains of patients with Parkinson's disease. Clinical trials with the use of positron emission tomography have shown that transplants of human dopamine-rich fetal ventral mesencephalic tissue can survive, grow, and release dopamine providing motor symptom relief, and also that they can restore brain activation related to movement. Positron emission tomography has aided in the elucidation of the pathophysiology of serious adverse effects, so-called graft-induced dyskinesias. With the use of newly established radioligands, positron emission tomography and single-photon emission computed tomography could help to improve Parkinson's patient selection in future clinical trials by selecting those with better predicted outcomes. Moreover, positron emission tomography could help monitoring postoperational inflammatory processes around the grafted tissue and the effect of immunosuppression. Recent evidence from positron emission tomography has provided insight of how ongoing extrastriatal serotonergic denervation may have relevance to nonmotor symptoms in transplanted Parkinson's disease patients indicating new cell therapy targets for a more complete relief of symptoms. Functional and structural magnetic resonance imaging techniques could help to better assess the integration of nigral graft with the host brain by assessing the restoration of brain activation during movement and of functional and structural connectivity. This knowledge should lead to the development of new, optimized in vivo imaging protocols that could help to better schedule, monitor, and modify the clinical outcomes of future human trials assessing the efficacy of fetal or stem cell therapy in Parkinson's disease.

Motility disorders in the patient with neurologic disease

Gastrointestinal symptoms are common in the patient with chronic neurologic disease and may loom large in terms of impact on quality of life and on nutrition and mobility. A knowledge of the range of gastrointestinal disorders associated with a given neurologic disease, together with an understanding of the risks and benefits of various therapeutic options and approaches, should aid gastroenterologists in their efforts to contribute to the care of these patients. In most instances a multidisciplinary team (neurologist/neurosurgeon, gastroenterologist, nutritionist, therapist, specialist nurse) aware of the wishes and needs of the family and their carers and mindful of the nature and the natural history of the underlying disease process are best placed to assess and manage these problems.