Linking clinical variables to health-related quality of life in Parkinson's disease

Patient With Parkinson Disease and Care Partner Perceptions of Key Domains Affecting Health-Related Quality of Life: Systematic Review

BACKGROUND AND OBJECTIVES

To effectively customize Parkinson disease (PD) programs, it is important to incorporate the "individual's voice" and have a thorough understanding of the symptom priorities of people with PD (PwP) and care partners (CP). In this convergent integrated mixed-method systematic review, we aimed to analyze qualitative and quantitative evidence of PD motor and nonmotor symptoms affecting health-related quality of life (HRQOL) in PwP and CP, comparing priorities across different levels of disease severity.

METHODS

We searched MEDLINE, PsycINFO, Web of Science, Embase, and Scopus; ProQuest Dissertations and Theses Global; and the Michael J. Fox Foundation Data Resources for studies published up to June 29, 2022. We included qualitative, quantitative, and mixed-method studies investigating PD symptom priorities among PwP and CP. We critically appraised eligible studies for methodological quality using the Mixed-Methods Appraisal Tool. Derived terms were mapped and coded according to thematic attribution. Independent syntheses of qualitative and quantitative evidence and transformation of quantitative data into qualitative formats were performed.

RESULTS

Of the 7,716 identified studies, we included 70 that provided qualitative (n = 13), quantitative (n = 53), and mixed (n = 4) evidence. We included 604 mapped terms representing 11 PwP-identified and CP-identified motor and nonmotor symptom categories. Across all PD stages, both PwP and CP considered 5 domains more affecting their HRQOL, namely: "motor functionality," "mood," "cognition," "gait, balance, posture, and falls," and "nighttime sleep disorders." In early disease, PwP and CP considered "mood" the domain that most affected their HRQOL. In advanced PD, PwP considered "pain" the domain that most affects their HRQOL, while CP considered "psychiatric symptoms." The domain "gait, balance, posture, and falls" was equally considered by both PwP and CP as the second domain that most affects their HRQOL in the advanced stage of PD.

DISCUSSION

The ranking of the priority of symptoms is largely shared by PwP and CP, and motor symptom priorities dominate the full disease spectrum. However, the nonmotor symptom priorities shift according to the disease severity stage. Tailored care and research require that providers consider these shifting priorities and incorporate the "individual's voice" into treatment decisions.

Systematic review of neuropsychological instruments used in subthalamic nucleus deep brain stimulation in Parkinson´s disease patients

In addition to drug treatment, surgical intervention represents an alternative to PD patients with motor deficits. The most common intervention is subthalamic nucleus deep brain stimulation (STN-DBS). It is extremely important to perform a neuropsychological assessment in patients with STN-DBS, not only to identify losses related to the disease, but also to compare influence on cognition both pre and postoperatively.

OBJECTIVE

the objective of this systematic review was to investigate the instruments frequently used in studies related to STN-DBS in PD patients.

METHODS

articles were retrieved from Medline/Pubmed databases published in the 2007-2017 period using PRISMA criteria.

RESULTS

after analyzing 27 articles, the absence of a specific evaluation protocol for PD with STN-DBS was evident.

CONCLUSION

non-motor symptoms are not given due importance in neuropsychological assessments. It is crucial to acknowledge that these symptoms have a major impact on the quality of life of patients. Greater engagement in assessing these aspects is required, in order to bridge the gaps in research.

Exploring the causal and effect nature of EQ-5D dimensions: an application of confirmatory tetrad analysis and confirmatory factor analysis

BACKGROUND

The relationship between the various items in an HRQoL instrument is a key aspect of interpreting and understanding preference weights. The aims of this paper were i) to use theoretical models of HRQoL to develop a conceptual framework for causal and effect relationships among the five dimensions of the EQ-5D instrument, and ii) to empirically test this framework.

METHODS

A conceptual framework depicts the symptom dimensions [Pain/discomfort (PD) and Anxiety/depression (AD)] as causal indicators that drive a change in the effect indicators of activity/participation [Mobility (MO), Self-care (SC) and Usual activities (UA)], where MO has an intermediate position between PD and the other two effect dimensions (SC and UA). Confirmatory tetrad analysis (CTA) and confirmatory factor analysis (CFA) were used to test this framework using EQ-5D-5L data from 7933 respondents in six countries, classified as healthy (n = 1760) or in one of seven disease groups (n = 6173).

RESULTS

CTA revealed the best fit for a model specifying SC and UA as effect indicators and PD, AD and MO as causal indicators. This was supported by CFA, revealing a satisfactory fit to the data: CFI = 0.992, TLI = 0.972, RMSEA = 0.075 (90% CI 0.062-0.088), and SRMR = 0.012.

CONCLUSIONS

The EQ-5D appears to include both causal indicators (PD and AD) and effect indicators (SC and UA). Mobility played an intermediate role in our conceptual framework, being a cause of problems with Self-care and Usual activities, but also an effect of Pain/discomfort. However, the empirical analyses of our data suggest that Mobility is mostly a causal indicator.

Palliative Care for Patients and Families With Parkinson's Disease

Parkinson's disease is the second most common neurodegenerative disease worldwide. There is widespread consensus that Parkinson patients, their carers, and clinicians involved in their care would benefit from a fully integrated, need-based provision of palliative care. However, the concept of palliative care in Parkinson's disease is still poorly defined and, consequently, poorly implemented into daily clinical practice. A particular challenge is the gradually progressive nature of Parkinson's disease-with insidiously increasing disability-making it challenging to clearly define the onset of palliative care needs for Parkinson patients. As people with Parkinson's disease are now living longer than in the past, future research needs to develop a more robust evidence-based approach to clarify the disease events associated with increased palliative care needs, and to examine these, prospectively, in an integrated palliative care service. The modern palliative care outlook, termed "simultaneous care,",is no longer restricted to the final stage of disease. It involves incorporating a continuity of care, effective management of the chronic-palliative interface, and a multidisciplinary network of professionals working both in the community and in specialized clinics, with active involvement of caregivers. Although promising, there is still a need to demonstrate the effectiveness of palliative care for patients with Parkinson's disease.

Factors influencing psychosocial adjustment and quality of life in Parkinson patients and informal caregivers

Objective

The influence that social conditions and personal attitudes may have on the quality of life (QoL) of Parkinson’s disease (PD) patients and informal caregivers does not receive enough attention in health care, as a result of it not being clearly identified, especially in informal caregivers. The aim of this study was to provide a comprehensive analysis of psychosocial adjustment and QoL determinants in PD patients and informal caregivers.

Methods

Ninety-one PD patients and 83 caregivers participated in the study. Multiple regression analyses were performed including benefit finding, coping, disease severity and socio-demographic factors, in order to determine how these aspects influence the psychosocial adjustment and QoL in PD patients and caregivers.

Results

Regression models showed that severity of PD was the main predictor of psychosocial adjustment and QoL in patients. Nevertheless, multiple regression analyses also revealed that coping was a significant predictor of psychosocial adjustment in patients and caregivers. Furthermore, psychosocial adjustment was significantly related to QoL in patients and caregivers. Also, coping and benefit finding were predictors of QoL in caregivers but not in patients.

Conclusions

Multidisciplinary interventions aimed at improving PD patients’ QoL may have more effective outcomes if education about coping skills, and how these can help towards a positive psychosocial adjustment to illness, were included, and targeted not only at patients, but also at informal caregivers.

Effects of Progressive Resistance Exercise Training on the Motor and Nonmotor Features of Parkinson's Disease: A Review

Objective:

This paper reviews the therapeutically beneficial effects of progressive resistance exercise training (PRET) on motor and nonmotor symptoms in Parkinson's disease (PD).

Methods:

First, we perform a systematic review of the literature on the effects of PRET on motor signs of PD, functional outcomes, quality of life, and patient perceived improvement, strength, and cognition in PD. Second, we perform a meta-analysis on the motor section of the UPDRS. Finally, we discuss the results of our review and we identify current knowledge gaps regarding PRET in PD.

Conclusion:

This systematic review synthesizes evidence that PRET can improve strength and motor signs of Parkinsonism in PD and may also be beneficial for physical function in individuals with PD. Further research is needed to explore the effects of PRET on nonmotor symptoms such as depression, cognitive impairment, autonomic nervous system dysfunction, and quality of life in individuals with PD.

Systematic review of outcomes used to evaluate enhanced recovery after surgery

BACKGROUND

Enhanced recovery pathways (ERPs) aim to improve patient recovery. However, validated outcome measures to evaluate this complex process are lacking. The objective of this review was to identify how recovery is measured in ERP studies and to provide recommendations for the design of future studies.

METHODS

A systematic search of MEDLINE, Embase and Cochrane databases was conducted. Prospective studies evaluating ERPs compared with traditional care in abdominal surgery published between 2000 and 2013 were included. All reported outcomes were classified into categories: biological and physiological variables, symptom status, functional status, general health perceptions and quality of life (QoL). The phase of recovery measured was defined as baseline, intermediate (in hospital) and late (following discharge).

RESULTS

A total of 38 studies were included based on the systematic review criteria. Biological or physiological variables other than postoperative complications were reported in 30 studies, and included return of gastrointestinal function (25 studies), pulmonary function (5) and physical strength (3). Patient-reported symptoms, including pain (16 studies) and fatigue (9), were reported less commonly. Reporting of functional status outcomes, including mobilization (16 studies) and ability to perform activities of daily living (4), was similarly uncommon. Health aspects of QoL were reported in only seven studies. Length of follow-up was generally short, with 24 studies reporting outcomes within 30 days or less. All studies documented in-hospital outcomes (intermediate phase), but only 17 reported postdischarge outcomes (late phase) other than complications or readmission.

CONCLUSION

Patient-reported outcomes, particularly postdischarge functional status, were not commonly reported. Future studies of the effectiveness of ERPs should include validated, patient-reported outcomes to estimate better their impact on recovery, particularly after discharge from hospital.

Predictors of quality of life in people with Parkinson's disease: evidence for both domain specific and general relationships

PURPOSE

To assess the determinants of health-related quality of life (HrQoL) in people with Parkinson's disease (PD).

METHOD

Eighty-one people with a diagnosis of idiopathic PD took part in a cross-sectional questionnaire-based study. Measures were collected in a community setting and included established determinants of HrQoL (demographic, clinical and cognitive variables) but also included a wide range of mental health variables (depression, anxiety and stress) and, for the first time, positive psychological functioning (optimism and self-esteem). HrQoL was measured by the full version of the Parkinson's Disease Questionnaire (PDQ-39) which includes eight domains of functioning.

RESULTS

Mental health measures (depression, anxiety and stress) were more influential than any other block of determinants and influenced a broader array of HrQoL domains including physical ones. There was some evidence of domain-specific relationships, e.g. between physical determinants and the more physically-oriented HrQoL domains, and between mental health determinants and emotional well-being. However, cognitive ability did not influence the HrQoL domain of cognitive impairment.

CONCLUSIONS

The contribution of a multi-disciplinary approach is crucial given the many variables which affect HrQoL; in particular, significant overall improvements on HrQoL are unlikely if only physical rehabilitation is offered. Rehabilitation is likely to be beneficial in terms of HrQoL only if it is planned and delivered holistically. Implications for Rehabilitation Interventions to improve physical function may have only limited impact on quality of life and might be limited to more physical HrQoL domains. Psychological interventions have the potential to improve quality of life over a wider range of both emotional and physical HrQoL domains. Clinician-measured level of functioning does not necessarily translate into patient-perceived levels of functional ability and relatively small objective decreases in ability can be appraised much more significantly disabling by people with PD.

Self-rated health mediates the association between functional status and health-related quality of life in Parkinson's disease

AIMS AND OBJECTIVES

To explore whether self-rated health acts as a potential mediator in the association between functional status and health-related quality of life in Parkinson's disease.

BACKGROUND

Older persons (as most patients with Parkinson's disease are) who reported poor self-rated health compared with those with excellent self-rated health were two-and-a-half times more likely to have experienced a decline in functional ability.

DESIGN

Cross-sectional.

METHODS

Socio-demographic and clinical data of the patients (n = 176) were obtained during a structured interview and from medical records. Functional status was measured with the Unified Parkinson's Disease Rating Scale (total score), self-rated health with the first item of the Short-Form 36-item Health Survey Questionnaire and health-related quality of life with the disease-specific questionnaire called the Parkinson's Disease Quality of Life Questionnaire-39. Multiple linear regression analyses and the Sobel test were employed to assess mediation.

RESULTS

Self-rated health seems to have a mediating effect on the association between functional status and health-related quality of life. The Sobel test confirmed an indirect effect of functional status via self-rated health on health-related quality of life and showed a statistically significant indirect effect of functional status on health-related quality of life via self-rated health against the direct route without the mediator.

CONCLUSIONS

Self-rated health partially mediates the deteriorating effect of functional status on health-related quality of life.

RELEVANCE TO CLINICAL PRACTICE

Supportive and adaptation psychosocial intervention programmes leading to restored self-rated health may enhance the quality of life regardless of disability in Parkinson's disease.

Automatic and objective assessment of alternating tapping performance in Parkinson's disease

This paper presents the development and evaluation of a method for enabling quantitative and automatic scoring of alternating tapping performance of patients with Parkinson's disease (PD). Ten healthy elderly subjects and 95 patients in different clinical stages of PD have utilized a touch-pad handheld computer to perform alternate tapping tests in their home environments. First, a neurologist used a web-based system to visually assess impairments in four tapping dimensions ('speed', 'accuracy', 'fatigue' and 'arrhythmia') and a global tapping severity (GTS). Second, tapping signals were processed with time series analysis and statistical methods to derive 24 quantitative parameters. Third, principal component analysis was used to reduce the dimensions of these parameters and to obtain scores for the four dimensions. Finally, a logistic regression classifier was trained using a 10-fold stratified cross-validation to map the reduced parameters to the corresponding visually assessed GTS scores. Results showed that the computed scores correlated well to visually assessed scores and were significantly different across Unified Parkinson's Disease Rating Scale scores of upper limb motor performance. In addition, they had good internal consistency, had good ability to discriminate between healthy elderly and patients in different disease stages, had good sensitivity to treatment interventions and could reflect the natural disease progression over time. In conclusion, the automatic method can be useful to objectively assess the tapping performance of PD patients and can be included in telemedicine tools for remote monitoring of tapping.

Independent contributors to overall quality of life in people with advanced cancer

Background:

The definition of health for people with cancer is not focused solely on the physiology of illness and the length of life remaining, but is also concerned with improving the well-being and the quality of the life (QOL) remaining to be lived. This study aimed to identify the constructs most associated with QOL in people with advanced cancer.

Methods:

Two hundred three persons with recent diagnoses of different advanced cancers were evaluated with 65 variables representing individual and environmental factors, biological factors, symptoms, function, general health perceptions and overall QOL at diagnosis. Three independent stepwise multiple linear regressions identified the most important contributors to overall QOL. R² ranking and effect sizes were estimated and averaged by construct.

Results:

The most important contributor of overall QOL for people recently diagnosed with advanced cancer was social support. It was followed by general health perceptions, energy, social function, psychological function and physical function.

Conclusions:

We used effect sizes to summarise multiple multivariate linear regressions for a more manageable and clinically interpretable picture. The findings emphasise the importance of incorporating the assessment and treatment of relevant symptoms, functions and social support in people recently diagnosed with advanced cancer as part of their clinical care.

Translation and validation of the korean version of the 39-item Parkinson's disease questionnaire

Background and Purpose

The importance of health-related quality of life (HrQoL) has been increasingly emphasized when assessing and providing treatment to patients with chronic, progressive, degenerative disorders. The 39-item Parkinson's disease questionnaire (PDQ-39) is the most widely used patient-reporting scale to assess HrQoL in Parkinson's disease (PD). This study evaluated the validity and reliability of the translated Korean version of the PDQ-39 (K-PDQ-39).

Methods

One hundred and two participants with PD from 10 movement disorder clinics at university-affiliated hospitals in South Korea completed the K-PDQ-39. All of the participants were also tested using the Unified Parkinson's Disease Rating Scale (UPDRS), Korean version of the Mini-Mental State Examination (K-MMSE), Korean version of the Montgomery-Asberg Depression Scale (K-MADS), Epworth Sleepiness Scale (ESS) and non-motor symptoms scale (NMSS). Retests of the K-PDQ-39 were performed over time intervals from 10 to 14 days in order to assess test-retest reliability.

Results

Each K-PDQ-39 domain showed correlations with the summary index scores (rS=0.559-0.793, p<0.001). Six out of eight domains met the acceptable standard of reliability (Cronbach's α coefficient ≥0.70). The Guttman split-half coefficient value of the K-PDQ-39 summary index, which is an indicator of test-retest reliability, was 0.919 (p<0.001). All of the clinical variables examined except for age, comprising disease duration, levodopa equivalent dose, modified Hoehn and Yahr stage (H&Y stage), UPDRS part I, II and III, mood status (K-MADS), cognition (K-MMSE), daytime sleepiness (ESS) and (NMSS) showed strong correlations with the K-PDQ-39 summary index (p<0.01).

Conclusions

The K-PDQ-39 has been validated for use in the Korean-speaking PD population. The questionnaire is a valid and reliable assessment tool for assessing the HrQoL of Korean PD patients.

Impact of anxiety on quality of life in Parkinson's disease

In Parkinson's disease (PD), both the patient and the health care provider look for ways to preserve the patient's quality of life. Many studies focus on the impact of depression and motor disability on poor life quality but neglect to examine the role of anxiety. We investigated the impact of anxiety and depression on health-related quality of life in PD, using the Parkinson's Disease Quality of Life measure (PDQ-39). Symptoms of anxiety, more than depression, cognitive status, or motor stage, significantly affected quality of life in 38 nondemented patients with mild-to-moderate motor disability. Stepwise regression analyses revealed that anxiety explained 29% of the variance in the PDQ-39 sum score, and depression explained 10% of the variance beyond that accounted for by anxiety. The findings suggest that primary management of anxiety as well as depression may be important to optimizing the quality of life of PD patients.

Exercise alleviates Parkinsonism: clinical and laboratory evidence

The present review examines the putative benefits for individuals afflicted with Parkinsonism, whether in the clinical setting or in the animal laboratory, accruing from different exercise regimes. The tendency for patients with Parkinson's disease (PD) to express either normal or reduced exercise capacity appears regulated by factors such as fatigue, quality-of-life and disorder severity. The associations between physical exercise and risk for PD, the effects of exercise on idiopathic Parkinsonism and quality-of-life, the effects of exercise on animal laboratory models of Parkinsonism and dopamine (DA) loss following neurotoxic insults, and the effects of exercise on the DA precursor, L-Dopa, efficacy are examined. It would appear to be case that in view of the particular responsiveness of the dopaminergic neurons to exercise, the principle of 'use it or lose' may be of special applicability among PD patients.

Odor identification deficits are associated with increased risk of neuropsychiatric complications in patients with Parkinson's disease

Olfactory deficits appear early in the course of Parkinson's disease (PD) but their prognostic significance is not known. The goal of this study was to determine whether the severity of olfactory impairment is associated with subsequent risk of developing complications of PD. One hundred patients with PD self-administered the University of Pennsylvania Smell Identification Test (UPSIT). Testing was done, on average, 3.6 years from the time of initial diagnosis. The incidence of neuropsychiatric features of PD, including cognitive decline and visual hallucinations, was ascertained through chart review after an average of 6.8 years of follow-up. Incidence of motor outcomes including falls and dyskinesias was also obtained. There was a significant trend for increased risk of neuropsychiatric complications across declining quartiles of olfactory test scores. In addition, subjects in the lowest quartile of olfactory performance had a significantly higher adjusted risk of hallucinations (HR = 4.70, 95% CI 1.64, 13.42) and cognitive decline (HR = 3.10, 95% CI 1.05, 9.21) than those in the reference quartile. There was no association between olfactory dysfunction and dyskinesias, and a very modest association with risk of falls. These findings suggest that severity of olfactory impairment early in the disease course may be a useful marker for the risk of neuropsychiatric complications of PD.

Quality improvement in neurology: AAN Parkinson disease quality measures: report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology

BACKGROUND

Measuring the quality of health care is a fundamental step toward improving health care and is increasingly used in pay-for-performance initiatives and maintenance of certification requirements. Measure development to date has focused on primary care and common conditions such as diabetes; thus, the number of measures that apply to neurologic care is limited. The American Academy of Neurology (AAN) identified the need for neurologists to develop measures of neurologic care and to establish a process to accomplish this.

OBJECTIVE

To adapt and test the feasibility of a process for independent development by the AAN of measures for neurologic conditions for national measurement programs.

METHODS

A process that has been used nationally for measure development was adapted for use by the AAN. Topics for measure development are chosen based upon national priorities, available evidence base from a systematic literature search, gaps in care, and the potential impact for quality improvement. A panel composed of subject matter and measure development methodology experts oversees the development of the measures. Recommendation statements and their corresponding level of evidence are reviewed and considered for development into draft candidate measures. The candidate measures are refined by the expert panel during a 30-day public comment period and by review by the American Medical Association for Current Procedural Terminology (CPT) II codes. All final AAN measures are approved by the AAN Board of Directors.

RESULTS

Parkinson disease (PD) was chosen for measure development. A review of the medical literature identified 258 relevant recommendation statements. A 28-member panel approved 10 quality measures for PD that included full specifications and CPT II codes.

CONCLUSION

The AAN has adapted a measure development process that is suitable for national measurement programs and has demonstrated its capability to independently develop quality measures.

Determinants of health-related quality of life in Parkinson's disease: a systematic review

This systematic review critically evaluates the literature to identify the demographic and clinical factors that predict the health-related quality of life (HRQOL) of people with Parkinson's disease (PD). Understanding how these factors relate to HRQOL in people with PD may assist clinicians minimise the functional and social impact of the disease by optimising their assessment and clinical decision making processes. A tailored search strategy in six databases identified 29 full-text reports that fulfilled the pre-defined inclusion and exclusion criteria. The quality of included studies was assessed by two independent reviewers using a customized assessment form. A best-evidence synthesis was used to summarise the demographic and clinical factors that were examined in relation to HRQOL. Depression was the most frequently identified determinant of HRQOL in people with idiopathic PD. Disease severity and disease disability were also found to be predictive of poor HRQOL outcomes in many studies. The motor symptoms that contributed most often to overall life quality were gait impairments and complications arising from medication therapy. To minimise the impact of PD on HRQOL, it may be necessary to consider the extent to which demographic factors and motor and non-motor symptoms contribute to life quality.

Health-related quality of life in Parkinson disease: correlation between Health Utilities Index III and Unified Parkinson's Disease Rating Scale (UPDRS) in U.S. male veterans

Objective

To apply a scaled, preference-based measure to the evaluation of health-related quality of life (HRQoL) in Parkinson's disease (PD); to evaluate the relationship between disease-specific rating scales and estimated HRQoL; and to identify predictors of diminished HRQoL.

Background

Scaled, preference-based measures of HRQoL ("utilities") serve as indices of impact of disease, and can be used to generate quality-adjusted estimates of survival for health-economic evaluations. Evaluation of utilities for PD and their correlation with standard rating scales have been limited.

Methods

Utilities were generated using the Health Utilities Index Mark III (HUI-III) on consecutive patients attending a PD Clinic between October 2003 and June 2006. Disease severity, medical, surgical (subthalamic nucleus deep brain stimulation (STN-DBS)), and demographic information were used as model covariates. Predictors of HUI-III utility scores were evaluated using the Wilxocon rank-sum test and linear regression models.

Results

68 men with a diagnosis of PD and a mean age of 74.0 (SD 7.4) were included in the data analysis. Mean HUI-III utility at first visit was 0.45 (SD 0.33). In multivariable models, UPDRS-II score (r² = 0.56, P < 0.001) was highly predictive of HRQoL. UPDRS-III was a weaker, but still significant, predictor of utility scores, even after adjustment for UPDRS-II (P = 0.01).

Conclusions

Poor self-care in PD reflected by worsening UPDRS-II scores is strongly correlated with low generic HRQoL. HUI-III-based health utilities display convergent validity with the UPDRS-II. These findings highlight the importance of measures of independence as determinants of HRQoL in PD, and will facilitate the utilization of existing UPDRS data into economic analyses of PD therapies.

Measuring quality of life in children and young people after transplantation: methodological considerations

The measurement of QoL has become an important area for research in paediatric transplantation over the past 15 yr. While much of this work remains descriptive and exploratory, advances in treatment and the trend towards outcomes being patient centred and not just survival based suggest the measurement of QoL will be of far more importance and relevance in the future. In this discussion article, we will outline some of the issues that need to be considered when embarking on a QoL study. The aim of our account is not to be prescriptive, rather to present researchers and clinicians with questions and possible solutions to help increase the scientific robustness of future studies. We have included summary tables of instruments that are currently available as a resource for those wanting to evaluate QoL in paediatric transplantation.

A comprehensive model of health-related quality of life in Parkinson's disease

BACKGROUND

Insight in how impairments and disabilities related to Parkinson's disease (PD) influence health-related quality of life (HRQoL) is required to review adequacy of current management strategies.

METHODS

The Scales for Outcomes in Parkinson's disease (SCOPA) evaluation was used to assess impairments and disabilities. HRQoL was assessed with the EuroQol-5D Visual Analogue Scale. 378 patients with PD who participated in the SCOPA/PROPARK cohort were assessed while on their usual treatment. Multiple linear regression analysis and structural equation modelling were used to construct a model of factors that influence HRQoL.

RESULTS

A model with good fit was constructed that identified various impairments and disabilities as important contributors to HRQoL in PD. Of the disabilities, psychosocial well-being had a larger impact on HRQoL than physical functioning. Of the impairments, depression had the largest contribution to HRQoL, followed by axial motor symptoms, gastrointestinal symptoms, and urinary symptoms. In addition, pain, psychiatric and motor complications, and daytime sleepiness had small but significant influences on HRQoL.

CONCLUSION

Multiple factors, including disabilities, nonmotor symptoms and axial motor symptoms, affect HRQoL in patients with PD. In patients who are on symptomatic treatment aiming to alleviate mainly motor symptoms, there is a large impact on HRQoL of nonmotor and nondopaminergic symptoms. Research is warranted to develop and evaluate management strategies for the aspects that currently impact on HRQoL as psychosocial well-being, depressive symptoms, axial motor symptoms, gastrointestinal symptoms, and urinary symptoms. These findings call for a multidisciplinary approach in the care of these features.

The evolution of disability in Parkinson disease

The objectives of this study are to assess the level of disease severity associated with disability in Parkinson disease (PD) and the sequence of loss of independence in basic and instrumental activities of daily living (ADLs and IADLs). Six hundred eighteen patients with PD were evaluated for disease severity with the Unified PD Rating Scale (UPDRS) and for disability with the Older Americans Resource and Services Disability Subscale (OARS). The association between patient-reported disability on ADLs and IADLs and level of disease severity on the total UPDRS was examined cross-sectionally. Disability, with loss of independent function is reported between total UPDRS scores 30 to 40, and HY stages II to III. Difficulty with daily activities, without loss of independent function is reported earlier, at UPDRS <20 and HY I to II. Difficulty with walking is initially reported, followed by problems with a number of gait-dependent activities including housework, dressing, transferring in and out of bed, and traveling in the community. The transition from HY stage II to III marks a pivotal milestone in PD, when gait and balance impairment results in disability in many gait-dependent activities. The onset of disability in PD can be identified by asking patients about their walking, housework, dressing, and traveling. While individual patients vary in progression, the benchmarks of disability in this study provide guidance when counseling patients about prognosis. Better understanding of the stages of disability may facilitate the development of novel outcome measures in clinical trials in PD.

Predictors of deterioration in health-related quality of life in Parkinson's disease: results from the DATATOP trial

The aim of this study was to investigate factors associated with decline in health-related quality of life in Parkinson's disease, by a retrospective cohort study from referral centers in Canada and the United States. Subjects were patients with early Parkinson's disease (N = 362) enrolled in a clinical trial of deprenyl (selegiline) and tocopherol (DATATOP) and followed prospectively. The main outcome measure was change in health-related quality of life using SF-36 Mental and Physical Component Summary scores. The mean interval between SF-36 measurements was 1.7 +/- 0.1 years, beginning 5 to 6 years after enrolment into the trial. In multivariable analysis, baseline Hamilton Depression Scale scores and self-rated cognitive function were associated with subsequent decline in Physical Component Summary scores, while older age and Schwab and England activities of daily living scores were associated with decline in Mental Component Summary scores. The Postural Instability Gait Disorder score was the only variable found to decline concurrently with HRQOL. Our results suggest that depression, self-rated cognitive function, and one's degree of functional independence are predictors of subsequent changes in HRQOL. Our focus in clinical care needs to be broadened beyond assessing and treating Parkinsonism, recognizing the impact of mood, cognition and function on HRQOL.

CBT for the treatment of depression in Parkinson's disease: a promising nonpharmacological approach

Depression is very common in Parkinson's disease (PD) and linked with a faster progression of physical symptoms, greater cognitive decline and poorer quality of life. Nonpharmacological approaches, such as cognitive-behavioral therapy (CBT), for the treatment of depression in PD (dPD) have received little experimental attention despite strong demonstrated efficacy in other geriatric and medical populations. Depressed PD patients often differ from the depressed non-PD elderly in that they present with increased rates of both executive dysfunction and comorbid psychiatric diagnoses, may differ in their depressive symptom presentation and typically have caregivers who are highly involved in their treatment. Therefore, it is not possible to conclude that empirically validated treatments in the depressed aged will generalize to those with PD. In order to be most effective for PD patients, CBT should be tailored to their unique needs. Additional controlled research is needed to further explore the efficacy of CBT for dPD.

Disparities of care in veterans with Parkinson's disease

BACKGROUND

Disparities of Parkinson's disease (PD) care have not been assessed.

METHODS

We examined the medical records of 309 (83%) non-Hispanic White and 65 (17%) non-White Los Angeles veterans with PD from 1998 to 2004 to determine if care quality as measured by 10 PD indicators different by race/ethnicity.

RESULTS

In multivariate modeling, adherence to indicators was higher among non-Hispanic Whites (71% vs. 65%, risk ratio 1.15, 95% CI [1.07-1.32]) compared to non-Whites. Differences in adherence by race/ethnicity were greatest for depression treatment (p<0.05).

CONCLUSIONS

We detected disparities in quality of PD care, particularly in depression treatment. Future research should determine causes for these so that interventions can be designed to reduce such disparities.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

Cognitive-behavioral therapy for depression in Parkinson's disease: a pilot study

The present study was conducted to examine the feasibility and effect of an individual cognitive-behavioral treatment (CBT) for depression that was modified to meet the unique needs of the PD patient and incorporated a separate social support intervention for caregivers. Fifteen PD patients with Major Depressive Disorder participated in the study with a caregiver. Patients received 10-14 sessions of modified individual CBT. Caregivers attended 3-4 psychoeducational sessions, occurring separately from the patients treatment sessions, which focused on strategies for offering appropriate support, and ways to respond to the patients' negative thoughts in a targeted manner. Patients experienced a significant reduction in depressive symptoms and negative cognitions, and an increased perception of social support over the course of treatment. Gains were maintained at 1-month follow-up. In conclusion, individual CBT, when modified appropriately, may be a feasible and effective option for PD depression. Larger, randomized controlled trials are needed to further evaluate the efficacy of this intervention and to identify specific mechanisms of change.

Association of specialist involvement and quality of care for Parkinson's disease

Because Parkinson's disease (PD) has multiple neurological symptoms and often complex treatments, the quality of PD care may be higher when a specialist is involved. We examined the medical records, from 1998 to 2004, of 401 Los Angeles veterans with Parkinson's disease to determine whether care met key indicators of PD care quality. All care following a visit to a movement-disorder specialist or general neurologist was classified as specialty care. We compared adherence to each indicator by level of specialist involvement through logistic regression models. Over the study period, 10 indicators of PD care quality were triggered 2,227 times. Overall, movement disorder specialist involvement (78%) was associated with higher adherence to indicators than did general neurologist involvement (70%, P = 0.006) and nonneurologist involvement (52%, P < 0.001). The differences between movement disorder specialist and nonneurologist involvement were especially large for four indicators: treatment of wearing-off, assessments of falls, depression, and hallucinations. There is significant room for improving aspects of PD care quality among patients who do not have the involvement of a specialist. Quality of care interventions should involve specialists in management of motor symptoms and incorporate methods for routine assessment of nonmotor PD symptoms.

Quality of life and related concepts in Parkinson's disease: A systematic review

Several studies have investigated the quality of life (QOL) of patients with Parkinson's disease (PD). The purpose of this study was to review the conceptual and methodological quality of quality of life (QOL) studies among patients with PD and to identify factors associated with poor (HR)QOL. Computerized bibliographic databases were screened for publications from 1960 to January 2007. According to a list of predefined criteria, the methodological quality of the 61 studies, was moderate. The term 'QOL' was often used inappropriately. In fact, almost all studies in this review actually assessed health status (HS) instead of QOL. The functioning of patients with PD on physical, social, and emotional domains is affected by PD. Their HS seems to be lower when compared to healthy persons or patients with other chronic diseases. HS studies augment the insight in self-perceived functioning. Therefore, HS is conceived as a valuable construct. However, QOL is also an important factor in health care. Attention towards QOL is needed in order to draw valid conclusions regarding a person's subjective experience of well-being in a broad sense. In order to accomplish this, future studies should apply the QOL concept with more rigor, should use an adequate operational definition, and should employ sound measures.

The Disability Discrimination Act, a necessary, but not sufficient safeguard for people with progressive conditions in the workplace? The experiences of younger people with Parkinson's disease

PURPOSE

This study explored the impact of Parkinson's disease (PD) on employment from the perspective of affected individuals. Particular attention was paid to factors that may affect the duration of employment after onset/diagnosis.

METHOD

Data were collected in two phases, i) a postal survey (n = 339), and ii) one to one interviews (n = 24).

RESULTS

Four out of five participants reported that PD had made work difficult for them, only 15.3% had worked for more than five years post-diagnosis at the time of the survey. Several participants reported having experienced considerable stress prior to leaving work. Factors that precipitated withdrawal from the labour market included severity of symptoms, lack of support in the workplace, and opportunities for 'early retirement'. Factors associated with maintaining employment included age at diagnosis, support received from employers, and manipulation of drug therapy.

CONCLUSIONS

It can be very difficult for people with PD to continue in paid employment for more than a few years post diagnosis. The relatively low level of contact between people with PD who were in employment and health professionals suggest that employment retention is not seen as major role for this group of professionals. There is a need for positive action to support people with progressive conditions in the workplace.

Putting Wilson and Cleary to the test: analysis of a HRQOL conceptual model using structural equation modeling

Wilson and Cleary (1995) proposed a conceptual model of health-related quality of life (HRQOL) that integrates both biological and psychological aspects of health outcomes. There are five different levels in their model, namely, physiological factors, symptom status, functional health, general health perceptions, and overall quality of life. Their model has been widely applied to different populations, including patients living with cancer, Parkinson's disease, arthritis, and HIV+/AIDS. However, their conceptual model has only been partially examined. That is, the five major concepts have not been examined simultaneously. Using structural equation modeling (SEM), the Wilson and Cleary HRQOL model was validated in patients living with HIV from the AIDS Time-Oriented Health Outcomes Study. The results showed that the HRQOL model fit the data adequately, and the relationships between the constructs were all significant (at p<0.05 level). Based on the modification indexes, an alternative model linking symptom status directly with general health perceptions and overall quality of life was specified. Implication and limitation of the findings are discussed.

Treatment of depression in Parkinson's disease

Depression is one of the most common nonmotor features observed in Parkinson's disease (PD), affecting approximately 40% of patients. Depression in Parkinson's disease (dPD) significantly affects quality of life of both patients and their families and has been shown to be more predictive of distress than motor disability. Depression frequently goes unrecognized in this population, however, in part because the diagnosis is often complicated by the overlap of psychiatric and PD symptoms. The etiology of dPD is unclear; dopaminergic, serotonergic, and noradrenergic systems may be implicated. Options for managing dPD include antidepressant medication; cognitive-behavioral therapy; behavioral lifestyle interventions such as exercise; and, in refractory cases, noninvasive brain stimulation (electroconvulsive therapy, transcranial magnetic stimulation). Randomized controlled trials are needed to evaluate the efficacy of interventional approaches for dPD; several trials are currently underway.

Impact of an exercise program on physical, emotional, and social aspects of quality of life of individuals with Parkinson's disease

We evaluated changes in different domains of quality of life (QL) for persons with Parkinson's disease after a program of physical activity. Twenty subjects with a diagnosis of Parkinson's disease classified as Stages 1 to 3 on the Hoehn and Yahr scale and with a mean age of 61.5 +/- 9.8 years participated in 36 group sessions of a combined group program of aerobic conditioning and muscular strengthening. QL was investigated by the Nottingham Health Profile, a generic questionnaire composed of six domains. Student's paired t tests indicated significant gains associated with the program (P < 0.05) on the total score and those related to emotional reactions (ER), social interactions (SI), and physical ability (PA). SI was the domain that showed the greatest program gains (41.4%). The program of physical activity performed with persons with Parkinson's disease at light to moderate stages resulted in improvements in their perception of QL, mainly in the domains of ER, SI, and PA.

Individualized assessment of quality of life in idiopathic Parkinson's disease

The purpose of this study was to assess quality of life (QoL) of patients with idiopathic Parkinson's disease (IPD). The Parkinson's Disease Questionnaire (PDQ-39) was compared with an individualized QoL tool: the Schedule for Evaluation of Individual Quality of Life Direct Weighting (SEIQoL-DW). One hundred twenty-three patients underwent interviews using these tools, together with the Mini Mental State examination, Beck Depression Inventory, a qualitative pain assessment, and the Palliative Care Assessment tool (for symptoms). The SEIQoL-DW was well tolerated and demonstrated that QoL not only was broad and highly individualistic but also was determined more by psychosocial than physical issues. Of the 87 domains nominated by patients, the most common were family (87.8%), health (52.8%), leisure activities (36.6%), marriage (35%), and friends (30.9%). The SEIQoL index score was predicted by depression but not by disease stage. However, the PDQ-39 was predicted by disease stage, the number of symptoms, and depression. Direct comparison of the tools confirmed that the SEIQoL index score was predicted by the PDQ-39 domains of social support, cognitive impairment, and emotion. The use of the SEIQoL-DW challenges current thinking within IPD research regarding QoL and its assessment using the PDQ-39.

Validation and cross-cultural adjustment of PDQL-questionnaire, Spanish version (Ecuador) (PDQL-EV)

OBJECTIVE

To validate the Ecuadorian Spanish-language version of the Parkinson's Disease Quality of Life Questionnaire (PDQL-EV).

METHOD

Cross-sectional study of patients with Parkinson's Disease attending a Movement Disorders Clinic. MEASURES APPLIED: Hoehn and Yahr (HY), Unified Parkinson's Disease Rating Scale (UPDRS-3.0), Schwab and England Scale (SES), Pfeiffer Questionnaire (SPMSQ), Hospital Anxiety and Depression Scale (HADS). PDQ-39 and PDQL-EV were applied, the latter after translation and back translation.

RESULTS

The study included 137 patients with an age range of 69.43 +/- 10.18 years (mean +/- SD), duration of illness 5.87 +/- 2.58 years, and HY 2.28 +/- 0.77. The PDQL-EV internal consistency (Cronbach's alpha) yielded: Parkinson's symptoms (PS) 0.85; systemic symptoms (SS) 0.69; social function (SF) 0.81; and emotional function (EF) 0.78. The correlation between measurements varied from 0.68 (PS-SS) to 0.46 (SS-EF), and total measurement correlation from 0.58 (EF) to 0.74 (PS) (altogether, p < 0.0001). The correlation of PDQL with clinical variables was: HY -0.62; UPDRS (subscales 1, 2 and 3) -0.55, -0.76, and -0.48, respectively; SES 0.65; SPMSQ -0.35; HADS-anxiety -0.55; HADS-depression -0.67; and PDQ-39 -0.91 (altogether p < 0.0001). PDQL-EV scores were significantly different (p < 0.0001) between moderate and advanced stages, for all domains except for EF (p = 0.006).

CONCLUSION

The PDQ-EV has satisfactory internal consistency, and converging and discriminating validity.

Wireless real-time electronic data capture for self-assessment of motor function and quality of life in Parkinson's disease

Frequent assessment of the symptoms in Parkinson's disease (PD) is important in both clinical and experimental settings, especially when motor fluctuations are present. Patient diaries are increasingly used in studies, allowing patients to stay in their home environments. However, traditional paper diaries may not reflect reality because of a lack in compliance or retrospective data entries. This study presents a comparison between paper diaries and a new method, real-time data capture with a hand-held computer (electronic diary). Twenty patients with PD diagnosed at least 5 years previously were randomly assigned to use either a paper diary or an electronic diary on 8 days during 1 month. Questions were answered every 2 hours over a 12-hour period on each day. Median compliance was 88% with the electronic diary and 98% with the paper diary, although strict compliance to the scheduled times by patients using the paper diary was 78%. Neither age nor earlier experience with computers affected the patient's ability to use the electronic diary. Electronic diaries can be used for self-assessment of PD symptoms. The real-time feature provides fast access to clean data with knowledge of true compliance.

Quality of life and pain in Parkinson's disease: a controlled cross-sectional study

PURPOSE

To compare health-related quality of life (HRQL) and pain symptoms in patients with PD with a matched control group. To our knowledge, controlled studies of Parkinson's disease (PD) patients within this area are rare.

SCOPE

Fifty-seven patients and 95 controls took part in a self-administered questionnaire study. The instruments were the SF-36, visual analogue scales, pain drawing and pain-specific questions.

CONCLUSIONS

Pain problems are common in PD patients but also to a large extent in the normal population. HRQL was reduced (p < or = 0.001) for the PD patients on all the scales on the SF-36 and consequently also in the pain dimension. The study indicates that even PD patients, who are optimally diagnosed and treated by a neurologist, might require additional rehabilitation treatment to improve their HRQL and pain problems.

Patients', doctors', and caregivers' assessment of disability using the UPDRS-ADL section: are these ratings interchangeable?

This multicenter study sought to analyze the validity and reliability of the Unified Parkinson's Disease Rating Scale (UPDRS)-section 2 (Activities of Daily Living, ADL) as applied by patients and caregivers. Sixty pairs of PD patients-caregivers were enrolled for study purposes. Neurologists used a set of scales to determine disease severity and patients' functional state. Patients and caregivers used adapted versions of the UPDRS-section 2 in tandem with other measures. Wilcoxon and Mann-Whitney tests, weighted kappa, intraclass and Spearman's correlation coefficients, as well as multivariate linear regression models were applied. On the whole, PD patient self-assessment and caregiver evaluation of patients' disability showed close concordance with neurologists' ratings. Correlation between caregiver ratings and clinical evaluation tended to be slightly lower than that for patient-based self-assessment. Depression showed a positive correlation with disability and had a nonsystematic influence on UPDRS-section 2 (ADL) scores. As expected, there was a significant correlation between perceived disability and health-related quality of life measures. Caregiver burden did not reduce the level of agreement with neurologists as to the overall rating of any given patient's disability. In PD, UPDRS-section 2-based assessment of disability by patients themselves and caregivers is a valid and reliable outcome.

Health-related quality of life evaluation by proxy in Parkinson's disease: Approach using PDQ-8 and EuroQoL-5D

Patient- and caregiver-based scores were compared and agreement levels ascertained to determine the reliability of proxy evaluation of Parkinson's Disease (PD) patients' health-related quality of life (HRQoL) using the EuroQoL and PD questionnaire (PDQ)-8. Of 72 patient-caregiver pairs, 64 (88.88%) returned the questionnaires. The degree of agreement varied for individual dimensions. Proxy evaluation of PD patients' HRQoL showed limitations mainly with assessments using the EuroQoL and especially in patients with severe disease and depression.

Psychosocial problems in Parkinson's disease: evaluation of a disease-specific questionnaire

Our objective was to evaluate the BELA-P-k, a questionnaire for measuring psychosocial problems and need for help in Parkinson's disease (PD) patients. The Belastungsfragebogen Parkinson kurzversion (BELA-P-k) was translated from German into Dutch. It consists of 19 items distributed over four subscales: achievement capability/physical symptoms, fear/emotional functioning, social functioning and partner-bonding/family, with a "Bothered by" (Bb) and a "Need for Help" (NfH) score. The BELA-P-k was tested for cultural differences, relevance, and feasibility in a pilot study (n = 10) and compared in a validation study (n = 54) with the Sickness Impact Profile, the COOP/WONCA Functional Health Assessment Charts and the Loneliness Questionnaire. All questionnaires were administered in person at home, in a prescribed order. The BELA-P-k was completed by 64 patients with PD. The internal-consistency reliability coefficients for the total Bb (0.90) and NfH (0.93) scales were excellent. The internal consistency of the subscales exceeded the 0.70 standard except for the "Bothered by partner-bonding/family scale" (0.61). Almost all BELA-P-k subscales correlated highly (P < 0.001) with the corresponding scales of the standard quality-of-life indices. There was no significant relationship between disease severity (Hoehn and Yahr) and the BELA-P-k. We conclude that the BELA-P-k is a relevant, reliable and valid measure for assessing psychosocial problems and need for help of PD patients.