Frequency of non-motor symptoms in Parkinson's disease presenting to tertiary care centre in Pakistan: an observational, cross-sectional study

Spectrum of neurodegenerative disorders in neurology outpatient department: A cross-sectional study

Background and Aims

Neurodegenerative disorders (NDDs) are a growing global health concern with a rise in prevalence with the aging population, leading to increased healthcare utilization and costs. Understanding its prevalence is crucial for effective diagnostics and resource allocation, especially in developing nations with limited resources. This study aims to explore the frequency and types of NDDs, while also collecting demographic, clinical, and neuro-radiological data from patients with NDDs attending a tertiary care hospital in Nepal.

Methods

This was a single-center based cross-sectional descriptive study conducted at a Neurology outpatient department in a tertiary level hospital in Nepal in which patients aged 18 and above diagnosed with NDDs (May 2023-July 2023) were included. Data were collected and analyzed in SPSS Inc. This study has been presented by the STROBES guidelines.

Results

The mean age of the 71 patients included in the study was 65.6 ± 13.3 years. Parkinsonian disorder (n = 41, 57.7%) was the most common NDD diagnosed. Patients belonging to the age group 60-79 years represented 62% of all outpatient visits. Tremors of the upper extremity and impairment of memory were the most commonly encountered first symptoms at onset. Predominant cognitive changes in our study were memory impairment and mood changes. Extrapyramidal features such as gait disturbance, resting tremor, rigidity, and bradykinesia were present. More than half of the patients had age-related cerebral atrophy on neuroimaging followed by chronic small vessel ischemic changes.

Conclusion

Diagnosing NDDs poses challenges, and our study underscores Parkinsonian disorder, specifically Parkinson's disease, as the prevailing neurodegenerative condition in our population. Emphasizing its prevalence among the elderly, particularly with tremors as the primary presenting symptom, highlights the necessity for targeted interventions in this demographic.

The effectiveness and safety of botulinum toxin injections for the treatment of sialorrhea with Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

Botulinum toxin (BoNT) injection is an important adjunctive method to treat sialorrhea. The purpose of this systematic review was to analyze the effect and safety of BoNT injections in the intervention of sialorrhea with Parkinson's disease (PD).

METHODS

We searched PubMed, Web Of Science (WOS), Scopus, Cochrane CENTRAL, and Embase from inception until April 2022. Randomized controlled trials or randomized crossover trials comparing BoNT with placebo in sialorrhea with PD were eligible. PRISMA guidelines were used to carry out the meta-analysis. The Drooling Severity Frequency Scale (DSFS) score and the number of adverse events (AEs) were the primary and secondary outcomes, respectively. Standardized mean differences (SMDs) and risk differences (RDs) are used to express continuous and categorical outcomes, respectively. Heterogeneity among these studies was evaluated using I2 tests. We used the GRADE tool to assess the certainty of evidence (COE).

RESULTS

Eight articles involving 259 patients compared BoNT injections with a placebo for PD with sialorrhea. This meta-analysis showed a significant reduction in DSFS scores between BoNT injections and placebo (SMD=-0.98; 95% CI, -1.27 to 0.70, p<0.001; COE: high). This meta-analysis showed a significant difference in AEs between BoNT injections and placebo (RD=0.15; 95% CI, 0.05 to 0.24, p=0.002; COE: low).

CONCLUSIONS

The pooled results suggest that BoNT injections have some effect on DSFS scores with sialorrhea caused by PD. There are also mild adverse events, which generally recover within a week or so. The results indicate that BoNT injection is one of the treatments for sialorrhea caused by PD, but we need to pay attention to adverse events. In addition, the follow-up time was extended to observe oral hygiene, ulceration or dental caries, and digestive function.

TRIAL REGISTRATION

Our review protocol was registered on PROSPERO (42021288334).

Gustatory dysfunction is related to Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

Olfactory dysfunction has been reported to be involved in Parkinson's disease (PD) pathogenesis. However, gustatory dysfunction in PD has not been evaluated as in-depth as olfactory dysfunction. We reviewed the previously published studies regarding gustatory function in PD patients and suggested the possibility that gustatory dysfunction may also be associated with PD.

METHODS

MEDLINE, Cochrane Library, Embase, and PubMed databases were searched for studies evaluating gustatory function in PD patients. We used the standardized mean difference and a 95% confidence interval (CI) as the effect analysis index regarding the taste strip test. The relative risk and 95% CI were used as the effect analysis index for the questionnaires and propylthiouracil (PTU)/phenylthiocarbamide (PTC) perception test. Statistical heterogeneity was assessed using forest plots, Cochran's Q, and the I2 statistic; heterogeneity was considered high when I2 was over 75%. Publication bias was assessed by funnel plots and the Egger bias test.

RESULTS

We identified 19 articles that reported the results of gustatory function tests in PD patients and healthy controls. Most of these studies used various gustatory tests, including taste strips, questionnaires, taste solutions, PTU/PTC perception tests, and electrogustometry, and reported significantly lower gustatory function in PD patients than in the controls. However, several articles reported contradictory results.

CONCLUSIONS

Based on these studies, gustatory dysfunction is closely related to PD. However, the number of studies and enrolled subjects was small, and a unified gustatory function test was lacking. Therefore, further studies with larger populations and normalized gustatory function tests are needed.

Depression After Parkinson's Disease: Treated Differently or Not At All?

Depression is a common, potentially debilitating non-motor symptom of Parkinson's disease which may manifest at any time and can respond to treatment. Although depression is a known primary mediator of health-related quality of life, it is currently unknown whether the timing of depression diagnosis relative to PD diagnosis affects receipt of depression treatment. Electronic health record data were examined to explore differences in depression treatment among patients diagnosed with depression before or after PD diagnosis. Compared to PD patients diagnosed with depression prior to PD, those diagnosed with depression following PD are less likely to receive any treatment, either pharmacologic or non-pharmacologic, indicating a temporal association between the time of PD diagnosis and receipt of depression treatment. This highlights a potentially substantial treatment gap, despite the existence of efficacious treatment. Diagnosis with PD appears to alter depression treatment and further research is warranted to determine potential causes and effective interventions.

Non-motor manifestation of Parkinson's disease: a cross-sectional study in a teaching hospital in Jordan

Background

Parkinson's disease (PD) is the most common degenerative movement disorder. It is featured by motor manifestations and up till now the clinical diagnosis is based on them. Since the progress in the symptomatic treatment of PD and the longer survival of patients, non-motor manifestations (NMM) were more recognized and considered to be significant. The importance of NMM is that they reflect the more diffuse pathology of PD and may represent an opportunity of earlier diagnosis and treatment. Here in this cross-sectional study, we try to estimate the frequency of such manifestations in PD patients in the country. Using slightly modified PD non-motor (28 of 30 responses) questionnaire (NMS Quest), we studied the incidence of NMM in 100 PD patients attending one major teaching hospital and compared their occurrence in 130 age- and gender-matched non-PD controls.

Results

Out of 100 PD patients (40% females) mean age 67.4 ± 12 with disease duration of 7.3 ± 5.8, range < 1–33.2 years), and 130 control subjects (48.5% females), mean age 65.0 ± 7.0. PD patients had 8.6 ± 5.3 NMM while controls had 3.4 ± 3.3 NMM, respectively (p < 0.00001 t test). Constipation, urgency, insomnia, sad feeling, panic, light headedness and recent memory impairment were the most prevalent NMM in PD compared to controls, while nocturia, restless legs, encopresis and falling were not different in the two groups. The number of NMM ranged from 0 to 21 in PD patients with 50% having ≥ 8 manifestations. The number of NMM did not correlate with age, gender, or disease duration as defined by the classical motor symptoms. Frequency of 23 of these 28 manifestations differed significantly in PD patients compared to controls.

Conclusions

This study confirms that NMM in Jordanian PD patients are very common as reported in other populations. This signifies the universal prevalence of such NMM reflecting their important impact on their daily life and their relevant contribution to better understanding of this disease.

The prevalence and associated factors of dysphagia in Parkinson's disease: A systematic review and meta-analysis

Background

The prevalence and associated factors of dysphagia in Parkinson's disease (PD) are different in studies conducted in different countries. The purpose of our systematic review and meta-analysis was to evaluate the prevalence of dysphagia in PD and to clarify its associated factors.

Methods

Two researchers systematically searched PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang Database, SinoMed and VIP databases and manually searched references in the retrieved articles to identify potential research subjects. The last search was conducted on June 28, 2022. Finally, a total of 58 studies including 60 observations with 20,530 PD patients were included in our meta-analysis.

Results

The meta-analysis estimated that the pooled prevalence rate of dysphagia in PD was 36.9% (95% CI: 30.7–43.6%) and instrumental examination showed a higher prevalence (57.3%, 95% CI: 44.3–69.1%). Oceania showed the highest prevalence of dysphagia in PD (56.3%) compared to Africa (39.5%), Asia (38.6%), Europe (36.1%) and America (28.9%). Dysphagia in PD was associated with older age, lower body mass index, longer disease duration, higher Hoehn and Yahr stage and levodopa equivalent daily dose, PIGD subtype, severe motor symptoms, drooling and higher levels of depression, and lower quality of life.

Conclusions

In conclusion, our meta-analysis showed that dysphagia occurs in more than one-third of PD patients and was associated with several demographic characteristics and PD-related characteristics, motor symptoms, non-motor symptoms, as well as decreased quality of life. It deserves early screening, diagnosis, and treatment in clinical practice to prevent serious complications from dysphagia.

Self-Reported Visual Complaints in People with Parkinson’s Disease: A Systematic Review

Background:

Scientific research increasingly focuses on visual symptoms of people with Parkinson’s disease (PD). However, this mostly involves functional measures, whereas self-reported data are equally important for guiding clinical care.

Objective:

This review provides an overview of the nature and prevalence of self-reported visual complaints by people with PD, compared to healthy controls.

Methods:

A systematic literature search was performed. Studies from three databases (PubMed, PsycInfo, and Web of Science) were screened for eligibility. Only studies that reported results of visual self-reports in people with idiopathic PD were included.

Results:

One hundred and thirty-nine eligible articles were analyzed. Visual complaints ranged from function-related complaints (e.g., blurred vision, double vision, increased sensitivity to light or changes in contrast sensitivity) to activity-related complaints (e.g., difficulty reading, reaching, or driving). Visual complaints were more prevalent in people with PD compared to healthy controls. The presence of visual complaints leads to a reduced quality of life (QoL). Increased prevalence and severity of visual complaints in people with PD are related to longer disease duration, higher disease severity, and off-state.

Conclusion:

A large proportion of people with PD have visual complaints, which negatively affect QoL. Complaints are diverse in nature, and specific and active questioning by clinicians is advised to foster timely recognition, acknowledgement, and management of these complaints.

Immunisation with UB-312 in the Thy1SNCA mouse prevents motor performance deficits and oligomeric α-synuclein accumulation in the brain and gut

Alpha synuclein has a key role in the pathogenesis of Parkinson's disease (PD), Dementia with Lewy Bodies (LBD) and Multiple System Atrophy (MSA). Immunotherapies aiming at neutralising toxic αSyn species are being investigated in the clinic as potential disease modifying therapies for PD and other synucleinopathies. In this study, the effects of active immunisation against αSyn with the UB-312 vaccine were investigated in the Thy1SNCA/15 mouse model of PD. Young transgenic and wild-type mice received an immunisation regimen over a period of 6 weeks, then observed for an additional 9 weeks. Behavioural assessment was conducted before immunisation and at 15 weeks after the first dose. UB-312 immunisation prevented the development of motor impairment in the wire test and challenging beam test, which was associated with reduced levels of αSyn oligomers in the cerebral cortex, hippocampus and striatum of Thy1SNCA/15 mice. UB-312 immunotherapy resulted in a significant reduction of theαSyn load in the colon, accompanied by a reduction in enteric glial cell reactivity in the colonic ganglia. Our results demonstrate that immunisation with UB-312 prevents functional deficits and both central and peripheral pathology in Thy1SNCA/15 mice.

Recalling the pathology of Parkinson's disease; lacking exact figure of prevalence and genetic evidence in Asia with an alarming outcome: A time to step-up

Parkinson's disease (PD) is the second most common and progressive neurodegenerative disease globally, with major symptoms like bradykinesia, impaired posture, and tremor. Several genetic and environmental factors have been identified but elucidating the main factors have been challenging due to the disease's complex nature. Diagnosis, prognosis, and management of such diseases are challenging and require effective targeted attention in developing countries. Recently, PD is growing rapidly in many crowded Asian countries as an alarming threat with inadequate knowledge of its prevalence, genetic architecture, and geographic distribution. This study gave an in-depth overview of the prevalence, incidence and genomic/genetics studies published so far in the Asian population. To the best of our knowledge, PD has increased significantly in several Asian countries, including China, South Korea, Japan, Thailand, and Israel over the past few years, requiring a greater level of care and attention. Genetic screening of families with PD at national levels and establishing an official database of PD cases are essential to get a comprehensive and conclusive view of the exact prevalence and genetic diversity of PD in the Asian population to properly manage and treat the disease.

Ethnic Variation in the Manifestation of Parkinson's Disease: A Narrative Review

The global prevalence of Parkinson's disease is increasing, yet the characteristics, risk factors and genetics of PD in Black, Asian and Hispanic populations is little understood. In this paper we review the published literature on clinical variation in the symptoms and signs of Parkinson's disease in different ethnic groups and responses to treatment. We included any study that sampled patients with Parkinson's disease from distinct ethnic backgrounds. We conclude that whilst there is little published evidence for ethnic variation in the clinical features of Parkinson's disease, there are substantial limitations and gaps in the current literature, which mean that the evidence does necessarily not fit with clinical observation. Possible explanations for expected differences in manifestation include genetic determinants, the co-existence of cerebrovascular disease and/or Alzheimer's disease pathology, healthcare inequalities and socio-cultural factors.

Parkinson disease and the gut: new insights into pathogenesis and clinical relevance

The classic view portrays Parkinson disease (PD) as a motor disorder resulting from loss of substantia nigra pars compacta dopaminergic neurons. Multiple studies, however, describe prodromal, non-motor dysfunctions that affect the quality of life of patients who subsequently develop PD. These prodromal dysfunctions comprise a wide array of gastrointestinal motility disorders including dysphagia, delayed gastric emptying and chronic constipation. The histological hallmark of PD - misfolded α-synuclein aggregates that form Lewy bodies and neurites - is detected in the enteric nervous system prior to clinical diagnosis, suggesting that the gastrointestinal tract and its neural (vagal) connection to the central nervous system could have a major role in disease aetiology. This Review provides novel insights on the pathogenesis of PD, including gut-to-brain trafficking of α-synuclein as well as the newly discovered nigro-vagal pathway, and highlights how vagal connections from the gut could be the conduit by which ingested environmental pathogens enter the central nervous system and ultimately induce, or accelerate, PD progression. The pathogenic potential of various environmental neurotoxicants and the suitability and translational potential of experimental animal models of PD will be highlighted and appraised. Finally, the clinical manifestations of gastrointestinal involvement in PD and medications will be discussed briefly.

Nocturia and Nocturnal Polyuria in Neurological Patients: From Epidemiology to Treatment. A Systematic Review of the Literature

CONTEXT

Nocturia is among the most common and bothersome lower urinary tract symptoms (LUTS), but there is no clear consensus on how to identify and manage this symptom in the neurological population.

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

Studies were identified by electronic search of Cochrane and Medline databases. The studies were included if their participants had acquired neurological pathology among multiple sclerosis (MS), Parkinson's disease (PD), stroke, spinal cord injury (SCI), and reported data on the epidemiology, aetiology, diagnosis, or treatment of nocturia. An independent extraction of the articles was performed by two authors using predetermined datasets, including quality-of-study indicators.

EVIDENCE SYNTHESIS

A total of 132 studies were included; 46 evaluated the epidemiology of nocturia, 28 the possible aetiologies, 10 the diagnostic tools, and 60 the treatments. Nocturia prevalence ranged from 15% to 96% depending on the pathology and definition used. It was one of the most frequently reported LUTS in PD and stroke patients. Several validated questionnaires were found to screen for nocturia in this population. Causalities were numerous: LUT, renal, sleep, cardiovascular dysfunctions, etc. Treatments targeted these mechanisms, with an overall risk of bias assessed as high or serious. The highest level of evidence was seen in MS patients: pelvic floor muscle training, cannabinoids, and desmopressin were effective, but not melatonin. In stroke patients, transcutaneous sacral and transcutaneous tibial nerve stimulation (TTNS) improved nocturia; in PD patients, TTNS, solifenacin, and rotigotine did not.

CONCLUSIONS

Nocturia is highly prevalent in patients with neurological disorders. Causalities and treatments are not different from the general population, but are poorly studied in neurological patients.

PATIENT SUMMARY

In this report, we looked at the published studies about nocturia-the fact of waking to void during the hours of sleep-in patients with neurological diseases. We found that nocturia is very frequent in this population, that the causes are the same as in the general population but may be combined, and that treatments are also the same but have an overall weak level of evidence. We conclude that more research is needed on this topic.

A comparison of auditory and vestibular dysfunction in Parkinson's disease and Multiple System Atrophy

INTRODUCTION

Vertigo and disequilibrium are common symptoms in idiopathic Parkinson's disease (PD) and in Multiple System Atrophy (MSA). Hearing loss has been recently recognized as an additional non-motor feature in PD. The aim of this study is to evaluate audio-vestibular function in patients affected by PD and MSA.

METHODS

Fifteen patients with PD, 16 patients with MSA and 20 age-matched healthy controls (HC) were enrolled. Audio-vestibular examination included pure-tone audiometry (PTA), vestibular bed-side examination, video Head Impulse Test (vHIT), and cervical Vestibular-Evoked Myogenic Potentials (cVEMPs).

RESULTS

PD and MSA patients showed worse PTA thresholds compared to HC at high frequencies. MSA patients showed worse PTA thresholds at 125 Hz compared to HC. In patients with PD, a direct correlation between disease duration and PTA thresholds was found at 2000 Hz and 4000 Hz. In patients with MSA, disease duration was directly related to PTA thresholds at 125 Hz and 250 Hz. Among PD patients, cVEMPs were absent bilaterally in 46.7% and unilaterally in 13.3% of the subjects. Among MSA patients, cVEMPs were absent bilaterally in 26.7% and unilaterally in 40% of the subjects; p13 latency was significantly increased in PD patients as compared to HC. A significant inverse relationship was found between disease duration and cVEMP amplitude in MSA patients.

CONCLUSION

We found that high-frequency hearing loss and cVEMP abnormalities are frequent features of both MSA and PD, suggesting that an audio-vestibular dysfunction may be present in these patients even in the absence of self-reported auditory or vestibular symptoms.

An overview of pain in Parkinson's disease

Pain is a common non-motor symptom of Parkinson's disease (PD) and the prevalence of pain among PD patients varies because of the disease stage, co-morbidities, and evaluating tools. Risk factors for pain in PD include an early age of onset, long disease duration, motor complications, concomitant depressive symptoms, female gender, and associated medical conditions. In patients with PD, pain can be classified as musculoskeletal pain, chronic body pain (central or visceral), fluctuation-related pain, nocturnal pain, orofacial pain, pain with discolouration/oedema/swelling, and radicular/neuropathic pain; musculoskeletal pain as the most common type. Potential underlying mechanisms include a disruption of peripheral nociception and alterations in central pain threshold/processing. Genetic polymorphisms in genes that confer pain susceptibility might also play a role in the occurrence of pain in PD. In advanced stage of patients with PD, polyneuropathy could occur in patients using high dosage of levodopa. Pain often correlates to other non-motor symptoms of PD, including depression, sleep, and autonomic symptoms. Dopaminergic drugs, non-dopaminergic medications, botulinum toxin, deep brain stimulation, and physiotherapy have shown some benefits for certain types of PD-related pain. An increased awareness of pain as a common non-motor symptom of PD provides further insights into sensory system dysregulation in this disease. In this review, we aim to summarizes the clinical features of pain in patients with PD and emphasize the latest evidence of pain related to levodopa treatment.

Frequency of Cognitive Impairment in Patients with Parkinson's Disease

Introduction

More than its motor symptoms, cognitive impairment is being increasingly identified as a cause of worse functional outcome, morbidity and mortality, and caregiver dependence in Parkinson’s disease (PD). The aim of this study was to identify the frequency of cognitive decline and evaluate the factors associated with it.

Methods

In this cross-sectional study, 124 PD patients fulfilling the United Kingdom Parkinson’s Disease Society Brain Bank Clinical Diagnostic Criteria were included. Motor and non-motor symptoms were recorded. Disease duration, age at the time of onset, and severity of disease on Hoehn and Yahr Scale (HY scale) were recorded. Data was entered and analyzed using SPSSs v. 22.0.

Results

The ratio of men to women was 7.2:1. The mean age of the participants was 64 ± 10 years (range: 38-82 years). Rigidity (n = 121; 97.5%), bradykinesia (n = 119; 95.9%), and tremor (n = 11; 90.3%) were the three most common symptoms. Cognitive impairment was present in 45 (36.3%) patients. Cognitive decline was more frequent in patients of age less than 50 years at the time of disease onset (p < 0.00001) and in those with disease duration more than 10 years (p = 0.00001). Patients with longer disease duration had more severe disease (stage III or above on HY scale; p = 0.008).

Conclusion

Motor symptoms such as rigidity, bradykinesia, and tremor remain the most frequent clinical presentation among Pakistani Parkinson’s patients. One-third of these patients have cognitive dysfunction. Early age at the time of disease onset and longer duration of disease were associated with cognitive impairment.