Clinical and genetic characteristics in patients with Huntington’s disease from China

A systematic review and meta-analysis of depression and apathy frequency in adult-onset Huntington's disease

Depression and apathy are associated with decreased functional capacity in Huntington's disease (HD) but frequency of depression and apathy in HD is largely unknown. Systematic literature searching was conducted across 21 databases until 30 June 2021. Inclusion criteria was limited to clinician-rated assessments of depression and apathy and adult-onset HD. Inverse-variance heterogeneity meta-analyses were conducted exploring depression and apathy frequency within individuals from families affected by HD, and within individuals with confirmed HD gene-positive status. Screening identified 289 articles for full-text review; nine remained for meta-analysis. Depression frequency in the lifetime in adults affected by or at-risk for HD was 38%, I² = 99%. Apathy frequency in the lifetime in adults affected by or at-risk for HD was 40%, I² = 96%. The robustness of the findings improved when limiting the analysis to gene-positive individuals only where apathy was found to be slightly more common than depression, 48% and 43% respectively. Future studies may consider reporting results from juvenile-onset HD and adult-onset HD cohorts separately to further explore phenotypic profiles.

The Comprehensive Analysis of Motor and Neuropsychiatric Symptoms in Patients with Huntington's Disease from China: A Cross-Sectional Study

Huntington’s disease (HD) is an autosomal dominant inherited neurodegenerative disorder caused by CAG repeats expansion. There is a paucity of comprehensive clinical analysis in Chinese HD patients due to the low prevalence of HD in Asia. We aimed to comprehensively describe the motor, neuropsychiatric symptoms, and functional assessment in patients with HD from China. A total of 205 HD patients were assessed by the Unified Huntington’s Disease Rating Scale (UHDRS), the short version of Problem-Behavior Assessment (PBA-s), Hamilton Depression Scale (HAMD) and Beck Depression Inventory (BDI). Multivariate logistic regression analysis was used to explore the independent variables correlated with neuropsychiatric subscales. The mean age of motor symptom onset was 41.8 ± 10.0 years old with a diagnostic delay of 4.3 ± 3.8 years and a median CAG repeats of 44. The patients with a positive family history had a younger onset and larger CAG expansion than the patients without a family history (p < 0.05). There was a significant increase in total motor score across disease stages (p < 0.0001). Depression (51%) was the most common neuropsychiatric symptom at all stages, whereas moderate to severe apathy commonly occurred in advanced HD stages. We found lower functional capacity and higher HAMD were independently correlated with irritability; higher HAMD and higher BDI were independently correlated with affect; male sex and higher HAMD were independently correlated with apathy. In summary, comprehensive clinical profile analysis of Chinese HD patients showed not only chorea-like movement, but psychiatric symptoms were outstanding problems and need to be detected early. Our study provides the basis to guide clinical practice, especially in practical diagnostic and management processes.

Huntington's disease: Mortality and risk factors in an Australian cohort

INTRODUCTION

There has not been any examination of the risk factors associated with mortality in Huntington's Disease (HD) in an Australian cohort.

METHOD

This retrospective study included inpatients admitted to a specialist neuropsychiatry service in Melbourne, Australia. HD status was based on genetic testing. Risk factors included age of onset, CAG repeat length and neuroimaging. Mortality data was acquired through the Australian Institute of Health and Welfare National Death Index.

RESULTS

The cohort included 83 participants, with 44 (53%) deceased. The median age of death was 59 years and median survival was 18.8 years from onset age (median 41.0 years). CAG repeat length (median 44.0, IQR 42.5, 47.0) was inversely correlated with age of onset (r = -0.73) and age at death (r = -0.80) but was not correlated with mortality status. There was no difference in functional and cognitive assessments, nor brain volumes, in the alive group compared to the deceased group. There were more people who were alive who had a positive family history of a psychiatric condition (p = 0.006) or dementia (p = 0.009). Standardised mortality ratios demonstrated a 5.9× increased risk of death for those with HD compared to the general population.

CONCLUSIONS

This is the first study to examine risk factors of mortality in HD in an Australian cohort. Median survival in our cohort is consistent with previous studies in HD, and markedly reduced compared to the general Australian population. CAG repeat length was not associated with mortality suggesting that non-genetic factors contribute to mortality status and warrant further investigation.

Frequency and Pathophysiology of Apathy in Huntington Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Apathy is a common behavioral symptom of Huntington disease (HD). This systematic review describes current evidence on the pathophysiology, assessment, and frequency of apathy in HD.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. Using a comprehensive search strategy, the investigators searched the MEDLINE, Embase, and PsycINFO databases. All studies that evaluated apathy in HD patients with a valid scale and reported apathy frequency or scores were included. Apathy scores were analyzed by mean or standardized mean differences in accordance with Cochrane guidelines.

RESULTS

A total of 1,085 records were screened and 80 studies were ultimately included. The Problem Behaviors Assessment-Short was the most frequently used apathy assessment tool. Apathy frequency generally ranged from 10%-33% in premanifest HD to 24%-76% in manifest HD. A meta-analysis of 5,311 records of patients with premanifest HD showed significantly higher apathy scores, with a standardized mean difference of 0.41 (CI=0.29-0.52; p<0.001). A comparison of 1,247 patients showed significantly higher apathy scores in manifest than premanifest HD, with a mean difference of 1.87 (CI=1.48-2.26; p<0.001). There was evidence of involvement of various cortical and subcortical brain regions in HD patients with apathy.

CONCLUSIONS

Apathy was more frequent among individuals with premanifest HD compared with those in a control group and among individuals with manifest HD compared with those with premanifest HD. Considering the complexity and unique pattern of development in neurodegenerative disease, further studies are required to explore the pathophysiology of apathy in HD.

Assessing Mental Health Difficulties of Persons With Huntington's Disease: Does Informant Presence Make a Difference?

OBJECTIVE

Persons with Huntington's disease (HD) often have communication difficulties and cognitive impairments, making mental health assessment difficult. Informants close to the patient are often included in assessments. The authors investigated effects of informant presence during assessment of persons with HD.

METHODS

Data for four subsamples from ENROLL-HD were examined: manifest for HD (N=4,109), premanifest (N=1,790), genotype negative (N=1,041), and family members with no genetic risk (N=974). Assessment interviews with and without an informant present were identified, and the subsamples were compared on three subscales of the short-form Problem Behaviors Assessment: affect, apathy, and irritability. Differences in scores between participant-only and informant-present interviews were examined via multiple regression, controlling for demographic, disease-related, and individual confounds.

RESULTS

Significant differences in apathy and irritability scores were found between participant-only and informant-present conditions for the premanifest, manifest, and genotype-negative subsamples. Affect subscale scores were not influenced by informant presence. When the analysis controlled for confounds, informant presence significantly increased irritability scores in the manifest, and genotype-negative groups and significantly increased apathy scores in the manifest group.

CONCLUSIONS

Apathy may have been systemically underreported in participant-only interviews, which supports previous findings that persons with HD underreport mental health symptoms. When an informant was present, irritability scores were higher for both HD and non-HD individuals, suggesting that underreporting via self-report may be attributable to non-HD factors. Informant contributions to apathy assessments may be particularly important for persons with HD. Clinicians should note potential underreporting regarding irritability and affect, which was not remediated by informant presence.

Irritability in Huntington's Disease

Huntington’s disease (HD) is a heritable and fatal neurodegenerative disease characterized by a triad of motor, cognitive and neuropsychiatric symptoms. A common and particularly detrimental neuropsychiatric alteration in HD gene carriers is irritability, which frequently manifests as abrupt and unpredictable outbursts of anger. This symptom increases the burden of HD in multiple ways, such as jeopardizing employment and straining familial or caregiver support. Although irritability in HD is diagnosed by the administration of standardized rating scales and clinical expertise, measurement of severity and progression is complicated by several factors. Currently, individuals with HD who present with irritability may be managed with a variety of psychotropic medications, primarily antidepressants and antipsychotics. While these therapies offer relief to individuals suffering from irritability in HD, they are often not sufficient. Here, we review irritability in the context of HD and emphasize the need for treatments that are better tailored to mitigate this troublesome symptom. An expeditious strategy in pursuit of this goal involves evaluating the efficacy of approved medications that are used to treat similar neuropsychiatric symptoms.

Huntington's disease in Turkey: genetic counseling, clinical features, and outcome

Objective: This study aims to report the data of genetic counseling and to identify the clinical features of Turkish Huntington's disease (HD) patients and to investigate its possible relationship with genetic data.Method: A regular weekly outpatient clinic has been held routinely since January 2018. Patients and their referred relatives have been evaluated regarding clinical features and genetic counseling. The database of our collaborative team was used for the study.Results: Total 141 individuals have been evaluated. Among 84 subjects genetic counseling was given, diagnosis of HD was confirmed genetically in 34 (42.0%) of individuals (25 were symptomatic-HD, 9 were presymptomatic-HD). Fifty-seven patients were previously diagnosed with HD. The mean age of onset was 42.4 (11.9) years. Chorea was mostly reported initial symptom. The mean CAG repeat number of the expanded allele was 44.1 (5.1) and correlated inversely with the age of onset (p < 0.001). During a 4.8 (3.1) year follow-up, 10% of the patients were deceased. At the last visit, over half of patients had all of the movement, behavioral and cognitive problems, and 41.6% of them had required 24-hr supervision appropriate (UHDRS-independence score 64.6 (24.4)). Paternal inheritance was related to higher CAG repeats, younger age of disease onset, and higher UHDRS-motor scores.Conclusion: HD in Turkey is a severe disabling disease affecting a younger adult population. Over half of patients had all of the movement, behavioral and cognitive problems. Genetic counseling gives the opportunity to diagnose subjects at the pre-symptomatic phase. A collaborative approach is rational in the management of HD.

Clinical, radiological, and genetic characteristics in patients with Huntington's disease in a Taiwanese cohort

Characteristics of Huntington's disease (HD) differ among various ethnicities. Few studies have explored the relationship between phenotypes and genotypes of HD in Asians. We evaluated the relationship between integrated clinical and imaging phenotypes and genotypes in a Taiwanese HD cohort, enrolling 123 HD patients genetically diagnosed between August 1994 and February 2019. The clinical presentations and brain magnetic resonance imaging characteristics were analyzed from 67 patients and examined the correlation with genetic findings. Chorea was the most common initial manifestation (66.1%), especially in patients with late-onset disease (onset age > 60 years old), followed by psychiatric symptoms (25%) and cognitive impairment (14.3%). Compared to patients with adult-onset HD, the prevalence of parkinsonism was significantly higher in juvenile-onset HD patients (onset age < 20 years old, p = .007). Disease burden, which was measured by CAG repeats and age, was significantly associated with atrophy in caudate nucleus (p = .004), followed by putamen (p = .029), nucleus accumbens (p = .002), thalamus (p = .003), and total cortical volume (p = .001) after correcting for total intracranial volume. Our findings, that provided the first series of Taiwanese HD patients, delineated the clinical, radiological, and genetic characteristics in Asian HD patients.

Validity of irritability in Huntington's disease: A scoping review

PURPOSE

To scope the literature concerning irritability in Huntington's disease to determine whether or not irritability is a valid and meaningful construct within this population.

METHOD

A scoping literature review was conducted based on findings from a search of five databases (Academic Search Ultimate, PsycINFO, CINAHL, Scopus and Web of Science) in November 2018. From an initial return of 453 papers, 40 were found suitable for review.

RESULTS

Review of the 40 studies highlighted several aspects of irritability in people with HD which influence its validity as an independent construct in context of the disease. While various measures are used to assess irritability, a gold standard has yet to be identified and consequently irritability is assessed inconsistently across the literature. In addition, the results suggest that irritability may not reflect pathological disease processes in HD, but rather comprises a multidimensional construct which appears to be strongly associated with other psychological difficulties such as depression and anxiety.

CONCLUSIONS

The current concept of irritability in people with HD continues to lack a general consensus in the clinical literature, in terms of both operationalisation and assessment. Consequently, further research is warranted in order to determine the extent to which irritability is a valid construct within the context of HD, including its associated behavioural, cognitive and affective dimensions.

Relationships Among Apathy, Health-Related Quality of Life, and Function in Huntington's Disease

Up to 90% of individuals with Huntington's disease (HD)-a progressive, inherited neurodegenerative disorder-experience apathy. Apathy is particularly debilitating because it is marked by a reduction in goal-directed behaviors, including self-care, social interactions, and mobility. The objective of this study was to examine relationships between variables of apathy, functional status, physical function, cognitive function, behavioral status/emotional function, and health-related quality of life. Clinician-rated measures of physical, cognitive, and behavioral function, including one clinician-rated item on apathy, and self-reported measures of physical function, health-related quality of life, and emotional, cognitive, and social function were collected in a single session from 487 persons with the HD mutation (prodromal, N=193; early-stage manifest, N=186; late-stage manifest, N=108). Multiple linear regression models were used to examine which outcomes best predicted clinician-rated apathy after controlling for disease stage. Greater apathy related to less independence, increased motor impairment, and more clinician-rated behavioral problems (i.e., anger, irritability, depression). Similarly, poorer self-reported health-related quality of life; greater chorea; greater upper- and lower-extremity dysfunction; greater speech and swallowing dysfunction; worse anxiety, depression, and behavioral dyscontrol; worse cognitive function; and less satisfaction with social roles related to greater apathy. In conclusion, apathy related to physical, cognitive, and behavioral dysfunction across disease stages. Future work should explore whether clinical interventions targeting different functional domains may have the potential to reduce apathy in this patient population.