Caregiver Burden in Parkinson Disease: A Scoping Review of the Literature from 2017-2022

The Prevalence of Depression Among Parkinson's Disease Patients in Saudi Arabia: A Cross-Sectional Study

Background and Aim

Depression is thought to affect up to half of Parkinson's patients at some point during their illness, while anxiety is reported by about 40% of PD patients. The study aimed to assess the prevalence of depression and anxiety among patients with Parkinson's disease (PD) in Saudi Arabia.

Methods

The study involved Saudi Arabian citizens and residents aged 40 or older with PD, who completed internet-survey (including online and email-based data collection) or telephone-survey by trained interviewers. We used the Parkinson's Disease Questionnaire for quality-of-Life assessment questionnaire (PDQ-39), Patient Health Questionnaire-9 for depression (PHQ-9), and General Anxiety Disorder-7 anxiety questionnaire (GAD-7).

Results

The study included 46 participants, of whom 37% were aged 60-69 years, 67% were male, 46% had completed a university education, and 87% were married. Depression symptoms were present in 84.8% of participants, while 73.9% experienced anxiety. PD patients lacking social support were 8 times more likely to develop major depression [OR = 8.27, 95% CI (1.47-46.31), p = 0.016] and 5 times more likely to experience anxiety symptoms [OR = 5.36, 95% CI (1.14-25.26), p = 0.034]. Those unable to perform daily living activities or who faced stigma had a 16.5 times higher likelihood of anxiety symptoms [OR = 16.5, 95% CI (1.62-168.48), p = 0.018]. Furthermore, cognitive impairment increased the likelihood of anxiety by 11 times [OR = 11.43, 95% CI (1.83-71.42), p = 0.009].

Conclusion

The study reveals a high prevalence of depression and anxiety among Parkinson's disease patients, linked to physical impairments and social isolation. Many patients report no mental health improvement despite treatment, highlighting the need for routine mental health assessments, social support, and tailored interventions to enhance their quality of life. The small sample size may limit the statistical power, precision, and generalizability of the study's findings.

How to advance the pharmacological management of cognitive impairment in Parkinson's disease

Cognitive impairment is a common non-motor symptom in people with Parkinson's disease (PD) and is associated to poor clinical outcomes. Currently, rivastigmine is the only approved medication for PD dementia, and there are no treatments available for people with PD and mild cognitive impairment. To advance the pharmacological management of cognitive impairment in PD, it is essential to optimize clinical trial design. This includes refining cognitive outcome measures, ensuring longer study durations, and incorporating PD-specific cognitive assessments. Biomarkers offer valuable opportunities for screening, stratification, enrichment, and monitoring in trials, increasing the likelihood of detecting treatment effects. Additionally, adopting patient-centered approaches that prioritize inclusivity can enhance trial validity and address the current lack of diversity in PD studies. Digital cognitive assessments offer a promising tool for improving participation and enabling longitudinal monitoring, especially in underrepresented and mobility-challenged populations. By tackling these challenges, this review outlines strategies for advancing the pharmacological management of cognitive impairment in PD. It emphasizes the need for precise, inclusive, and biomarker-driven trials to accelerate drug development.

Reporting standards in randomized controlled trials involving neuro-oncology caregivers: A systematic review report from the RANO-Cares working group

Background

Family caregivers in neuro-oncology (eg, spouse, family member, friend to a patient) have high unmet support needs, yet intervention trials and effective support options are scarce. The Response Assessment in Neuro-Oncology (RANO)-Cares working group investigated the methodological quality of neuro-oncology caregiver outcomes reporting in randomized controlled trials (RCTs).

Methods

A systematic review was performed to evaluate to what extent RCTs assessing outcomes of caregivers of adult primary brain tumor patients adhere to minimum reporting standards. A 33-item checklist (23 applicable to secondary analysis reports) based on the International Society for Quality of Life Research (ISOQOL) criteria for patient-reported outcome reporting was used. Risk of bias was assessed per RCT.

Results

Fifteen publications from 11 unique RCTs included 676 neuro-oncology caregivers, with low overall risk of bias. Ten publications (66%) reported on caregiver outcomes as a primary aim, of which 8 (80%) satisfied ≥2/3 of the key methodological criteria. Of the 5 secondary analysis reports (33%), 2 (40%) met ≥2/3 of applicable key criteria. Criteria often not reported adequately included sample size calculations (reported adequately in n = 8, 53%), participant flow (n = 9, 60%) window for data collection (n = 1, 6%), and extent of (n = 10, 66%), reasons for (n = 9, 60%), and statistical approaches in dealing with (n = 4, 26%) missing data.

Conclusions

Whilst there are opportunities to enhance reporting standards, RCTs that include neuro-oncology caregiver outcomes generally adhere to high-quality reporting standards and have low risk of bias, indicating good potential to impact clinical practice.

Comprehensive assessment of caregiver burden and strain in early-stage Parkinson's disease: An exploratory study

Parkinson's Disease (PD) is a progressive neurodegenerative disorder affecting motor and cognitive functions, reducing the quality of life (QoL) for both patients and caregivers. This study explored correlations between clinical and psychological factors in early-stage PD patients and their caregivers, focusing on disease burden and caregiver stress. Nineteen PD patients and their caregivers were assessed. For patients, we evaluated disease severity (Hoehn and Yahr), cognitive functions (Montreal Cognitive Assessment, MoCA), anxiety levels (Hamilton Rating Scale for Anxiety, HRS-A), and quality of life (Parkinson's Disease Questionnaire, PDQ-39). For caregiver, we assessed caregiver burden (Caregiver Burden Inventory, CBI), functional social support (Family Strain Questionnaire, FSQ), and anxiety level (HRS-A). Spearman's correlation analyzed relationships between patient factors and caregiver burden. Cognitive impairment (MoCA) negatively correlated with patient QoL (PDQ-Cogn; r = -0.48, p = 0.04). Caregiver anxiety (HRS-A) was positively correlated with physical (r = 0.65, p = 0.003) and emotional stress (r = 0.57, p = 0.01), and higher family stress (FSQ). Our study highlights the complex relationships between clinical and psychological factors in PD patients and their caregivers. This supports the need for integrated approaches that address the clinical management of PD and the caregivers' psychological well-being.

Parkinson's Disease and Caregiving Roles, Demands, and Support Needs and Experiences: A Scoping Review

Background and Objectives: A public health priority is the increasing number of persons with Parkinson's disease (PwP), and the need to provide them with support. We sought to synthesize the experiences of relatives or friends-family caregivers-who provide such support. Eligibility Criteria: This study was a scoping literature review modeled by the PRISMA guidelines. The articles for this review fit the following inclusion criteria: (1) studies including the perspective of caregivers of PwP, (2) studies conducted in the United States, and (3) studies conducted between January 2019 to January 2024. Sources of Evidence: Articles were identified by searching the PubMed, EBSCO, and Ovid databases between January 2019 and January 2024. The search terms included the following: (Parkinson's disease) AND (caregiver OR caregiving OR carer). Results: A total of 31 articles were included. Most of the included articles are descriptive (n = 26), including quantitative (n = 17), qualitative (n = 7), and mixed-methods studies (n = 2). Gender, race, and ethnicity were not consistently reported. Findings across studies demonstrated common roles of caregiving (e.g., assistance with personal care), extensive physical and mental health strains, social isolation, and work and financial strain. Benefit-finding was also evident among caregivers including a goal of securing the PwP dignity and comfort as the disease progressed. The studies of this review provide perspectives on benefits and challenges of caregiving in this context and caregiver resources. Conclusions: Future studies need to improve racial and gender-related diversity and address caregiver strain and health.

Parkinson's Disease Carepartners' Perceptions of the Challenges and Rewards of Caregiving

BACKGROUND

Multiple debilitating symptoms and the progressive nature of Parkinson's disease (PD) affect carepartners' quality of life. Although, there is abundant knowledge on caregiver burden there is limited knowledge on PD carepartners' perceptions of caregiving.

AIM

To understand family members' perception of their role, and of the challenges and rewards of PD caregiving.

METHOD

Using a qualitative descriptive research design, we conducted semi-structured interviews with current and former PD carepartners (n = 16). Interviews were audio-recorded, de-identified, and transcribed verbatim. Data were coded and analyzed to identify themes.

RESULTS

We identified 5 themes: (a) Unpredictability is the hardest part of caregiving. It was hard to cope with the unpredictable daily and longer-term fluctuations in PD symptoms; (b) Disease progression and multiple symptoms contribute to carepartners' emotional distress. Carepartners felt unprepared and were saddened by the patient's and their own losses; (c) Caring for a family member is not a "burden." Though stressful, carepartners resisted associating caregiving with the term "burden"; (d) Caregiving is a partnership. Carepartners saw their role as being less of "givers" and more of partners in disease management; and (e) Caregiving is an opportunity for personal satisfaction, joy, and growth. Caregiving was seen as a "gift" that enabled carepartners to express love and experience personal growth.

CONCLUSIONS

Despite challenges PD carepartners view their role as "partners" in the management of the disease and find meaning and strength in caregiving. A palliative care approach emphasizing the positives and challenges of caregiving may provide carepartners with better support.

Epidemiology of early-onset Parkinson disease (EOPD) worldwide: East versus west

Parkinson disease (PD) is characterized by the presence of bradykinesia with either rest tremor, muscle rigidity, or postural instability. If the features for PD are present but the age at onset (AAO) is before the usual but later than 21 years of age, it is considered as early-onset PD (EOPD). With Eastern countries projected to account for over 60 % of the world's population, it is paramount to understand the differences in EOPD between Western and Eastern countries. Epidemiology can differ substantially between the East and West, such as China showing a much steeper rise in EOPD prevalence and incidence with age, or Japan and Korea showing a female predominance in EOPD for certain age groups. Symptomatology appears to be similar across Western and Eastern populations, though some Eastern populations may have a higher prevalence of the akinetic-rigid or postural instability/gait difficulty motor phenotypes. Genetic epidemiology, conversely, varies significantly between the East and West, though some genes are frequently implicated in both (such as LRRK2, PINK1, PRKN, and GBA). Next, treatment patterns also exhibit substantial geographical variation, which could be driven by local availability of medications, adequacy of staff training and infrastructure, and local regulatory bodies. Lastly, regardless of region, EOPD exerts a profound psychosocial impact on patients, such as strained relationships, unemployment, and psychological distress. In summary, understanding these differences (and similarities) between the East and West could help generate innovative solutions, while the development of healthy habits and robust social networks should also be actively encouraged in all patients.

Caregiving burden, depression, and anxiety in informal caregivers of people with mental illness in China: a cross-sectional survey

BACKGROUND

Caregiving for people with mental illness (PwMI) could be burdensome, especially for informal caregivers. However, there is a scarcity of research investigating caregiving burden among informal caregivers of PwMI in China at the national level. To fill this gap, this study examined the prevalence of caregiving burden, depression, and anxiety, as well as their associated factors, among a cross-sectional sample of informal caregivers of PwMI in China.

METHODS

Data were collected via an online survey between June and November 2023. Caregiving burden, depression, and anxiety were measured by the Zarit Burden Interview, the Patient Health Questionnaire, and the Generalized Anxiety Disorder Scale. Information on caregivers' sociodemographic, care recipients' sociodemographic and disease-related, and caregiving-related characteristics was also collected. Hierarchical regression analyses were performed to identify associated factors of caregiving burden, depression, and anxiety.

RESULTS

A total of 1,224 informal caregivers of PwMI in China were included in the final analysis. 72.1% of the participants had high caregiving burden, 53.5% had moderate to severe depression, and 43.1% had moderate to severe anxiety. Caregiving burden, depression, and anxiety were inter-correlated with each other but exhibited different profiles of associated factors. The most important factors associated with all the three outcomes were disease-related characteristics, particularly care recipients' symptom stability, medication compliance, and insight. Informal caregivers of males with mental illness had higher levels of caregiving burden, depression, and anxiety than those of females. There was a lack of differentiation in caregiving burden, depression, and anxiety based on care recipients' diagnosis. Formal or common-law marriage was a protective factor for caregiver depression and anxiety but not for caregiving burden.

CONCLUSION

Informal caregivers of PwMI in China experienced a high level of caregiving burden, depression, and anxiety. Urgent actions are needed to relieve caregiving burden, depression, and anxiety among informal caregivers of PwMI in China.

Treatment of Parkinson's Disease Psychosis-A Systematic Review and Multi-Methods Approach

OBJECTIVES

Parkinson's disease psychosis (PDP) is a prevalent non-motor symptom associated with Parkinson's disease. The treatment options for PDP are limited, and its pharmacological management remains ambiguous. This study aimed to evaluate the existing evidence in relation to clinical practice.

METHODS

This multi-methods study consisted of a systematic review of reviews, adhering to the PRISMA guidelines. The review was registered with PROSPERO. Following data extraction and assessment using the AMSTAR 2 tool, a narrative synthesis was performed. In the second phase of the study, a questionnaire was developed, validated, piloted, and distributed to the heads of specialized PD clinics in Germany and Austria.

RESULTS

The search resulted in the inclusion of eleven reviews. The quality of eight of these reviews was rated as high (n = 7) or moderate (n = 1). The reviews indicated that clozapine and pimavanserin demonstrated the highest efficacy and tolerability. Other antipsychotic medications either failed to alleviate PDP symptoms or resulted in distinct motor complications. The survey findings also favored clozapine for its efficacy in managing PDP and improving quality of life, although quetiapine was regarded as effective and pimavanserin was not available. Clinicians reported initiating antipsychotic treatment at various stages of PDP, with a tendency to reduce the dosage or discontinue D2 agonists or anticholinergics.

CONCLUSIONS

The reviewed literature and the survey results consistently favored clozapine for its efficacy and tolerability in treating PDP. It may be considered the first-line treatment, with pimavanserin as an alternative option.

Parkinson's Disease Bradykinesia, Forward Posture, and Drug-Induced Pisa Syndrome Alleviated With Traditional Japanese Acupuncture: A Case Report

Parkinson's disease (PD) is a common progressive neurodegenerative disease. The management of PD including Pisa syndrome (PS), a postural deformity in PD characterized by reversible lateral bending of the trunk on the side, is often challenging. Recently, acupuncture has been a recognized intervention for treating motor or non-motor symptoms in PD management. However, very few of these studies or cases have been reported from Japan. A 58-year-old man with a four-year history of PD (Hoehn and Yahr Scale: Stage 2) presented to the acupuncture department of our hospital with dysphasia, bradykinesia, forward posture, and newly appeared right-side bending of the trunk after he increased the dose of rotigotine delivered via skin patches six months earlier. There was no change in the right-sided bending of the trunk two months after the withdrawal of the dopaminergic agents. A traditional Japanese acupuncture and moxibustion treatment, Hokushin-kai, was started. According to the Oriental medical diagnosis, he was categorized with "liver depression," "kidney deficiency," and "dampness" patterns. The treatment was administered once a week, and only one or two needles were used. The acupoints, such as Ququan (LR8) or Houxi (SI3), were selected according to the Oriental medical diagnosis and the findings of the acupoint examination. At first, the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) score was 34 points, and the Parkinson's Disease Questionnaire (PDQ-39) score was 42 points; the Cobb angle was 45°. After 10 weeks, he could walk smoothly and almost upright. MDS-UPDRS-3 and PDQ-39 scores improved to 12 points and 34 points, respectively, while the Cobb angle improved to 32°. Changes (improvements) in his gait and posture are shown in the videos included in this case report. We present a case of PD bradykinesia, forward posture, and drug-induced PS alleviated with traditional Japanese acupuncture. This case report suggests that acupuncture using this Japanese method would achieve similar efficacies to those achieved in conventional case reports or clinical trials, and it could be one of the optional treatments available for PD. Further studies, such as the long-term effect of acupuncture on PD patients or improved outcomes of PD patients with early-phase intervention, are required.

Sustaining Joy in Serious Neurologic Illnesses

The goals of medicine tend to be framed around addressing suffering, pathology, and functional deficits. While this is a natural orientation when dealing with serious illness, it is also incomplete and neglects significant opportunities to improve the quality of life of patients, families, and clinicians. The "total enjoyment of life" is a multidimensional framework that can serve as a positive counterbalance to the "total pain of illness." It allows clinicians, researchers, policymakers, and other stakeholders to take a systematic and comprehensive approach to the active promotion of well-being. The five opportunities for enhancing well-being in this framework are meaning, social connections, happiness/contentment, spiritual transcendence, and pleasure. Applying these concepts in clinical settings, patients, families, and clinicians can together find opportunities to increase the total enjoyment of life in the face of incurable and intractable illnesses. For family care partners, these concepts can be applied to improve self-care, enhance relationships, and develop more creative approaches to supporting a loved one living with illness. Clinicians working with these concepts may find their clinical work more satisfying and impactful and can also apply these concepts to their own lives to increase wellness. In clinical research, this framework can be applied to improve intervention effectiveness and relevance of outcome measures. Lastly, these concepts have the potential to impact public health approaches that focus on well-being and flourishing as the goal and metric of a healthy society.

Analysis of mortality in Parkinson disease in China: Exploration of recent and future trends

Objectives

Parkinson disease (PD) is the third leading cause of mortality among middle-aged and older individuals in China. This study aimed to explore the trends and distribution features of PD mortality in China from 2013 to 2021 and make predictions for the next few decades.

Methods

Relevant data were obtained from the Chinese Center for Disease Control and Prevention Disease Surveillance Point system. The joinpoint regression model was used to evaluate trends. The R software was used to predict future trends.

Results

Age-standardized mortality rate (ASMR) of PD increased from 0.59 per 100,000 individuals to 1.22 per 100,000 individuals from 2013 to 2021, with an average annual percent change (AAPC) of 9.50 (95% CI: 8.24-10.78). The all-age ASMR of PD were higher in male individuals than in female individuals, and ASMR increased with age. The number of deaths and ASMR increased gradually from west to east and from rural to urban areas. Furthermore, ASMR is expected to increase to 2.66 per 100,000 individuals by 2040.

Conclusions

The heightened focus on the ASMR of PD among male individuals, urban areas, eastern China, and individuals aged ≥85 years has become a key determinant in further decreasing mortality, thereby exhibiting novel challenges to effective strategies for disease prevention and control.

Staging Parkinson's disease according to the MNCD classification correlates with caregiver burden

BACKGROUND AND OBJECTIVE

Recently, we demonstrated that staging Parkinson's disease (PD) with a novel simple classification called MNCD, based on four axes (motor, non-motor, cognition, and dependency) and five stages, correlated with disease severity and patients' quality of life. Here, we analyzed the correlation of MNCD staging with PD caregiver's status.

PATIENTS AND METHODS

Data from the baseline visit of PD patients and their principal caregiver recruited from 35 centers in Spain from the COPPADIS cohort from January 2016 to November 2017 were used to apply the MNCD total score (from 0 to 12) and MNCD stages (from 1 to 5) in this cross-sectional analysis. Caregivers completed the Zarit Caregiver Burden Inventory (ZCBI), Caregiver Strain Index (CSI), Beck Depression Inventory-II (BDI-II), PQ-10, and EUROHIS-QOL 8-item index (EUROHIS-QOL8).

RESULTS

Two hundred and twenty-four PD patients (63 ± 9.6 years old; 61.2% males) and their caregivers (58.5 ± 12.1 years old; 67.9% females) were included. The frequency of MNCD stages was 1, 7.6%; 2, 58.9%; 3, 31.3%; and 4-5, 2.2%. A more advanced MNCD stage was associated with a higher score on the ZCBI (p < .0001) and CSI (p < .0001), and a lower score on the PQ-10 (p = .001), but no significant differences were observed in the BDI-II (p = .310) and EUROHIS-QOL8 (p = .133). Moderate correlations were observed between the MNCD total score and the ZCBI (r = .496; p < .0001), CSI (r = .433; p < .0001), and BDI-II (r = .306; p < .0001) in caregivers.

CONCLUSION

Staging PD according to the MNCD classification is correlated with caregivers' strain and burden.

Spirituality and Spiritual Distress in Parkinson's Disease Caregivers: A Scoping Review

Despite recognition that spiritual concerns contribute to caregiver burden, little is known about spirituality, spiritual well-being, and spiritual distress in Parkinson's disease caregivers. In this scoping review of the literature through October 2022, we searched PubMed, PsychINFO, Embase, and CINAHL. From an initial pool of 328 studies, 14 were included. Caregiver factors (e.g., depression, age) and patient factors (e.g., faith, motor function) affected caregiver spirituality and spiritual well-being. Caregivers experienced loss of meaning, existential guilt, and loneliness, and coped through acquiescence, cultural beliefs, prayer, and gratitude. Future research should focus on the specific spiritual needs of Parkinson's disease caregivers and interventions to address them.

Unique characteristics of end-of-life hospitalizations in Parkinson disease

Introduction

Persons with Parkinson disease (PD) are hospitalized at higher rates, have longer lengths of stay, and are more likely to die in the hospital than age-matched peers. Although prior studies have compared inpatient outcomes between persons with and without PD, little is known about inpatient outcomes across the PD trajectory, or whether hospitalizations occurring in the last 6 months of life differ from earlier hospitalizations.

Methods

This cross-sectional study compared Medicare Part A and B beneficiaries aged 65 and older with a qualifying PD diagnosis who were hospitalized in 2017: decedents who died between 7/1/2017 and 12/31/2017 from all causes and were hospitalized at least once in their last 6 months of life, and non-decedents who were hospitalized between 1/1/2017 and 6/30/2017 and lived 6 or more months after discharge. End-of-life (EoL) hospitalizations were defined as those occurring in the last 6 months of life. Descriptive analyses compared patient-level variables (e.g., demographics, comorbidities, treatment intensity) and encounter-level variables (e.g., length of stay, total charges) between groups. Multivariable logistic regression models also compared rates of intensive care unit (ICU) admission and 30-day readmission between hospitalized decedents and hospitalized non-decedents, adjusting for age, sex, race/ethnicity, rural residence, and Charlson Comorbidity Index Score.

Results

Of 26,492 Medicare decedents with PD, 16,187 (61.1%) were hospitalized in their last 6 months of life. Of 347,512 non-decedents with PD, 62,851 (18.1%) were hospitalized in a 6-month period. Hospitalized decedents were slightly older than hospitalized non-decedents (82.3 [SD 7.40] vs. 79.5 [SD 7.54] years) and had significantly more comorbidities. Compared to non-EoL hospitalizations, EoL hospitalizations were slightly longer (5 [IQR 3-9] vs. 4 [IQR 3-7] days) and more expensive based on total charges per admission ($36,323 [IQR 20,091-69,048] vs. $32,309 [IQR 18,789-57,756]). In covariate-adjusted regression models using hospitalized non-decedents as the reference group, hospitalized decedents were more likely to experience an ICU admission (AOR 2.36; CI 2.28-2.45) and 30-day readmission (AOR 2.43; CI 2.34-2.54).

Discussion

Hospitalizations occurring in the last 6 months of life among persons with PD in the United States are longer, more costly, and more resource intensive than earlier hospitalizations and may stem from medical comorbidities. Once hospitalized, ICU admission and 30-day readmission may aid in prognostication and serve as markers of transition to the EoL period.