Management of non-motor symptoms in advanced Parkinson disease

Nucleus of the solitary tract neuronal degeneration and impaired hypoxia response in a model of Parkinson's disease

Parkinson's disease (PD) involves the degeneration of dopaminergic neurons in the substantia nigra (SNpc) and manifests with both classic and non-classic motor symptoms, including respiratory failure. Our study aims to investigate the involvement of the commissural and intermediate nucleus of the solitary tract (cNTS and iNTS) in the attenuated respiratory response to hypoxia in PD. Using a PD rat model induced by bilateral injection of 6-hydroxydopamine (6-OHDA) into the striatum of male Wistar rats, we explored potential alterations in the population of Phox2b neurons or hypoxia-activated neurons in the NTS projecting to the retrotrapezoid nucleus (RTN). Additionally, we explored neuronal connectivity between SNpc and cNTS. Projections pathways were assessed using unilateral injection of the retrograde tracer Fluorogold (FG) in the cNTS and RTN. Neuronal activation was evaluated by analyzing fos expression in rats exposed to hypoxia. In the PD model, the ventilatory response, measured through whole-body plethysmography, was impaired at both baseline and in response to hypoxia. A reduction in Phox2b-expressing neurons or hypoxia-activated neurons projecting to the RTN was observed. Additionally, we identified an indirect pathway linking the SNpc and cNTS, which passes through the periaqueductal gray (PAG). In conclusion, our findings suggest impairment in the SNpc-PAG-cNTS pathway in the PD model, explaining the loss of Phox2b-expressing neurons or hypoxia-activated neurons in the cNTS and subsequent respiratory impairment during hypoxic stimulation. We propose that the reduced population of Phox2b-expressing neurons in the NTS may include the same neurons activated by hypoxia and projecting to the RTN.

Cognitive Effects of Three β-Adrenoceptor Acting Drugs in Healthy Volunteers and Patients with Parkinson's Disease

Background

Noradrenergic signaling declines in Parkinson's disease (PD) following locus coeruleus neurodegeneration. Epidemiologic studies demonstrate that β-acting drugs slow PD progression.

Objective

The primary objective was to compare the safety and effects of 3 β-adrenoceptor (β-AR) acting drugs on central nervous system (CNS) function after a single dose in healthy volunteers (HVs) and evaluate the effects of multiple doses of β-AR acting drugs in HVs and PD-patients.

Methods

In Part A, HVs received single doses of 32 mg salbutamol, 160μg clenbuterol, 60 mg pindolol and placebo administered in a randomized, 4-way cross-over study. In Part B (randomized cross-over) and Part C (parallel, 2:1 randomized), placebo and/or clenbuterol (20μg on Day 1, 40μg on Day 2, 80μg on Days 3-7) were administered. CNS functions were assessed using the NeuroCart test battery, including pupillometry, adaptive tracking and recall tests.

Results

Twenty-seven HVs and 12 PD-patients completed the study. Clenbuterol improved and pindolol reduced the adaptive tracking and immediate verbal recall performance. Clenbuterol and salbutamol increased and pindolol decreased pupil-to-iris ratios. Clenbuterol was selected for Parts B and C. In Part B, clenbuterol significantly increased performance in adaptive tracking with a tendency toward improved performance in immediate and delayed verbal recall. In Part C trends toward improved performance in immediate and delayed verbal recall were observed in PD-patients. Typical cardiovascular peripheral β2-AR effects were observed with clenbuterol.

Conclusions

This study demonstrates the pro-cognitive effects of clenbuterol in HVs with similar trends in PD-patients. The mechanism of action is likely activation of β2-ARs in the CNS.

Rosinidin inhibits NF-κB/ Nrf2/caspase-3 expression and restores neurotransmitter levels in rotenone-activated Parkinson's disease

Objectives

The examination was sighted to study the preventive effects of rosinidin against rotenone-activated Parkinson's disease in rats.

Methods

Animals were randamoized into five groups: I-saline, II-rotenone (0.5 mg/kg/b.wt.), III- IV-10 and 20 mg/kg rosinidin after rotenone and V-20 mg/kg rosinidin per se for 28 days and were assigned for behavioral analysis., Biochemical parameters i.e. lipid peroxidation, endogenous antioxidants, nitrite level, neurotransmitter levels, proinflammatory biomarkers such as interleukin- 6 (IL-6), tumor necrosis factor-α, IL-1β, nuclear factor kappa B, nuclear factor erythroid 2-related factor 2, and caspase-3 were assessed on the 29th day of the research.

Results

Rosinidin augmented the effectiveness of rotenone on akinesia, catalepsy, forced-swim test, rotarod, and open-field test. Biochemical findings indicated that treatment of rosinidin showed restoring neuroinflammatory cytokines, antioxidants, and neurotransmitter levels in rotenone-injected rats.

Conclusion

As a result of rosinidin treatment, the brain was protected from oxidative stress-induced neuronal damage and inhibited neuroinflammatory cytokines.

High-frequency rTMS improves quality of life and depressive symptoms in Parkinson's disease: A case report

Introduction

Parkinson's disease (PD) is a common neurodegenerative disorder, characterised by both motor and nonmotor symptoms. There is currently no cure for PD, although there are several treatment options for relieving PD symptoms. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation therapy that shows promising results for the treatment of PD.

Methods

Here, we present a patient with PD. We investigated whether an accelerate form of high-frequency (HF) rTMS on the contralateral side to the patient's main difficulties is clinically effective in treating health-related quality of life (QoL) symptomatology and depressive symptoms in PD as well as the long-term effects of rTMS in PD during the maintenance phase.

Results

Results showed that HF-rTMS administered over the right primary motor cortex (M1) is a safe and well-tolerated treatment that improved the patient's health related QoL and depressive symptoms. These positive effects lasted at least five months post treatment.

Conclusion

Therefore, HF-rTMS over the right M1 can be a possible treatment option for patients with PD, although further investigations are necessary to validate the findings of the present case report.

Delusional parasitosis as premotor symptom of parkinson’s disease: A case report

BACKGROUND

Delusional parasitosis is characterized by a false belief of being infested with parasites, insects, or worms. This illness is observed in patients with Parkinson’s disease and is usually related to dopaminergic treatment. To our knowledge, no cases of delusional parasitosis have been reported as a premotor symptom or non-motor symptom of Parkinson’s disease.

CASE SUMMARY

A 75-year-old woman presented with a complaint of itching that she ascribed to the presence of insects in her skin, and she had erythematous plaques on her trunk, arms, buttocks, and face. These symptoms started two months before the visit to the hospital. She took medication, including antipsychotics, with a diagnosis of delusional parasitosis, and the delusion improved after three months. A year later, antipsychotics were discontinued, and anxiety and depression were controlled with medication. However, she complained of bradykinesia, masked face, hand tremor, and mild rigidity, and we performed fluorinated N-3-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl) nortropane positron emission tomography (PET), which showed mildly decreased DAT binding in the right anterior putamen and caudate nucleus. Parkinson’s disease was diagnosed on the basis of PET and clinical symptoms.

CONCLUSION

In conclusion, delusional parasitosis can be considered a non-motor sign of Parkinson’s disease along with depression, anxiety, and constipation.

Intraperitoneal Administration of Forskolin Reverses Motor Symptoms and Loss of Midbrain Dopamine Neurons in PINK1 Knockout Rats

BACKGROUND

Parkinson's disease (PD) is a relentless, chronic neurodegenerative disease characterized by the progressive loss of substantia nigra (SN) neurons that leads to the onset of motor and non-motor symptoms. Standard of care for PD consists of replenishing the loss of dopamine through oral administration of Levodopa; however, this treatment is not disease-modifying and often induces intolerable side effects. While the etiology that contributes to PD is largely unknown, emerging evidence in animal models suggests that a significant reduction in neuroprotective Protein Kinase A (PKA) signaling in the SN contributes to PD pathogenesis, suggesting that restoring PKA signaling in the midbrain may be a new anti-PD therapeutic alternative.

OBJECTIVE

We surmised that pharmacological activation of PKA via intraperitoneal administration of Forskolin exerts anti-PD effects in symptomatic PTEN-induced kinase 1 knockout (PINK1-KO), a bona fide in vivo model of PD.

METHODS

By using a beam balance and a grip strength analyzer, we show that Forskolin reverses motor symptoms and loss of hindlimb strength with long-lasting therapeutic effects (> 5 weeks) following the last dose.

RESULTS

In comparison, intraperitoneal treatment with Levodopa temporarily (24 h) reduces motor symptoms but unable to restore hindlimb strength in PINK1-KO rats. By using immunohistochemistry and an XF24e BioAnalyzer, Forskolin treatment reverses SN neurons loss, elevates brain energy production and restores PKA activity in SN in symptomatic PINK1-KO rats.

CONCLUSION

Overall, our collective in vivo data suggest that Forskolin is a promising disease-modifying therapeutic alternative for PD and is superior to Levodopa because it confers long-lasting therapeutic effects.

What neurologists wish palliative care physicians knew

As the incidence of neurologic (particularly neurodegenerative) diseases continues to rise, so too will the palliative needs in this patient population. To appropriately care for these patients and families, neurologists and palliative care providers will need to strengthen collaboration. Palliative care providers not formally trained in neurology may feel ill-equipped to manage some of the distinct neuropalliative care needs of these patients. Here, we provide insights into the unique characteristics of patients with neurologic disease and emphasize the relevance of the palliative care skillset in this population to aid the collaboration between palliative care providers and neurologists.

The impact of clinical scales in Parkinson’s disease: a systematic review

Background

Parkinson’s disease is one of the non-curable diseases and occurs by the prominent loss of neurotransmitter (dopamine) in substantia nigra pars compacta (SNpc). The main cause behind this is not yet identified and even its diagnosis is very intricate phase due to non-identified onset symptoms. Despite the fact that PD has been extensively researched over the decades, and various algorithms and strategies for early recognition and avoiding misdiagnosis have been published. The objective of this article is to focus on the current scenario and to explore the involvement of various clinical diagnostic scales in the detection of PD.

Method

An exhaustive literature review is conducted to synthesize the earlier work in this area, and the articles were searched using different keywords like Parkinson disease, motor/non-motor, treatment, diagnosis, scales, PPMI, etc., in all repositories such as Google scholar, Scopus, Elsevier, PubMed and many more. From the year 2017 to 2021, a total of 451 publications were scanned, but only 24 studies were chosen for a review process.

Findings

Mostly as clinical tools, UPDRS and HY scales are commonly used and even there are many other scales which can be helpful in detection of symptoms such as depression, anxiety, sleepiness, apathy, smell, anhedonia, fatigue, pain, etc., that affect the QoL of pateint. The recognition of non-motor manifests is typically very difficult than motor signs.

Conclusion

This study can give the beneficial research paths at an early stage diagnosis by focusing on frequent inspection of daily activities, interactions, and routine, which may also give a plethora of information on status changes, directing self-reformation, and clinical therapy.

Effect of ketogenic diet versus regular diet on voice quality of patients with Parkinson's disease

Diets that have effects on health problems can vary in their composition. Whilst following a regular diet (RD) a person typically consumes about 30% of calories from fat. Ketogenic diet (KD) is a form of diet whereby a person consumes as much as 90% of calories from fat. KD has been trialed as a treatment for neurological diseases and obesity. Parkinson's disease (PD) is a neurologic disease that impacts the quality of voice. Voice Handicap Index (VHI) is a test that gives information to clinical and physiological assessment about voice. We assessed the impact of KD and RD on voice quality (VQ). Seventy-four patients with PD who reported a voice disorder related to their disease were randomly assigned to the KD or RD groups. We investigated the VHI change of subjects before and 3 months after diet. Sixty-eight PD patients completed the study. Baseline VHI values did not differ significantly between groups. All mean VHI parameters improved in KD group (p˂ 0.001). Currently there are different therapies that address speech and voice disorders in patients with PD. As such KD may be an alternative therapy to improve VQ of patients with PD. A larger sample size is necessary to determine the role and pathophysiology of KD on VQ of PD patients.

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

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

Managing Advanced Parkinson Disease

Advanced Parkinson disease (PD) is associated with treatment-related motor fluctuations and reduced ability to perform activities of daily living. Progression of non-motor symptoms and medication-induced adverse effects complicate focused approach to motor symptom management, frequently accelerating reduced quality of life. It is thus critical for clinicians to consider disease progression versus therapeutic contributions when balancing management decisions. Such an approach requires careful recognition of inflection points resulting from therapeutic decisions and should prompt consideration of reduced pharmacologic burden and increased reliance on non-pharmacologic strategies in advanced disease. The successful approach to advanced PD requires a multidisciplinary effort focused on improving the patient's and family's quality of life, sometimes requiring sacrifice of motor symptom benefit. Here, we emphasize management strategies in advanced PD, focusing on the need to balance the therapeutic approach across advancing motor symptoms, progressive non-motor features, and potential pharmacologic adverse effects.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Constipation and sleep behaviour disorder associate with processing speed and attention in males with Parkinson's disease over five years follow-up

Constipation and REM sleep behaviour disorder (RBD) are the earliest non-motor manifestations of Parkinson's disease (PD). Among non-motor symptoms of PD, it is unclear whether constipation and RBD at early stages of PD are related to cognitive outcomes at later stages. Herein, this study aims to investigate whether the presence of constipation and RBD have an impact on future cognitive outcomes in PD. Access to Parkinson's Progression Markers Initiative (PPMI) database of 360 PD patients with longitudinal observation was requested. Constipation, probable RBD (pRBD) and neuropsychological task scores of PD patients were assessed at baseline and after 5 years. Linear mixed-effects modelling, controlling for gender, age, years of education and LEDD was used to evaluate the association between baseline constipation, pRBD and cognitive performance on follow-up. Gender differences in neuropsychological test performances were found, with men having worse global cognition, speed-attention processing, verbal learning and memory than women at early stages of the disease. We found constipation and pRBD are strongly associated with future decline in some cognitive measures among PD patients, more prominently in men. Our data suggest that early assessment of pRBD and constipation may allow better understanding of the progression of cognitive changes in later phases of PD.

Regulatory roles of the miR-200 family in neurodegenerative diseases

Neurodegenerative diseases are chronic and progressive disorders which are not effectively treated through adopting conventional therapies. For this unmet medical need, alternative therapeutic methods including gene-based therapies are emphasized. MicroRNAs (miRNAs) are small non-coding RNAs which can regulate gene expression at the post-transcriptional level. In recent years, dysregulated miRNAs have been indicated to be implicated in the occurrence and development of neurodegenerative diseases. They are investigated as candidates for diagnostic and prognostic biomarkers, as well as therapeutic targets. The miR-200 family consists of miR-200a, -200b, -200c, -141, and -429. Numerous studies have found that miR-200 family members are associated with the pathogenesis of neurodegenerative diseases. It is reported that miR-200 family members are aberrantly expressed in several neurodegenerative diseases, participating in various cellular processes including beta-amyloid (Aβ) secretion, alpha-synuclein aggregation and DNA repair, etc. In the present review, we summarize the recent progress in the roles of miR-200 family in neurodegenerative diseases.

Analysis of repetitive element expression in the blood and skin of patients with Parkinson's disease identifies differential expression of satellite elements

Repetitive elements (RE) constitute the majority of the human genome and have a range of functions both structural and regulatory on genomic function and gene expression. RE overexpression has been observed in several neurodegenerative diseases, consistent with the observation of aberrant expression of RE posing a mutagenic threat. Despite reports that associate RE expression with PD no study has comprehensively analysed the role of these elements in the disease. This study presents the first genome-wide analysis of RE expression in PD to date. Analysis of RNA-sequencing data of 12 PD patients and 12 healthy controls identified tissue-specific expression differences and more significantly, differential expression of four satellite elements; two simple satellite III (repName = CATTC_n and _GAATG_n) a high-copy satellite II (HSATII) and a centromeric satellite (ALR_Alpha) in the blood of PD patients. In support of the growing body of recent evidence associating REs with neurodegenerative disease, this study highlights the potential importance of characterization of RE expression in such diseases.

Impact of levodopa treatment in the voice pattern of Parkinson’s disease patients: a systematic review and meta-analysis

Abstract Purpose Investigate the association between levodopa therapy and vocal characteristics in Parkinson’s disease patients. Search strategy Studies published at MEDLINE, LILACS, and SciELO, from 1960 to December 2016. A systematic review and meta-analysis was performed using the following keywords: Parkinson’s disease; levodopa; L-dopa; voice; speech disorders; dysphonia; dysarthria. After analyzing titles and abstracts, two independent reviewers selected all clinical trials that met the eligibility criteria and selected the articles and the data recorded in a previously standardized table. Selection criteria Trials published in English between 1960 and December 2016 individuals with clinical diagnosis of Parkinson’s disease; use of levodopa therapy in stable doses; acoustic analysis combined or not with auditory-perceptual analysis to evaluate the vocal parameters under investigation. Data analysis The following vocal parameters were analyzed: fundamental frequency (F 0), jitter, and vocal intensity. Standardized mean differences (SMD) were calculated using the Comprehensive Meta-analysis V2 software. Results Nine articles met the eligibility criteria and were selected, with a total of 119 individuals. From these, six articles with 83 individuals were included in the meta-analysis. During the levodopa therapy “on” state, modifications in F 0 (SMD=0.39; 95% CI - 0.21-0.57) and jitter (SMD=0.23; 95% CI - 0.02-0.45) were observed. Vocal intensity was not affected (SMD=0.09; 95% CI - 0.22-0.39) by levodopa ingestion. Data of the included studies were controversial in the auditory-perceptual analysis of voice. Conclusion Levodopa therapy modifies F0 and jitter. No changes in vocal intensity were observed in either the “on” or “off” states of levodopa therapy.

Antibody biomarker for de novo Parkinson disease: attempted validation

Parkinson disease (PD) is a progressive neurodegenerative disease with motor symptoms that result from degeneration of midbrain dopaminergic neurons. Biomarker research seeks to identify the disease during the pre-symptomatic phase, which is a time when therapeutic intervention will be most helpful. Previously, we screened a combinatorial peptoid library to search for antibodies that are present at much higher levels in the serum of PD patients than in control subjects. One such compound, called the PD2 peptoid, was 84% accurate for the identification of de novo PD when employed as the capture agent in an enzyme-linked immunosorbent assay. This peptoid recognized an IgG3 antibody, and IgG3 levels were also found to be significantly higher in PD vs. control serum. In that study we used samples from the NINDS Parkinson's Disease Biomarker Program. The current study sought to validate that finding using serum samples from de novo and control subjects in the Parkinson's Progression Markers Initiative study. We found no difference in levels of antibodies captured by the PD2 peptoid in the de novo PD vs. control subjects, and no difference in IgG3 serum levels in the two groups. The failure to replicate our previous study appears to be due to the lack of difference in serum IgG3 levels between the PD and control subjects in the current study.

Capturing nighttime symptoms in Parkinson disease: Technical development and experimental verification of inertial sensors for nocturnal hypokinesia

Although nocturnal hypokinesia represents one of the most common nocturnal disabilities in Parkinson disease (PD), it is often a neglected problem in daily clinical practice. We have developed a portable ambulatory motion recorder (the NIGHT-Recorder), which consists of 16-bit triaxial integrated microelectromechanical system inertial sensors that are specifically designed to measure movements, register the position of the body with respect to gravity, and provide information on rotations on the longitudinal axis while lying in bed. The signal processing uses the forward derivative method to identify rolling over and getting out of bed as primary indicators. The prototype was tested on six PD pairs to measure their movements for one night. Using predetermined definitions, 134 movements were captured consisting of rolling over 115 times and getting out of bed 19 times. Patients with PD rolled over significantly fewer times than their spouses (p = 0.03), and the position change was significantly smaller in patients with PD (p = 0.03). Patients with PD rolled over at a significantly slower speed (p = 0.03) and acceleration (p = 0.03) than their spouses. In contrast, patients with PD got out of bed significantly more often than their spouses (p = 0.02). It is technically feasible to develop an easy-to-use, portable, and accurate device that can assist physicians in the assessment of nocturnal movements of patients with PD.

[Syndrome dopamine dysregulation and deep brain stimulation of the subthalamic nucleus in Parkinson's disease]

AIM

Dopamine dysregulation syndrome (DDS) is a complication of the dopaminergic therapy in Parkinson's disease (PD); it is manifested as a compulsive medication use and may have negative impact on patients' social, psychological, and physical functioning. An effect of deep brain stimulation in the subthalamic nucleus (DBS STN) on DDS is not fully understood. Therefore, the degree of DDS during DBS STN in PD patients was evaluated in the study.

MATERIAL AND METHODS

The main group included 15 patients with DDS symptoms in the preoperative period. The comparison group consisted of 15 patients without DDS symptoms and the control group consisted of 15 patients who did not undergo surgery.

RESULTS AND CONCLUSION

The severity of motor disturbances in the surgery groups has decreased significantly (by 45%). Motor complications during DBS STN in patients with DDS have decreased by 50%; a decrease in the reduction of doses of dopaminergic preparations was noted as well.

Current understanding of the molecular mechanisms in Parkinson's disease: Targets for potential treatments

Gradual degeneration and loss of dopaminergic neurons in the substantia nigra, pars compacta and subsequent reduction of dopamine levels in striatum are associated with motor deficits that characterize Parkinson’s disease (PD). In addition, half of the PD patients also exhibit frontostriatal-mediated executive dysfunction, including deficits in attention, short-term working memory, speed of mental processing, and impulsivity. The most commonly used treatments for PD are only partially or transiently effective and are available or applicable to a minority of patients. Because, these therapies neither restore the lost or degenerated dopaminergic neurons, nor prevent or delay the disease progression, the need for more effective therapeutics is critical. In this review, we provide a comprehensive overview of the current understanding of the molecular signaling pathways involved in PD, particularly within the context of how genetic and environmental factors contribute to the initiation and progression of this disease. The involvement of molecular chaperones, autophagy-lysosomal pathways, and proteasome systems in PD are also highlighted. In addition, emerging therapies, including pharmacological manipulations, surgical procedures, stem cell transplantation, gene therapy, as well as complementary, supportive and rehabilitation therapies to prevent or delay the progression of this complex disease are reviewed.

Management of impulse control disorders with deep brain stimulation: A double-edged sword

Deep brain stimulation (DBS) is a surgical option for advanced Parkinson's disease. Although DBS is used to treat motor fluctuation, DBS may affect non-motor symptoms including mood disorders, cognitive dysfunction, and behavior problems. Impulse control disorders (ICDs) are abnormal behaviors with various manifestations such as pathological gambling, hypersexuality, compulsive shopping, and binge eating, which can affect the quality of life in patients with Parkinson's disease. The effect of DBS on ICD is controversial. Reducing medication by DBS may improve ICDs, however, worsening or even developing new ICDs after DBS can occur. We will review the impact of DBS on ICDs and reveal factors associated with a good response to DBS as well as risk factors for developing ICDs after DBS. We also propose a strategy to manage preexisting ICD and prevent postoperative de novo ICDs.

Cardiovascular dysfunction associated with neurodegeneration in an experimental model of Parkinson's disease

Patients with Parkinson's disease (PD) exhibit both motor and non-motor symptoms. Among the non-motor symptoms, cardiovascular autonomic dysfunction is frequently observed. Here, we evaluated baroreflex function, vascular reactivity and neuroanatomical changes in brainstem regions involved in the neural control of circulation in the 6-hydroxydopamine (6-OHDA) model of PD. Male Wistar rats received a bilateral injection of 6-OHDA or vehicle into the striatum. After 61days, baroreflex function and vascular reactivity were assessed. The 6-OHDA and vehicle groups showed similar increases in mean arterial pressure (MAP) in response to phenylephrine (PE). However, the bradycardia observed in the vehicle group was blunted in the 6-OHDA-treated rats. Injection of sodium nitroprusside (SNP) decreased hypotension, tachycardia and vascular relaxation in 6-OHDA-treated rats. Bilateral intrastriatal 6-OHDA led to massive degeneration of tyrosine hydroxylase (TH)-immunoreactive neurons in the substantia nigra and to reductions in the numbers of A1/C1 and A5 catecholaminergic neurons while sparing A2 neurons within the nucleus of the solitary tract (NTS). 6-OHDA-treated rats also showed decreases in Phox2b-expressing neurons in the NTS and in choline acetyltransferase (ChAT) immunoreactivity in the nucleus ambiguus. Altogether, our data suggest that this model of PD includes neuroanatomical and functional changes that lead to cardiovascular impairment.

Nonmotor symptoms in patients with Parkinson disease: A cross-sectional observational study

Parkinson disease (PD) is usually accompanied by numerous nonmotor symptoms (NMS), such as neuropsychiatric symptoms, sleep disorders, autonomic dysfunctions, and sensory disturbances. However, it is not clear that the factors influencing the occurrence of NMS and its sequence with motor symptoms (MS).We conducted comprehensive assessments of NMS by using 13 scales in 1119 PD patients.A total of 70.8% PD patients present NMS. Olfactory dysfunction tends to occur in PD patients with older age, more severe depression, sleep problems, and autonomic dysfunctions. Older patients are more likely to have olfactory dysfunction before MS than younger patients. Rapid eye movement behavior disorder is more prone to happen in patients with older age, older onset age, more severe depression, sleep problems, and autonomic dysfunctions. Patients with rapid eye movement behavior disorder before MS are older in onset age than after group.Olfactory dysfunction, constipation, rapid eye movement behavior disorder, and depression, as early warning NMSs of PD, connected to each other. There is a clinical heterogeneity that older patients are more likely to have NMS before MS, while younger patients are opposite.

Sigma receptors [σRs]: biology in normal and diseased states

This review compares the biological and physiological function of Sigma receptors [σRs] and their potential therapeutic roles. Sigma receptors are widespread in the central nervous system and across multiple peripheral tissues. σRs consist of sigma receptor one (σ₁R) and sigma receptor two (σ₂R) and are expressed in numerous regions of the brain. The sigma receptor was originally proposed as a subtype of opioid receptors and was suggested to contribute to the delusions and psychoses induced by benzomorphans such as SKF-10047 and pentazocine. Later studies confirmed that σRs are non-opioid receptors (not an µ opioid receptor) and play a more diverse role in intracellular signaling, apoptosis and metabolic regulation. σ₁Rs are intracellular receptors acting as chaperone proteins that modulate Ca²⁺ signaling through the IP₃ receptor. They dynamically translocate inside cells, hence are transmembrane proteins. The σ₁R receptor, at the mitochondrial-associated endoplasmic reticulum membrane, is responsible for mitochondrial metabolic regulation and promotes mitochondrial energy depletion and apoptosis. Studies have demonstrated that they play a role as a modulator of ion channels (K⁺ channels; N-methyl-d-aspartate receptors [NMDAR]; inositol 1,3,5 triphosphate receptors) and regulate lipid transport and metabolism, neuritogenesis, cellular differentiation and myelination in the brain. σ₁R modulation of Ca²⁺ release, modulation of cardiac myocyte contractility and may have links to G-proteins. It has been proposed that σ₁Rs are intracellular signal transduction amplifiers. This review of the literature examines the mechanism of action of the σRs, their interaction with neurotransmitters, pharmacology, location and adverse effects mediated through them.

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.

[Critical issues of the biopsychosocial treatment of Parkinson's disease]

This paper is a summary report on the basic questions of the biopsychosocial approach to Parkinson's disease. It deals with cognitive, affective and psychological health issues which significantly influence the outcome of the physical rehabilitation. In spite of the unchanged cognitive status, the psychological burden of the changes in the quality of life, the obstruction, the change in the affective tone, and the shrinking ability to fulfil social roles decrease the patient's quality of life. An interdisciplinary approach is best suited for mitigating these effects. Not only the patient but also his/her family and environment is seriously affected by the disease and its consequences. Treatment and rehabilitation options for increasing or maintaining the quality of life of the affected patients are diverse, and significantly depend on the features of the health care system. The authors believe that the following review emphasizing health psychological principles may contribute to the work of professionals working in clinical and rehabilitational fields and through them may increase the quality of life of patients and their family.

Biomarkers of Parkinson's disease: present and future

Sporadic or idiopathic Parkinson's disease (PD) is an age-related neurodegenerative disorder of unknown origin that ranks only second behind Alzheimer's disease (AD) in prevalence and its consequent social and economic burden. PD neuropathology is characterized by a selective loss of dopaminergic neurons in the substantia nigra pars compacta; however, more widespread involvement of other CNS structures and peripheral tissues now is widely documented. The onset of molecular and cellular neuropathology of PD likely occurs decades before the onset of the motor symptoms characteristic of PD. The hallmark symptoms of PD, resting tremors, rigidity and postural disabilities, are related to dopamine (DA) deficiency. Current therapies treat these symptoms by replacing or boosting existing DA. All current interventions have limited therapeutic benefit for disease progression because damage likely has progressed over an estimated period of ~5 to 15years to a loss of 60%-80% of the nigral DA neurons, before symptoms emerge. There is no accepted definitive biomarker of PD. An urgent need exists to develop early diagnostic biomarkers for two reasons: (1) to intervene at the onset of disease and (2) to monitor the progress of therapeutic interventions that may slow or stop the course of the disease. In the context of disease development, one of the promises of personalized medicine is the ability to predict, on an individual basis, factors contributing to the susceptibility for the development of a given disease. Recent advances in our understanding of genetic factors underlying or contributing to PD offer the potential for monitoring susceptibility biomarkers that can be used to identify at-risk individuals and possibly prevent the onset of disease through treatment. Finally, the exposome concept is new in the biomarker discovery arena and it is suggested as a way to move forward in identifying biomarkers of neurological diseases. It is a two-stage scheme involving a first stage of exposome-wide association studies (EWAS) to profile omic features in serum to discover molecular biomarkers. The second stage involves application of this knowledge base in follow-up studies. This strategy is unique in that it promotes the use of data-driven (omic) strategies in interrogating diseased and healthy populations and encourages a movement away from using only reductionist strategies to discover biomarkers of exposure and disease. In this short review we will examine 1) advances in our understanding of the molecular mechanisms underlying PD that have led to candidate biomarkers for diagnosis and treatment efficacy and 2) new technologies on the horizon that will lead to novel approaches in biomarker development.

Development and psychometric evaluation of a scale to measure impaired self-awareness of hyper- and hypokinetic movements in Parkinson's disease

OBJECTIVE

Patients with Parkinson's disease (PD) can show impaired self-awareness of motor deficits (ISAm). We developed a new scale that measures ISAm severity of hyper- and hypokinetic movements in PD during medication on state and defined its psychometric criteria.

METHOD

Included were 104 right-handed, non-depressed, non-demented patients. Concerning ISAm, 38 motor symptoms were assessed using seven tasks, which were performed and self-rated concerning presence of deficit (yes/no) by all patients. The whole procedure was videotaped. Motor symptoms were then evaluated by two independent experts, blinded for patient's ratings, concerning presence, awareness of deficit, and severity. Exploratory principal component analysis (promax rotation) was applied to reduce items. Principal axis factoring was conducted to extract factors. Reliability was examined regarding internal consistency, split-half reliability, and interrater reliability. Validity was verified by applying two additional measures of ISAm.

RESULTS

Of the initial 38 symptoms, 15 remained, assessed in five motor tasks and merged to a total severity score. Factor analysis resulted in a four factor solution (dyskinesia, resting tremor right hand, resting tremor left hand, bradykinesia). For all subscales and the total score, measures of reliability (values 0.64-0.89) and validity (effect sizes>0.3) were satisfactory. Descriptive results showed that 66% of patients had signs of ISAm (median 2, range 0-15), with ISAm being most distinct for dyskinesia.

CONCLUSIONS

We provide the first validation of a test for ISAm in PD. Using this instrument, future studies can further analyze the pathophysiology of ISAm, the psychosocial sequelae, therapeutic strategies and compliance with therapy.

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.

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.

Co-morbidities of persons dying of Parkinson's disease

Introduction

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

Methods

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

Results

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

Discussion

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

Non-motor symptoms in Chinese Parkinson's disease patients

This study was designed to survey the prevalence and distribution of non-motor symptoms (NMS) in Parkinson's disease (PD) patients in Shanghai, China, and to investigate the association between NMS and health-related quality of life (HRQoL). One hundred fifty-five PD patients were evaluated using the NMS Questionnaire 30 (NMSQuest), Unified Parkinson's Disease Rating Scale (UPDRS) and Parkinson's Disease Questionnaire-39 (PDQ-39). These data were compared with an international cross-sectional study, and the associations of motor and non-motor measures with HRQoL were estimated. Predictors of HRQoL were sought through multiple linear regression analyses. Each PD patient had eight different individual NMS on average. The problems of memory (65.82%), constipation (64.56%) and nocturia (61.39%) were the most frequent complaints. NMS prevalence in PD patients in Shanghai was consistent with that in the international study, although the composition proportions were different. There was a significant association of PDQ-39 score with NMSQuest score (rs=0.433, p=0.000), UPDRS III score (rs=0.473, p=0.000), Hoehn and Yahr (H-Y) stage (rs=0.567, p=0.000), disease duration (rs=0.220, p=0.005), and levodopa equivalent dosage (rs=0.263, p=0.001). H-Y stage (disease severity) and NMS score were the strongest predictors for PDQ-39 score. This study confirmed that NMS are common in PD, occurring across all disease stages and have a great impact on quality of life. NMS progression contributes significantly to HRQoL decline, and should be well recognized and treated.

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.

Delusional misidentification syndrome and other unusual delusions in advanced Parkinson's disease

BACKGROUND

Unusual delusional syndromes are rare protean diseases with speculative etiopathogenic mechanisms.

METHODS

Seven consecutive patients with advanced PD were evaluated over a 15-year period at the Movement Disorders Unit in the Neurology Service, Hospital de Clínicas, Federal University of Paraná, and the Paraná State Parkinson's Patients Association.

RESULTS

We describe advanced Parkinson's disease patients presenting with unusual delusional syndromes, including cases of Ekbom, Othello, Capgras' and Diogenes syndromes, reduplicative paramnesia and mirrored-self misidentification.

CONCLUSION

There are a few isolated reports of unusual neuropsychiatric disorders in patients with PD. We believe that these syndromes associated with advanced PD in elderly patients presenting with cognitive impairment and polypharmacy are probably often underestimated. Neurologists should be aware for these rare and treatable conditions.

Differentiating non-motor symptoms in Parkinson's disease from controls and hemifacial spasm

Background and Aims

Non-motor symptoms (NMS) are important manifestations of Parkinson's disease (PD) that reduce patients' health-related quality of life. Some NMS may also be caused by age-related changes, or manifested as a psychological reaction to a chronic neurological condition. This case-control study compared the NMS burden among PD patients, healthy controls and hemifacial spasm (HFS) patients. In addition, we determined the NMS that discriminated between PD and non-PD subjects.

Methods

425 subjects were recruited from a tertiary hospital in Singapore (200 PD patients, 150 healthy controls and 75 HFS patients). NMS burden in subjects was measured using the Non-Motor Symptoms Scale (NMSS).

Results

NMSS total score was significantly higher in PD patients (37.9±2.6) compared to healthy controls (11.2±0.9) (p<0.0001) and HFS patients (18.0±2.1) (p<0.0001). In addition, NMSS total score was significantly higher in HFS patients compared to healthy controls (p = 0.003). PD patients experienced a higher NMS burden than healthy controls in all domains, and a higher NMS burden than HFS patients in all but attention/memory and urinary domains. NMS burden for HFS and healthy controls differed only in the sleep/fatigue and urinary domains. Using stepwise logistic regression, problems of ‘constipation’, ‘restless legs’, ‘dribbling saliva’, ‘altered interest in sex’ and ‘change in taste or smell’ were found to have significant discriminative power in differentiating between PD patients and healthy controls and between PD patients and HFS patients.

Conclusion

PD patients experienced a greater overall NMS burden compared to both healthy controls and HFS patients. HFS patients demonstrated a higher NMS burden than controls, and some NMS may be common to chronic neurological conditions while others are more specific to PD. Differentiating patients using NMS domains may help refine the clinical management of NMS in PD patients.

Feasibility of clinical hypnosis for the treatment of Parkinson's disease: a case study

Parkinson's disease is a severe neurodegenerative disorder with a prevalence rate of approximately 1.6% in elderly Americans. This case study reports on a 51-year-old male Parkinson's patient who received 3 weekly sessions of a hypnosis intervention, as well as instruction in self-hypnosis. Actigraphy was used to assess rest-tremor severity. Results revealed a 94% reduction in rest tremors following treatment. Self-reported levels of anxiety, depression, sleep quality, pain, stiffness, libido, and quality of life also showed improvements. The patient reported a high level of satisfaction with treatment. These findings suggest clinical hypnosis is potentially feasible and beneficial treatment for some Parkinson's symptoms. Further investigation with diverse samples and an ambulatory monitoring device is warranted.

Therapeutic strategies for nonmotor symptoms in early Parkinson's disease: the case for a higher priority and stronger evidence

It is now recognized that the neuropathology of early Parkinson's disease (PD) is not limited to the nigrostriatal dopaminergic system, but also involves various brainstem nuclei, the hypothalamus, the olfactory system, and the peripheral autonomic nervous system. Given the disseminated neuropathology of early PD, the earliest clinical signs include a myriad of non-motor manifestations including sleep-wake cycle regulation, cognition, mood and motivation, olfactory and gustatory functions, autonomic functions, and sensory and pain processing. Despite this realization, there is clearly a paucity of trials that have systematically evaluated the treatment of non-motor symptoms of PD in the early stages. For example, only one large-scale, placebo-controlled randomized trial has been conducted on the treatment of depression in PD patients. There are no reports of randomized controlled trials of therapeutic agents looking at the frequently reported anxiety and fatigue in early PD patients. Based on this lack of evidence, therapy for early non-motor manifestations is often ignored and the focus remains on dopamine replacement strategies with main outcomes being restricted to motor measurements, such as the Unified Parkinson's Disease Rating Scale. This article presents the case for prioritizing well-designed, controlled clinical trials of therapeutic interventions focusing on non-motor symptoms in early PD patients.

Management of sexual dysfunction in Parkinson's disease

Nonmotor symptoms, among them sexual dysfunction, are common and underrecognized in patients with Parkinson disease; they play a major role in the deterioration of quality of life of patients and their partners. Loss of desire and dissatisfaction with their sexual life is encountered in both genders. Hypersexuality (HS), erectile dysfunction and problems with ejaculation are found in male patients, and loss of lubrication and involuntary urination during sex are found in female patients. Tremor, hypomimia, muscle rigidity, bradykinesia, 'clumsiness' in fine motor control, dyskinesias, hypersalivation and sweating may interfere with sexual function. Optimal dopaminergic treatment should facilitate sexual encounters of the couple. Appropriate counselling diminishes some of the problems (reluctance to engage in sex, problems with ejaculation, lubrication and urinary incontinence). Treatment of erectile dysfunction with sildenafil and apomorphine is evidence based. HS or compulsive sexual behaviour are side effects of dopaminergic therapy, particularly by dopaminergic agonists, and should be treated primarily by diminishing their dose. Neurologists should actively investigate sexual dysfunction in their Parkinsonian patients and offer treatment, optimally within a multidisciplinary team, where a dedicated professional would deal with sexual counselling.

Static posturography in aging and Parkinson's disease

Introduction: In clinical practice, evaluation of postural control is based on the neurological examination, including Romberg's test, examination of gait and performance of pull test as part of the Unified Parkinson's Disease Rating Scale (UPDRS). The goal of our study was to identify posturographic parameters since quantitative technical methods for the measurement of postural control are not established in clinical routine yet. Methods: In this cross-sectional study design we examined patients with Parkinson's disease (PD) (Hoehn and Yahr < 3; PD n = 12) on a static posturographic platform (eyes open and eyes closed), performing a standard Romberg's test during neurological examination and compared the results with an age-matched healthy adult control (HAC n = 10) and a healthy young control (HYC n = 21). Results: In the platform Romberg's test with open eyes, the patients with PD showed a significantly greater mean sway [PD: 14.98 vs. HAC: 8.77 (mm), p < 0.003 vs. HYC 7.80 (mm)], greater mean radius [PD: 28.31 vs. HAC: 16.36 (mm), p < 0.008 vs. HYC: 14.19 (mm)] and greater marked area [PD: 2.38 vs. HAC: 0.88 (cm²), p < 0.016 vs. HYC: 0.78 (cm²)] compared to the HAC. The Romberg's test with closed eyes revealed a significantly greater mean sway [PD: 13.83 vs. HAC: 10.12 (mm), p < 0.033 vs. HYC: 5.82 (mm)] and greater mean radius [PD: 25.03 vs. HAC: 18.15 (mm), p < 0.045 vs. HYC: 9.11 (mm)] compared to both groups. Conclusions: The platform Romberg-test with closed eyes detected significant differences in elderly people and patients with Parkinson's disease, which could be objectively quantified with static posturography testing. Age alone showed significant changes, only detectable with closed eyes. Therefore, balance testing with a new computerized approach could help to identify balance problems in a geriatric assessment in clinical routine, especially with the parameters marked area and mean sway.

Initial motor symptoms of Parkinson disease

Parkinson disease (PD) is characterized by a wide variety of motor and nonmotor symptoms. Although recently nonmotor symptoms have gained considerable relevance and interest, especially in advanced stages, motor symptoms define the main core of PD and are essential for clinical diagnosis. In this article, we review the characteristics, presentation, and evolution of motor symptoms in early PD.