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Huang YC, Hong CT, Chi WC, Yen CF, Fang Liao H, Liou TH, Chan L. Deterioration of fine motor skills and functional disability in patients with moderate-to-advanced Parkinson disease: A longitudinal follow-up study. Arch Gerontol Geriatr 2024; 121:105366. [PMID: 38341958 DOI: 10.1016/j.archger.2024.105366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 01/09/2024] [Accepted: 02/05/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Parkinson disease (PD) caused substantially disability. The impairment of fine motor skills (FMSs) is correlated with the severity of functional disability (FD) cross-sectionally in people with PD (PwP). The present study investigated the decline in FMSs and the predictive value of baseline FMSs for the progression of FD. METHODS People with moderate-to-advanced PD who received two evaluations within 1-5 years were identified from the Taiwan Data Bank of Persons with Disability database. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) was used to evaluate FD, and FMSs including pen-holding, buttoning, and knotting were assessed. RESULTS Our study included 2,271 people with moderate-to-advanced PD. We observed annual progression of FD in each domain of the WHODAS 2.0, with no difference between the sexes. The most significant correlation between FD and FMSs was that of decline in buttoning ability and deterioration of summary WHODAS 2.0 scores. Deterioration in FD across all domains of WHODAS 2.0 was associated with at least one FMS. The extent of disability in all three types of FMS at baseline was also correlated with deterioration of motility. Additionally, baseline disability in buttoning was significantly correlated with cognitive decline, and disability in knotting was significantly associated with the progression of FD. CONCLUSION FMSs may be reliable markers for further FD, particularly in the areas of cognition, motility, and life activity. Because of the significant FD observed in people with moderate-to-advanced PD, the availability of predictors is essential for applying precautionary measures and providing appropriate treatment.
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Affiliation(s)
- Yin-Chia Huang
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Chien-Tai Hong
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 11031, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, 11031, Taiwan
| | - Wen-Chou Chi
- Taiwan Society of International Classification of Functioning, Disability and Health, TSICF, New Taipei City, 23561, Taiwan; Department of Occupational Therapy, Chung Shan Medical University, Taichung, 40201, Taiwan
| | - Chia-Feng Yen
- Taiwan Society of International Classification of Functioning, Disability and Health, TSICF, New Taipei City, 23561, Taiwan; Department of Public Health, Tzu Chi University, Hualien City, 97004, Taiwan
| | - Hua- Fang Liao
- Taiwan Society of International Classification of Functioning, Disability and Health, TSICF, New Taipei City, 23561, Taiwan; School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, 10617, Taiwan
| | - Tsan-Hon Liou
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, 11031, Taiwan; Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan.
| | - Lung Chan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 11031, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, 11031, Taiwan; Department of Neurology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan.
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Yu YW, Tan CH, Su HC, Chien CY, Sung PS, Lin TY, Lee TL, Yu RL. A New Instrument Combines Cognitive and Social Functioning Items for Detecting Mild Cognitive Impairment and Dementia in Parkinson’s Disease. Front Aging Neurosci 2022; 14:913958. [PMID: 35783135 PMCID: PMC9243636 DOI: 10.3389/fnagi.2022.913958] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/16/2022] [Indexed: 11/22/2022] Open
Abstract
Background The commonly used screening tests for Parkinson’s disease (PD) are the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE), both of which only focus on cognitive function. A composite assessment that considers both cognitive and social dysfunction in PD would be helpful in detecting mild cognitive impairment (MCI) and PD dementia (PDD). Objective We aimed to simplify the commonly used tools and combine cognitive and social functioning tests to detect early MCI and PDD. Materials and Methods A total of 166 participants (84 PD patients and 82 healthy) were recruited who completed the MMSE, MoCA, PD social functioning scale (PDSFS), clock drawing test, activities of daily living, comprehensive neuropsychological assessment (e.g., executive, attention, language, memory, and visuospatial functions), and movement disorder society (MDS)-unified PD rating scale. According to the MDS diagnostic criteria, the patients were grouped into PD-nonMCI, PD-MCI, or PDD. Results To detect PD-MCI, the optimal cut-off scores for the simplified MoCA and the combined test were 9 and 35. The discrimination values measured by the area under the receiver operating characteristic curve (AUC) of the two tests were 0.767 (p < 0.001) and 0.790 (p < 0.001). When the simplified MoCA was 7 or the combined test 30, the patients would be classified as having PDD. The AUCs of the two tests were 0.846 (p < 0.001) and 0.794 (p = 0.003). Conclusion We suggest considering both cognitive and social functions when detecting PD-MCI and PDD.
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Affiliation(s)
- Ya-Wen Yu
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Chun-Hsiang Tan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Hui-Chen Su
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Chung-Yao Chien
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Tien-Yu Lin
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Tsung-Lin Lee
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Rwei-Ling Yu
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
- *Correspondence: Rwei-Ling Yu,
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Wang X, Chen L, Zhou H, Xu Y, Zhang H, Yang W, Tang X, Wang J, Lv Y, Yan P, Peng Y. Enriched Rehabilitation Improves Gait Disorder and Cognitive Function in Parkinson's Disease: A Randomized Clinical Trial. Front Neurosci 2021; 15:733311. [PMID: 34924926 PMCID: PMC8674725 DOI: 10.3389/fnins.2021.733311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Studies on non-pharmacological strategies for improving gait performance and cognition in Parkinson's disease (PD) are of great significance. We aimed to investigate the effect of and mechanism underlying enriched rehabilitation as a potentially effective strategy for improving gait performance and cognition in early-stage PD. Methods: Forty participants with early-stage PD were randomly assigned to receive 12 weeks (2 h/day, 6 days/week) of enriched rehabilitation (ER; n = 20; mean age, 66.14 ± 4.15 years; 45% men) or conventional rehabilitation (CR; n = 20; mean age 65.32 ± 4.23 years; 50% men). In addition, 20 age-matched healthy volunteers were enrolled as a control (HC) group. We assessed the general motor function using the Unified PD Rating Scale-Part III (UPDRS-III) and gait performance during single-task (ST) and dual-task (DT) conditions pre- and post-intervention. Cognitive function assessments included the Montreal Cognitive Assessment (MoCA), the Symbol Digit Modalities Test (SDMT), and the Trail Making Test (TMT), which were conducted pre- and post-intervention. We also investigated alteration in positive resting-state functional connectivity (RSFC) of the left dorsolateral prefrontal cortex (DLPFC) in participants with PD, mediated by ER, using functional magnetic resonance imaging (fMRI). Results: Compared with the HC group, PD participants in both ER and CR groups performed consistently poorer on cognitive and motor assessments. Significant improvements were observed in general motor function as assessed by the UPDRS-III in both ER and CR groups post-intervention. However, only the ER group showed improvements in gait parameters under ST and DT conditions post-intervention. Moreover, ER had a significant effect on cognition, which was reflected in increased MoCA, SDMT, and TMT scores post-intervention. MoCA, SDMT, and TMT scores were significantly different between ER and CR groups post-intervention. The RSFC analysis showed strengthened positive functional connectivity between the left DLPFC and other brain areas including the left insula and left inferior frontal gyrus (LIFG) post-ER. Conclusion: Our findings indicated that ER could serve as a potentially effective therapy for early-stage PD for improving gait performance and cognitive function. The underlying mechanism based on fMRI involved strengthened RSFC between the left DLPFC and other brain areas (e.g., the left insula and LIFG).
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Affiliation(s)
- Xin Wang
- Department of Rehabilitation Medicine, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - LanLan Chen
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Hongyu Zhou
- Department of Rehabilitation Medicine, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Yao Xu
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Hongying Zhang
- Department of Medical Imaging, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Wenrui Yang
- Graduate School, Dalian Medical University, Dalian, China
| | - XiaoJia Tang
- Department of Rehabilitation Medicine, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Junya Wang
- Medical College, Yangzhou University, Yangzhou, China
| | - Yichen Lv
- School of Rehabilitation Medicine, Binzhou Medical University, Yantai, China
| | - Ping Yan
- School of Nursing, Yangzhou University, Yangzhou, China
| | - Yuan Peng
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou, China
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Wang W, Dong FM, Shao K, Guo SZ, Zhao ZM, Yang YM, Song YX, Wang JH. The montreal cognitive assessment and mini-mental state examination visuoexecutive subtests in acute ischemic stroke patients and their correlations with demographic and clinical factors. Acta Neurol Belg 2021; 121:1707-1714. [PMID: 33219489 DOI: 10.1007/s13760-020-01479-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/17/2020] [Indexed: 01/04/2023]
Abstract
Visuoexecutive impairment is common among acute ischemic stroke patients. This study aimed to examine the ability of the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) visuoexecutive subtests to detect visuoexecutive abnormality in acute ischemic stroke patients and to identify the predictors for their impairments. 336 patients who completed the MMSE and MoCA were enrolled in this study. We compared the proportion of participants with incorrect MoCA visuoexecutive tasks and MMSE pentagon copying. Multivariate logistic regression analysis was used to evaluate the associations between the visuoexecutive dysfunction and demographic and clinical characteristics in the samples. Among all the participants, the MoCA detected more visuoexecutive dysfunction than the MMSE (88.69% vs. 45.83%, respectively; p < 0.001). The predictors identified by the univariate analysis included the factors of gender, age, educational level, smoking, alcohol consumption, Oxfordshire Community Stroke Project (OCSP), previous strokes, initial NIHSS score and number of old lacunar infarctions, while from the multivariate logistic regression analysis, the factors of age, educational level, NIHSS score, previous strokes and number of old lacunar infarctions served as predictive factors for the visuoexecutive impairment in acute stroke patients. In conclusion, visuoexecutive impairment is associated with the factors of the educational level, stroke severity, stroke history and number of old lacunar infarctions. Our findings may guide the clinicians to intervene the risks for the patients at an early stage after stroke and form the basis for good rehabilitation plans.
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Olfaction in patients with Parkinson's disease: a new threshold test analysis through turning points trajectories. J Neural Transm (Vienna) 2021; 128:1641-1653. [PMID: 34328564 PMCID: PMC8536637 DOI: 10.1007/s00702-021-02387-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022]
Abstract
Olfactory deficit is a widely documented non-motor symptom in Parkinson’s disease (PD). Abnormal turning points trajectories through olfactory threshold testing have been recently reported in patients with olfactory dysfunction, who seem to adapt faster to olfactory stimuli, but data on PD patients are lacking. The aim of this study is to perform olfactory threshold test and explore the turning points trajectories in PD patients in comparison to normal controls. We recruited 59 PD patients without dementia, and no conditions that could influence evaluation of olfaction and cognition. Sixty healthy subjects served as controls. Patients and controls underwent a comprehensive olfactory evaluation with the Sniffin’ Sticks extended test assessing threshold, discrimination and identification and a full neuropsychological evaluation. Besides, threshold test data were analyzed examining all the turning points trajectories. PD patients showed a different olfactory threshold test pattern, i.e., faster olfactory adaptation, than controls with no effect of age. Normosmic PD patients showed different olfactory threshold test pattern, i.e., better threshold score, than normosmic controls. Visuospatial dysfunction was the only factor that significantly influenced this pattern. Olfactory threshold trajectories suggested a possible adaptation phenomenon in PD patients. Our data offered some new insights on normosmic PD patients, which appear to be a subset with a specific psychophysical profile. The analysis of the turning points trajectories, through an olfactory threshold test, could offer additional information on olfactory function in PD patients. Future larger studies should confirm these preliminary findings.
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Statucka M, Cherian K, Fasano A, Munhoz RP, Cohn M. Multiculturalism: A Challenge for Cognitive Screeners in Parkinson's Disease. Mov Disord Clin Pract 2021; 8:733-742. [PMID: 34307746 PMCID: PMC8287166 DOI: 10.1002/mdc3.13240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The Montreal Cognitive Assessment (MoCA) and the Dementia Rating Scale-2 (DRS-2) are recommended screeners for Parkinson's disease mild cognitive impairment (PD-MCI). Cross-cultural studies examining their diagnostic precision have not addressed cultural bias in a multicultural setting. OBJECTIVES To compare DRS-2 and MoCA performance between patients born in Canada, the USA, and the UK (Anglosphere group) and immigrant patients born elsewhere (International group). To identify sources of cultural bias by comparing group characteristics, and by assessing the relationships between performance and immigration and socio-development variables. To examine the diagnostic precision of both tools in detecting PD-MCI in each group. METHODS We conducted a clinical chart review of advanced PD patients who completed cognitive screeners (MoCA: n = 288, 30% International group; DRS-2: n = 426, 31% International group). All completed a comprehensive neuropsychological assessment to apply Level II PD-MCI diagnostic criteria. RESULTS The International group performed worse than the Anglosphere group on the MoCA and DRS-2, and the only variable that accounted for some of the group difference was the Historical Index of Human Development, a societal variable, which fully mediated the group effect on the DRS-2. Diagnostic precision of the MoCA was at chance level in the International group, and was poorer than that of the DRS-II in this group and that of the MoCA in the Anglosphere group, although these were considered poor. CONCLUSIONS Our results support the recommendation to exert caution in using cognitive screeners to capture PD-MCI in all patients and particularly with first generation immigrants.
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Affiliation(s)
- Marta Statucka
- Krembil Brain InstituteToronto Western Hospital UHNTorontoOntarioCanada
| | - Kirsten Cherian
- Baycrest, Neuropsychology & Cognitive HealthTorontoOntarioCanada
- Palo Alto UniversityPalo AltoCaliforniaUSA
| | - Alfonso Fasano
- Krembil Brain InstituteToronto Western Hospital UHNTorontoOntarioCanada
- Edmond J. Safra Program in Parkinson's DiseaseMorton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHNTorontoOntarioCanada
- Division of NeurologyUniversity of TorontoTorontoOntarioCanada
| | - Renato P. Munhoz
- Krembil Brain InstituteToronto Western Hospital UHNTorontoOntarioCanada
- Edmond J. Safra Program in Parkinson's DiseaseMorton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHNTorontoOntarioCanada
- Division of NeurologyUniversity of TorontoTorontoOntarioCanada
| | - Melanie Cohn
- Krembil Brain InstituteToronto Western Hospital UHNTorontoOntarioCanada
- Psychology DepartmentUniversity of TorontoOntarioCanada
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The correlation of non-motor symptoms and sleep on balance in Parkinson's disease patients with normal cognition and mild cognitive impairment. Ir J Med Sci 2021; 190:1577-1584. [PMID: 33449322 DOI: 10.1007/s11845-020-02462-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Parkinson's disease (PD) is characterized by non-motor symptoms (NMS) as well as by motor symptoms. Together with the impairment of cognitive functions, NMS and sleep also affect motor symptoms negatively. The aim of our study is to examine the correlation of NMS and sleep on balance in PD patients with normal cognition (PD-NC) and with mild cognitive impairment (PD-MCI). METHODS A total of 69 patients were included in our study. Using the Standardized Mini-Mental State Examination, participants were divided into 2 groups, PD-NC and PD-MCI. Patients were assessed with the Unified Parkinson's Disease Rating Scale (UPDRS), the Berg Balance Scale (BBS), the Tinetti Balance Assessment Tool (TBAT), the Non-Motor Symptoms Questionnaire (NMSQ), and the Parkinson's Disease Questionnaire (PDQ-39). RESULTS PD-MCI patients had statistically significant worse motor symptoms and more balance disorder compared to PD-NC (UPDRS: p = 0.009; BBS: p = 0.010; TBAT: p = 0.004). PD-MCI patients had greater severity of non-motor symptoms and worse sleep quality than the PD-NC group (NMSQ-total: p = 0.02; NMSQ-sleep total: p = 0.01). The evaluation has shown that with a diagnosis of MCI, NMS, and sleeping problems were correlated, and the correlation was associated with impairment of the balance function. While being more pronounced in the PD-MCI group, quality of life was affected in both groups (p < 0.05). CONCLUSION Our data demonstrate a negative effect on the balance function in patients with cognitive impairment suffering increased NMS and sleeping disorders. Treatment of these patients needs to concentrate on NMS and cognitive functions as much as on motor symptoms.
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Freezing of Gait in Parkinson's Disease: Risk Factors, Their Interactions, and Associated Nonmotor Symptoms. PARKINSONS DISEASE 2021; 2021:8857204. [PMID: 33505652 PMCID: PMC7815408 DOI: 10.1155/2021/8857204] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/22/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
Background Freezing of gait (FOG) is a debilitating and incompletely understood symptom in Parkinson's disease (PD). Objective To determine the principal clinical factors predisposing to FOG in PD, their interactions, and associated nonmotor symptoms. Methods 164 PD subjects were assessed in a cross-sectional retrospective study, using the MDS-UPDRS scale, MMSE, and Clinical Dementia Rating Scale. Clinical factors associated with FOG were determined using univariate analysis and nominal logistic regression. Receiver operating characteristic curves were computed, to obtain measures of sensitivity and specificity of predictors of FOG. Subgroups of patients with FOG were compared with those without FOG, based on defining aspects of their clinical phenotype. Results Relative to non-FOG patients, those with FOG had a longer disease duration, higher PIGD and balance-gait score, higher LED, and more motor complications (p < 0.0001) and were more likely to exhibit urinary dysfunction (p < 0.0003), cognitive impairment, hallucinations, and psychosis (p=0.003). The balance-gait score and motor complications, at their optimum cutoff values, together predicted FOG with 86% accuracy. Interactions were noted between cognitive dysfunction and both the Bal-Gait score and motor complication status, cognitive impairment or dementia increasing the likelihood of FOG in subjects without motor complications (p=0.0009), but not in those with motor complications. Conclusions Both disease and treatment-related factors, notably LED, influence the risk of FOG in PD, with a selective influence of cognitive dysfunction in patients with balance-gait disorder but not in those with motor fluctuations. These findings may help to inform clinical management and highlight distinct subgroups of patients with PD-FOG, which are likely to differ in their network pathophysiology.
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Mazancova AF, Růžička E, Jech R, Bezdicek O. Test the Best: Classification Accuracies of Four Cognitive Rating Scales for Parkinson's Disease Mild Cognitive Impairment. Arch Clin Neuropsychol 2020; 35:1069–1077. [PMID: 32681175 DOI: 10.1093/arclin/acaa039] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/15/2020] [Accepted: 06/09/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE A progressive cognitive impairment is one of the frequent non-motor symptoms during Parkinson's disease (PD) course. A short and valid screening tool is needed to detect an incipient cognitive deficit at the mild cognitive impairment stage in Parkinson's disease (PD-MCI). METHOD The present study aims to evaluate the classification accuracies of four cognitive screenings: Montreal Cognitive Assessment (MoCA), Mattis Dementia Rating Scale second edition (DRS-2), Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) in a cohort of PD patients (PD-MCI, n = 46; and Parkinson's disease with normal cognition, PD-NC, n = 95) and Controls (n = 66). All subjects underwent a standard neuropsychological battery as recommended by the International Parkinson and Movement Disorder Society and underwent all four screening tools. RESULTS In the detection of PD-MCI versus PD-NC, the MoCA showed a sensitivity of 84% and a specificity of 66% with a screening cutoff score at ≤25 points. The MoCA's AUC was 86% (95% CI 78.7-93.1). In the detection of PD-MCI versus Controls, the FAB displayed 84% sensitivity and 79% specificity with a cutoff ≤16 points, to screen. The FAB's AUC was 87% (79.0-95.0). CONCLUSIONS Our results show that the MoCA is the most discriminative tool for screening MCI in the PD population.
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Affiliation(s)
- Adela Fendrych Mazancova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Evžen Růžička
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Robert Jech
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondrej Bezdicek
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Tan S, Hong CT, Chen JH, Chan L, Chi WC, Yen CF, Liao HF, Liou TH, Wu D. Hand Fine Motor Skill Disability Correlates with Cognition in Patients with Moderate-to-Advanced Parkinson's Disease. Brain Sci 2020; 10:brainsci10060337. [PMID: 32498218 PMCID: PMC7349665 DOI: 10.3390/brainsci10060337] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/21/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022] Open
Abstract
In older individuals, hand fine motor skill disability is associated with cognitive levels. Similarly, patients with moderate-to-advanced Parkinson's disease (PD) often have cognitive dysfunction. Here, we investigated the association between hand fine motor skill and cognitive dysfunction in patients with moderate-to-advanced PD. Moderate and advanced PD patients with and without dementia were identified from the Taiwan Data Bank of Persons with Disability. Hand fine motor capacities, namely pen holding, buttoning, and knotting, were assessed with the World Health Organization Disability Assessment Schedule 2.0. Statistical analyses were performed on Statistical Analysis System (SAS) and a p value of <0.05 was considered significant. In total, 3440 patients with PD were enrolled, of which 612 had dementia, exhibiting significant disability in all three tasks. After adjustments for age, sex, and PD severity, pen holding and knotting were significantly associated with PD dementia. The presence of any disability in either task was not only sensitive to the presence of dementia but also associated with cognitive disability in moderate and advanced PD patients without dementia. In conclusion, hand fine motor skill disability was associated with cognitive disability in patients with moderate-to-advanced PD. These simple hand fine motor skills may thus be applicable in screening tests for the early identification of cognitive dysfunction in patients with moderate-to-advanced PD.
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Affiliation(s)
- Shennie Tan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (S.T.); (C.T.H.); (J.-H.C.); (L.C.)
| | - Chien Tai Hong
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (S.T.); (C.T.H.); (J.-H.C.); (L.C.)
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 23561, Taiwan
| | - Jia-Hung Chen
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (S.T.); (C.T.H.); (J.-H.C.); (L.C.)
| | - Lung Chan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (S.T.); (C.T.H.); (J.-H.C.); (L.C.)
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 23561, Taiwan
| | - Wen-Chou Chi
- Taiwan Society of International Classification of Functioning, Disability and Health, TSICF, New Taipei City 23561, Taiwan; (W.-C.C.); (C.-F.Y.); (H.-F.L.); (T.-H.L.)
- Department of Occupational Therapy, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Chia-Feng Yen
- Taiwan Society of International Classification of Functioning, Disability and Health, TSICF, New Taipei City 23561, Taiwan; (W.-C.C.); (C.-F.Y.); (H.-F.L.); (T.-H.L.)
- Department of Public Health, Tzu Chi University, Hualien City 97004, Taiwan
| | - Hua-Fang Liao
- Taiwan Society of International Classification of Functioning, Disability and Health, TSICF, New Taipei City 23561, Taiwan; (W.-C.C.); (C.-F.Y.); (H.-F.L.); (T.-H.L.)
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei 10617, Taiwan
| | - Tsan-Hon Liou
- Taiwan Society of International Classification of Functioning, Disability and Health, TSICF, New Taipei City 23561, Taiwan; (W.-C.C.); (C.-F.Y.); (H.-F.L.); (T.-H.L.)
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
| | - Dean Wu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (S.T.); (C.T.H.); (J.-H.C.); (L.C.)
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 23561, Taiwan
- Correspondence: or
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Siqueira GSA, Hagemann PDMS, Coelho DDS, Santos FHD, Bertolucci PHF. Can MoCA and MMSE Be Interchangeable Cognitive Screening Tools? A Systematic Review. THE GERONTOLOGIST 2019; 59:e743-e763. [PMID: 30517634 DOI: 10.1093/geront/gny126] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cognitive disorders may be an early sign of neuropsychiatric disorders; however, it remains unclear whether the screening measures are interchangeable. The aim of this study was to contrast the most commonly used screening tools-Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)-for early detection of neurocognitive disorder (NCD). RESEARCH DESIGN AND METHODS This study presents a descriptive systematic review and informative literature according to the Cochrane Foundation's guidelines. The keywords "Mini-Mental State Examination" and "Montreal Cognitive Assessment" were searched in the Web of Science, SciELO, and LILACS databases. RESULTS Fifty-one studies were selected including a total sample of 11,870 participants (8,360 clinical patients and 3,510 healthy controls). Most studies were published in the past 5 years using a cross-sectional design, carried out across the world. They were organized by age ranges (18-69 years and 20-89 years), years of schooling, and mental status (with and without mental and behavior disorders). Sixteen of 18 studies had participants aged 18-69 years, and 21 out of 33 studies within the older set suggested that the MoCA is a more sensitive tool for detecting NCD. DISCUSSION AND IMPLICATIONS Thirty-seven studies suggested that the MoCA is a more sensitive tool for NCD detection because it assesses executive function and visuospatial abilities. Some individuals who demonstrated normal cognitive function on the MMSE had lower performance on the MoCA. However, it seems necessary to establish different cutoffs based on years of schooling to avoid false positives. Future studies should contrast MoCA with other screening tools designed for NCD assessment.
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Affiliation(s)
| | | | - Daniela de S Coelho
- Departments of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Flávia Heloísa Dos Santos
- Faculty of Sciences, São Paulo State University (UNESP), Bauru
- Departments of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
- Department of Basic Psychology and Methodology, University of Murcia, Murcia, Spain
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Paulo H F Bertolucci
- Departments of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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Cecchini MP, Federico A, Zanini A, Mantovani E, Masala C, Tinazzi M, Tamburin S. Olfaction and taste in Parkinson's disease: the association with mild cognitive impairment and the single cognitive domain dysfunction. J Neural Transm (Vienna) 2019; 126:585-595. [PMID: 30911822 DOI: 10.1007/s00702-019-01996-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/19/2019] [Indexed: 01/01/2023]
Abstract
Mild cognitive impairment (MCI) and chemosensory dysfunction are non-motor symptoms of Parkinson's disease (PD), but their association is unclear. We explored if MCI and the involvement of single cognitive domains influence olfaction and taste in PD. The role of demographic, clinical and neuropsychiatric variables was tested. We recruited 50 PD patients without dementia, no other reasons for cognitive impairment, no condition that could influence evaluation of cognition, olfaction and taste. They underwent a full neuropsychological and chemosensory (i.e., olfaction and taste) test with the Sniffin' Sticks Extended test (SSET), Whole Mouth test (WMT) and Taste Strips test (TST). Fifty age- and sex-matched healthy subjects served as controls. Olfactory function and sweet identification were worse in PD than controls. MCI negatively influenced odor identification. Factors associated with poor olfactory function were age, overall cognition, apathy, and visuospatial dysfunction. Sour identification was affected by MCI and executive dysfunction, and salty identification by executive dysfunction. MCI, age and executive dysfunction worsened TST score. Awareness of olfactory dysfunction was impaired in PD with MCI. Education positively influenced SSET and TST scores. Our data confirmed that olfaction is abnormal in PD, while taste was only slightly impaired. Olfaction was worse in PD patients with visuospatial dysfunction, while sour and salty identification was worse in those with MCI and executive dysfunction, suggesting different underlying anatomical abnormalities. Future studies should incorporate neuroimaging and cerebrospinal fluid data to confirm this hypothesis. SSET odor identification and TST sour identification could be explored as quick screening tests for PD-MCI.
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Affiliation(s)
- Maria Paola Cecchini
- Section of Anatomy and Histology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Strada Le Grazie, 8, 37134, Verona, Italy.
| | - Angela Federico
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy
| | - Alice Zanini
- Section of Anatomy and Histology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Strada Le Grazie, 8, 37134, Verona, Italy
| | - Elisa Mantovani
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy
| | - Carla Masala
- Department of Biomedical Sciences, Section of Physiology, University of Cagliari, Cagliari, Italy
| | - Michele Tinazzi
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy
| | - Stefano Tamburin
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy.
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13
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Siciliano M, Chiorri C, Passaniti C, Sant'Elia V, Trojano L, Santangelo G. Comparison of alternate and original forms of the Montreal Cognitive Assessment (MoCA): an Italian normative study. Neurol Sci 2019; 40:691-702. [PMID: 30637545 DOI: 10.1007/s10072-019-3700-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 01/03/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The Montreal Cognitive Assessment (MoCA) is a screening test widely used in clinical practice and suited for detection of Mild Cognitive Impairment. Alternate forms of the MoCA were developed to avoid "learning effect" in serial assessments, and the present study aimed at investigating inter-form parallelism and at providing normative values for the Italian versions of MoCAs 2 and 3. METHOD Three separate convenience samples were recruited: the first (n = 78) completed three alternate MoCA versions for ascertaining inter-form parallelism; the second (n = 302) and the third (n = 413) samples were administered MoCA 2 or 3 to compute normative data. RESULTS A three-step procedure complemented by confirmatory factor analysis and a mixed factorial ANOVA suggested that the three MoCA versions are not strictly parallel. Multiple linear regression analysis revealed that age and education significantly influenced MoCA 2 and 3 total scores. No significant effect of sex was found. From the derived linear equation, correction grids for MoCA 2 and 3 raw scores were built and equivalent scores computed. Inferential cutoff for adjusted scores, estimated using a non-parametric technique, were 17.49 for MoCA 2 and 18.34 for MoCA 3. Correlation analysis showed strong correlations of MoCA 2 (r = 0.69, p < .001) and MoCA 3 (r = 0.61, p < .001) adjusted total scores with MMSE adjusted scores. CONCLUSION The three MoCA forms are not strictly parallel. Specifically developed normative data must be adopted for using MoCA in serial cognitive assessments for clinical and research studies.
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Affiliation(s)
- Mattia Siciliano
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences - MRI Research Center SUN-FISM, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
- Department of Psychology, University of Campania "Luigi Vanvitelli", Viale Ellittico 31, 81100, Caserta, Italy
| | - Carlo Chiorri
- Department of Educational Sciences, University of Genova, Genoa, Italy
| | - Carla Passaniti
- Department of Psychology, University of Campania "Luigi Vanvitelli", Viale Ellittico 31, 81100, Caserta, Italy
| | - Valeria Sant'Elia
- Department of Psychology, University of Campania "Luigi Vanvitelli", Viale Ellittico 31, 81100, Caserta, Italy
| | - Luigi Trojano
- Department of Psychology, University of Campania "Luigi Vanvitelli", Viale Ellittico 31, 81100, Caserta, Italy.
| | - Gabriella Santangelo
- Department of Psychology, University of Campania "Luigi Vanvitelli", Viale Ellittico 31, 81100, Caserta, Italy
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14
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Federico A, Trentin M, Zanette G, Mapelli D, Picelli A, Smania N, Tinazzi M, Tamburin S. Diagnosing mild cognitive impairment in Parkinson's disease: which tests perform best in the Italian population? Neurol Sci 2017; 38:1461-1468. [PMID: 28550344 DOI: 10.1007/s10072-017-3000-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 05/17/2017] [Indexed: 08/30/2023]
Abstract
Mild cognitive impairment (MCI) is common in patients with Parkinson's disease (PD) and should be recognized early because it represents a predictor of PD-related dementia and worse disease course. Diagnostic criteria for PD-related MCI (PD-MCI) have recently been defined by a Movement Disorders Society (MDS) task force. The present study explored which neuropsychological tests perform best for a level II (i.e., comprehensive neuropsychological assessment) diagnosis of PD-MCI according to the MDS task force criteria in Italian-speaking PD patients. To this aim, we assessed a comprehensive 23-item neuropsychological battery, derived the best-performing 10-test battery (i.e., two tests per domain for each of the five cognitive domains), and explored its accuracy for diagnosing PD-MCI in comparison to the full battery in a group of PD patients. A secondary aim was to explore the role of this battery for subtyping PD-MCI according to single-domain vs. multiple-domain involvement. The 10-test battery showed 73% sensitivity and 100% specificity for diagnosing PD-MCI, and 69% sensitivity and 100% specificity for PD-MCI subtyping. In patients older than 70 years, we derived a slightly different 10-test battery with 84% sensitivity and 100% specificity for PD-MCI diagnosis, and 86% sensitivity and 100% specificity for PD-MCI subtyping. These 10-item neuropsychological batteries might represent a good trade-off between diagnostic accuracy and time of application, and their role in PD-MCI diagnosis and subtyping should be further explored in future prospective studies.
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Affiliation(s)
- Angela Federico
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy
| | - Michela Trentin
- Neurology Unit Pederzoli Hospital, Peschiera del Garda, Italy
| | | | - Daniela Mapelli
- Department of General Psychology, Human Inspired Technologies Research Center, University of Padua, Padua, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy.,Neuromotor and Cognitive Rehabilitation Research Centre, University of Verona, Verona, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy.,Neuromotor and Cognitive Rehabilitation Research Centre, University of Verona, Verona, Italy
| | - Michele Tinazzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134, Verona, Italy.
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15
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Magrinelli F, Picelli A, Tocco P, Federico A, Roncari L, Smania N, Zanette G, Tamburin S. Pathophysiology of Motor Dysfunction in Parkinson's Disease as the Rationale for Drug Treatment and Rehabilitation. PARKINSON'S DISEASE 2016; 2016:9832839. [PMID: 27366343 PMCID: PMC4913065 DOI: 10.1155/2016/9832839] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 04/03/2016] [Accepted: 05/10/2016] [Indexed: 11/17/2022]
Abstract
Cardinal motor features of Parkinson's disease (PD) include bradykinesia, rest tremor, and rigidity, which appear in the early stages of the disease and largely depend on dopaminergic nigrostriatal denervation. Intermediate and advanced PD stages are characterized by motor fluctuations and dyskinesia, which depend on complex mechanisms secondary to severe nigrostriatal loss and to the problems related to oral levodopa absorption, and motor and nonmotor symptoms and signs that are secondary to marked dopaminergic loss and multisystem neurodegeneration with damage to nondopaminergic pathways. Nondopaminergic dysfunction results in motor problems, including posture, balance and gait disturbances, and fatigue, and nonmotor problems, encompassing depression, apathy, cognitive impairment, sleep disturbances, pain, and autonomic dysfunction. There are a number of symptomatic drugs for PD motor signs, but the pharmacological resources for nonmotor signs and symptoms are limited, and rehabilitation may contribute to their treatment. The present review will focus on classical notions and recent insights into the neuropathology, neuropharmacology, and neurophysiology of motor dysfunction of PD. These pieces of information represent the basis for the pharmacological, neurosurgical, and rehabilitative approaches to PD.
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Affiliation(s)
- Francesca Magrinelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
- Neuromotor and Cognitive Rehabilitation Research Centre, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
| | - Pierluigi Tocco
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
| | - Angela Federico
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
| | - Laura Roncari
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
- Rehabilitation Unit, Pederzoli Hospital, Via Monte Baldo 24, 37019 Peschiera del Garda, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
- Neuromotor and Cognitive Rehabilitation Research Centre, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
| | - Giampietro Zanette
- Neurology Unit, Pederzoli Hospital, Via Monte Baldo 24, 37019 Peschiera del Garda, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Scuro 10, 37134 Verona, Italy
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16
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Jaberi E, Rohani M, Shahidi GA, Nafissi S, Arefian E, Soleimani M, Moghadam A, Arzenani MK, Keramatian F, Klotzle B, Fan JB, Turk C, Steemers F, Elahi E. Mutation inADORA1identified as likely cause of early-onset parkinsonism and cognitive dysfunction. Mov Disord 2016; 31:1004-11. [DOI: 10.1002/mds.26627] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/10/2016] [Accepted: 02/28/2016] [Indexed: 11/09/2022] Open
Affiliation(s)
- Elham Jaberi
- School of Biology, College of Science, University of Tehran; Tehran Iran
| | - Mohammad Rohani
- Department of Neurology; Hazrat Rasool Hospital, Iran University of Medical Sciences; Tehran Iran
| | - Gholam Ali Shahidi
- Department of Neurology; Hazrat Rasool Hospital, Iran University of Medical Sciences; Tehran Iran
| | - Shahriar Nafissi
- Department of Neurology; Tehran University of Medical Sciences; Tehran Iran
| | - Ehsan Arefian
- School of Biology, College of Science, University of Tehran; Tehran Iran
| | - Masoud Soleimani
- School of Medical Sciences; Tarbiat Modares University; Tehran Iran
| | - Abolfazl Moghadam
- School of Biology, College of Science, University of Tehran; Tehran Iran
| | | | - Farid Keramatian
- Department of Biotechnology; College of Science, University of Tehran; Tehran Iran
| | | | | | | | | | - Elahe Elahi
- School of Biology, College of Science, University of Tehran; Tehran Iran
- Department of Biotechnology; College of Science, University of Tehran; Tehran Iran
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