Young onset Parkinson's disease. Practical management of medical issues

Epidemiology of early-onset Parkinson disease (EOPD) worldwide: East versus west

Parkinson disease (PD) is characterized by the presence of bradykinesia with either rest tremor, muscle rigidity, or postural instability. If the features for PD are present but the age at onset (AAO) is before the usual but later than 21 years of age, it is considered as early-onset PD (EOPD). With Eastern countries projected to account for over 60 % of the world's population, it is paramount to understand the differences in EOPD between Western and Eastern countries. Epidemiology can differ substantially between the East and West, such as China showing a much steeper rise in EOPD prevalence and incidence with age, or Japan and Korea showing a female predominance in EOPD for certain age groups. Symptomatology appears to be similar across Western and Eastern populations, though some Eastern populations may have a higher prevalence of the akinetic-rigid or postural instability/gait difficulty motor phenotypes. Genetic epidemiology, conversely, varies significantly between the East and West, though some genes are frequently implicated in both (such as LRRK2, PINK1, PRKN, and GBA). Next, treatment patterns also exhibit substantial geographical variation, which could be driven by local availability of medications, adequacy of staff training and infrastructure, and local regulatory bodies. Lastly, regardless of region, EOPD exerts a profound psychosocial impact on patients, such as strained relationships, unemployment, and psychological distress. In summary, understanding these differences (and similarities) between the East and West could help generate innovative solutions, while the development of healthy habits and robust social networks should also be actively encouraged in all patients.

Pregnancy, fertile life factors, and associated clinical course in PRKN early-onset Parkinson's disease

INTRODUCTION

As the most common cause of autosomal recessive early onset Parkinson's disease (EOPD), parkin type Parkinson's disease (PRKN-PD) may affect female patients in childbearing age. Accordingly, issues related to fertility must be adequately addressed. Here, we landscaped fertile life factors and pregnancy course of a PRKN-PD cohort, including both novel cases directly observed at our center and published ones.

METHODS

Six patients with confirmed PRKN-PD were examined by a structured interview on reproductive factors and associated modifications of PD disturbances, including one case followed up throughout pregnancy which was described in greater detail. Six studies reporting fertile life factors of nine PRKN-PD patients were reviewed collecting homogeneous data on fertile life and pregnancy course.

RESULTS

PRKN-PD female patients experienced motor fluctuations with the menstrual cycle, pregnancy, and puerperium, which suggests a role for sex hormones in PD clinical burden. In some cases, abortion and miscarriages occurred during the organogenesis phase in patients receiving oral antiparkinsonian therapy; however, levodopa/benserazide monotherapy resulted to be the safest choice in pregnancy.

CONCLUSION

Collectively these data disclose the importance of pre-conception counseling in childbearing age PRKN-PD patients and EOPD in general.

Early-onset and late-onset Parkinson's disease exhibit a different profile of gait and posture features based on the Kinect

INTRODUCTION

Gait and posture abnormalities are the common disabling motor symptoms in Parkinson's disease (PD). This study aims to investigate the differential characteristics of gait and posture in early-onset PD (EOPD) and late-onset PD (LOPD) using the Kinect depth camera.

METHODS

Eighty-eight participants, including two subgroups of 22 PD patients and two subgroups of 22 healthy controls (HC) matched for age, sex, and height, were enrolled. Gait and posture features were quantitatively assessed using a Kinect-based system. A two-way analysis of variance was used to compare the difference between different subgroups.

RESULTS

EOPD had a significantly higher Gait score than LOPD (p = 0.031). Specifically, decreased swing phase (p = 0.034) was observed in the EOPD group. Although the Posture score was similar between the two groups, LOPD was characterized by an increased forward flexion angle of the trunk at the thorax (p = 0.042) and a decreased forward flexion angle of the head relative to the trunk (p = 0.009). Additionally, age-independent features were observed in both PD subgroups, and post hoc tests revealed that EOPD generally performed worse gait features. In comparison, LOPD was characterized by worse performance in posture features.

CONCLUSIONS

EOPD and LOPD exhibit different profiles of gait and posture features. The phenotype-specific characteristics likely reflect the distinct neurodegenerative processes between them.

Shaping the course of early-onset Parkinson's disease: insights from a longitudinal cohort

INTRODUCTION

Early -onset Parkinson's disease (EOPD) labels those cases with onset earlier than fifty. Although peculiarities emerged either in clinical or pathological features, EOPD is managed alike typical, late-onset PD. A customized approach would be, instead, better appropriate. Accordingly, a deeper characterization of the clinical course, with an estimation of the disease progression rate, the therapy flow, and the main motor and non-motor complications occurrence, is needed.

METHODS

A longitudinal cohort of 193 EOPD patients (selected on a single-centre population of 2000 PD cases) was retrospectively analysed, providing descriptive statics on a series of clinical parameters (genetics, phenotype, comorbidities, therapies, motor and non-motor complications, marital and gender issues) and modelling the trajectories from diagnosis to 10 years later of both Hoehn and Yahr (H&Y) stage and levodopa equivalent daily dose (LEDD).

RESULTS

EOPD had a prevalence of 9.7%, including few monogenic cases. It mostly appeared as a motor syndrome, with asymmetric, rigid-akinetic presentation. H&Y linearly progressed with an increment of 0.92 points/10 years; LEDD flow had a non-linear trend, increasing of 526.90 mg/day in 0-5 years, and 166.83 mg/day in 5-10 years. Motor fluctuations started 6.5 ± 3.2 years from onset, affecting up to 80% of the cohort. Neuropsychiatric troubles interested the 50%, sexual complaints the 12%. Gender-specific motor disturbances emerged.

CONCLUSION

We shaped EOPD course, modelling a "brain-first" PD subtype, slowly progressive, with non-linear dopaminergic requirement. Major burden mostly resulted from motor fluctuations, neuropsychiatric complications, sexual and marital complaints, with a considerable gender-effect.

Speech rate and fluency in young-onset Parkinson's disease: A longitudinal case study from early to post brain surgery stage

The aim of this study is to analyse the speech rate, pausing and fluency of a patient with young-onset Parkinson's Disease in different stages of the disease. Speech samples of the patient were recorded in the early stages of the disease until after the brain surgery. The recordings were compared to the speech of healthy control speakers. Speech rate, articulation rate, pausing and the frequency of disfluencies were analysed. Results show that all parameters are influenced by the severity of the disease, but articulation rate is the most affected.

Deep brain stimulation in Early Onset Parkinson's disease

INTRODUCTION

Subthalamic Deep Brain Stimulation (STN-DBS) is a safe and well-established therapy for the management of motor symptoms refractory to best medical treatment in patients with Parkinson's disease (PD). Early intervention is discussed especially for Early-onset PD (EOPD) patients that present with an age of onset ≤ 45-50 years and see themselves often confronted with high psychosocial demands.

METHODS

We retrospectively assessed the effect of STN-DBS at 12 months follow-up (12-MFU) in 46 EOPD-patients. Effects of stimulation were evaluated by comparison of disease-specific scores for motor and non-motor symptoms including impulsiveness, apathy, mood, quality of life (QoL), cognition before surgery and in the stimulation ON-state without medication. Further, change in levodopa equivalent dosage (LEDD) after surgery, DBS parameter, lead localization, adverse and serious adverse events as well as and possible additional clinical features were assessed.

RESULTS

PD-associated gene mutations were found in 15% of our EOPD-cohort. At 12-MFU, mean motor scores had improved by 52.4 ± 17.6% in the STIM-ON/MED-OFF state compared to the MED-OFF state at baseline (p = 0.00; n = 42). These improvements were accompanied by a significant 59% LEDD reduction (p < 0.001), a significant 6.6 ± 16.1 points reduction of impulsivity (p = 0.02; n = 35) and a significant 30 ± 50% improvement of QoL (p = 0.01). At 12-MFU, 9 patients still worked full- and 6 part-time. Additionally documented motor and/or neuropsychiatric features decreased from n = 41 at baseline to n = 14 at 12-MFU.

CONCLUSION

The present study-results demonstrate that EOPD patients with and without known genetic background benefit from STN-DBS with significant improvement in motor as well as non-motor symptoms. In line with this, patients experienced a meaningful reduction of additional neuropsychiatric features. Physicians as well as patients have an utmost interest in possible predictors for the putative DBS outcome in a cohort with such a highly complex clinical profile. Longitudinal monitoring of DBS-EOPD-patients over long-term intervals with standardized comprehensive clinical assessment, accurate phenotypic characterization and documentation of clinical outcomes might help to gain insights into disease etiology, to contextualize genomic information and to identify predictors of optimal DBS candidates as well as those in danger of deterioration and/or non-response in the future.

Age Cutoff for Early-Onset Parkinson's Disease: Recommendations from the International Parkinson and Movement Disorder Society Task Force on Early Onset Parkinson's Disease

Background

Early-onset Parkinson's disease (EOPD)/young-onset Parkinson's disease (YOPD) is defined as Parkinson's disease (PD) with an age at onset (AAO) after age 21 years but before the usual AAO for PD. Consensus is lacking, and the reported maximal age for EOPD/YOPD has varied from 40 to 60 years, leading to a lack of uniformity in published studies and difficulty in harmonization of data. EOPD and YOPD have both been used in the literature, somewhat interchangeably.

Objective

To define the nomenclature and AAO cutoff for EOPD/YOPD.

Methods

An extensive review of the literature and task force meetings were conducted. Conclusions were reached by consensus.

Results

First, the literature has seen a shift from the use of YOPD toward EOPD. This seems motivated by an attempt to avoid age-related stigmatization of patients. Second, in defining EOPD, 56% of the countries use 50 or 51 years as the cutoff age. Third, the majority of international genetic studies in PD use an age cutoff of younger than 50 years to define EOPD. Fourth, many studies suggest that changes in the estrogen level can affect the predisposition to develop PD, making the average age at menopause of 50 years an important factor to consider when defining EOPD. Fifth, considering the differential impact of the AAO of PD on professional and social life, using 50 years as the upper cutoff for the definition of EOPD seems reasonable.

Conclusions

This task force recommends the use of EOPD rather than YOPD. It defines EOPD as PD with AAO after 21 years but before 50 years.

Parkinson's Disease in the Era of Personalised Medicine: One Size Does Not Fit All

The concept of personalised medicine in Parkinson's disease has arrived where the implications of findings made in research are certain to have an increasing impact upon clinical practice. Disease heterogeneity in Parkinson's disease has been well described and lends itself to the construct of personalised medicine where it is hypothesised that a greater understanding of genetic and pathophysiological contributions may underpin the sub-groups described. This in turn has driven the development of potentially individualised disease-modifying therapies where, for example, we are beginning to see treatments that target patients with Parkinson's disease with specific genetic mutations. Furthermore, clinicians are increasingly recognising the need to tailor their management approach to patients depending on their age of presentation, acknowledging differential side-effect profiles and responses especially when considering the use of device-assisted technologies such as infusion or surgery. Clearly, individualising the treatment of both motor and non-motor symptoms will remain imperative but, in the future, personalised medicine may provide clearer insights into various aspects of a patient's symptomatology, disease course and thus the best therapeutic approaches.

Patients are doing it for themselves: A survey on disease-specific knowledge acquisition among people with Parkinson's disease in Sweden

Effective self-management is key to living well with Parkinson's disease and one important aspect is disease-specific knowledge. This article explores how people with Parkinson's disease in Sweden (1) acquire disease-specific knowledge and (2) use Parkinson's disease-related healthcare. Data were collected through an online survey, which had 346 respondents (16-87 years old, median age: 68 years, 51% male; time since diagnosis: 0-31 years, median time: 7 years). Our results show that disease-specific knowledge is mainly found online, especially for women with Parkinson's disease and people with Parkinson's disease of working age, that most people with Parkinson's disease in Sweden see their neurologist for 1 h or less per year and only one in two people with Parkinson's disease has regular contact with other Parkinson's disease-related healthcare professionals. We also find that people with Parkinson's disease reporting higher levels of specific knowledge also are more likely to be satisfied with the amount of time they get with their neurologist, regardless of the amount of time.

Deep Brain Stimulation during Pregnancy and Delivery: Experience from a Series of "DBS Babies"

Introduction

Deep brain stimulation (DBS) is widely used to improve quality of life in movement disorders (MD) and psychiatric diseases. Even though the ability to have children has a big impact on patients’ life, only a few studies describe the role of DBS in pregnancy.

Objective

To describe risks and management of women treated by DBS for disabling MD or psychiatric diseases during pregnancy and delivery.

Methods

We report a retrospective case series of women, followed in two DBS centers, who became pregnant and went on to give birth to a child while suffering from disabling MD or psychiatric diseases [Parkinson’s disease, dystonia, Tourette’s syndrome (TS), Obsessive Compulsive Disorder (OCD)] treated by DBS. Clinical status, complications and management before, during, and after pregnancy are reported. Two illustrative cases are described in greater detail.

Results

DBS improved motor and behavioral disorders in all patients and allowed reduction in, or even total interruption of disease-specific medication during pregnancy. With the exception of the spontaneous early abortion of one fetus in a twin pregnancy, all pregnancies were uneventful in terms of obstetric and pediatric management. DBS parameters were adjusted in five patients in order to limit clinical worsening during pregnancy. Implanted material limited breast-feeding in one patient because of local pain at submammal stimulator site and led to local discomfort related to stretching of the cable with increasing belly size in another patient whose stimulator was implanted in the abdominal wall.

Conclusion

Not only is it safe for young women with MD, TS and OCD who have a DBS-System implanted to become pregnant and give birth to a baby but DBS seems to be the key to becoming pregnant, having children, and thus greatly improves quality of life.

Recovery performance and factors that classify young fallers and non-fallers in Parkinson's disease

Postural instability is a major problem for Parkinson's disease patients (PDs). Identifying the causes of postural instability at a young age would contribute to the development of adequate training interventions aiming to reduce falls. The purpose of this study was to investigate the effect of muscle strength and balance ability on dynamic stability control after simulated disturbances and to develop an applicable tool able to classify young PDs into fallers and non-fallers. Twenty-five young PDs (12 fallers, 13 non-fallers, 48±5 yrs.) and 14 healthy controls participated in the study. Dynamic stability was examined during simulated forward falls. Muscle strength was assessed by isometric maximal plantarflexion and knee extension contractions. Balance ability was evaluated by measuring the anterior and posterior limits of stability (LoS). The fallers showed lower recovery performance in forward falls and lower muscle strength compared to controls. Muscle strength and anterior LoS were significantly associated to stability performance. These two factors could correctly classify 90% of PD fallers, establishing an accurate assessment tool to predict the falling risk in young PDs. Furthermore, muscle strength partly explained recovery performance; therefore, we can argue that young PDs with an increased falling risk may benefit from leg-extensors strengthening and stability training.

An update on the management of young-onset Parkinson's disease

In the text that follows, we review the main clinical features, genetic characteristics, and treatment options for Parkinson's disease (PD), considering the age at onset. The clinical variability between patients with PD points at the existence of subtypes of the disease. Identification of subtypes is important, since a focus on homogenous group may lead to tailored treatment strategies. One of the factors that determine variability of clinical features of PD is age of onset. Young-onset Parkinson's disease (YOPD) is defined as parkinsonism starting between the ages of 21 and 40. YOPD has a slower disease progression and a greater incidence and earlier appearance of levodopa-induced motor complications; namely, motor fluctuations and dyskinesias. Moreover, YOPD patients face a lifetime of a progressive disease with gradual worsening of quality of life and their expectations are different from those of their older counterparts. Knowing this, treatment plans and management of symptoms must be paid careful attention to in order to maintain an acceptable quality of life in YOPD patients.

Parkinson's disease: how is employment affected?

BACKGROUND

Rates of unemployment and early retirement are increased in Parkinson's disease (PD) and contribute to disease burden.

AIMS

To investigate time to loss of employment from PD onset and predictors of continued employment; to identify common issues and possible interventions in the workplace.

METHODS

Eighty-eight patients with PD diagnosed at age≤65 years took part in a retrospective cohort study. Veterans RAND Short Form-36 and an employment survey were administered.

RESULTS

Unemployment rates for males were increased compared to the general Irish population (standardized ratio of 1.6, 95% CI 1.2-2.2, P<0.05). There was no significant difference for females. Median retirement age was 58 years for males and 61 years for females compared to 63.5 and 65 years, respectively, in the general population. In survival analysis, median time to loss of employment was 7 years (95% CI 4.8-9.2). After 5 years, 40% remained working and 14% after 10 years. Early age of PD onset (P<0.001), early diagnosis (P<0.002) and high scores in vitality (P<0.005) were associated with prolonged employment. There was no association with sex, education, type or hours of work. Slowness, fatigue and tremor were the most challenging symptoms at work. Changes in work schedule and type of work were suggested helpful adjustments.

CONCLUSION

Loss of employment places a significant socioeconomic burden on young PD patients. More detailed examination of specific issues and reasonable adjustments is needed, along with patient and employer education.

Discovery and verification of panels of T-lymphocyte proteins as biomarkers of Parkinson's disease

The diagnosis of Parkinson's disease (PD) is currently based on the clinical evaluation of extrapyramidal signs with a considerable error rate. The identification of specific markers might allow PD diagnosis before the onset of classical motor symptoms. By two-dimensional electrophoresis we identified proteome alterations in T-lymphocytes of 17 control subjects and 15 PD patients. The observed changes were used to build predictive models that were verified by the leave-one-out cross-validation. We further built two functions able to stage the subjects. We chose to verify by Western blotting the identity of spots corresponding to β-fibrinogen and transaldolase, two recurrent proteins in six out of 20 spots. β-Fibrinogen levels are lowered in PD patients, whereas a heavy transaldolase set of isoforms was more abundant. Eventually, we identified a list of seven proteins showing different levels in early-onset with respect to late-onset PD patients.

Epidemiology and neuropsychiatric manifestations of Young Onset Parkinson's Disease in the United States

BACKGROUND

To determine the demographic distribution of Young Onset Parkinson's Disease (YOPD) in the United States and to quantify the burden of neuropsychiatric disease manifestations.

METHODS

Cross sectional study of 3,459,986 disabled Americans, aged 30-54, who were receiving Medicare benefits in the year 2005. We calculated race and sex distributions of YOPD and used logistic regression to compare the likelihood of common and uncommon psychiatric disorders between beneficiaries with YOPD and the general disability beneficiary population, adjusting for race, age, and sex.

RESULTS

We identified 14,354 Medicare beneficiaries with YOPD (prevalence = 414.9 per 100,000 disabled Americans). White men comprised the majority of cases (48.9%), followed by White women (34.7%), Black men (6.8%), Black women (5.0%), Hispanic men (2.4%), and Hispanic women (1.2%). Asian men (0.6%) and Asian women (0.4%) were the least common race-sex pairs with a YOPD diagnosis in this population (chi square, p < 0.001). Compared to the general population of medically disabled Americans, those with YOPD were more likely to receive medical care for depression (OR: 1.89, 1.83-1.95), dementia (OR: 7.73, 7.38-8.09), substance abuse/dependence (OR: 3.00, 2.99-3.01), and were more likely to be hospitalized for psychosis (OR: 3.36, 3.19-3.53), personality/impulse control disorders (OR: 4.56, 3.28-6.34), and psychosocial dysfunction (OR: 3.85, 2.89-5.14).

CONCLUSIONS

Young Onset Parkinson's Disease is most common among white males in our study population. Psychiatric illness, addiction, and cognitive impairment are more common in YOPD than in the general population of disabled Medicare beneficiaries. These may be key disabling factors in YOPD.

Challenges in diagnosis of young onset Parkinson's disease

Young onset Parkinson's disease patients, typically aged 21 to between 40 and 55, have symptomatology similar to regular onset patients. Despite this, we suspect that physicians take longer to diagnose young onset patients since Parkinson's disease is ruled out due to the younger age. The history prior to diagnosis of 14 young onset patients (within 21 to 45 years of age) was compared with an equivalent number of regular onset patients matched by gender, tremor presence, and Hoehn and Yahr stage. Indeed, a longer period of time was taken to diagnose younger patients with an average of additional 15 months (p<0.001). This trend of older patients being diagnosed sooner was present in the regular onset group analyzed in isolation, but not so for the younger group. The lack of age-dependent variation in time required for diagnosis suggests that Parkinson's disease is not considered at all in the diagnosis for an extended period, accounting for the large difference in prevalence of young onset group to the regular onset group. We also observed a significantly higher number of neurologist visits (p=0.002) and clinical investigations (p<0.001) prior to diagnosis of young-onset patients. Due to the impact of delayed diagnoses on young onset patients and clinical resources, we propose that Parkinson's disease be more actively considered in differential diagnoses of younger patients presenting associated symptoms.

Successful birth of an IVF baby in a patient with Parkinson's disease

Parkinson's disease, although rare in young patients, may be encountered in the reproductive age group. We report a rare combination of this disease with infertility, which has not been previously reported. The case record of a 29-year-old woman with infertility and Parkinson's disease are retrospectively reviewed. An IVF indicated for tubal factor infertility resulted in a successful singleton pregnancy. She delivered a healthy male baby without experiencing any worsening of her Parkinsonism. The course of pregnancy remained unaffected by the Parkinson's disease and anti-Parkinsonian drugs. The details of the infertility management, antenatal and postnatal course, and medications are described. With careful evaluation, counseling, and monitoring, IVF may be safely used in women with Parkinson's disease.

Treatment of young-onset Parkinson's disease: role of dopamine receptor agonists

For mostly arbitrary reasons, the term "juvenile parkinsonism" is restricted to patients aged 20 years or younger, and "young-onset PD" (YOPD) is onset between ages 21 and 40 years. Previous studies suggest that YOPD has a slower disease progression and a greater incidence and earlier appearance of L-dopa-induced dyskinesias and motor fluctuations. Therefore, our therapeutic strategies have to respect the fact that YOPD patients face many years of gradual progression of disease and disability, a greater probability for developing various adverse effects of treatment, and worsening of quality of life. As an individually tailored treatment should be our primary goal, we must bear in mind that the needs and expectations of YOPD patients are different from those of their older counterparts. The therapeutic strategy for YOPD patients should include a relatively low threshold for initiation of treatment, and initiating treatment with a dopamine receptor agonist while maintaining an individually adjusted, moderately high threshold for switching to or adding L-dopa in cases where treatment response is suboptimal or if problematic adverse effects develop. It has been shown that some dopamine receptor agonists may also have antidepressive efficacy, thus potentially managing an additional problem associated with PD.