Cognitive fluctuations in Parkinson's disease dementia: blood pressure lability as an underlying mechanism

The Effect of Dysautonomia on Motor, Behavioral, and Cognitive Fluctuations in Parkinson's Disease

BACKGROUND

Motor and nonmotor fluctuations adversely impact the quality of life in Parkinson's disease (PD). Dysautonomia, a feature frequently associated with PD and a possible adverse effect of dopaminergic therapy, may be comorbid with fluctuations.

OBJECTIVE

We sought to evaluate the effect of dysautonomia on motor and nonmotor fluctuations in PD.

METHODS

Two hundred subjects with PD were evaluated in both on and off dopamine states to assess changes in symptoms related to dopaminergic fluctuations. Multivariable logistic regression was performed to assess the association of dysautonomia with motor, cognitive, and psychiatric worsening from on to off states with adjustment for disease duration, levodopa equivalent daily dosage (LEDD), and dopamine-agonist LEDD.

RESULTS

Subjects with dysautonomia had greater odds of clinically meaningful change in motor features (odds ratio [OR]: 3.0), cognition (OR: 3.4), and anxiety (OR: 4.3) compared to those without dysautonomia.

CONCLUSIONS

Dysautonomia may be a contributory mechanism behind fluctuations in PD. The exact nature of this relationship deserves further evaluation. © 2024 International Parkinson and Movement Disorder Society.

Gaps and Controversies in Catatonia as a Movement Disorder

The term "catatonia" was introduced by German psychiatrist Karl Kahlbaum in 1874. Although historically tied to schizophrenia, catatonia exhibits a diverse range of phenotypes and has been observed in various medical and neuropsychiatric conditions. Its intrinsic movement characteristics and association with hypokinetic and hyperkinetic phenomenologies place catatonia within the purview of movement disorders. Despite the presence of catatonia in psychiatry literature for over 150 years, many gaps and controversies persist regarding its etiopathogenesis, phenomenology, diagnostic criteria, and treatment. The current versions of the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) require clinicians to identify any three signs of 15 (ICD-11) or 12 (DSM-5) for the diagnosis of catatonia. Catalepsy and waxy flexibility are the only motor features with high specificity for the diagnosis. We highlight the gaps and controversies in catatonia as a movement disorder, emphasize the lack of a clear definition, and discuss the inconsistencies in the description of various catatonic signs. We propose the exploration of a bi-axial classification framework similar to that used for dystonia and tremor to encourage the evaluation of underlying etiologies and to guide therapeutic decisions to improve the outcome of these patients. © 2024 International Parkinson and Movement Disorder Society.

Episodic Coma in Lewy Body Disorders: An Observational Report

Background

and Purpose: Episodes of unresponsiveness are one of several criteria used to diagnose dementia with Lewy bodies and are also seen in people with Parkinson's disease dementia. Patients examined during episodes of coma, whose evaluations found no other explanation than the neurological disorder, have not been described. This paper describes four cases, seen in the past two years. The objective is to bring this uncommon phenomenon to the attention of hospital based neurologists and to demonstrate that this may not be due to autonomic dysfunction.

Methods

These are brief case descriptions by medical personnel observing affected patients supplemented by family reports of similar episodes described on the internet.

Results

Four cases are described, all older men with either dementia with Lewy bodies or Parkinson's disease dementia, who had single, or multiple episodes of otherwise unexplained coma and were examined during a spell. IRB approval waived.

Conclusions

Episodic coma may occur in demented patients with an alpha-synucleinopathy and is the likely explanation when evaluations have found no other cause. This information will reassure the family and patient that this is the likely explanation but that spells may recur.

The effect of dysautonomia on motor, behavioral and cognitive fluctuations in Parkinson's disease

Background

Motor and non-motor fluctuations adversely impact quality of life in Parkinson's disease (PD). Dysautonomia, a feature frequently associated with PD and a possible adverse effect of dopaminergic therapy, may be comorbid with fluctuations.

Objectives

We sought to evaluate the effect of dysautonomia on motor and non-motor fluctuations in PD.

Methods

Two hundred subjects with PD were evaluated in both "on" and "off" dopamine states to assess changes in symptoms related to dopaminergic fluctuations. Multivariable logistic regression was performed to assess the association of dysautonomia with motor, cognitive, and psychiatric worsening from ON to OFF states with adjustment for disease duration, levodopa equivalent daily dosage (LEDD), and dopamine agonist LEDD.

Results

Subjects with dysautonomia had greater odds of clinically meaningful change in motor features (OR 3.0), cognition (OR 3.4) and anxiety (OR 4.3) compared to those without dysautonomia.

Conclusions

Dysautonomia may be a contributory mechanism behind fluctuations in PD. The exact nature of this relationship deserves further evaluation.

Self-perceived cognitive fluctuations and their relationship to everyday functioning in older adults with and without HIV disease

Objective: HIV is associated with elevated performance-based cognitive intra-individual variability (IIV) in the laboratory that can reflect difficulty regulating cognitive resources over time (i.e., cognitive fluctuations) and disrupt everyday functioning. Whether persons living with HIV (PLWH) experience appreciable cognitive fluctuations in their daily lives is unclear. This study examined the presence of cognitive fluctuations and their relationship to everyday functioning in PLWH. Methods: Participants were 145 PLWH and 61 seronegative individuals age ≥ 50 years who completed a self-report version of the Mayo Fluctuations Scale (MFS), structured psychiatric interview, medical evaluation, and well-validated measures of mood, cognitive symptoms, and activities of daily living (ADLs). A confirmatory factor analysis of the MFS yielded three factors, including a 7-item cognitive fluctuations scale. Results: Univariable analyses showed that HIV was associated with moderately higher MFS Cognitive Fluctuation subscale scores (d = 0.46), but this effect was no longer significant a multiple regression model that included medical comorbidities and affective disorders, which emerged as unique predictors. Of clinical relevance, higher MFS Cognitive Fluctuation subscale scores were independently associated with more frequent cognitive symptoms and dependence in ADLs in the full sample. Conclusions: Higher frequency of self-perceived cognitive fluctuations disrupts management of ADLs among middle-aged and older adults independent of HIV status and general cognitive symptoms. Future studies are needed to understand the full clinical significance of self-perceived cognitive fluctuations among PLWH and their impact on daily life.

Later-Onset Hypertension Is Associated With Higher Risk of Dementia in Mild Cognitive Impairment

To investigate the correlation between hypertension development and the progression of mild cognitive impairment (MCI) to dementia in middle-aged and elderly people. A population-based longitudinal cognition survey of people aged 55+ was conducted. The hypertension onset age was estimated by self-reported information and medical insurance card records. To study the effect of later-onset hypertension on dementia, the incidence of dementia was compared between the two groups. Of 277 hypertensive MCI participants without dementia, 56 (20.22%) progressed to dementia (MCIp) over the 6-year follow-up. The proportion of MCIp participants in the old-age-onset hypertension group (≥65 years) was higher than that in the middle-age-onset hypertension group (27.0 vs. 15.4%, respectively; X 2 = 5.538, P = 0.019). In the old-age-onset hypertension group, the proportion of MCIp without diabetes mellitus was higher than those with diabetes mellitus (24.7 vs. 12.6%, respectively; X 2 = 5.321, P = 0.021) and those with increased pulse pressure was higher than those without increased pulse pressure (33.3 vs. 15.4%, respectively; X 2 = 3.902, P = 0.048). However, the cox proportional hazard showed that older age was the only risk factor for MCIp (HR = 0.618, p = 0.000). These results suggest that individuals with later-onset hypertension may have greater cognition decline, even with blood pressure maintained at 130/80 mmHg with antihypertensive management.

Orthostatic Hypotension Is Associated With Cognitive Decline in Parkinson Disease

Introduction: Cognitive impairment and orthostatic hypotension (OH) are common, disabling Parkinson disease (PD) symptoms that are strongly correlated. Whether the relationship is causative or associative remains unknown. OH may occur without classic orthostatic symptoms of cerebral hypoperfusion (i.e., lightheadedness or dizziness). Whether longitudinal differences in cognition occur between symptomatic and asymptomatic OH patients has not been explored.

Objectives: We characterized the prevalence of OH, orthostatic symptoms, and cognitive impairment among PD patients and compared cognition between patients with and without OH, and between patients with symptomatic and asymptomatic OH.

Methods: Our cross-sectional, retrospective, observational study included 226 clinically diagnosed PD patients who underwent repeated standardized evaluations. Among these, 62 had longitudinal follow-up of > 3.5 years. We compared longitudinal Montreal Cognitive Assessment (MoCA) scores between patients remaining OH-free (n = 14) and those without baseline OH that developed OH (n = 28), matched for age, sex, education, and PD duration. We also compared MoCA scores between groups with asymptomatic OH (n = 13) and symptomatic OH (n = 13) matched for the same factors.

Results: In the cross-sectional analysis, OH patients had worse cognition. In the longitudinal analysis (mean follow-up = 5.3 years), OH patients had worse cognitive decline (p = 0.027). Cognitive impairment was similar between asymptomatic and symptomatic OH patients in the cross-sectional and longitudinal analyses.

Conclusions: OH is associated with cognitive impairment in PD. Further studies are needed in larger cohorts to expand our findings and to determine whether treating OH can prevent or delay cognitive dysfunction.

Trouble Concentrating is an Easily Overlooked Symptom of Orthostatic Hypotension in Early Parkinson's Disease

BACKGROUND

Trouble concentrating during orthostasis is one symptom of orthostatic hypotension (OH), but it is often ignored in clinical practice because OH incorporates many nonspecific symptoms. Blunted cognition during orthostasis may affect various aspects of the clinical status of patients with Parkinson's disease (PD), but its impact on drug-naïve, early PD patients is not clear.

OBJECTIVE

This study investigated the association between trouble concentrating during orthostasis and orthostatic blood pressure changes and the influence of trouble concentrating during orthostasis on other non-motor symptoms and health-related quality of life in de novo PD.

METHODS

A total of 124 patients with early PD were enrolled and received a structured clinical interview, physical examination, and validated questionnaires to evaluate motor and non-motor symptoms and quality of life. Disturbed concentration was evaluated with question 5 of the Orthostatic Hypotension Questionnaire system assessment (part I). Supine blood pressure and blood pressure change during tilt table testing were recorded, and any association was analyzed.

RESULTS

Among the study population, 76 (61.3%) patients had trouble concentrating. Patients with blunted concentration had a steeper decrease in blood pressure during orthostasis. The score for trouble concentrating was positively associated with non-motor symptoms and quality of life scores.

CONCLUSIONS

Trouble concentrating when standing was a frequent finding in early, drug-naïve PD patients. It was positively associated with non-motor burden, mood and quality of life in patients with PD. OH was correlated with the incidence of trouble concentrating. Such findings complicate treatment but provide valuable information for managing early PD.

Orthostatic hypotension and dementia incidence: links and implications

Orthostatic hypotension (OH) is a common condition, particularly in patients with α-synucleinopathies such as Parkinson's disease, and has a significant impact on activities of daily living and quality of life. Recent data suggest an association with cognitive impairment. Herein, we review the evidence that OH increases the odds of incident mild cognitive impairment and dementia. Potential mechanisms underlying the putative relationship are discussed, including cerebral hypoperfusion, supine hypertension, white matter hyperintensities, and neurodegeneration. Finally, we highlight the challenges with respect to treatment and the negative impact on the quality of life and long-term prognosis presented by the coexistence of OH and dementia. Large population-based studies have reported that OH is associated with about a 20% increased risk of dementia in the general population, while smaller cohort studies suggest an even greater effect in patients with α-synucleinopathies (3- to 7-fold higher than controls). Ultimately, OH exposure is difficult to quantify, predominantly limited to pressure regulation during a one-time orthostatic challenge, and the causative association with dementia may turn out to be bidirectional, especially in α-synucleinopathies. Early diagnosis and treatment of OH may improve long-term prognosis.