Co-morbidity and polypharmacy in Parkinson's disease: insights from a large Scottish primary care database

Relative contribution of comorbid diseases to health-related quality of life in patients with Parkinson's disease

BACKGROUND

Multimorbidity is common in elderly people, and one of the major consequences of multimorbidity is low health-related quality of life (HRQoL). The aim of this study was to investigate the frequency of comorbid diseases in patients with Parkinson's disease (PD) and to analyze their relative importance in HRQoL. The aim was also to examine agreement between the generic 15D questionnaire and the PD-specific Parkinson's Disease Questionnaire (PDQ-8) to further validate 15D in the evaluation of HRQoL in patients with PD.

METHODS

Patients with PD (N = 551) filled a questionnaire on comorbid diseases, and the 15D questionnaire yielding a 15-dimensional health profile and a score representing the overall HRQoL. Self-organizing map was used for an unsupervised pattern recognition of the health profiles. Relative importance analysis was used to evaluate the contribution of 16 comorbid diseases to the 15D score. The agreement between 15D and PDQ-8 questionnaires was studied in a subset of 81 patients that were examined clinically.

RESULTS

533 patients (96.7%) reported comorbid diseases. The most affected dimensions in the 15D questionnaire were secretion, usual activities, discomfort and symptoms, and sexual activity. Self-organizing map identified three patterns of health profiles that included patients with high, low or transition HRQoL. The transition subgroup was similar to low HRQoL subgroup in non-motor dimensions. Sixteen comorbid diseases explained 33.7% of the variance in the 15D score. Memory deficit, depression, heart failure, and atrial fibrillation had the highest relative importance. The intraclass correlation coefficient between the generic 15D and the PD-specific PDQ-8 was 0.642 suggesting moderate reliability.

CONCLUSIONS

The most marked differences in HRQoL were in the dimensions of secretion, usual activities, and sexual activity. Pattern detection of 15D health dimensions enabled the detection of a subgroup with disproportionately poor HRQoL in non-motor dimensions. The comorbid diseases affecting most to HRQoL were memory deficit and depression. The generic 15D questionnaire can be used in the evaluation of HRQoL in PD patients.

Frailty and Parkinson's disease: the role of diabetes mellitus

Parkinson's disease (PD) is a chronic neurodegenerative disease associated with a progressive loss of dopaminergic neurons, clinically characterized by motor and non-motor signs. Frailty is a clinical condition of increased vulnerability and negative health outcomes due to the loss of multiple physiological reserves. Chronic hyperglycemia and insulin resistance, which characterize diabetes mellitus (DM), have been reported to alter dopaminergic activity, increase the risk of PD, and influence the development of frailty. Even though diabetes may facilitate the development of frailty in patients with PD, this relationship is not established and a revision of the current knowledge is necessary. Furthermore, the synergy between DM, PD, and frailty may drive clinical complexity, worse outcomes, and under-representation of these populations in the research. In this review, we aimed to discuss the role of diabetes in the development of frailty among patients with PD. We summarized the clinical characteristics and outcomes of patients with concomitant DM, PD, and frailty. Finally, interventions to prevent frailty in this population are discussed.

Safety and efficacy of continuous subcutaneous levodopa-carbidopa infusion (ND0612) for Parkinson's disease with motor fluctuations (BouNDless): a phase 3, randomised, double-blind, double-dummy, multicentre trial

BACKGROUND

Conventional oral levodopa therapy for the treatment of Parkinson's disease can be associated with variations in plasma concentrations. Levodopa infusion strategies might provide more consistent drug delivery and fewer motor fluctuations. We aimed to assess the safety and efficacy of a continuous 24 h/day subcutaneous infusion of ND0612 (a levodopa-carbidopa solution) compared with oral immediate-release levodopa-carbidopa for the treatment of motor fluctuations in people with Parkinson's disease.

METHODS

We conducted a phase 3, randomised, double-blind, double-dummy, active-controlled, multicentre trial at 117 academic and community neurology sites in 16 countries, including in Europe, Israel, and the USA. Eligible participants were men and women aged 30 years or older with a diagnosis of Parkinson's disease (Hoehn and Yahr stage ≤3 in the on state) who experienced at least 2·5 h/day of off time. Participants underwent an open-label run-in phase (<12 weeks), during which time optimal regimens were established for both oral immediate-release levodopa-carbidopa and for 24 h/day subcutaneous ND0612 infusion (levodopa-carbidopa 60·0/7·5 mg/mL), with supplemental oral levodopa-carbidopa if needed. Participants were then randomly assigned (1:1) to 12 weeks of double-blind treatment with their optimised regimen of either subcutaneous ND0612 or oral levodopa-carbidopa, with matching oral or subcutaneous placebo given as required to maintain blinding. Randomisation was done via an interactive web response system, stratified by region, using a permuted block schedule. Participants, study partners, treating investigators, study site personnel, and the sponsor were masked to treatment group allocation. The primary efficacy endpoint was the change from baseline (ie, time of randomisation, when all patients were receiving an optimised open-label ND0612 regimen) to end of the double-blind phase in total daily on time without troublesome dyskinesia, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, NCT04006210, and is complete.

FINDINGS

Between Sept 30, 2019, and April 8, 2022, 381 participants were enrolled, of whom 259 (68%) were randomly assigned, 128 (49%) to subcutaneous ND0612 and 131 (51%) to oral levodopa-carbidopa. 243 (94%) participants completed the study. Treatment with subcutaneous ND0612 provided an additional 1·72 h (95% CI 1·08 to 2·36) of on time without troublesome dyskinesia compared with oral levodopa-carbidopa (change from baseline of -0·48 h [-0·94 to -0·02] with subcutaneous ND0612 vs -2·20 h [-2·65 to -1·74] with oral levodopa-carbidopa; p<0·0001). Significant treatment differences favouring subcutaneous ND0612 were also found in the first four of nine prespecified hierarchical outcomes of daily off time (-1·40 h [95% CI -1·99 to -0·80]), Movement Disorders Society-Unified Parkinson's Disease Rating Scale part II scores (-3·05 [-4·28 to -1·81]), Patients Global Impression of Change (odds ratio [OR] 5·31 [2·67 to 10·58]), and Clinical Global Impression of Improvement (OR 7·23 [3·57 to 14·64]). Hierarchical testing ended after the fourth secondary endpoint. Adverse events were reported by 287 (89%) of 322 participants during open-label ND0612 optimisation, and by 103 (80%) of 128 in the ND0612 group and 97 (74%) of 131 in the oral levodopa-carbidopa group during the double-blind phase. The most common adverse events were infusion-site reactions (266 [83%] participants during open-label ND0612, and 73 [57%] in the ND0612 group vs 56 [43%] in the oral levodopa-carbidopa group during the double-blind phase), most of which were mild. Serious adverse events in four participants in the ND0612 group were related to study treatment (infusion-site cellulitis [n=2], infusion-site abscess and infusion-site ulcer [n=1]; and paraesthesia and peripheral sensorimotor neuropathy [n=1]). One participant in the ND0612 group died during the double-blind phase, but the death was not related to study treatment (fall leading to traumatic brain injury).

INTERPRETATION

Results of this phase 3 study showed that subcutaneous ND0612 used in combination with oral immediate-release levodopa-carbidopa increased on time without troublesome dyskinesia and reduced off time, with a favourable benefit-risk profile. ND0612 might offer a safe and efficacious subcutaneous levodopa infusion approach to managing motor fluctuations in people with Parkinson's disease. The ongoing open-label extension phase will provide further information on the long-term efficacy and safety of treatment.

FUNDING

NeuroDerm.

Long COVID and its association with neurodegenerative diseases: pathogenesis, neuroimaging, and treatment

Corona Virus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has presented unprecedented challenges to the world. Changes after acute COVID-19 have had a significant impact on patients with neurodegenerative diseases. This study aims to explore the mechanism of neurodegenerative diseases by examining the main pathways of central nervous system infection of SARS-CoV-2. Research has indicated that chronic inflammation and abnormal immune response are the primary factors leading to neuronal damage and long-term consequences of COVID-19. In some COVID-19 patients, the concurrent inflammatory response leads to increased release of pro-inflammatory cytokines, which may significantly impact the prognosis. Molecular imaging can accurately assess the severity of neurodegenerative diseases in patients with COVID-19 after the acute phase. Furthermore, the use of FDG-PET is advocated to quantify the relationship between neuroinflammation and psychiatric and cognitive symptoms in patients who have recovered from COVID-19. Future development should focus on aggressive post-infection control of inflammation and the development of targeted therapies that target ACE2 receptors, ERK1/2, and Ca2+.

Safety Profile of Pimavanserin Therapy in Elderly Patients with Neurodegenerative Disease-Related Neuropsychiatric Symptoms: A Phase 3B Study

Background

Pimavanserin, a 5-HT2A receptor inverse agonist/antagonist, is the only medication approved by the FDA for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Further expanding knowledge of the safety profile of pimavanserin in PDP and neurodegenerative diseases (NDD) such as Alzheimer's disease is of great interest for informing its use in patients with PDP (with or without dementia), given this population is highly sensitive to adverse effects following antipsychotic use.

Objective

This trial evaluated the effects of pimavanserin compared to placebo in frail older adults and elderly patients with neuropsychiatric symptoms related to NDD, such as hallucinations and delusions, to better understand the safety of pimavanserin in this population.

Methods

This was a phase 3b, 8-week treatment (study duration of up to 16 weeks), multicenter, randomized, double-blind, placebo-controlled, two-arm parallel-group trial (NCT03575052). The primary endpoint was safety and tolerability, measured by treatment-emergent adverse events (TEAEs). Secondary safety endpoints were change from baseline in motor and cognitive function; exploratory endpoints included suicidality, sleep quality, and neuropsychiatric symptoms.

Results

Incidences of TEAEs were similar between treatment groups; 29.8% reported ≥1 TEAE (pimavanserin: 30.4%; placebo: 29.3%), and 1.8% reported serious TEAEs (pimavanserin: 2.0%; placebo: 1.5%). Pimavanserin did not impact motor- or cognitive-related function.

Conclusions

Pimavanserin was well tolerated and not associated with motor or cognitive impairment. Together, these findings highlight the manageable and generally favorable safety profile of pimavanserin in patients with NDD, contributing to our knowledge on the safety of pimavanserin as it generalizes to patients with PDP.

Investigating the impact of physical activity on mitochondrial function in Parkinson's disease (PARKEX): Study protocol for A randomized controlled clinical trial

Parkinson's disease (PD) is characterized by the progressive dopaminergic neuron degeneration, resulting in striatal dopamine deficiency. Mitochondrial dysfunction and oxidative stress are associated with PD pathogenesis. Physical activity (PA) has been shown to ameliorate neurological impairments and to impede age-related neuronal loss. In addition, skin fibroblasts have been identified as surrogate indicators of pathogenic processes correlating with clinical measures. The PARKEX study aims to compare the effects of two different PA programs, analyzing the impact on mitochondrial function in patients' skin fibroblasts as biomarkers for disease status and metabolic improvement. Early-stage PD patients (n = 24, H&Y stage I to III) will be randomized into three age- and sex-matched groups. Group 1 (n = 8) will undergo basic physical training (BPT) emphasizing strength and resistance. Group 2 (n = 8) will undergo BPT combined with functional exercises (BPTFE), targeting the sensorimotor pathways that are most affected in PD (proprioception-balance-coordination) together with cognitive and motor training (Dual task training). Group 3 (n = 8) will serve as control (sedentary group; Sed). Participants will perform three sessions per week for 12 weeks. Assessment of motor function, quality of life, sleep quality, cognitive aspects and humor will be conducted pre- and post-intervention. Patient skin fibroblasts will be collected before and after the intervention and characterized in terms of metabolic remodeling and mitochondrial bioenergetics. Ethical approval has been given to commence this study. This trial is registered at clinicaltrials.gov (NCT05963425). Trial registration. https://classic.clinicaltrials.gov/ct2/history/NCT05963425.

Safety comparisons among monoamine oxidase inhibitors against Parkinson's disease using FDA adverse event reporting system

Monoamine oxidase B (MAO-B) inhibitors are used to control Parkinson's disease (PD). Selegiline, rasagiline, and safinamide are widely used as MAO-B inhibitors worldwide. Although these drugs inhibit MAO-B, there are pharmacological and chemical differences, such as the inhibitory activity, the non-dopaminergic properties in safinamide, and the amphetamine-like structure in selegiline. MAO-B inhibitors may differ in adverse events (AEs). However, differences in actual practical clinics are not fully investigated. A retrospective study was conducted using FAERS, the largest database of spontaneous adverse events. AE signals for MAO-B inhibitors, including selegiline, rasagiline, and safinamide, were detected using the reporting odds ratio method and compared. Hypocomplementemia, hepatic cyst, hepatic function abnormal, liver disorder and cholangitis were detected for selegiline as drug-specific signals. The amphetamine effect was not confirmed for any of the three MAO-B inhibitors. The tyramine reaction was detected as an AE signal only for rasagiline. Moreover, the REM sleep behavior disorder was not detected as an AE signal for safinamide, suggesting that non-dopaminergic effects might be beneficial. Considering the differences in AEs for MAO-B inhibitors will assist with the appropriate PD medication.

The Impact of Polypharmacy on Management of Lower Urinary Tract Symptoms in Parkinson's Disease

Lower urinary tract (LUT) symptoms are a common presentation of autonomic dysfunction in Parkinson's disease (PD). Symptoms significantly impact quality of life and are associated with worsening of motor symptoms and increased risk for falls. Different medical co-morbidities can often contribute to LUT symptoms, and a thorough evaluation therefore becomes essential. The effects of medications used for Parkinson's disease and other co-existing medical co-morbidities on LUT symptoms is often underestimated. Treatment options include behavioural therapy, oral agents such as antimuscarinic and beta-3 receptor agonist agents, botulinum toxin and neuromodulation. The first-line oral agents cause adverse effects that may exacerbate pre-existing Parkinson's disease-related symptoms. Furthermore, these oral agents can interact with other medications used in Parkinson's disease, and the challenges posed by interactions on pharmacological effects and metabolism are discussed. Knowledge about drug interactions can help in effective management of such patients and mitigate the risks for developing adverse effects.

Potentially inappropriate medications in older adults with Parkinson disease before and after hospitalization for injury

BACKGROUND

Parkinson disease (PD) patients are at increased risk of serious injury, such as fall-related fractures. Prescription medications are a modifiable factor for injury risk.

OBJECTIVES

To determine the extent to which a serious injury requiring hospitalization affects prescribing of potentially inappropriate medications (PIMs) among older adults with PD.

METHODS

We conducted a quasi-experimental difference-in-difference (DID) study using 2013-2017 Medicare data. The cohort consisted of beneficiaries with PD hospitalized for injury versus for other reasons. PIMs were classified into PD and injury-relevant categories (CNS-active PIMs, PD motor symptom PIMs, PD non-motor symptom PIMs, PIMs that reduce bone mineral density). We estimated mean standardized daily doses (SDDs) of medications within each PIM category before and at 3, 6, and 12 months after hospitalization. We used generalized linear regression models to compare changes in mean SDDs for each PIM category between the injury and non-injury group at each timepoint, adjusting for biological, clinical and social determinants of health variables.

RESULTS

Both groups discontinued PIMs and/or reduced PIM doses after hospitalization. There were no between-group differences in mean SDD changes, after covariate adjustment, for any PIM category, except for the CNS-active PIMs category at 3 months (DID p-value = 0.00) and for the category of PIMs that reduce bone mineral density at all timepoints (DID p-values = 0.02, 0.04, 0.02 at 3, 6, and 12 months).

CONCLUSIONS

Similar patterns of PIM among persons with PD after hospitalization for serious injury versus for other reasons may represent a missed opportunity to deprescribe high-risk medications during care transitions.

Depressive symptoms in Parkinson's disease are insufficiently but more often treated than in other chronic conditions

Depressive symptoms in Parkinson's disease (PD) are multifactorial and are partly linked to the underlying dopaminergic deficit. However, at least a subset of PD patients may exhibit an unspecific depressive reaction to chronic illness. Here, we compared the prevalence and severity of depressive symptoms in PD patients and disease controls (DC). PD patients reported depressive symptoms at similar frequencies as DC but were on antidepressants, especially Mirtazapine, more frequently. Still, in both groups, a high proportion of patients with clinically significant depressive symptoms was not receiving medication. Diagnosis and treatment of depressive symptoms both in PD and DC should be improved.

Characteristics and outcomes of elderly patients with Parkinson's disease hospitalized due to COVID‑19‑associated pneumonia

Patients with Parkinson's disease (PD) and coronavirus disease 2019 (COVID-19)-associated pneumonia present, according to the literature, high mortality rates due to the nature of the disease, advanced age, and underlying diseases. Most available studies, however, refer to the first waves of the pandemic. The aim of the present study was to investigate the clinical characteristics and outcomes of elderly patients (≥65 years old) with PD hospitalized with COVID-19-associated pneumonia during the period of prevalence of various severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, as well as to determine possible prognostic factors for poor outcomes. During the period from February 15, 2021, to July 15, 2022, 1,144 elderly patients with COVID-19 pneumonia were hospitalized. Age, sex, Charlson comorbidity index, vaccination status against SARS-CoV-2, and admission laboratory parameters were recorded for all patients. A total of 36 (3.1%) patients with PD were hospitalized due to COVID-19-associated pneumonia (18 males, 50%). The mean age of the patients was 82.72±8.18 years. In total, 8 patients (22.2%) were hospitalized during the period of alpha variant predominance, 3 patients (8.3%) during the period of delta variant predominance, and 25 patients (69.4%) during the omicron variant predominance period. Of note, 16 patients (44.4%) were vaccinated with at least two doses. In addition, 17 (47.2%) patients succumbed to the disease. Between the patients who survived and those who succumbed, a statistically significant difference was only found in the mean value of albumin (37.48±6.02 vs. 31.97±5.34 g/l, P=0.019). In particular, as shown by receiver operating characteristic curve analysis, albumin exhibited a satisfactory predictive ability for mortality (area under the curve, 0.780; P=0.013) with an albumin value ≤37.7 g/l being able to predict mortality with 85.7% sensitivity and 54.8% specificity. Overall, the findings of the present study indicate that mortality among elderly patients with PD hospitalized with COVID-19-associated pneumonia was high in all phases of the pandemic. A low albumin value, not only as an indicator of the immune status, but also of the nutritional status, is a predictor of adverse outcomes.

Prescribing patterns and determinants for elderly patients with Parkinson's disease in Japan: a retrospective observational study using insurance claims databases

Background

This study aimed to determine real-world prescribing patterns and determinants for Japanese patients with Parkinson's disease (PD), with a focus on patients ≥75 years.

Methods

This was a retrospective, observational, longitudinal study of patients with PD (≥30 years, ICD-10: G20 excluding Parkinson's syndrome) from three Japanese nationwide healthcare claim databases. Prescription drugs were tabulated using database receipt codes. Changes in treatment patterns were analyzed using network analysis. Factors associated with prescribing patterns and prescription duration were analyzed using multivariable analysis.

Results

Of 18 million insured people, 39,731 patients were eligible for inclusion (≥75-year group: 29,130; <75-year group: 10,601). PD prevalence was 1.21/100 people ≥75 years. Levodopa was the most commonly prescribed anti-PD drug (total: 85.4%; ≥75 years: 88.3%). Network analysis of prescribing patterns showed that most elderly patients switched from levodopa monotherapy to adjunct prescription patterns, as did younger patients, but with less complexity. Elderly patients who newly initiated PD treatment remained on levodopa monotherapy longer than younger patients; factors significantly associated with levodopa prescriptions were older age and cognitive impairment. Commonly prescribed adjunct therapies were monoamine oxidase type B inhibitors, non-ergot dopamine agonists, and zonisamide, regardless of age. Droxidopa and amantadine were prescribed as adjunct levodopa therapy slightly more frequently among elderly patients; levodopa adjunct therapy was prescribed when the levodopa dose was 300 mg, regardless of age.

Conclusion

Prescribing patterns for patients ≥75 years were levodopa centered and less complex than for those <75 years. Factors significantly associated with levodopa monotherapy and continued use of levodopa were older age and cognitive disorder.

Clinical trial registration

UMIN Clinical Trials Registry, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053425 (UMIN000046823).

Chaudhuri's Dashboard of Vitals in Parkinson's syndrome: an unmet need underpinned by real life clinical tests

We have recently published the notion of the "vitals" of Parkinson's, a conglomeration of signs and symptoms, largely nonmotor, that must not be missed and yet often not considered in neurological consultations, with considerable societal and personal detrimental consequences. This "dashboard," termed the Chaudhuri's vitals of Parkinson's, are summarized as 5 key vital symptoms or signs and comprise of (a) motor, (b) nonmotor, (c) visual, gut, and oral health, (d) bone health and falls, and finally (e) comorbidities, comedication, and dopamine agonist side effects, such as impulse control disorders. Additionally, not addressing the vitals also may reflect inadequate management strategies, leading to worsening quality of life and diminished wellness, a new concept for people with Parkinson's. In this paper, we discuss possible, simple to use, and clinically relevant tests that can be used to monitor the status of these vitals, so that these can be incorporated into clinical practice. We also use the term Parkinson's syndrome to describe Parkinson's disease, as the term "disease" is now abandoned in many countries, such as the U.K., reflecting the heterogeneity of Parkinson's, which is now considered by many as a syndrome.

COVID-19 and neurological disorders: what might connect Parkinson's disease to SARS-CoV-2 infection

SARS-CoV-2 infection leading to Coronavirus disease 19 (COVID-19) rapidly became a worldwide health emergency due to its elevated infecting capacity, morbidity, and mortality. Parkinson’s disease (PD) is the second most common neurodegenerative disorder and, nowadays the relationship between SARS-CoV-2 outbreak and PD reached a great interest. Apparently independent one from the other, both diseases share some pathogenetic and clinical features. The relationship between SARS-CoV-2 infection and PD is complex and it depends on the direction of the association that is which of the two diseases comes first. Some evidence suggests that SARS-CoV-2 infection might be a possible risk factor for PD wherein the exposure to SARS-CoV-2 increase the risk for PD. This perspective comes out from the increasing cases of parkinsonism following COVID-19 and also from the anatomical structures affected in both COVID-19 and early PD such as olfactory bulb and gastrointestinal tract resulting in the same symptoms such as hyposmia and constipation. Furthermore, there are many reported cases of patients who developed hypokinetic extrapyramidal syndrome following SARS-CoV-2 infection although these would resemble a post-encephalitic conditions and there are to date relevant data to support the hypothesis that SARS-CoV-2 infection is a risk factor for the development of PD. Future large, longitudinal and population-based studies are needed to better assess whether the risk of developing PD after COVID-19 exists given the short time span from the starting of pandemic. Indeed, this brief time-window does not allow the precise estimation of the incidence and prevalence of PD after pandemic when compared with pre-pandemic era. If the association between SARS-CoV-2 infection and PD pathogenesis is actually putative, on the other hand, vulnerable PD patients may have a greater risk to develop COVID-19 being also more prone to develop a more aggressive disease course. Furthermore, PD patients with PD showed a worsening of motor and non-motor symptoms during COVID-19 outbreak due to both infection and social restriction. As well, the worries related to the risk of being infected should not be neglected. Here we summarize the current knowledge emerging about the epidemiological, pathogenetic and clinical relationship between SARS-CoV-2 infection and PD.

Clinicians' view on the management of oral health in Parkinson's disease patients: a qualitative study

BACKGROUND

due to numerous motor and non-motor symptoms, dental treatment in patients with Parkinson's Disease (PD) can be challenging. Knowledge regarding optimal management of oral health in PD patients is lacking.

AIM

to gain a deeper understanding of the experiences of dentists regarding oral health care for PD patients in the Netherlands.

MATERIAL AND METHOD

semi-structured interviews were conducted with (specialized) dentists working with PD patients. A thematic analysis was performed using a framework-based approach.

RESULTS

ten dentists were interviewed. They reported that dental care in PD patients requires 1) adaptation of timing and length of treatments and consultations, and 2) intensifying preventive measures. Dentists experienced the organization as bureaucratic and difficult. Moreover, differences between being institutionalized or living at home were present. Education and research are needed to improve PD patients' oral health. The experience level and affinity for treating PD patients positively influences confidence levels of the practitioner. Finally, points of improvement were suggested.

CONCLUSION

managing oral health in PD patients is challenging, and interdisciplinary collaboration is needed to overcome difficulties. Reducing the bureaucratic burden and improving knowledge could help and stimulate oral health care providers to treat PD patients more effectively and, consequently, improve their oral health.

Hypnotics and injuries among older adults with Parkinson's disease: a nested case-control design

BACKGROUND

Patients with Parkinson's disease often experience sleep disorders. Hypnotics increase the risk of adverse events, such as injuries due to falls. In this study, we evaluated the association between hypnotics and injuries among older adults with Parkinson's disease.

METHODS

The study used a nested case-control design. The participants were 5009 patients with Parkinson's disease aged ≥ 75 years based on claims data between April 2016 and March 2019 without prescription hypnotics 1 year before the study started. Hypnotics prescribed as oral medications included benzodiazepines, non-benzodiazepines, orexin receptor antagonists, and melatonin receptor agonists. The incidences of outcomes, including injuries, fractures, and femoral fractures, were determined. Each case had four matched controls. Conditional logistic regression analyses were performed to calculate the odds ratios and 95% confidence intervals for the number of hypnotics taken per day for each type of hypnotic.

RESULTS

The proportion of participants taking at least one type of hypnotic was 18.6%, with benzodiazepines being the most common. The incidence of injuries, fractures, and femoral fractures was 66.7%, 37.8%, and 10.2%, respectively. Benzodiazepines significantly increased the risk of injuries (odds ratio: 1.12; 95% confidence interval: 1.03-1.22), and melatonin receptor agonists significantly increased the risk of femoral fractures (odds ratio: 2.84; 95% confidence interval: 1.19-6.77).

CONCLUSIONS

Benzodiazepines and non-benzodiazepines, which are not recommended according to current guidelines, were the most prevalent among older adults with Parkinson's disease. Benzodiazepines significantly increased the risk of injuries, and melatonin receptor agonists significantly increased the risk of femoral fractures.

Parkinson's disease and oral health: A systematic review

OBJECTIVE

in patients with Parkinson's Disease (PD), oral health can be affected by motor and non-motor symptoms and/or medication use. Therefore, the aim was to systematically review the literature on oral health and associated factors of oral health in PD patients.

DESIGN

a literature search was performed from inception up to April 5th, 2023. Original studies that assessed oral health-related factors in PD patients and were written in English or Dutch, were included.

RESULTS

11276 articles were identified, of which 43 met the inclusion criteria (quality range poor-good). A higher prevalence of dental biofilm, bleeding/gingivitis, pocket depth (≥4 mm), tooth mobility, caries, and number of decayed missing filled teeth/surfaces was found in PD patients than in controls. However, no difference between both groups was found when analysing edentulism and wearing dentures. Poor oral health of PD patients was associated with a longer disease duration, higher disease severity, and more prescribed medications.

CONCLUSIONS

oral health of PD patients is worse than that of healthy individuals. It is associated with the duration and severity of PD and medication use. Therefore, we advise regular appointments with oral health care professionals, with an important focus on prevention.

Pharmacological management of acute spinal cord injury: a longitudinal multi-cohort observational study

Multiple types and classes of medications are administered in the acute management of traumatic spinal cord injury. Prior clinical studies and evidence from animal models suggest that several of these medications could modify (i.e., enhance or impede) neurological recovery. We aimed to systematically determine the types of medications commonly administered, alone or in combination, in the transition from acute to subacute spinal cord injury. For that purpose, type, class, dosage, timing, and reason for administration were extracted from two large spinal cord injury datasets. Descriptive statistics were used to describe the medications administered within the first 60 days after spinal cord injury. Across 2040 individuals with spinal cord injury, 775 unique medications were administered within the two months after injury. On average, patients enrolled in a clinical trial were administered 9.9 ± 4.9 (range 0-34), 14.3 ± 6.3 (range 1-40), 18.6 ± 8.2 (range 0-58), and 21.5 ± 9.7 (range 0-59) medications within the first 7, 14, 30, and 60 days post-injury, respectively. Those enrolled in an observational study were administered on average 1.7 ± 1.7 (range 0-11), 3.7 ± 3.7 (range 0-24), 8.5 ± 6.3 (range 0-42), and 13.5 ± 8.3 (range 0-52) medications within the first 7, 14, 30, and 60 days post-injury, respectively. Polypharmacy was commonplace (up to 43 medications per day per patient). Approximately 10% of medications were administered acutely as prophylaxis (e.g., against the development of pain or infections). To our knowledge, this was the first time acute pharmacological practices have been comprehensively examined after spinal cord injury. Our study revealed a high degree of polypharmacy in the acute stages of spinal cord injury, raising the potential to impact neurological recovery. All results can be interactively explored on the R_XSCI web site ( https://jutzelec.shinyapps.io/RxSCI/ ) and GitHub repository ( https://github.com/jutzca/Acute-Pharmacological-Treatment-in-SCI/ ).

Salivation in Parkinson's disease: A scoping review

OBJECTIVES

We aimed to provide an overview of the available literature that includes both objective assessments (namely hypersalivation and hyposalivation) and the subjective experience (namely xerostomia and drooling) of salivary problems in patients with Parkinson's disease.

BACKGROUND

In patients with Parkinson's disease, there may be complaints of salivary problems such as xerostomia or drooling. This can have consequences for their oral health and quality of life. To date, systematic reviews have focused on drooling only.

MATERIALS AND METHODS

A literature search in 4 databases was performed up to 12 February 2021. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 63 studies were included. The prevalence of self-reported xerostomia ranged from 49% to 77%, and that of self-reported drooling ranged from 5% to 80%. Ten articles reported a significantly lower mean salivary flow in patients with Parkinson's disease than in controls. None of the articles with both a control group and a patient group reported a significantly higher salivary flow in patients with Parkinson's disease. When questioned about subjective salivary problems, a significantly higher prevalence of both xerostomia (7 studies) and drooling (14 studies) was found in patients with Parkinson's disease than in controls. Patients with Parkinson's disease have a lower salivary flow rate and higher prevalence of both xerostomia and drooling than controls.

CONCLUSION

The complexity of salivary problems present in patients with Parkinson's disease necessitates a multidisciplinary approach in order to avoid mutually counteracting treatments from different healthcare professionals.

Trends and Sex Differences in Hospitalizations and Mortality in Parkinson's Disease in Spain (2010-2019): A Nationwide Population-Based Study

The incidence of hospitalizations of Parkinson´s disease (PD) in Spain suffered a steady rise from 1997 to 2012. However, data on the trends during the following decade (2010-2019) are lacking. Hospital admissions with a primary and secondary diagnosis of PD were selected using the Spanish National Hospital Discharge Database (SNHDD) for the period 2010-2019. The primary endpoint was the incidence of hospitalizations and in-hospital mortality, stratified in biannual periods. The incidence of PD hospitalizations increased progressively over time from 81.25 cases in 2010-2011 to 94.82 cases in 2018-2019 per 100,000 inhabitants. Male sex, age and comorbidity also increased progressively in PD inpatients. PD as a comorbid condition presented a higher increment (annual percentage of change, APC +1.71%, p < 0.05) than PD as the main reason of hospitalization (APC +1.26%, p < 0.05). In the multivariate regression model, factors associated with mortality were male sex (OR = 1.15, 95% CI 1.01-1.35), age (>80 years, OR = 12.76, 95% CI 3.96-29.64) and comorbidity (Charlson index ≥ 2, OR 1.77, 95% CI 1.69-1.85). Adjusted mortality by age, sex, comorbidity and diagnostic position remained stable. In conclusion, PD hospitalizations in Spain have increased, with a parallel increment in mean age, male sex and higher comorbidities. However, adjusted mortality remains unchanged. The burden of this disease may increase the complexity and costs of hospital care in the future.

Degenerative Spine Surgery in Patients with Parkinson Disease: A Systematic Review

BACKGROUND

Parkinson disease (PD) has been recognized as responsible for concurrent spinal disorders. Surgical correction may be necessary, but the complexity of such fragile patients may require specific considerations. We systematically reviewed the literature on degenerative spine surgery in patients with PD.

METHODS

PubMed, Scopus, Web of Science, and Cochrane were searched according to the PRISMA guidelines to include studies reporting clinical data of patients with PD undergoing degenerative spine surgery. Clinical characteristics, treatment protocols, and outcomes were analyzed.

RESULTS

We included 22 articles comprising 442 patients (61.5% female). Mean age was 66.9 ± 3.5 years (range, 41-83 years). Mean PD duration and modified Hoehn and Yahr stage were 4.46 ± 2.39 years and 2.3 ± 0.8, respectively. Operation types included fusion (55.3%) and decompression (41.6%). Mean operated spine levels were 6.0 ± 5.08. A total of 377 postoperative complications occurred in 34.6% patients, categorized into mechanical failure (58.0%), infection (15.1%), or neurologic (10.7%). Of patients, 31.8% required surgical revisions, with an average of 1.88 ± 1.03 revisions per patient. The average normalized presurgery, postsurgery, and final aggregate numeric patient outcome scores were 0.37 ± 0.13, 0.63 ± 0.18, and 0.61 ± 0.19, respectively, with a score of 0 and 1 representing the worst and best possible score.

CONCLUSIONS

Degenerative spine surgery in patients with PD is challenging, with complications and revisions occurring in up to a third of treated patients. Surgery should be offered when other treatment options have proved ineffective and is typically reserved for patients with myelopathy or significant disability. Successful outcomes depend on strong interdisciplinary support to control the movement disorder before and after surgery.

Association Between Parkinson's Disease and Coronary Artery Disease: A Systematic Review and Meta-Analysis

BACKGROUND

The relationship between Parkinson's disease (PD) and coronary artery disease (CAD) is unclear.

OBJECTIVE

This study aims to investigate whether PD and CAD are associated through systematic review and meta-analysis of observational studies.

METHODS

Electronic database search of PubMed, EMBASE, and Web of Science for observational studies published from 1 January 2010 to 1 August 2021 was conducted using terms related to PD and CAD. Unadjusted risk ratios (RR) and odds ratios (OR) of included cohort and case-control studies respectively were used to ascertain the association between PD and CAD. Study heterogeneity was evaluated using the I2 test.

RESULTS

Forty-one full-text studies were initially retrieved for eligibility assessment. Five studies that satisfied the inclusion criteria, consisting of three cohort and two case-control studies, were eventually included in this meta-analysis. The five studies enrolled 35,237 PD patients and 650,866 non-PD patients. PD and CAD were found to be significantly associated in cohort studies (RR = 2.23, 95% CI = 1.08-4.59, p = 0.03; Fig. 2), which held after sensitivity analysis (RR = 1.45, 95% CI = 1.31-1.60, p < 0.001; Fig. 3). Case-control studies found a trend towards association of PD and CAD approaching significance (OR = 1.47, 95% CI = 0.84-2.56, p = 0.18; Fig. 2).

CONCLUSION

Overall, this meta-analysis suggests that PD is associated with CAD. The underlying mechanisms, as well as the role of ethnicity and other comorbidities on the relationship between PD and CAD should be further explored.

Comparison of the Effects of COVID-19 Pandemic on Male and Female Gender in Patients Diagnosed with Idiopathic Parkinson's Disease: A Case of Sakarya Province, Turkey

INTRODUCTION

The study aims to evaluate the motor, non-motor, cognitive and psychiatric conditions of our patients diagnosed with Idiopathic Parkinson's Disease (IPD) before and after the COVID-19 pandemic and to investigate the effect of the pandemic on male and female genders.

METHODS

Ninety patients were included in the study. Demographic data such as age, gender, and duration of disease, type of disease of the patients were recorded. Patients were then divided into 2 groups: male and female. Movement disorders of both groups before the pandemic, disease stage determined by H&Y and UPDRS at the admission and after the pandemic, Levodopa equivalent dose used were recorded and all patients were surveyed to evaluate their motor, non-motor, cognitive, and psychiatric conditions during the COVID-19 pandemic. The effects of the COVID-19 pandemic on male and female genders were investigated.

RESULTS

Of the patients, 40 were male and 50 were female. Daytime drowsiness, weakness, impaired walking, constipation, sleep disorders, and inability to turn in the bed worsened compared to the period before the pandemic. Yet, of the psychiatric symptoms, boredom, unhappiness, anhedonia, irritability, and tension were found to increase during the pandemic. There was a statistically significant difference in UPDRS, H&Y and disease stages before and after the COVID-19 pandemic in both groups, especially in the female group (p<0.05).

CONCLUSION

Although it was more pronounced in female patients with IPD diagnosis, both motor and non-motor symptoms were found to worsen during the COVID-19 pandemic in both groups.

Prevalence and factors associated with polypharmacy: a systematic review and Meta-analysis

Introduction

Polypharmacy is commonly associated with adverse health outcomes. There are currently no meta-analyses of the prevalence of polypharmacy or factors associated with polypharmacy. We aimed to estimate the pooled prevalence of polypharmacy and factors associated with polypharmacy in a systematic review and meta-analysis.

Methods

MEDLINE, EMBASE, and Cochrane databases were searched for studies with no restrictions on date. We included observational studies that reported on the prevalence of polypharmacy among individuals over age 19. Two reviewers extracted study characteristics including polypharmacy definitions, study design, setting, geography, and participant demographics. The risk of bias was assessed using the Newcastle-Ottawa Scales. The main outcome was the prevalence of polypharmacy and factors associated with polypharmacy prevalence. The pooled prevalence estimates of polypharmacy with 95% confidence intervals were determined using random effects meta-analysis. Subgroup analyses were undertaken to evaluate factors associated with polypharmacy such as polypharmacy definitions, study setting, study design and geography. Meta-regression was conducted to assess the associations between polypharmacy prevalence and study year.

Results

106 full-text articles were identified. The pooled estimated prevalence of polypharmacy in the 54 studies reporting on polypharmacy in all medication classes was 37% (95% CI: 31-43%). Differences in polypharmacy prevalence were reported for studies using different numerical thresholds, study setting, and publication year. Sex, study geography, study design and geographical location were not associated with differences in polypharmacy prevalence.

Discussion

Our review highlights that polypharmacy is common particularly among older adults and those in inpatient settings. Clinicians should be aware of populations who have an increased likelihood of experiencing polypharmacy and efforts should be made to review the appropriateness of prescribed medications and occurrence of adverse effects potentially associated with polypharmacy.

Conclusions and implications

Clinicians should be aware of the common occurrence of polypharmacy and undertake efforts to minimize inappropriate polypharmacy whenever possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03279-x.

Targeting Physical Inactivity Using Behavioral Theory in Chronic, Disabling Diseases

Physical inactivity and comorbidities (e.g., hypertension) result in poor prognoses among persons with chronic, disabling conditions including multiple sclerosis, Parkinson disease, and stroke. Theory can guide the design of behavior change interventions that can be delivered remotely for broad scale implementation. We hypothesize that theory-based behavior change interventions can increase physical activity and reduce comorbidities and associated consequences among persons with chronic, disabling conditions.

Influence of Drugs on Mild Cognitive Impairment in Parkinson's Disease: Evidence from the PACOS Study

BACKGROUND

polytherapy and the anticholinergic activity of several drugs negatively influence cognition in the elderly. However, little is known on the effect on Mild Cognitive Impairment (MCI) in Parkinson's Disease (PD).

METHODS

patients with PD belonging to the baseline PACOS cohort with full pharmacological data have been included in this study. MCI diagnosis was made according to the MDS level II criteria. Polytherapy was defined as patients assuming ≥6 drugs. The anticholinergic burden has been calculated using the Anticholinergic Drug Scale (ADS). Molecules have been classified according to the ATC classification. Association with MCI has been assessed with a multivariate logistic regression analysis with MCI as the dependent variable.

RESULTS

pharmacological data were available for 238 patients (mean age 64.7±9.7). One hundred (42.0%) were diagnosed with MCI. No association was found in the full multivariate model (correcting for age, sex, disease duration, education, UPDRS-ME, LEDD-DAs) with either polytherapy or the ADS. Concerning drug classes, anti-hypertensive medications were positively associated with PD-MCI (OR 2.02;95%CI 1.04-3.89; p=0.035) while gastroprotective agents were negatively associated (OR 0.51; 95%CI 0.27-0.99; p=0.047).

CONCLUSION

the magnitude of polytherapy and anticholinergic drugs burden does not appear to modulate MCI risk in PD, probably due to cautious prescription patterns. The effect of antihypertensive and gastroprotective agents on PD-MCI risk, while needing further confirmations, could be relevant for clinical practice.

Similarities, differences and overlaps between frailty and Parkinson's disease

Parkinson's disease is a neurodegenerative disorder clinically characterized by bradykinesia, rest tremor, rigidity, and postural and gait disturbances, which are frequently observed in older people. It also shows non-motor symptoms, such as depression, anxiety, cognitive impairment and dementia. The number of patients is gradually increasing worldwide. Aging is a risk factor for the onset of Parkinson's disease, and various physiological effects of aging influence its progression. Frailty is a geriatric syndrome in which the reversible and vulnerable status between robustness and disability is affected by various physiological stressors with aging. Frailty consists of physical, psychological and social aspects. Furthermore, sarcopenia, a syndrome characterized by the loss of muscle mass, strength and function, is also significantly associated with frailty. To maintain the quality of life of older people, frailty, including sarcopenia, should be quickly and appropriately managed. Polypharmacy is an important factor causing the progression of frailty in geriatric syndrome. Although Parkinson's disease and frailty have similar symptoms, and are considered to affect each other, the clinical features and mechanisms of both largely remain unclear. Nevertheless, little literature on the relationship between frailty and Parkinson's disease is currently available. This narrative review aims to clarify the relationships between Parkinson's disease and frailty, not only on the physical, but also on the mental, cognitive, and social aspects and issues regarding polypharmacy in Parkinson's disease explored by previous studies. Geriatr Gerontol Int 2022; 22: 259-270.

[Treatment practice of patients with Parkinson's disease in Saxony : A secondary data-based analysis of utilization in the observation period 2011-2019]

BACKGROUND

The consequences of demographic change are already noticeable in Saxony, the federal state with the highest average age in Germany and predominantly rural areas. In order to improve medical care for patients with Parkinson's disease (PwP), a status quo analysis of current care practice is required.

OBJECTIVE

To what extent does the utilization of medical services by PwP differ a) between urban and rural areas in Saxony and b) between PwP with and without neurologist contact in the observation period from 2011 to 2019?

MATERIAL AND METHODS

The cohort study was based on extensive routine data for Saxony from the health insurance company AOK PLUS from 2010 to 2019. A cohort of 15,744 PwP (n = 67,448 patient-years) was compared to a matched cohort (n = 674,480 patient-years; criteria: year of birth, gender, year of insurance, place of residence: urban/rural) without an ICD-10 coding of a movement disorder.

RESULTS

Overall, there was a steady increase in the number of PwP in the dynamic cohort from 2011 (n = 6829) to 2019 (n = 8254). Urban-rural differences included a smaller proportion of patients being seen by a neurologist in rural areas. The PwP had a 3.5 to 4‑fold higher risk of dying compared to those in the comparison cohort. Changes in drug therapy for Parkinson's disease (i.e., increases in COMT and MAO inhibitors) and in remedy delivery (i.e., increases in occupational therapy and speech therapy) over the observation period were primarily seen in PwP who were seen by a neurologist.

DISCUSSION

The study identified increased morbidity and mortality in PwP who are suitable targets for innovative care concepts. The increasing number of patients and the described differences document the need for this. At the same time, changes in prescription practice show that innovative forms of treatment are being used by neurologists in outpatient care.

Impact of a Collaborative Pharmaceutical Care Service for Patients With Parkinson's Disease

Objective: To identify the impact of a collaborative pharmaceutical care service (CPCS) on medication safety and establish the impact of the CPCS on patient reported outcomes for Parkinson's disease (PD) patients. Methods: Initially, PD outpatients receiving the CPCS between March 2017 and March 2019 were compared with PD patients receiving standard of care to identify differences in management. Pharmacist interventions data were coded and patients with PD receiving the CPCS were compared with those receiving standard of care to determine differences in medicines prescribed and dosage associated with these. Following this, data of patients receiving CPCS at baseline and 3-months follow-up were collected using a questionnaire consisting of validated measures of two patient-reported outcomes [adherence and quality of life (QoL)]. Mean scores for continuous variables were calculated, with descriptive analysis of categorical variables consisting of frequency counts and percentages. Change in adherence score before and after CPCS was investigated using a Wilcoxon sign rank sum test, spearman correlation analysis was used to correlate the changes in QoL before and after CPCS with the number of interventions, and p < 0.05 indicates that the difference is statistically significant. Results: A total of 331 PD outpatients received CPCS over 490 outpatient visits with an average age of 71.83 (±12.54). Five hundred and forty-five drug related problems were recorded as pharmacist interventions, of which most involved change to dosage (n = 226, 41.47%), adverse drug reactions (n = 135, 24.77%), and change in a medication (n = 102, 18.72%). Compared with those receiving standard of care, patients receiving CPCS were significantly less likely to have been prescribed pramipexole (18.52 versus 23.77%, p < 0.001) and more likely to have been prescribed amantadine (5.40 versus 3.70%, p = 0.02) and selegiline (17.36 versus 11.64%, p < 0.001). Lower dosages of levodopa/benserazide (0.51 ± 0.31 g versus 0.84 ± 0.37 g, p < 0.001), levodopa/carbidopa (0.33 ± 0.23 g versus 0.66 ± 0.47 g, p < 0.001), pramipexole (1.14 ± 1.63 mg versus 1.27 ± 0.69 mg, p = 0.01), and entacapone (130.00 ± 79.76 mg versus 173.09 ± 97.86 mg, p < 0.001) were also recorded. At baseline 119 PD outpatients with an average age of 69.98 (±9.90) were recruited for the longitudinal study. At 3-month follow-up, participants reported improvement in bodily pain subscale (baseline versus 3-months follow-up, 30.04 ± 22.21 versus 23.01 ± 20.98, p = 0.037) and medication adherence (6.19 ± 1.50 versus 6.72 ± 1.73, p = 0.014). Frequency of CPCS use was related to activity of daily living subscale (p = 0.047), the bodily pain subscale (p = 0.026), and medication adherence (p = 0.011). Total score of PDQ-39 was associated with patient education (p = 0.005) and usage and dosage combined with patient education (p = 0.006), while medication adherence score was associated with usage and dosage (p = 0.005). Conclusion: The CPCS was effective in resolving drug-related problems and in improving patients' medication regimens, medication adherence, and QoL through patient education and dosage adjustments. This is the first step in the development and feasibility testing of pharmacy services for PD patients in China.

The Effect of a Structured Medication Review on Quality of Life in Parkinson's Disease

BACKGROUND

Drug therapy is important for controlling symptoms in Parkinson's disease (PD). However, it often results in complex medication regimens and could easily lead to drug related problems (DRP), suboptimal adherence and reduced treatment efficacy. A structured medication review (SMR) could address these issues and optimize therapy, although little is known about clinical effects in PD patients.

OBJECTIVE

To analyze whether an SMR improves quality of life (QoL) in PD.

METHODS

In this multicenter randomized controlled trial, half of the 202 PD patients with polypharmacy received a community pharmacist-led SMR. The control group received usual care. Assessments at baseline, and after three and six months comprised six validated questionnaires. Primary outcome was PD specific QoL [(PDQ-39; range 0 (best QoL) - 100 (worst QoL)]. Secondary outcomes were disability score, non-motor symptoms, general health status, and personal care giver's QoL. Furthermore, DRPs, proposed interventions, and implemented modifications in medication schedules were analyzed.

RESULTS

No improvement in QoL was seen six months after an SMR, with a non-significant treatment effect difference of 2.09 (-0.63;4.80) in favor of the control group. No differences were found in secondary outcomes. In total, 260 potential DRPs were identified (2.6 (±1.8) per patient), of which 62% led to drug therapy optimization.

CONCLUSION

In the current setting, a community pharmacist-led SMR did not improve QoL in PD patients, nor improved other pre-specified outcomes.

Parkinson's disease and Covid-19: Is there an impact of ethnicity and the need for palliative care

Under the traditional models of care for People with Parkinson's Disease (PD, PwP), many of their needs remain unmet and a substantial burden of motor and non-motor symptoms they experience may not be tackled sufficiently. An introduction of palliative care (PC) interventions early in the course of PD offers profound benefits: it may improve quality of life of patients, their families and caregivers through the prevention and relief of medical symptoms, while, at the same time, emphasizing their emotional needs and spiritual wellbeing, establishing goals of care, and engaging in the advance care planning (ACP).

The ongoing Coronavirus Disease 2019 (Covid-19) pandemic poses an unprecedented set of challenges for PwP and has in many ways (both directly and indirectly) magnified their suffering, thus rapidly raising the demand for PC interventions. Covid-19, as well as the repercussions of prolonged mobility restrictions and limited health-care access might exacerbate the severity of PD motor symptoms and interact negatively with a range of non-motor symptoms, with a detrimental effect on quality of life. Greater motor disability, higher amount of levodopa-induced motor fluctuations with an increased daily off-time, fatigue, anxiety, depression, sleep disturbances, pain and worsening of cognitive complaints might dominate the clinical presentation in PwP during the Covid-19 pandemic, alongside raising psychological and spiritual concerns and anticipatory grief.

Here, we aim to provide a foundation for pragmatic and clinically orientated PC approach to improve quality of life and relieve suffering of PwP in the context of the current, ongoing Covid-19 pandemic.

Parkinson's Disease and the COVID-19 Pandemic: A Review Article on the Association between SARS-CoV-2 and α-Synucleinopathy

There is an extensive debate on the neurological consequences of 2019 novel coronavirus disease (COVID-19) and its impact on Parkinson's disease (PD) patients, which seems to puzzle neurologists. Links between viral infections and PD have long been suspected and studied, but the exact relationship remains elusive. Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters the brain through multiple routes and has a direct impact on the brain, cumulative damage occurs due to the activation of proinflammatory cytokines and chemokines. SARS-CoV-2 seems to aggravate PD due to its effects on α-synuclein, mitochondrial dysfunction, and dopamine depletion. A few studies have even highlighted the higher vulnerability of PD patients to COVID-19. The sudden dramatic change in lifestyle caused by the pandemic and the widespread lockdowns that were implemented have added to the hidden sorrows of PD patients, as they already have a compromised mechanism for coping with stress. This review summarizes insights from basic science and the clinical effect of SARS-CoV-2 infection on the human brain, with a specific focus on PD.

The Impact of Non-dopaminergic Medication on Quality of Life in Parkinson's Disease

BACKGROUND AND OBJECTIVES

Quality of life (QoL) in Parkinson's disease (PD) depends on multiple factors. Due to PD treatment and accompanying, age-related or independent comorbidities, pill burden is often high. The relation of QoL and pharmacotherapy for comorbidities in PD has not been widely studied. This study investigated if and to what extent non-dopaminergic drugs are related to QoL in PD. Second, the impact of demographics and non-motor symptoms were evaluated. A better understanding of the impact of different non-dopaminergic drugs and polypharmacy on QoL will have added value in selecting appropriate (medication) interventions.

METHODS

In a cross-sectional analysis, medication prescription data of 209 PD patients were analyzed and grouped according to the Rx-Risk comorbidity index. QoL was measured using the PDQ-39 questionnaire. Non-motor symptoms were analyzed with the Non-Motor Symptoms questionnaire. Independent factors associated with a reduced QoL were identified with a multivariate linear regression analysis.

RESULTS

Non-dopaminergic drugs, subdivided into Rx-Risk comorbidity categories, were not associated with reduced QoL, except for the use of anti-epileptic drugs. However, using more daily non-dopaminergic drugs was also negatively associated with QoL, as well as female sex, increased PD severity, and more non-motor symptoms. Contraindicated non-dopaminergic medication was barely prescribed (0.4%).

CONCLUSION

Non-dopaminergic drugs are frequently prescribed, and higher numbers are associated with impaired QoL in PD. However, when divided in drug types, only anti-epileptic drugs were negatively associated with QoL. In these patients, physicians might improve QoL by further optimizing the condition it was prescribed for (e.g., pain or anxiety), or managing of side effects.

TRIAL REGISTRATION

Netherlands Trial Register; NL4360.

The Parkinson's Real-World Impact Assessment (PRISM) Study: A European Survey of the Burden of Parkinson's Disease in Patients and their Carers

Background:

A greater understanding of the everyday experiences of people with Parkinson’s disease (PD) and their carers may help improve clinical practice.

Objective:

The Parkinson’s Real-world Impact assesSMent (PRISM) study evaluated medication use, health-related quality of life (HRQoL) and the use of healthcare resources by people with PD and their carers.

Methods:

PRISM is an observational cross-sectional study, in which people with PD and their carers completed an online survey using structured questionnaires, including the Parkinson’s Disease Quality of Life Questionnaire (PDQ-39), Non-Motor Symptoms Questionnaire (NMSQuest) and Zarit Burden Interview (ZBI).

Results:

Data were collected from 861 people with PD (mean age, 65.0 years; mean disease duration, 7.7 years) and 256 carers from six European countries. People with PD reported a large number of different co-morbidities, non-motor symptoms (mean NMSQuest score, 12.8), and impaired HRQoL (median PDQ-39 summary score, 29.1). Forty-five percent of people with PD reported at least one impulse control behaviour. Treatment patterns varied considerably between different European countries. Levodopa was taken in the last 12 months by 85.9% of participants, and as monotherapy by 21.8%. Carers, who were mostly female (64.8%) and the partner/spouse of the person with PD (82.1%), reported mild to moderate burden (mean ZBI total score, 26.6).

Conclusions:

The PRISM study sheds light on the lives of people with PD and those who care for them, re-emphasising the many challenges they face in everyday life. The study also provides insights into the current treatment of PD in Europe.

The Experiences of Treatment Burden in People with Parkinson's Disease and Their Caregivers: A Systematic Review of Qualitative Studies

BackgroundHigh treatment burden is associated with poor adherence, wasted resources, poor quality of life and poor health outcomes. Identifying factors that impact treatment burden in Parkinson's disease can offer insights into strategies to mitigate them.ObjectiveTo explore the experiences of treatment burden among people with Parkinson's disease (PwP) and their caregivers.MethodsA systematic review of studies published from year 2006 was conducted. Qualitative and mixed-method studies with a qualitative component that relate to usual care in Parkinson's disease were included. Quantitative studies and grey literature were excluded. Data synthesis was conducted using framework synthesis.Results1757 articles were screened, and 39 articles included. Understanding treatment burden in PwP and caregivers was not the primary aim in any of the included studies. The main issues of treatment burden in Parkinson's disease are: 1) work and challenges of taking medication; 2) healthcare provider obstacles including lack of patient-centered care, poor patient-provider relationships, lack of care coordination, inflexible organizational structures, lack of access to services and issues in care home or hospital settings; and 3) learning about health and challenges with information provision. The treatment burden led to physical and mental exhaustion of self-care and limitations on the role and social activities of PwP and caregivers.Conclusion:There are potential strategies to improve the treatment burden in Parkinson's disease at an individual level such as patient-centered approach to care, and at system level by improving access and care coordination between services. Future research is needed to determine the modifiable factors of treatment burden in Parkinson's disease.

Polypharmacy in chronic neurological diseases: Multiple sclerosis, dementia and Parkinson's disease

Polypharmacy is an important aspect of medication management and particularly affects elderly and chronically ill people. Patients with dementia, Parkinson's disease (PD) or multiple sclerosis (MS) are at high risk for multimedication due to their complex symptomatology. Our aim was to provide an overview of different definitions of polypharmacy and to present the current state of research on polypharmacy in patients with dementia, PD or MS. The most common definition of polypharmacy in the literature is the concomitant use of ≥5 medications (quantitative definition approach). Polypharmacy rates of up to >50% have been reported for patients with dementia, PD or MS, although MS patients are on average significantly younger than those with dementia or PD. The main predictor of polypharmacy is the complex symptom profile of these neurological disorders. Potentially inappropriate medication (PIM), drug-drug interactions, poor treatment adherence, severe disease course, cognitive impairment, hospitalisation, poor quality of life, frailty and mortality have been associated with polypharmacy in patients with dementia, PD or MS. For patients with polypharmacy, either the avoidance of PIM (selective deprescribing) or the substitution of PIM with more suitable drugs (appropriate polypharmacy) is recommended to achieve a more effective therapeutic management.

The impact of Parkinson's disease on manifestations and outcomes of Covid-19 patients: A systematic review and meta-analysis

Parkinson's disease (PD) patients who contracted Coronavirus disease 2019 (Covid‐19) had a decline in motor functions; nevertheless, there is limited evidence on whether PD patients have a higher risk for contracting Covid‐19 or have worse outcomes. This is the first systematic review and meta‐analysis to review the impact of PD on the prognosis of Covid‐19 patients. We performed a systematic search through seven electronic databases under the recommendations of the Preferred Reporting Items for Systematic Review and Meta‐analyses statement (PRISMA) guidelines. The R software version 4.0.2 was used to calculate pooled sample sizes and their associated confidence intervals (95%CI). Finally, we included 13 papers in this study. The pooled prevalence rate of Covid‐19 was 2.12% (95%CI: 0.75–5.98). Fever, cough, fatigue and anorexia were the most common symptoms with a rate of 72.72% (95% CI: 57.3 ‐ 92.29), 66.99% (95% CI: 49.08–91.42), 61.58% (95% CI: 46.69–81.21) and 52.55% (95% CI: 35.09–78.68), respectively. The pooled rates were 39.89% (95% CI: 27.09–58.73) for hospitalisation, 4.7% (95% CI: 1.56–14.16) for ICU admission and 25.1% (95%CI: 16.37–38.49) for mortality. On further comparison of hospitalisation and mortality rates among Covid‐19 patients with and without PD, there were no significant differences. In conclusion, the prevalence and prognosis of Covid‐19 patients seem comparable in patients with PD and those without it. The increased hospitalisation and mortality may be attributed to old age and co‐morbidities.

Diagnosis and Management of Pain in Parkinson's Disease: A New Approach

Pain is a frequent and disabling non-motor feature of Parkinson's disease (PD). The recently proposed PD Pain Classification System (PD-PCS) allows for an association of pain with PD to be determined before being allocated to the main pain mechanism (i.e. nociceptive, neuropathic, and nociplastic). In this article, previous studies on treatments for pain in PD are summarized according to the pain mechanisms. A mechanistic approach to treatment is discussed. We suggest that the first step should be optimizing dopaminergic therapy before other therapy is started. When these treatments remain unsuccessful, further causes of pain must be considered. The role of drugs, invasive treatments, and physiotherapeutic interventions are discussed with a focus on older PD patients and considering polypharmacy, altered pharmacokinetics, and comorbidities.

Cardiovascular Events Associated with Antipsychotics in Newly Diagnosed Parkinson's Disease Patients: A Propensity Score Matched Cohort Study

Purpose

Observational studies have examined the association between antipsychotics and ischemic heart disease (IHD) in general populations, but results did not take into account other comorbid diseases, such as Parkinson's disease (PD). This study investigates the one-year risk of IHD, all cardiovascular events, and all-cause mortality among newly diagnosed PD patients who used antipsychotics compared to non-users.

Materials and Methods

This study included individuals aged 40 years or older with a first definitive PD diagnosis Read Code in the Secure Anonymised Information Linkage (SAIL) databank who had been initiated on any PD medication between 2000 and 2016. Antipsychotic users were matched 1:1 with non-users by a propensity score model to control the confounding effects of patients' demographics, social deprivation status, comorbidities, and medication history. Cox regression was performed to calculate the hazard ratios (HR) and 95% CIs for the association between antipsychotics and study outcomes.

Results

A total of 1837 participants were included in the analysis. Users of first-generation antipsychotics (FGA) were significantly more likely to develop IHD compared to non-users, with an HR of 2.60 (95% CI 1.103-6.167). Among the FGAs, haloperidol had the highest likelihood of IHD developing, with an HR of 3.01 (95% CI 1.038-8.729). Any use of antipsychotics, regardless of whether they were FGA or second-generation antipsychotics (SGA), was linked to all-cause mortality, with an HR of 4.201 (95% CI 3.272-5.394). When subdividing antipsychotics into FGAs and SGAs, mortality was more likely in FGA users, with an HR of 7.557 (95% CI 5.633-10.139). Mortality also occurred in SGA users, but with a lower HR of 3.278 (95% CI 2.509-4.282).

Conclusion

FGAs were associated with an increased risk of IHD and all-cause mortality in newly diagnosed PD patients with psychosis. This finding emphasizes the need to use antipsychotics with caution in PD patients with psychosis.

What about regular hematological monitoring during clozapine treatment? A compliance analysis using the French health insurance database

BACKGROUND

The inherent risk of agranulocytosis associated with clozapine requires the realization of weekly white blood cell monitoring (WBCM) during the 18 first weeks of treatment. The aim of this study was to assess the compliance with WBCM during clozapine initiation for schizophrenia and Parkinson's disease (PD) subjects.

RESEARCH DESIGN AND METHOD

The analysis was conducted using SNDS data on a cohort of new users of clozapine in 2018. We analyzed all reimbursements for WBCM from 2 weeks before the index date to 18 weeks after (optimal monitoring during hospitalization was assumed). The primary outcome was the proportion of good realization of WBCM according to different thresholds of completion (70%; 80%; 90%). Descriptive and comparative analyses with chi-squared test or Student's t-test were performed.

RESULTS

Two hundred and ninety-six subjects were included. Rates of patients with WBCM realization over 70%, 80%, and 90% of WBCM expected were, respectively, 78.1%, 70.0%, and 56.9% for subjects with schizophrenia and 71.3%, 63.2%, and 47.8% for PD subjects. Only hospitalization during the follow-up period for schizophrenia subjects was significantly associated with good WBCM realization.

CONCLUSIONS

We observed rather good results for compliance with clozapine initial monitoring. Other studies are needed to confirm our results.

Factors associated with COVID-19 in people with Parkinson's disease: a systematic review and meta-analysis

Background

There is debate as to whether there is an increased risk of COVID‐19 infection in people with Parkinson's disease (PD), possibly due to associated factors. This study aimed to systematically review the factors associated with COVID‐19 in people with PD.

Methods

A search was carried out in PubMed, Scopus, and Web of Science up to November 2020 (updated until 1 April 2021). Observational studies that analyzed factors associated with COVID‐19 in people with PD were selected and revised.

Results

The authors included six studies (four case‐controlled studies and two cross‐sectional studies) in the qualitative and quantitative syntheses. The authors found that the following factors were associated with COVID‐19 in people with PD: obesity (OR: 1.79, 95% CI: 1.07–2.99, I²: 0%), any pulmonary disease (OR: 1.92, 95% CI: 1.17–3.15, I²: 0%), COVID‐19 contact (OR: 41.77, 95% CI: 4.77 – 365.56, I²: 0%), vitamin D supplementation (OR: 0.50, 95% CI: 0.30–0.83, I²: 0%), hospitalization (OR: 11.78, 95% CI: 6.27–22.12, I²: 0%), and death (OR: 11.23, 95% CI: 3.92–32.18, I²: 0%). The authors did not find any significant association between COVID‐19 and hypertension, diabetes, cardiopathy, cancer, any cognitive problem, dementia, chronic obstructive pulmonary disease, renal or hepatic disease, smoking, and tremor.

Conclusions

Meta‐analyses were limited by the number of events and some methodological limitations. Despite this, the authors assessed the available evidence, and the results may be useful for future health policies.

The impact of SARS-COV2 infection on people in residential care with Parkinson Disease or parkinsonisms: Clinical case series study

On March 2019 the World Health Organization declared Coronavirus disease (COVID-19) pandemic. Several recent reports disclose that the outcome of the infection is related to age, sex and can be influenced by underlying clinical conditions. Parkinson's disease (PD) and other parkinsonisms are the most common chronic disease which can cause, directly or indirectly, the patient to be more exposed to other diseases, mostly respiratory system's ones. Our primary outcome is to evaluate if PD patients are more susceptible than non-PD to take COVID-19 infection. Second, to detect if the infection course is worse in PD-COVID+ patients versus non-PD. This is a retrospective observational study on a cohort of 18 patients (13 PD- 5 non-PD), hospitalized in a Rehabilitative Unit during the occurrence of SARS-CoV2 epidemic outbreak. All patients performed laboratory tests, lung Computed Tomography (CT) and have been tested for COVID-19 thorough pharyngeal swab. PD and non-PD groups were comparable for age, gender and Hoehn and Yahr stage. Seventy-seven (77)% of PD and 60% of non-PD resulted positive for COVID-19. PD-COVID+ and PD-COVID- did not differ for age, disease duration and L-dopa daily dose. PD COVID-19+ subjects were mainly asymptomatic (50%) while non-PD ones were all symptomatic, mostly with respiratory difficulties. PD doesn't seem to be a risk factor to take SARS-COV2 infection, even if our study is related to a limited sample size. Our results, together with those of other recent studies, highlight the need to evaluate the actual susceptibility of patients with Parkinson's disease to develop COVID-19 disease, and how the infection may influence the risk of clinical worsening and increase of mortality.

Clinical Profiles and Mortality of COVID-19 Inpatients with Parkinson's Disease in Germany

BACKGROUND

Comprehensive, nationwide data regarding Parkinson's disease (PD) hospitalizations, coronavirus disease 2019 (COVID-19) in-hospital frequency, and COVID-19-associated inpatient mortality during the first wave of the COVID-19 pandemic are not available.

OBJECTIVE

To provide a nationwide analysis on hospitalized PD patients in Germany and evaluate the impact of the COVID-19 pandemic.

METHODS

We conducted a cross-sectional study using an administrative claims database covering 1468 hospitals and 5,210,432 patient hospitalizations including a total of 30,872 COVID-19⁺ cases between January 16 and May 15, 2020.

RESULTS

Compared to 2019, hospitalizations for PD transiently decreased by up to 72.7% in 2020. COVID-19 frequency was significantly higher in the population of 64,434 PD patients (693 being COVID-19⁺ ) than in non-PD patients (1.1% vs. 0.6%, P < 0.001), especially in subjects with advanced age (≥ 65 years). Regarding established COVID-19 risk comorbidities, COVID-19⁺ inpatients with PD showed higher incidences than non-PD COVID-19⁺ subjects, particularly hypertension and chronic kidney disease. Advanced age and male sex were significantly more frequent in COVID-19⁺ than in COVID-19^- PD patients. The COVID-19 inpatient mortality rate was much higher in PD patients than in non-PD patients (35.4% vs. 20.7%, P < 0.001), especially in patients aged 75-79 years. Of note, overall inpatient mortality of PD patients was significantly higher in 2020 than in 2019 (5.7% vs. 4.9%, P < 0.001).

CONCLUSIONS

PD inpatients are more frequently affected by COVID-19 and suffer from increased COVID-19-associated mortality in comparison to non-PD patients. More comprehensive studies are needed to assess the significance of associated comorbidities for COVID-19 risk and mortality in PD. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Is dopaminergic medication dose associated with self-reported bruxism in Parkinson's disease? A cross-sectional, questionnaire-based study

OBJECTIVES

It is not clear whether dopaminergic medication influences bruxism behaviour in patients with Parkinson's disease (PD). Therefore, the aims are to investigate (i) the prevalence of possible (i.e., self-reported) bruxism (sleep and awake) in PD patients, and (ii) whether the use of dopaminergic medication and other factors (viz., demographic characteristics, PD-related factors, and possible consequences of bruxism) are associated with possible bruxism (sleep or awake).

MATERIALS AND METHODS

This study concerns a secondary analysis of an earlier published study. Three hundred ninety-five PD patients (67.9 ± 8.6 years of age; 58.7% males) were included. The levodopa equivalent daily dosage (LEDD) was used as a measure of the dopaminergic medication level. Subsequently, a logistic regression analysis was performed for the dependent variables 'awake bruxism' and 'sleep bruxism', with the following predictors: gender, age, LEDD, time since PD diagnosis, temporomandibular disorder (TMD) pain, jaw locks, and tooth wear.

RESULTS

The prevalence of possible awake and sleep bruxism was 46.0% and 24.3%, respectively. Awake bruxism was associated with sleep bruxism (OR = 8.52; 95% CI 3.56-20.40), TMD pain (OR = 4.51; 95% CI 2.31-8.79), and tooth wear (OR = 1.87; 95% CI 1.02-3.43). Sleep bruxism was associated with tooth wear (OR = 12.49; 95% CI 4.97-31.38) and awake bruxism (OR = 9.48; 95% CI 4.24-21.19). Dopaminergic medication dose was not associated with awake bruxism (OR = 1.0; 95% CI 0.99-1.00) or sleep bruxism (OR = 1.0; 95% CI 0.99-1.00).

CONCLUSION

Bruxism is a common condition in PD patients, but is not associated with the dopaminergic medication dose.

CLINICAL RELEVANCE

(Oral) health care providers should be alerted about the possibility of sleep and awake bruxism activity in PD patients, along with this activity's possible negative health outcomes (viz., TMD pain, tooth wear).

People with Parkinson's Disease: What Symptoms Do They Most Want to Improve and How Does This Change with Disease Duration?

Background:

Parkinson’s disease (PD) is a neurodegenerative condition with a diverse and complex pattern of motor and non-motor symptoms which change over time with disease duration.

Objective:

The aims of the present study were to discover what symptoms matter most to people with the condition and to examine how these priorities change with disease duration.

Methods:

A simple free-text online survey (using SmartSurvey) was developed by Parkinson’s UK, which asked participants to identify up to three aspects of the condition they would most like to see improvement in.

Results:

790 people participated reporting 2,295 issues related to PD which were grouped into 24 broad symptom domains. Of these, 1,358 (59.1%) were categorised as motor symptoms, 859 (37.4%) as non-motor issues and 78 (3.4%) as medication problems. This study reveals how certain features of PD become more or less important to patients as the condition progresses. Non-motor symptoms were highly cited from the very earliest stages of PD. Problems with walking, balance and falls, speech problems, freezing and dyskinesia become increasingly important as the condition progresses whereas tremor, stiffness and psychological health become decreasingly important as the condition progresses.

Conclusions:

The data suggest that the priorities of people affected by PD for improving life are personal and change with duration of the condition. These findings have implications for developing person-centred management and care, as well as for directing future research to improve quality of life.

Increased atrial fibrillation risk in Parkinson's disease: A nationwide population-based study

OBJECTIVE

Parkinson's disease (PD) is the second most common neurodegenerative disorder associated with various morbidities. Although the relationship between cardiovascular disease and PD has been studied, a paucity of information on PD and atrial fibrillation (AF) association exists. Thus, we aimed to investigate whether patients with PD have an increased risk of AF.

METHODS

This study included 57,585 patients with newly diagnosed PD (≥40-year-old, mean age 69.7 years, men 40.2%) and without a history of AF from the Korean National Health Insurance Service (NHIS) database between 2010 and 2015. Furthermore, an equal number of age- and sex-matched subjects without PD were selected for comparison. The primary outcome was new-onset AF.

RESULTS

During the mean follow-up period of 3.4 ± 1.8 years, AF was newly diagnosed in 3,665 patients. A significantly higher incidence rate of AF was noted among patients with PD than among patients without PD (10.75 and 7.86 per 1000 person-year, respectively). Multivariate Cox-regression analysis revealed that PD was an independent risk factor for AF (hazard ratio [HR]: 1.27, 95% confidence interval [CI]: 1.18-1.36). Furthermore, subgroup analyses revealed that AF risk was higher in the younger age subgroups, and compared with the non-PD group, the youngest PD group (age: 40-49 years) had a threefold increased risk of AF (HR: 3.06, 95% CI: 1.20-7.77).

INTERPRETATION

Patients with PD, especially the younger age subgroups, have an increased risk of AF. Active surveillance and management of AF should be considered to prevent further complications.

People with Parkinson's disease are more willing to do additional exercise if the exercise program has specific attributes: a discrete choice experiment

QUESTION

What specific attributes of exercise programs influence the preferences of people with Parkinson's disease for additional exercise compared with their current practice? What trade-offs are participants willing to make between exercise program attributes?

DESIGN

Discrete choice experiment.

PARTICIPANTS

Five hundred and forty people with Parkinson's disease.

INTERVENTION

Participants decided whether they would adopt a hypothetical program in addition to their current exercise routine.

OUTCOME MEASURES

Exercise program attributes included: type, number of sessions/week, location, travel time/session, delivery mode, supervisor's expertise, extent of supervision, benefits for physical and psychological function and out-of-pocket cost/session.

RESULTS

Participants preferred additional exercise when programs: provided physical (OR 1.85, 95% CI 1.61 to 2.13) or psychological (OR 1.45, 95% CI 1.26 to 1.67) benefit, involved less travel time (ORs 1.50 to 2.02) and were supervised by qualified professionals with Parkinson's disease expertise (ORs 1.51 to 1.91). Participants were most willing to add multimodal exercise to their exercise routine (ORs 2.01 to 2.19). Participants were less likely to prefer higher cost programs (OR 0.65, 95% CI 0.60 to 0.71, per AU$10 cost increase) or group sessions compared to individual sessions (OR 0.72, 95% CI 0.54 to 0.96). Men preferred adding strengthening exercises (OR 2.00, 95% CI 1.23 to 3.26) and women had a preference against adding aerobic exercise (OR 0.33, 95% CI 0.15 to 0.73). Participants not currently exercising were more likely to prefer adding exercise compared with those already exercising 300 minutes weekly (OR 1.74, 95% CI 1.15 to 2.63).

CONCLUSION

People with Parkinson's disease were more willing to participate in exercise programs that cost less, involve less travel, provide physical or psychological benefits and are supervised by qualified professionals. To enable more people with Parkinson's disease to exercise, health services should provide programs addressing these factors and account for sex differences.

QTc Interval Prolongation with Therapies Used to Treat Patients with Parkinson's Disease Psychosis: A Narrative Review

In addition to the classic motor symptoms of Parkinson's disease (PD), people with PD frequently experience nonmotor symptoms that can include autonomic dysfunction and neuropsychiatric symptoms such as PD psychosis (PDP). Common patient characteristics, including older age, use of multiple medications, and arrhythmias, are associated with increased risk of corrected QT interval (QTc) prolongation, and treatments for PDP (antipsychotics, dementia medications) may further increase this risk. This review evaluates how medications used to treat PDP affect QTc interval from literature indexed in the PubMed and Embase databases. Although not indicated for the treatment of psychosis, dementia therapies such as donepezil, rivastigmine, memantine, and galantamine are often used with or without antipsychotics and have minimal effects on QTc interval. Among the antipsychotics, data suggesting clinically meaningful QTc interval prolongation are limited. However, many antipsychotics have other safety concerns. Aripiprazole, olanzapine, and risperidone negatively affect motor function and are not recommended for PDP. Quetiapine is often sedating, can exacerbate underlying neurogenic orthostatic hypotension, and may prolong the QTc interval. Pimavanserin was approved by the US Food and Drug Administration (FDA) in 2016 and remains the only FDA-approved medication available to treat hallucinations and delusions associated with PDP. However, pimavanserin can increase QTc interval by approximately 5-8 ms. The potential for QTc prolongation should be considered in patients with symptomatic cardiac arrhythmias and those receiving QT-prolonging medications. In choosing a medication to treat PDP, expected efficacy must be balanced with potential safety concerns for individual patients.

Impact of Antidepressants on Cardiac Events and All-Cause Mortality in Parkinson's Disease: A National Data-Linkage Study

PURPOSE

This study investigated the 1-year risk of ischemic heart disease (IHD), all cardiovascular events, and all-cause mortality among newly diagnosed Parkinson's disease (PD) patients who used antidepressants compared to those who did not.

PATIENTS AND METHODS

Patients with PD aged 40 years or older were identified using data from 2000 through 2016 held within the Welsh Secure Anonymized Information Linkage (SAIL) databank. Antidepressant users were propensity-score matched 1:1 with non-users, adjusting for patients' demographics, socioeconomic status, and multiple comorbidities. Cox proportional hazard regression analyses were performed to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between the antidepressants and the study outcomes. The follow-up period was 1 year after the initial prescription of antidepressants.

RESULTS

The study group comprised a total of 3364 participants, with numbers split equally between the antidepressant-user and non-user groups, based on the propensity score-matching process. Overall, the propensity score-adjusted model showed that antidepressant usage in PD patients was not significantly associated with the risk of IHD (HR = 1.05; 95% CI 0.63-1.75) or all cardiovascular events (HR = 1.01; 95% CI 0.71-1.45) compared to non-users. The propensity score-adjusted model also showed that the use of any antidepressant, regardless of its category, was not statistically significantly associated with all-cause mortality (HR = 0.81; 95% CI 0.65-1.02). However, this association reached statistical significance in the multivariate adjusted model (HR = 0.67; 95% CI 0.54-0.84).

CONCLUSION

There was no evidence that antidepressant use was associated with an increased risk of IHD or all cardiovascular events in newly diagnosed PD patients who suffered from depression. Furthermore, antidepressant use might reduce the mortality rate in PD patients during the first year after initiation.