Self-Awareness of Deficits in Parkinson Disease

Validation of the Italian version of the Parkinson's Disease- Cognitive Functional Rating Scale

A key distinguishing factor between mild cognitive impairment (MCI) and dementia in Parkinson's disease (PD) lies in the notable decrease in functioning due to cognitive impairment. The Parkinson's Disease-Cognitive Functional Rating Scale (PD-CRFS) was developed to assess functional limitations caused by cognitive impairment, while reducing the influence of motor impairment. The aim of this multicenter study was to (i) validate the Italian version of the PD-CFRS in PD, (ii) determine optimal cut-off scores for detecting MCI and dementia in PD, (iii) compare its performances with the most established functional assessment tool (IADL). Six hundred and sixty nine PD participants were recruited from 4 Italian Movement Disorders centers (Venice, Milan, Gravedona, and Salerno). They underwent Level-II cognitive evaluation, which resulted in 282 PD-NC, 310 PD-MCI, and 77 PDD. The PD-CFRS's psychometric and clinimetric properties, applicability, and responsiveness were analyzed. The PD-CFRS showed high acceptability. Floor and ceiling effects were acceptable. It also displayed strong internal consistency (Cronbach's α = 0.738), and test-retest reliability (ICC = .854). The PD-CFRS demonstrated higher coefficient of variation to detect dysfunction in PD-MCI patients in comparison to the IADL scale (PD-CFRS 96% vs IADL 22.5%). Convergent validity with the IADL was r = - 0.638 and - 0.527 in males and females, respectively. PD-CFRS total score negatively correlated with global cognition (MoCA corrected score r = - 0.61; p < 0.001). A cut-off score > 6.5 identified PDD with a sensitivity of 90% and specificity of 88% (AUC = .959). A cut-off value of > 1 detected PD-MCI with a sensitivity of 68% and specificity of 69% (AUC = .695). The Italian version of the PD-CFRS demonstrated to be an easy, valid and reliable tool that properly captures functional impairment due to cognitive decline in PD. It also proved to be particularly effective in the advanced stages of PD, and would be a useful support for the diagnosis of PD-MCI and PDD.

Discordance between Reports of Internalized Symptoms in Persons with Parkinson's Disease and Informants: Results from an Online Survey

BACKGROUND

Self-report of motor and non-motor symptoms is integral to understanding daily challenges of persons with Parkinson's disease (PwPD). Care partners are often asked to serve as informants regarding symptom severity, raising the question of concordance with PwPD self-reports, especially regarding internalized (not outwardly visible) symptoms.

OBJECTIVES

Concordance between PwPD and informant ratings of motor and non-motor symptoms was evaluated across multiple domains.

METHODS

In 60 PwPD-informant pairs, we compared ratings on 11 online self-report measures comprising 33 total scores, 2/3 of which represented purely internalized symptoms. For discordant scores, multiple regression analyses were used to examine demographic/clinical predictors.

RESULTS

Though concordant on 85% of measures, PwPD endorsed more non-motor symptoms, bodily discomfort, stigma, and motor symptoms than informants. For PwPD, younger age, greater disease severity, and female gender predicted discordance.

CONCLUSIONS

Discordance between PwPD and informants on measures assessing symptoms that cannot be outwardly observed may require targeted education.

Motor awareness: a model based on neurological syndromes

Motor awareness is a complex, multifaceted construct involving the awareness of both (i) one's motor state while executing a movement or remaining still and (ii) one's motor abilities. The analysis of neurological syndromes associated with motor disorders suggests the existence of various different components which are, however, integrated into a model of motor awareness. These components are: (i) motor intention, namely, a conscious desire to perform an action; (ii) motor monitoring and error recognition, that is, the capacity to check the execution of the action and identify motor errors; and (iii) a general awareness of one's own motor abilities and deficits, that is, the capacity to recognize the general state of one's motor abilities about the performance of specific actions and the potential consequences of motor impairment. Neuroanatomical correlates involving the parietal and insular cortices, the medial and lateral frontal regions, and subcortical structures (basal ganglia and limbic system) support this multi-component model. Specific damage (or disconnections) to these structures results in a number of different disorders in motor awareness, such as anosognosia for hemiplegia and apraxia, and a number of symptoms which are specific to motor intention disorders (e.g., the Anarchic Hand Syndrome and Tourette's Syndrome) or motor monitoring (e.g., Parkinson's and Huntington's diseases). All of these clinical conditions are discussed in the light of a motor awareness model.

Apathy in Parkinson’s Disease: Defining the Park Apathy Subtype

Apathy is a neurobehavioural symptom affecting Parkinson’s disease patients of all disease stages. Apathy seems to be associated with a specific underlying non-motor disease subtype and reflects dysfunction of separate neural networks with distinct neurotransmitter systems. Due to the complicated neuropsychiatric aetiology of apathy, clinical assessment of this invalidating non-motor symptom remains challenging. We aim to summarize the current findings on apathy in Parkinson’s disease and highlight knowledge gaps. We will discuss the prevalence rates across the different disease stages and suggest screening tools for clinically relevant apathetic symptoms. We will approach the fundamental knowledge on the neural networks implicated in apathy in a practical manner and formulate recommendations on patient-tailored treatment. We will discuss the Park apathy phenotype in detail, shedding light on different clinical manifestations and implications for prognosis. With this review, we strive to distil the vast available theoretical knowledge into a clinical and patient-oriented perspective.

Validation of the PD home diary for assessment of motor fluctuations in advanced Parkinson's disease

The Parkinson's disease (PD) home diary is frequently used in clinical trials to measure efficacy of medical treatments for motor fluctuations in advanced PD. This prospective study in fluctuating PD patients examines the validity of the diary for quantification of motor states in comparison to direct clinical observation. 51 patients (median age: 65 years, disease duration: 11 years) completed the diary half-hourly for two consecutive days and were simultaneously rated by an experienced observer, who independently evaluated motor states half-hourly throughout daytime. Overall agreement (Cohen's kappa) between patient and observer diary entries was 59.8% (0.387). Patients documented more On without dyskinesia (52.3% vs. 38.9%, P < 0.001) and less On with dyskinesia (21.5% vs. 34.2%, P < 0.001), whereas proportions for Off intervals were not different between patient and observer diaries (26.2% vs. 27.0%, P = 0.97). Temporal agreement between diary ratings was unsatisfactory, particularly for On with dyskinesia. Taken together, our study suggests that the PD home diary only inadequately reflects actual motor states compared to direct clinical observation.

Is Being Physically Active Enough or Do People with Parkinson's Disease Need Structured Supervised Exercise? Lessons Learned from COVID-19

Social isolation imposed by the COVID-19 pandemic negatively impacted people’s lifestyles and daily activities. In this work we compared pre- and post-pandemic clinical outcomes in people with Parkinson’s disease, to assess differences according to the type of behaviour and exercise habits adopted by participants. After two months of COVID-19 lockdown, we assessed: changes in exercise behaviour; motor and non-motor aspects of daily life experiences (MDS-UPDRS I & II); activities of daily living (The Schwab & England scale); quality of life (Parkinson Disease Questionnaire); sleep (Parkinson Disease Sleep Scale); falls; and Clinical Global Impression Change. Twenty-seven individuals aged between 57 and 92 years old participated; from these, ten individuals (37%) completely interrupted physical activities, while seventeen (63%) maintained some level of active lifestyle. Regardless of whether they remained active or not, all participants perceived a significant worsening of their clinical condition, reporting an increase in difficulties completing daily activities or chores (37%) and worsening of their health condition (51.8%). The quantifiable influence of exercise habits was borderline for the group who kept active. The active group seem to have a better self-perception of their health condition, although it was not enough to show a clear benefit. People with Parkinson’s disease should be informed that being physically active may not be enough and more structured exercise could be needed.

Divergence Between Informant and Self-Ratings of Activities of Daily Living Impairments in Parkinson’s Disease

Objective

To examine the agreement between self- and informant-reported activities of daily living (ADL) deficits in Parkinson’s Disease (PD) patients, and to examine factors influencing ADL ratings.

Background

In PD, the loss of functional independence is an important outcome of disease progression. The valid assessment of ADL function in PD is essential, but it is unclear to what extent informants’ and patients’ perceptions of their daily functions concur, and how other factors may influence both ratings.

Methods

Data of 150 PD patients who underwent cognitive and motor testing, as well as their informants were analyzed. The 10-item Functional Activities Questionnaire (FAQ), completed separately by patients (FAQ-S) and their informants (FAQ-I), assessed ADL function. Weighted κ statistics summarized level of agreement, and a discrepancy score (FAQ-I – FAQ-S) quantified agreement. Correlation analyses between FAQ total scores, patient and informant characteristics, and cognitive scores were conducted, with post hoc regressions to determine the associations between both FAQ scores and cognition, independent of patient characteristics.

Results

The sample included 87 patients with normal cognition, 50 with mild cognitive impairment, and 13 with dementia. Overall, there was fair to moderate agreement between patients and informants on individual FAQ items (0.27 ≤ κ ≤ 0.61, p &lt; 0.004), with greater discrepancies with increasing cognitive impairment. Patients’ age, motor severity, non-motor burden, and depression also affected both ratings (0.27 ≤ r ≤ 0.50, p &lt; 0.001), with motor severity showing the greatest influence on both ratings. Both the FAQ-I and FAQ-S were correlated with almost all cognitive domains. Post hoc regression analyses controlling for patient characteristics showed that the attention domain was a significant predictor of both the FAQ-S and FAQ-I scores, and memory was also a significant predictor of the FAQ-I score. Only 29.3% of patients agreed perfectly with informants on the FAQ total score, with informants most commonly rating ADL impairments as more severe than patients.

Conclusions

Patient and informant ratings of ADL function using FAQ items showed moderate agreement, with only few items reaching substantial agreement. Ratings of both were associated with patient cognitive status, but also other characteristics. In addition to patient and informant reports, objective measures are needed to accurately classify ADL deficits in PD.

Changes in Self- and Informant-Reported Frontal Behaviors in Parkinson's Disease: A Longitudinal Study

OBJECTIVE

Frontal behaviors (i.e., executive dysfunction, disinhibition, apathy) are common in Parkinson's disease (PD). However, it is unclear if patient and informant reports of patient frontal behaviors are in agreement over time.

METHOD

Sixty-two PD patients without dementia and their informants (87% spouses/partners) completed the self- and informant-versions of the Frontal Systems Behavior Scale at baseline and 2-year follow-up. Dyad ratings were compared and predictors of behavior ratings were examined.

RESULTS

Patient and informant reports at baseline and follow-up were in agreement, with significant increases in overall frontal behaviors, executive dysfunction, and apathy. Higher levels of baseline patient depression and caregiver burden predicted decrements in patient-reported executive function; worse patient cognition at baseline predicted worsening apathy as rated by informants.

CONCLUSIONS

PD patients and their informants are concordant in their ratings of worsening frontal behaviors over time. Targeting patient depression, cognition, and caregiver burden may improve decrements in frontal behaviors (executive dysfunction and apathy) in PD.

Self-Report versus Clinician Examination in Early Parkinson's Disease

Background

Evaluating the discrepancies between patient‐reported measures and clinician examination has implications for formulating individual treatment regimens.

Objective

This study investigated the association between health outcomes and level of self‐reported motor‐related function impairment relative to clinician‐examined motor signs.

Methods

Recently diagnosed PD patients were evaluated using the Parkinson's Progression Marker Initiative (PPMI, N = 420) and the PASADENA phase II clinical trial (N = 316). We calculated the average normalized difference between each participant's part II and III MDS‐UPDRS (Movement Disorder Society Unified Parkinson's Disease Rating Scale) scores. Individuals with score differences <25th or >75th percentiles were labeled as low‐ and high‐self‐reporters, respectively (those between ranges were labeled intermediate‐self‐reporters). We compared a wide range of clinical/biomarker readouts among these three groups, using Kruskal–Wallis nonparametric and Pearson's χ² tests. Spearman's correlations were tested for associations between MDS‐UPDRS subscales.

Results

In both cohorts, high‐self‐reporters reported the largest impairment/symptom experience for most motor and nonmotor patient‐reported variables. By contrast, these high‐self‐reporters were similar to or less impaired on clinician‐examined and biomarker measures. Patient‐reported nonmotor symptoms on MDS‐UPDRS part IB showed the strongest positive correlation with self‐reported motor‐related impairment (PPMI r_s = 0.54, PASADENA r_s = 0.52). This correlation was numerically stronger than the part II and clinician‐examined MDS‐UPDRS part III correlation (PPMI r_s = 0.38, PASADENA r_s = 0.28).

Conclusion

Self‐reported motor‐related impairments reflect not only motor signs/symptoms but also other self‐reported nonmotor measures. This may indicate (1) a direct impact of nonmotor symptoms on motor‐related functioning and/or (2) the existence of general response tendencies in how patients self‐rate symptoms. Our findings suggest further investigation into the suitability of MDS‐UPDRS II to assess motor‐related impairments. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

"No One Can Tell Me How Parkinson's Disease Will Unfold": A Mixed Methods Case Study on Palliative Care for People with Parkinson's Disease and Their Family Caregivers

Background:

Palliative care for persons with Parkinson’s disease (PD) is developing. However, little is known about the experiences of patients with PD in the palliative phase and of their family caregivers.

Objective:

To explore needs of patients with PD in the palliative phase and of their family caregivers.

Methods:

A mixed methods case study design. Health care professionals included patients for whom the answer on the question “Would you be surprised if this patient died in the next 12 months?” was negative. At baseline, and after six and twelve months, we conducted semi-structured interviews with patients and caregivers. Participants completed questionnaires on quality of life, disease burden, caregiver burden, grief, and positive aspects of caregiving. We analyzed quantitative data using descriptive statistics, while we used thematic analysis for qualitative data.

Results:

Ten patients and eight family caregivers participated, of whom five patients died during the study period. While the quantitative data reflected a moderate disease burden, the qualitative findings indicated a higher disease burden. Longitudinal results showed small differences and changes in time. Patients reported a diverse range of symptoms, such as fatigue, immobility, cognitive changes, and hallucinations, which had a tremendous impact on their lives. Nevertheless, they rated their overall quality of life as moderate to positive. Family caregivers gradually learned to cope with difficult situations such delirium, fluctuations in functioning and hallucinations. They had great expertise in caring for the person with PD but did not automatically share this with health care professionals. Patients sensed a lack of time to discuss their complex needs with clinicians. Furthermore, palliative care was rarely discussed, and none of these patients had been referred to specialist palliative care services.

Conclusion:

Patients with PD experienced many difficulties in daily living. Patients seems to adapt to living with PD as they rated their quality of life as moderate to positive. Family caregivers became experts in the care for their loved one, but often learned on their own. An early implementation of the palliative care approach can be beneficial in addressing the needs of patients with PD and their family caregivers.

Autonomic factors do not underlie the elevated self-disgust levels in Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) is manifested along with non-motor symptoms such as impairments in basic emotion regulation, recognition and expression. Yet, self-conscious emotion (SCEs) such as self-disgust, guilt and shame are under-investigated. Our previous research indicated that Parkinson patients have elevated levels of self-reported and induced self-disgust. However, the cause of that elevation-whether lower level biophysiological factors, or higher level cognitive factors, is unknown.

METHODS

To explore the former, we analysed Skin Conductance Response (SCR, measuring sympathetic activity) amplitude and high frequency Heart Rate Variability (HRV, measuring parasympathetic activity) across two emotion induction paradigms, one involving narrations of personal experiences of self-disgust, shame and guilt, and one targeting self-disgust selectively via images of the self. Both paradigms had a neutral condition.

RESULTS

Photo paradigm elicited significant changes in physiological responses in patients relative to controls-higher percentages of HRV in the high frequency range but lower SCR amplitudes, with patients to present lower responses compared to controls. In the narration paradigm, only guilt condition elicited significant SCR differences between groups.

CONCLUSIONS

Consequently, lower level biophysiological factors are unlikely to cause elevated self-disgust levels in Parkinson's disease, which by implication suggests that higher level cognitive factors may be responsible.

The Role of Mental Imagery in Parkinson's Disease Rehabilitation

Parkinson’s disease (PD) is a disabling neurodegenerative disease whose manifestations span motor, sensorimotor, and sensory domains. While current therapies for PD include pharmacological, invasive, and physical interventions, there is a constant need for developing additional approaches for optimizing rehabilitation gains. Mental imagery is an emerging field in neurorehabilitation and has the potential to serve as an adjunct therapy to enhance patient function. Yet, the literature on this topic is sparse. The current paper reviews the motor, sensorimotor, and sensory domains impacted by PD using gait, balance, and pain as examples, respectively. Then, mental imagery and its potential for PD motor and non-motor rehabilitation is discussed, with an emphasis on its suitability for addressing gait, balance, and pain deficits in people with PD. Lastly, future research directions are suggested.

Everyday Function in Alzheimer’s and Parkinson’s Patients with Mild Cognitive Impairment

Background: Instrumental activities of daily living (IADL) impairment can begin in mild cognitive impairment (MCI), and is the core criteria for diagnosing dementia in both Alzheimer’s (AD) and Parkinson’s (PD) diseases. The Functional Activities Questionnaire (FAQ) has high discriminative power for dementia and MCI in older age populations, but is influenced by demographic factors. It is currently unclear whether the FAQ is suitable for assessing cognitive-associated IADL in non-demented PD patients, as motor disorders may affect ratings. Objective: To compare IADL profiles in MCI patients with PD (PD-MCI) and AD (AD-MCI) and to verify the discriminative ability of the FAQ for MCI in patients with (PD-MCI) and without (AD-MCI) additional motor impairment. Methods: Data of 42 patients each of PD-MCI, AD-MCI, PD cognitively normal (PD-CN), and healthy controls (HC), matched according to age, gender, education, and global cognitive impairment were analyzed. ANCOVA and binary regressions were used to examine the relationship between the FAQ scores and groups. FAQ cut-offs for PD-MCI (versus PD-NC) and AD-MCI (versus HC) were separately identified using receiver operating characteristic analyses. Results: FAQ total score did not differentiate between MCI groups. PD-MCI subjects had greater difficulties with tax records and traveling while AD-MCI individuals were more impaired in managing finances and remembering appointments. Classification accuracy of the FAQ was good for diagnosing AD-MCI (69%, cut-off ≥1) compared to HC, and sufficient for differentiating PD-MCI (38.1%, cut-off ≥3) from PD-CN. Conclusion: The FAQ task profiles and classification accuracy differed between MCI related to PD and AD.

Establishment of a Visual Analog Scale for DBS Programming (VISUAL-STIM Trial)

Background: Deep brain stimulation (DBS) has become a standard treatment for advanced stages of Parkinson's disease, essential tremor, and dystonia. In addition to the correct surgical device implantation, effective programming is regarded to be the most important factor for clinical outcome. Despite established strategies for adjusting neurostimulation, DBS programming remains time- and resource-consuming. Although kinematic and neuronal biosignals have recently been examined as potential feedback for closed-loop DBS (CL-DBS), there is an ongoing need for programming strategies to adapt the stimulation parameters and electrode configurations accurately and effectively.

Methods: Here, we tested the usefulness of a patient-rated visual analog scale (VAS) for real-time adjustment of DBS parameters. The stimulation parameters (contact and amplitude) in Parkinson's patients with STN-DBS (n = 17) were optimized based on the patient's subjective VAS rating. A Minkowski distance (M_d) was calculated to compare the individual combination of contact selection and amplitude to the stimulation parameters that resulted from classical programming based on clinical signs and symptoms.

Results: We found no statistically significant difference between VAS-based and classical programming in regard to the specific contact or amplitude used or in regard to the clinical disease severity (UPDRS).

Conclusions: Our data suggest that VAS-based and classical programming strategies both lead to similar short-term results. Although further research will be required to assess the validity of VAS-based DBS programming, our results support the investigation of the patient's subjective rating as an additional and valid feedback signal for individualized DBS adjustment.

A time-efficient screening tool for activities of daily living functions in Parkinson's disease dementia

INSTRUCTION

In Parkinson's disease (PD), activities of daily living (ADL) impairments are crucial for diagnosis of dementia (PDD). Performance-based tests are promising tools to discriminate between different levels of cognitive impairment in PD; however, the value of those tests for diagnosis of PDD is only sparsely investigated. Therefore, we evaluated the Erlangen Test of Activities of Daily Living (E-ADL), a time-efficient performance-based ADL test, in PD.

METHOD

In this cross-sectional study, 40 PD patients with normal cognition (PD-NC), 45 patients with mild cognitive impairment (PD-MCI) and 21 patients with PDD were assessed with a comprehensive ADL and cognitive test battery.

RESULTS

Interrater reliability (r_s =.86) indicated high consistency of the standardized E-ADL scoring system between raters. The E-ADL correlated significantly with other tests of ADL functions (p <.01), highest with an alternative performance-based ADL test (r_s = -.52), and lowest with self-ratings and a physician-rated scale. The E-ADL was also associated with cognitive impairment (p <.01), but also with motor impairment. A binary logistic regression model verified that the E-ADL (p =.04) was an independent predictor of PDD, in addition to motor impairment explaining 53.3% of variance. Receiver operating characteristic curve analysis of the E-ADL revealed an area under the curve of 0.78, a specificity of 77%, and a sensitivity of 67% for diagnosis PDD.

CONCLUSIONS

The standardized, easy, and quick to administer E-ADL showed acceptable levels of reliability, and validity in PD and measures cognitive-driven ADL functions. Therefore, it might be a suitable test to support diagnosis of PDD in the clinical daily routine.

Altered awareness of motor symptoms in Parkinson's disease and Dementia with Lewy Bodies: A systematic review

OBJECTIVES

Altered awareness of motor symptoms is reported in people with Parkinson's disease and Dementia with Lewy Bodies, and may adversely affect quality of life and medication concordance. How symptom awareness is influenced by motor and cognitive disease severity, age and medication use is not fully understood. We carried out a systematic review of the literature on motor symptom awareness in Parkinson's disease and Dementia with Lewy Bodies.

METHODS

Pubmed and Wed of Science were searched for relevant articles published in or prior to March 2019. Data regarding participant demographics, diagnosis, cognitive status, method of assessing awareness and study findings were extracted from relevant publications.

RESULTS

Sixteen relevant publications were identified. Motor symptom awareness appears to decline over the course of Parkinson's disease. Imaging studies implicate the prefrontal cortex, with different mechanisms involved in hypokinesia and dyskinesia awareness. The hypothesis that people with right hemisphere based disease would have more severely reduced awareness is only weakly supported. Most studies focused on cognitively intact individuals, and on awareness of dyskinesia rather than hypokinesia.

CONCLUSIONS

Whilst reduced awareness of dyskinesia and to a lesser extent hypokinesia is common, there is a lack of longitudinal data on how awareness changes over time, and how it interacts with global cognitive changes. Motor symptom awareness in Dementia with Lewy Bodies is understudied. Future studies of symptom awareness should include robust assessment of overall cognitive functioning, and use a longitudinal design to elucidate how awareness changes over time. J Am Geriatr Soc 68:-, 2020.

Deficits in monitoring self-produced speech in Parkinson's disease

OBJECTIVE

Speech deficits are common in Parkinson's disease, and behavioural findings suggest that the deficits may be due to impaired monitoring of self-produced speech. The neural mechanisms of speech deficits are not well understood. We examined a well-documented electrophysiological correlate of speech self-monitoring in patients with Parkinson's disease and control participants.

METHODS

We measured evoked electroencephalographic responses to self-produced and passively heard sounds (/a/ phonemes) in age-matched controls (N = 18), and Parkinson's disease patients who had minor speech impairment, but reported subjectively experiencing no speech deficits (N = 17).

RESULTS

During speaking, auditory evoked activity 100 ms after phonation (N1 wave) was less suppressed in Parkinson's disease than controls when compared to the activity evoked by passively heard phonemes. This difference between the groups was driven by increased amplitudes to self-produced phonemes, and reduced amplitudes passively heard phonemes in Parkinson's disease.

CONCLUSIONS

The finding indicates that auditory evoked activity is abnormally modulated during speech in Parkinson's patients who do not subjectively notice speech impairment. This mechanism could play a role in producing speech deficits in as the disease progresses.

SIGNIFICANCE

Our study is the first to show abnormal early auditory electrophysiological correlates of monitoring speech in Parkinson's disease patients.

Cognition, function and awareness of disease impact in early Parkinson's and Huntington's disease

Purpose: Patients with Parkinson's and Huntington's Disease (PD and HD) present impairments in cognitively challenging everyday activities. This study contrasts these two basal ganglia disorders on the ability to perform daily life- like tasks and their level of awareness regarding the disease impact on function.Methods: 19 controls, 10 early-onset PD, 20 early stage PD, and 15 early manifest HD patients were compared in the "EcoKitchen," a virtual reality task with increasing executive load, the "Behavioural Assessment of Dysexecutive Syndrome battery - BADS," and "The Adults and Older Adults Functional Assessment Inventory - IAFAI," a self-report functional questionnaire. The EcoKitchen clinical correlates were investigated.Results: All clinical groups presented slower EcoKitchen performance than controls, however, only HD patients showed decreased accuracy. HD and PD patients exhibited reduced BADS scores compared to the other study participants. Importantly, on the IAFAI, PD patients signalled more physically related incapacities and HD patients indicated more cognitively related incapacities. Accordingly, the EcoKitchen performance was significantly associated with PD motor symptom severity.Conclusions: Our findings suggest differential disease impact on cognition and function across PD and HD patients, with preserved awareness regarding disease- related functional sequelae. These observations have important implications for clinical management, research and rehabilitation.Implications for rehabilitationPatients with early stage Parkinson's and Huntington's disease have diagnosis-specific impairments in the performance of executively demanding everyday activities and, yet, show preserved awareness about the disease impact on their daily life.An active involvement of patients in the rehabilitation process should be encouraged, as their appraisal of the disease effects can help on practical decisions about meaningful targets for intervention, vocational choices, quality-of-life issues and/or specific everyday skills to boost.The EcoKitchen, a non-immersive virtual reality task, can detect and quantify early deficits in everyday-like tasks and is therefore a valuable tool for assessing the effects of rehabilitation strategies on the functional cognition of these patients.Rehabilitation efforts in the mild stages of Parkinson's and Huntington's disease should be aware of greater time needs from the patients in the performance of daily life tasks, target executive skills, and give a more prominent role to patients in symptoms report and management.

Progression of Cognitive Decline in Parkinson's Disease

Background:

Cognitive dysfunction is one of the most prevalent non-motor symptoms in Parkinson’s disease (PD), often experienced as more debilitating for patients and caregivers than motor problems. Therefore, a deeper understanding of the course of cognitive decline and the identification of valid progression markers for Parkinson’s disease dementia (PDD) is essential.

Objective:

This systematic review summarizes the current state of knowledge on cognitive decline over time by reporting effect sizes of cognitive changes in neuropsychological tests.

METHODS:

1368 studies were identified by a PubMed database search and 25 studies by additionally scanning previous literature. After screening all records, including 69 full-text article reviews, 12 longitudinal studies on the progression of cognitive decline in PD met our criteria (e.g., sample size ≥50 patients).

Results:

Only a few studies monitored cognitive decline over a longer period (>4 years). Most studies focused on the evaluation of change in global cognitive state by use of the Mini-Mental State Examination, whereas the use of neuropsychological tests was highly heterogenic among studies. Only one study evaluated patients’ cognitive performance in all specified domains (executive function, attention & working memory, memory, language, and visual-spatial function) allowing for diagnosis of cognitive impairment according to consensus guidelines. Medium to strong effect sizes could only be observed in studies with follow-up intervals of four years or longer.

Conclusions:

The results emphasize the need for the assessment of larger PD cohorts over longer periods of follow-up with a comprehensive neuropsychological battery.

Role of the Cingulate Cortex in Dyskinesias-Reduced-Self-Awareness: An fMRI Study on Parkinson's Disease Patients

Objectives: The detection of dyskinesias-reduced-self-awareness (DRSA), in Parkinson’s disease (PD), was previously associated to executive and metacognitive deficits mainly due to dopaminergic overstimulation of mesocorticolimbic circuits. Response-inhibition dysfunction is often observed in PD. Apart from being engaged in response-inhibition tasks, the anterior cingulate cortex (ACC), is part of a functional system based on self-awareness and engaged across cognitive, affective and behavioural contexts. The purpose of the study was to examine the relationship between response-inhibition disabilities and DRSA using whole-brain event-related functional magnetic resonance imaging (fMRI), over the course of a specific executive task.

Methods: Twenty-seven cognitively preserved idiopathic PD patients – presenting motor fluctuations and dyskinesias – were studied. They underwent a neurological and neuropsychological evaluation. The presence of DRSA was assessed using the Dyskinesias Subtracted-Index (DS-I). Cingulate functionality was evaluated with fMRI, while patients performed an ACC-sensitive GO-NoGO task. Association between blood oxygenation level dependent response over the whole-brain during the response-inhibition task and DS-I scores was investigated by regression analysis.

Results: The presence of DRSA was associated with reduced functional recruitment in the bilateral ACC, bilateral anterior insular cortex and right dorsolateral prefrontal cortex (p_FWE<0.05). Moreover, DS-I scores significantly correlated with percent errors on the NoGO condition (r = 0.491, p_FWE = 0.009).

Discussion: These preliminary findings add evidence to the relevant role of executive dysfunctions in DRSA pathogenesis beyond the effects of chronic dopaminergic treatment, with a key leading role played by ACC as part of a functionally impaired response-inhibition network. Imaging biomarkers for DRSA are important to be studied, especially when the neuropsychological assessment seems to be normal.

How Well Do Caregivers Detect Depression and Anxiety in Patients With Parkinson Disease?

Depression and anxiety are prevalent in Parkinson disease (PD) yet underrecognized in clinical practice. Caregiver reports are frequently utilized to aid in the assessment of neuropsychiatric symptoms but little is known about caregivers' ability to recognize them in patients with PD. This study sought to examine the accuracy of caregiver reports. Eighty patient-caregiver dyads were involved. Accuracy of caregiver recognition was assessed by examining the level of agreement between caregiver ratings on the Neuropsychiatric Inventory and patients' diagnosis of depression and anxiety on the Mini-International Neuropsychiatric Interview (MINI)-Plus. The agreement between caregiver report and MINI-Plus diagnosis was low for both depression (6.3%) and anxiety (17.5%). The presence of depression was overreported, while anxiety was largely underestimated by caregivers. Caregiver distress significantly predicted inaccurate caregiver identification of depression ( R² = .51, P < .001) and anxiety ( R² = .08, P < .05). Results indicate that caregivers may be poor at recognizing depression and anxiety in patients with PD. Utilization of caregiver report should take into account potential biases that affect caregiver judgment.

The Multiple Object Test as a performance-based tool to assess the decline of ADL function in Parkinson's disease

INTRODUCTION

As cognitive-driven worsening of activities of the daily living (ADL) in Parkinson's disease (PD) is the core feature of PD dementia (PDD), there is great need for sensitive quantitative assessment. Aim of our study was the evaluation of cognitive-driven worsening of ADL by the performance-based Multiple Object Test (MOT), offering an essential clinical advantage as it is quick and easy to apply in a clinical context even on severely impaired patients.

METHODS

73 PD patients were assessed longitudinally over a period of 37 (6-49) months. According to their neuropsychological profile the sample was divided into two groups: PD patients with (n = 34, PD-CI) and without cognitive impairment (n = 39, PD-noCI). The MOT comprises five routine tasks (e.g. to make coffee) quick and easy to apply. Quantitative (total error number, processing time) and qualitative parameters (error type) were analyzed using non-parametric test statistic (e.g.Wilcoxon signed-rank test, binary logistic regression).

RESULTS

Median number of total errors (p = 0.001), processing time (p<0.001), perplexity (p = 0.035), and omission errors (p<0.001) increased significantly from baseline to follow-up in the total sample. Worsening of MOT performance was correlated to cognitive decline in the attention/ executive function and visuo-constructive domain. PD-CI showed an increase in omission errors (p = 0.027) compared to PD-noCI over time. This increase in omission errors between visits was further identified as a risk marker for PDD conversion.

CONCLUSION

The MOT, especially frequency of omission errors, is a promising tool to rate PD patients objectively and might help to identify patients with a high risk for having mild cognitive impairment or dementia.

Action Semantics at the Bottom of the Brain: Insights From Dysplastic Cerebellar Gangliocytoma

Recent embodied cognition research shows that access to action verbs in shallow-processing tasks becomes selectively compromised upon atrophy of the cerebellum, a critical motor region. Here we assessed whether cerebellar damage also disturbs explicit semantic processing of action pictures and its integration with ongoing motor responses. We evaluated a cognitively preserved 33-year-old man with severe dysplastic cerebellar gangliocytoma (Lhermitte-Duclos disease), encompassing most of the right cerebellum and the posterior part of the left cerebellum. The patient and eight healthy controls completed two semantic association tasks (involving pictures of objects and actions, respectively) that required motor responses. Accuracy results via Crawford’s modified t-tests revealed that the patient was selectively impaired in action association. Moreover, reaction-time analysis through Crawford’s Revised Standardized Difference Test showed that, while processing of action concepts involved slower manual responses in controls, no such effect was observed in the patient, suggesting that motor-semantic integration dynamics may be compromised following cerebellar damage. Notably, a Bayesian Test for a Deficit allowing for Covariates revealed that these patterns remained after covarying for executive performance, indicating that they were not secondary to extra-linguistic impairments. Taken together, our results extend incipient findings on the embodied functions of the cerebellum, offering unprecedented evidence of its crucial role in processing non-verbal action meanings and integrating them with concomitant movements. These findings illuminate the relatively unexplored semantic functions of this region while calling for extensions of motor cognition models.

Subjective Perceived Motor Improvement after Acute Levodopa Challenge in Parkinson's Disease

BACKGROUND

Previous studies found a poor association between parkinsonian patient's reported subjective improvement after commencing dopaminergic treatment and improvements in objective measures of motor impairment by clinician.

OBJECTIVE

To compare PD patient's subjective perceived motor improvement after acute levodopa challenge test with objective motor improvement assessed by the clinician using the UPDRS part III. To analyze clinical characteristics, i.e. age, disease duration, cognitive performance or severity of axial features, that may have influenced patient's perception.

METHODS

Fifty-seven consecutive PD patients (23 women, 34 men; mean age, 63.4±7.7 years) (Hoehn and Yahr off score, 2.5±0.7; mean disease duration, 11.4±4.1 years) completed the acute levodopa challenge. The percentage of improvement in motor disability, i.e. objective motor improvement, was determined with respect to the off-drug condition.

RESULTS

Bland & Altman visual analysis reveals a high degree of correlation between objective and subjective perceived motor improvement. Both the axial sub-scores in the off- and on-state (respectively, P = 0.006 and P = 0.024) and the presence of peak-dose dyskinesia (P = 0.043) significantly influence the difference between objective and subjective perceived motor improvement.

CONCLUSIONS

This is the first study reporting on how PD patients assessed their motor improvement after acute levodopa challenge. These findings suggest a strong correlation between objective motor improvement assessed by the clinician using the UPDRS part III and subjective perceived motor improvement reported by the patient.

Differences between Subjective and Objective Assessment of Speech Deficiency in Parkinson Disease

OBJECTIVES

This study aims to establish the frequency at which patients with Parkinson disease subjectively assess the intensity of their speech disorders, factors that the patients believe determine the severity of their vocal impairment, and how their subjective self-assessment of vocal impairment by means of the Voice Handicap Index compares with the objective evaluation of the performance of the articulatory organs by means of Frenchay Dysarthria Assessment.

MATERIALS AND METHODS

The methods used Voice Handicap Index, Frenchay Dysarthria Assessment, and the Hoehn and Yahr scale.

RESULTS

Positive correlation was found between the subjective assessment of the performance of the speech organs and the impaired differentiation of lip movements and tongue sideways movements, impaired saliva control, dysfunction of the soft palate, and the pitch. Negative correlation was found between the subjective assessment of the severity of speech disorder, breathing at rest, and sentence comprehension.

CONCLUSIONS

Although we observed correlation between the subjective perception of certain speech disorders of patients with Parkinson disease and the objective assessment carried out by means of the Frenchay Dysarthria Assessment scale, the subjects did not believe the disorders had a significant impact on the quality of speech. Negative results of an examination do not necessarily reflect the subjective perception of the decline in the functioning of the articulatory organs. It should be assumed that lack of correlation between the subjective perception measured using Voice Handicap Index and the objective Frenchay Dysarthria-based assessment of the performance of the articulatory organs may result from a good adaptation to the progressive changes.

Prescription pattern and awareness of disease and treatment in patients of Parkinson's disease

AIM

This cross-sectional study aimed to evaluate the prescription pattern, awareness of disease and treatment in patients with Parkinson's disease (PD).

MATERIALS & METHODS

A total of 100 PD patients, attending a tertiary care hospital in Mumbai were included. Prescriptions were analyzed and awareness was evaluated using a questionnaire.

RESULTS

The mean number of anti-Parkinson agents (APA) prescribed was 1.52 ± 0.65. Number of APA strongly correlated with disease duration (ρ = 0.818; p < 0.001). Many APA were underutilized (prescribed daily dose/defined daily dose < 1). There was no awareness of all items on symptoms and alternative therapeutic options. Awareness of disease impairments (32%), long-term complications (28%), dosing regimen (46%) and follow-up (36%) was poor.

CONCLUSION

More than one APA is commonly prescribed in PD patients. Awareness of disease and treatment of PD is poor among the patients.

Presence or absence of cognitive complaints in Parkinson's disease: mood disorder or anosognosia?

We intended to evaluate whether non-demented Parkinsons's disease (PD) patients, with or without subjective cognitive complaint, demonstrate differences between them and in comparison to controls concerning cognitive performance and mood. We evaluated 77 subjects between 30 and 70 years, divided as follows: PD without cognitive complaints (n = 31), PD with cognitive complaints (n = 21) and controls (n = 25). We applied the following tests: SCOPA-Cog, Trail Making Test-B, Phonemic Fluency, Clock Drawing Test, Boston Naming Test, Neuropsychiatric Inventory, Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory. PD without complaints presented lower total score on Scales for outcome of Parkinson's disease-cognition as compared to controls (p = 0.048). PD with complaints group showed higher scores on HADS (p = 0.011). PD without complaints group showed poorer cognitive performance compared to controls, but was similar to the PD with complaints group. Moreover, this group was different from the PD without complaints and control groups concerning mood.

Comparison of self and proxy ratings for voice handicap index and motor-related quality-of-life of individuals with Parkinson's disease

PURPOSE

Quality-of-life (QoL) consists of health, psychological well-being and communication-related domains. Due to the heterogeneous nature of Parkinson disease (PD), it is important to examine effects of different domains including motor and cognitive performance or motor and speech performance among the same set of individuals. Existing studies indicate mixed findings due to use of different QoL measures and lack of general consensus regarding QoL components.

METHOD

The present study examined self and proxy ratings for 20 individuals with PD on Voice Handicap Index (VHI) and PDQ-39 mobility to determine effects on speech and motor-related QoL, respectively.

RESULT

There was good level of agreement between self and proxy ratings for PDQ-39 mobility ratings alone. In addition, no overall group differences were found for self and proxy ratings of VHI and PDQ-39 mobility ratings, thus indicating similar perceptions by individuals with PD and their communication partners for speech and motor-related changes associated with PD. Further, no significant correlations between speech and motor-related QoL were found, thereby suggesting these domains to be independent of each other.

CONCLUSION

The present study indicates the need to consider both self and proxy reports to understand the impact of PD on a person's overall functioning.

The patient's perspective: The effect of levodopa on Parkinson symptoms

BACKGROUND

Dopaminergic medication adjustments in Parkinson's disease are often solely based on patient reports. However, it is unclear how well patient-based ratings of the levodopa response correlate with clinician-based ratings, and whether this correlation differs between motor symptoms. Here we compare patient-clinician agreement for the effect of levodopa on resting tremor and bradykinesia/rigidity. Furthermore, given patients' reports that tremor is most troublesome during stress, we test for differences in patient-clinician agreement between tremor at rest and stress-induced tremor.

METHODS

We included 42 tremulous Parkinson patients, who were clinically rated (using the MDS-UPDRS) in a practically defined OFF-state and after levodopa-benserazide 200/50 mg. Using accelerometry, we quantified the effect of dopaminergic medication and behavioral context (rest vs. cognitive stress) on tremor intensity. Patients rated medication effects on tremor and bradykinesia/rigidity using visual analogue scales.

RESULTS

There was only moderate patient-clinician agreement for the effect of levodopa on bradykinesia/rigidity (R² = 0.18; p < 0.01), and a tendency towards larger agreement for tremor (R² = 0.44; p < 0.001; difference between correlation coefficients: z = 1.64; p = 0.051). Patient ratings of tremor changes correlated significantly better with accelerometry for tremor during cognitive stress (R² = 0.35; p < 0.001) vs. tremor at rest (R² = 0.12; p < 0.05; difference: z = -2.35, p < 0.01).

CONCLUSION

The moderate correlations between patient ratings and clinical/accelerometry changes indicate the need for methods to better monitor symptom severity and impairments in daily life, for example wearable sensors. Our findings also suggest that context matters: Parkinson patients' subjective experience of levodopa effectiveness on tremor was largely based on the ability of levodopa to reduce tremor during cognitive stress.

Computerized assessment of goal-directed behavior in Parkinson's disease

INTRODUCTION

Apathy is a syndrome characterized by a reduction in goal-directed behavior. Neurodegenerative diseases frequently exhibit apathy. However, we lack an objective measure of apathy. The Philadelphia Apathy Computerized Task (PACT) measures impairments in goal-directed behavior that contribute to apathy, including initiation, planning, and motivation. We sought to examine these mechanisms in Parkinson's disease (PD) patients.

METHOD

PD patients and healthy controls with a caregiver were recruited for the study. Participants were administered the PACT, a novel computerized assessment of goal-directed behavior based on reaction times, and the Starkstein Apathy Scale (AS). Care partners completed the Neuropsychiatric Inventory (NPI). Baseline demographic characteristics of PD and control participants were compared using t tests and Wilcoxon rank sum tests. Linear regressions were used to compare PD patients to controls on each of the three PACT subtasks (initiation, planning, and motivation) while controlling for motor slowing. We then compared performance on each PACT subtask between PD subjects defined as apathetic using the NPI and Starkstein Apathy Scale and controls.

RESULTS

We included 30 PD and 15 control participants in the analysis. When controlling for motor slowing, both all PD and PD apathetic subjects were significantly slower than controls on the planning task and on the initiation task. There were no significant differences between PD patients and controls on the motivation tasks.

CONCLUSIONS

PD patients showed specific initiation and planning deficits compared to control participants. After using traditional scales to define apathy, PD apathetic patients still exhibited impaired initiation and planning behaviors. These results suggest that the PACT measures aspects of impaired goal-directed behavior that may contribute to apathy in PD.

Goal Setting for Cognitive Rehabilitation in Mild to Moderate Parkinson's Disease Dementia and Dementia with Lewy Bodies

Alongside the physical symptoms associated with Parkinson's disease dementia and dementia with Lewy bodies, health services must also address the cognitive impairments that accompany these conditions. There is growing interest in the use of nonpharmacological approaches to managing the consequences of cognitive disorder. Cognitive rehabilitation is a goal-orientated behavioural intervention which aims to enhance functional independence through the use of strategies specific to the individual's needs and abilities. Fundamental to this therapy is a person's capacity to set goals for rehabilitation. To date, no studies have assessed goal setting in early-stage Parkinson's disease dementia or dementia with Lewy bodies. Semistructured interviews were carried out with 29 participants from an ongoing trial of cognitive rehabilitation for people with these conditions. Here, we examined the goal statements provided by these participants using qualitative content analysis, exploring the types and nature of the goals set. Participants' goals reflected their motivations to learn new skills or improve performance in areas such as technology-use, self-management and orientation, medication management, and social and leisure activities. These results suggest that goal setting is achievable for these participants, provide insight into the everyday cognitive difficulties that they experience, and highlight possible domains as targets for intervention. The trial is registered with ISRCTN16584442 (DOI 10.1186/ISRCTN16584442 13/04/2015).

Metacognitive knowledge of olfactory dysfunction in Parkinson's disease

It is well known that patients with Parkinson's Disease (PD) suffer from olfactory impairments, but it is not clear whether patients are aware of their level of deficit in olfactory functioning. Since PD is a neurodegenerative disorder and its progression may be correlated with olfactory loss (Ansari & Johnson, 1975; but see also Doty, Deems, & Stellar, 1988), it is possible that these patients would be subject to metacognitive errors of over-estimation of olfactory ability (White & Kurtz, 2003). Nineteen non-demented PD patients and 19 age-matched controls were each given an objective measure of olfactory identification (the UPSIT, Doty, Shaman, Kimmelman, & Dann, 1984) and a subjective measure involving a questionnaire that asked them to self-rate both their olfactory function generally and their ability to smell each of 20 odors, 12 of which were assessed on the UPSIT. All of the PD patients showed impaired olfactory ability, as did 7 of the controls, according to the UPSIT norms. Self-rated and performance-based olfactory ability scores were significantly correlated in controls (r=.49, p=.03) but not in patients with PD (r=.20, p=.39). When the 12 odors common to both the self-rated questionnaire and UPSIT were compared, PD patients were less accurate than controls (t(36)=-4.96, p<.01) at estimating their own ability and the number of over-estimation errors was significantly higher (tone-tailed(29)=1.80, p=.04) in PD patients than in the control group, showing less metacognitive awareness of their ability than controls. These results support the idea that olfactory metacognition is often impaired in PD, as well as in controls recruited for normosmic ability (Wehling, Nordin, Espeseth, Reinvang, & Lundervold, 2011), and indicate that people with PD generally exhibit over-estimation of their olfactory ability at a rate that is higher than controls. These findings imply that PD patients, unaware of their olfactory deficit, are at greater risk of harm normally detected through olfaction, such as smoke or spoiled foods.

Caregiver report of apathy predicts dementia in Parkinson's disease

INTRODUCTION

Apathy is a common, troublesome symptom in Parkinson's disease (PD). However, little is known about its relationship with long-term cognition. We sought to determine if a caregiver-reported apathy measure predicts the development of PD dementia.

METHODS

Non-demented PD patients were recruited as part of a longitudinal study of cognition. Demographics, medications, Dementia Rating Scale-2, Unified Parkinson's Disease Rating Scale, Geriatric Depression Scale and the Neuropsychiatric Inventory-Questionnaire (NPI-Q) ratings were obtained. Apathy was defined as an NPI-Q apathy score ≥1. Participants were evaluated annually with cognitive and functional assessments until the end of the study period or a physician consensus diagnosis of dementia was assigned. Cox proportional hazard models were used to assess the effects of baseline apathy on dementia development while controlling for other clinical and demographic factors.

RESULTS

Of 132 PD patients 12.1% (N = 16) scored in the apathetic range at baseline. A total of 19.6% (N = 26) individuals developed dementia over the course of the study, 8 of whom (30.8% of future dementia patients) had baseline apathy. In bivariate analyses baseline apathy, older age, and worse cognitive, motor, and depressive symptom scores predicted the development of dementia. In a multivariate analysis the predictive effects of baseline apathy were still significant (HR = 3.56; 95% CI = 1.09-11.62; p = 0.04).

CONCLUSIONS

A simple, caregiver-reported measure of apathy is an independent predictor of progression to dementia in PD. This highlights the importance of apathy as a clinical characteristic of PD and could prove useful for the prediction of future dementia.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Subjectively perceived personality and mood changes associated with subthalamic stimulation in patients with Parkinson's disease

BACKGROUND

Clinical and ethical implications of personality and mood changes in Parkinson's disease (PD) patients treated with subthalamic deep brain stimulation (STN-DBS) are under debate. Although subjectively perceived personality changes are often mentioned by patients and caregivers, few empirical studies concerning these changes exist. Therefore, we analysed subjectively perceived personality and mood changes in STN-DBS PD patients.

METHOD

In this prospective study of the ELSA-DBS group, 27 PD patients were assessed preoperatively and 1 year after STN-DBS surgery. Two categories, personality and mood changes, were analysed with semi-structured interviews. Patients were grouped into personality change yes/no, as well as positive/negative mood change groups. Caregivers were additionally interviewed about patients' personality changes. Characteristics of each group were assessed with standard neurological and psychiatric measurements. Predictors for changes were analysed.

RESULTS

Personality changes were perceived by six of 27 (22%) patients and by 10 of 23 caregivers (44%). The preoperative hypomania trait was a significant predictor for personality change perceived by patients. Of 21 patients, 12 (57%) perceived mood as positively changed. Higher apathy and anxiety ratings were found in the negative change group.

CONCLUSIONS

Our results show that a high proportion of PD patients and caregivers perceived personality changes under STN-DBS, emphasizing the relevance of this topic. Mood changed in positive and negative directions. Standard measurement scales failed to adequately reflect personality or mood changes subjectively perceived by patients. A more individualized preoperative screening and preparation for patients and caregivers, as well as postoperative support, could therefore be useful.

Self-unawareness of levodopa induced dyskinesias in patients with Parkinson's disease

The study analyzes the presence of dyskinesias-reduced-self-awareness in forty-eight patients suffering from Parkinson's disease (PD). As the association with executive dysfunction is a matter of debate and we hypothesize it plays an important role in dyskinesias self-unawareness, we analyzed the role of dopaminergic treatment on the medial-prefrontal-ventral-striatal circuitry using a neurocognitive approach. Special attention was given to metacognitive abilities related to action-monitoring that represent a novel explanation of the phenomenon. PD patients were assessed using different rating scales that we devised to measure movement awareness disorders. In order to ascertain whether each variable measured at a cognitive-clinical level contributes to predicting the scores of the movement-disorder-awareness-scales, we conducted multiple logistic regression models using the latter as binary dependent variables. We used the Wisconsin Card Sorting Test-metacognitive-version to assess the executive functions of the prefrontal-ventral-striatal circuitry. Data showed that a reduction of self-awareness using the Dyskinesia rating scale was associated with global monitoring (p=.04), monitoring resolution (p=.04) and control sensitivity (p=.04). Patients failed to perceive their performance, distinguish between correct and incorrect sorts, be confident in their choice and consequently decide to gamble during the task. We did not find any association with executive functions using the hypo-bradykinesia rating scale. Our findings indicate that when the comparator mechanism for monitoring attentive performance is compromised at a prefrontal striatal level, patients lose the ability to recognize their motor disturbances that do not achieve conscious awareness.

Metacognition in the behavioral variant of frontotemporal dementia and Alzheimer's disease

OBJECTIVE

Impaired self-awareness is characteristic of nearly all dementias, including Alzheimer's disease (AD), but the deficit is most severe in the behavioral variant of frontotemporal dementia (bvFTD). The prominence of frontal pathology in bvFTD suggests that failure of online monitoring, the process by which individuals monitor their own cognitive processing in real time, is an important contributor. Metacognitive research offers several approaches to measure self-assessment, some more and others less sensitive to online monitoring. The goal of this study was to assess metacognition in bvFTD using several approaches, and to compare the results with those in AD.

METHOD

We examined metacognition in 12 patients with bvFTD, 14 with AD, and 35 healthy controls using feeling of knowing (FOK), ease of learning (EOL), judgment of learning (JOL), and retrospective confidence rating (CR) tasks, as well as response to feedback about performance.

RESULTS

BvFTD and AD were both impaired at FOK compared with controls, although AD showed some sparing. Both groups were similarly impaired at CR and neither group was impaired at JOL after accounting for memory performance. Most striking, bvFTD patients failed to appropriately adjust their predictions about future memory performance even after receiving explicit feedback that they had performed worse than they expected.

CONCLUSIONS

Both bvFTD and AD show deficits in online monitoring, although the deficit appears more severe in bvFTD. The insensitivity of bvFTD patients to overt feedback may point to unique mechanisms, possibly frontally mediated, that add to their severe lack of self-awareness.

Predictors of discrepancies in Parkinson's disease patient and caregiver ratings of apathy, disinhibition, and executive dysfunction before and after diagnosis

Parkinson’s disease (PD) patient and caregiver reports of patient functioning are often used interchangeably in clinical and research settings; however, the consistency of these reports is largely unknown. This study aimed to investigate the consistency and predictors of discrepancy between self- and caregiver reports of patient apathy, disinhibition, and executive dysfunction. Fifty-one pairs of nondemented PD patients and their caregivers completed the frontal systems behavior scale (FrSBe). Patients were administered a neuropsychological battery, and mood and burden were assessed in a subset of caregivers. Patients and caregivers significantly differed in their ratings of all retrospective prediagnosis behaviors and current levels of disinhibition. Current levodopa equivalent dosages predicted patient-caregiver rating differences in prediagnosis and current apathy and current executive dysfunction, while patient motor function, cognition, and mood failed to predict any disparities in ratings. Caregiver burden and depression were associated with apathy rating discrepancies, while burden was associated with discrepancies in ratings of disinhibition. These results suggest that consistency of patient and caregiver behavioral ratings may vary depending on the behavior assessed; and underscore the importance of considering the reporter when using subjective measures, as discrepancies in behavioral reports may be influenced by specific patient and/or caregiver symptoms or factors.

Web-based assessment of visual and visuospatial symptoms in Parkinson's disease

Visual and visuospatial dysfunction is prevalent in Parkinson's disease (PD). To promote assessment of these often overlooked symptoms, we adapted the PD Vision Questionnaire for Internet administration. The questionnaire evaluates visual and visuospatial symptoms, impairments in activities of daily living (ADLs), and motor symptoms. PD participants of mild to moderate motor severity (n = 24) and healthy control participants (HC, n = 23) completed the questionnaire in paper and web-based formats. Reliability was assessed by comparing responses across formats. Construct validity was evaluated by reference to performance on measures of vision, visuospatial cognition, ADLs, and motor symptoms. The web-based format showed excellent reliability with respect to the paper format for both groups (all P′s < 0.001; HC completing the visual and visuospatial section only). Demonstrating the construct validity of the web-based questionnaire, self-rated ADL and visual and visuospatial functioning were significantly associated with performance on objective measures of these abilities (all P′s < 0.01). The findings indicate that web-based administration may be a reliable and valid method of assessing visual and visuospatial and ADL functioning in PD.

Promoting exercise in Parkinson's disease through community-based participatory research

Parkinson's disease (PD) is a chronic, progressive, as-of-yet incurable, neurodegenerative condition affecting the nigro-striatal dopaminergic system. Emerging evidence suggests the importance of exercise in improving the trajectory of PD. Yet few people with PD are physically active. One challenge that healthcare professionals face in the 21st century is how to deliver physical activity programs to the population of individuals living with PD. A novel approach to delivering physical activity to people with PD is introduced - termed community-based participatory research (CBPR) - which engages people with PD and patient advocates as co-researchers in the development and implementation of community-based exercise programs. The authors describe the CBPR approach and provide several recent examples of community exercise programs that are steps in the direction of developing the CBPR model. This is followed by a discussion of what a more fully realized CBPR model might look like. Finally, the authors describe some obstacles to conducting CBPR and suggest strategies for overcoming them. It is argued that people with PD are an integral component of delivering the exercise intervention.

Self-awareness of motor dysfunction in patients with Huntington's disease in comparison to Parkinson's disease and cervical dystonia

Individuals suffering from Huntington's disease (HD) have been shown to present with poor self-awareness of a variety of symptoms. The aim of this study was to better assess the self-awareness of motor symptoms and activities of daily living (ADL) impairment in HD, in comparison to Parkinson's disease (PD) and cervical dystonia (CD). In particular, the anosognosia/anosodiaphoria of involuntary movements has been investigated. Self-awareness was tested in 23 patients with HD by comparing patient and caregiver ratings in reference to clinical control groups (25 PD with dyskinesias, PDdys; 21 PD without dyskinesias, PDndys; and 20 with CD). Patients were assessed neurologically by relevant rating scales. Self-awareness was tested using a scale based on 15 films demonstrating 3 types of motor symptoms (chorea/dyskinesias, parkinsonism, torticollis) as well as the Self-Assessment Parkinson's Disease Disability Scale. General cognitive status, verbal learning, cognitive control, and mood were also analyzed. Our results indicate that self-awareness of choreic movements was affected more severely in HD than in PDdys, despite comparable cognitive status. Patient-proxy agreement on ADL impairment was roughly similar in all clinical groups. The results are discussed in the context of orbitofrontal-limbic pathology as a potential trigger of anosognosia/anosodiaphoria in individuals with HD.

Metacognitive monitoring in moderate and severe traumatic brain injury

The ability to engage in self-reflective processes is a capacity that may be disrupted after neurological compromise; research to date has demonstrated that patients with traumatic brain injury (TBI) show reduced awareness of their deficits and functional ability compared to caretaker or clinician reports. Assessment of awareness of deficit, however, has been limited by the use of subjective measures (without comparison to actual performance) that are susceptible to report bias. This study used concurrent measurements from cognitive testing and confidence judgments about performance to investigate in-the-moment metacognitive experiences after moderate and severe traumatic brain injury. Deficits in metacognitive accuracy were found in adults with TBI for some but not all indices, suggesting that metacognition may not be a unitary construct. Findings also revealed that not all indices of executive functioning reliably predict metacognitive ability.

Anosognosia in neurodegenerative disease

Patients with neurological disorders are often partially or completely unaware of the deficits caused by their disease. This impairment is referred to as anosognosia, and it is very common in neurodegenerative disease, particularly in frontotemporal dementia. Anosognosia has significant impacts on function and quality of life for patients with neurodegenerative disease and their caregivers, but the phenomenon has received little formal study, especially in non-Alzheimer's (non-AD) dementias. Furthermore, few studies have attempted to systematically verify the potential role of specific cognitive impairments in producing anosognosia. As a result, the mechanisms underlying this phenomenon are poorly understood. Episodic memory likely plays an important role. In addition, the frontal lobe systems are important for intact self-awareness, but the most relevant frontal functions have not been identified. Motivation required to engage in self-monitoring and emotional activation marking errors as significant are often-overlooked aspects of performance monitoring that may underlie anosognosia in some patients. The present review offers a working model that incorporates these functions and stipulates specific processes that may be important for awareness of changes in one's abilities. Specification of the specific processes whose potential failure results in anosognosia can establish a roadmap for future studies.