Early constipation predicts faster dementia onset in Parkinson's disease

Constipation is a common but not a universal feature in early PD, suggesting that gut involvement is heterogeneous and may be part of a distinct PD subtype with prognostic implications. We analysed data from the Parkinson's Incidence Cohorts Collaboration, composed of incident community-based cohorts of PD patients assessed longitudinally over 8 years. Constipation was assessed with the MDS-UPDRS constipation item or a comparable categorical scale. Primary PD outcomes of interest were dementia, postural instability and death. PD patients were stratified according to constipation severity at diagnosis: none (n = 313, 67.3%), minor (n = 97, 20.9%) and major (n = 55, 11.8%). Clinical progression to all three outcomes was more rapid in those with more severe constipation at baseline (Kaplan-Meier survival analysis). Cox regression analysis, adjusting for relevant confounders, confirmed a significant relationship between constipation severity and progression to dementia, but not postural instability or death. Early constipation may predict an accelerated progression of neurodegenerative pathology.

Medium-term prognosis of an incident cohort of parkinsonian patients compared to controls

Background

The best data on prognosis comes from population-based incident cohorts but few such cohorts exist for Parkinson's disease and atypical parkinsonism.

Methods

The PINE study is a prospective follow-up study of an incident cohort of people with degenerative or vascular parkinsonism and age-sex matched controls. Participants have annual follow-up from diagnosis until death with review of primary/secondary care records and linkage to the UK death register. Data are collected on survival, disability (dependency on others for activities of daily living) and institutionalization. Research criteria are used to guide the clinical diagnosis, which is updated annually. We compared all-cause mortality, disability and institutionalization in patients (subdivided by diagnosis) and controls, adjusted for important confounders.

Results

323 incident parkinsonian patients (199 Parkinson's disease, 124 atypical parkinsonism, mean age at diagnosis 75yrs) and 262 controls (mean age 75yrs) had 1349 and 1334 person-years follow-up respectively (maximum follow-up 10 years). All outcomes were worse in parkinsonian patients than controls, especially in atypical parkinsonism (adjusted mortality hazards ratios Parkinson's disease 2.49, 95%CI 1.72–3.58, atypical parkinsonism, 6.85, 95%CI 4.78–9.81). Median survival times for Parkinson's disease and atypical parkinsonism were 7.8 and 2.7 years respectively but were very age-dependent. At three years the rates of death or dependency were controls 21%, Parkinson's disease 46%, atypical parkinsonism 96% whilst overall institutionalization rates were 5%, 15% and 55% respectively.

Conclusion

The prognosis of Parkinson's disease and atypical parkinsonism in this unselected incident cohort was significantly worse than previously reported. This has important implications for patient management.

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323 incident parkinsonian patients were followed for up to 10 years.

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Mortality was 2.5–6.8 times higher in patients compared to controls.

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After 3 years 46% (PD) and 96% (atypical parkinsonism) were dead or dependent.

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14% (PD) and 55% (atypical parkinsonism) were institutionalized during follow-up.

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Prognosis was significantly worse than in previous non-incident younger cohorts.

Motor complications in an incident Parkinson's disease cohort

BACKGROUND AND PURPOSE

Levodopa treatment in Parkinson's disease (PD) causes motor fluctuations and dyskinesias, but few data describe their development or severity in unselected incident cohorts.

METHODS

Demographic, clinical, treatment, smoking, caffeine and alcohol data from 183 people with PD were gathered from the Parkinsonism Incidence in Northeast Scotland (PINE) study, a community-based, incident cohort. With Kaplan-Meier survival analysis and Cox regression modelling the development, and severity, of dyskinesias and motor fluctuations and which factors independently influenced their onset were assessed.

RESULTS

After a mean follow-up of 59 months, 39 patients (21.3%) developed motor fluctuations and 52 (28.4%) developed dyskinesias. Kaplan-Meier estimates of the probability of motor fluctuations and dyskinesias after 5 years of dopaminergic treatment were 29.2% [95% confidence interval (CI) 21.5%-38.8%] and 37.0% (95% CI 28.5%-47.1%) respectively. 19.8% developed motor fluctuations requiring treatment changes but only 4.0% (95% CI 1.5%-10.4%) developed dyskinesias requiring treatment changes by 5 years. Cumulative levodopa dose [hazard ratio (HR) 1.38 (95% CI 1.19-1.60)], female sex [HR 2.41 (1.19-4.89)] and younger age at diagnosis [HR 1.08 (1.04-1.11)] were independently associated with development of motor fluctuations. Cumulative levodopa dose [HR 1.23 (1.08-1.40)] and female sex [HR 2.51 (1.40-4.51)] were independently associated with dyskinesias. In exploratory analyses, moderate caffeine exposure was associated with fewer motor fluctuations, longer symptom duration with more dyskinesias, and tremor at diagnosis with higher rates of both complications.

CONCLUSIONS

In this community-based incident PD cohort, severe dyskinesias were rare. Cumulative levodopa dose was the strongest predictor of both dyskinesias and motor fluctuations.

Adverse effects of opioids on the central nervous systems of palliative care patients

Opioids, defined as drugs that stimulate opioid receptors, are primarily used in the treatment of moderate to severe pain. They induce central nervous system (CNS) adverse effects which can be divided into three groups. The first group includes effects that lower the level of consciousness-sedation, drowsiness and sleep disturbance. The second group affects the thinking process and the ability to react-cognitive impairment, psychomotor impairment, delirium, hallucinations, dreams and nightmares. The third group is of the direct toxic effects of opioids on neurons and includes myoclonus (perhaps), hyperalgesia and tolerance. This review addresses the incidence, possible mechanisms, and treatment of each of these groups of opioid-induced adverse effects.

Delirium: The clinical concept

Delirium is a common syndrome complicating terminal illness. It is underrecognized partly because it is a difficult clinical concept. Consciousness, awareness, alertness, arousal, awakeness, vigilance, and attention are some of the terms used to describe the deficits occurring in delirium. Though interconnected, they are often loosely defined. Alertness is the primary impairment, and attentional deficits are objective clinical indices of the cognitive impairments of delirium. Simple bedside assessments of delirium are considered. The “deliriant” threshold and the symptomatic fluctuations of delirium are important concepts in the understanding of delirium. Jackson's conceptualization of the nervous system is relevant to delirium. Raising the deliriant threshold by multicomponent interventions is the intent of the palliative management of terminal delirium.

Haloperidol in palliative care

Haloperidol is one of 20 'essential' medications in palliative care. Its use is widespread in palliative care patients. The pharmacology of haloperidol is complex and the extent and severity of some of its adverse effects, particularly extrapyramidal adverse effects (EPS), may be related to the route of administration. Indications for the use of haloperidol in palliative care are nausea and vomiting and delirium. Adverse effects include EPS and QT prolongation. Sedation is not a common adverse effect of haloperidol. It is important that palliative care practitioners have a comprehensive understanding of the indications, doses, adverse effects and pharmacology of haloperidol. This review is intended to address these issues.

Neurogenic pulmonary edema in palliative care

Neurogenic pulmonary edema may be a complication of the terminal phase of cerebral tumors. Clinically, it is likely to be considered the "death rattle" and is likewise very distressing to attending relatives. Positional change tends to aggravate neurogenic pulmonary edema but not the "death rattle." Its occurrence may be an indication for sedation for the intractable distress of the dying patient.

Ondansetron in multiple sclerosis

Two young women with chronic nausea and vertigo caused by multiple sclerosis responded to the introduction and maintenance of the 5HT3 receptor antagonist, ondansetron. Palliative care is a neglected aspect of management of degenerative neurological diseases and these cases highlight the approaches that may be used to manage difficult symptoms in the population with multiple sclerosis.

Psychiatric casualties of World War II

AIMS

To observe the natural history of traumatised war veterans.

METHODS

A clinical audit of 147 World War II psychiatric war pensioners.

RESULTS

Of these veterans only 37% have a clinically sustainable DSM diagnosis of chronic post traumatic stress disorder (PTSD). Trauma-related and somatic symptoms of severity attributable to active war service, were volunteered by 48%. These symptoms were insufficient to fulfil DSM diagnosis criteria for PTSD.

CONCLUSIONS

PTSD is a robust clinical entity, yet many victims of trauma appear to suffer chronic sub-syndromal PTSD. The clinical spectrum of trauma response is more variable than is currently diagnostically acceptable by DSM criteria.

Posttraumatic stress disorder, dissociative fugue and a locator beacon

OBJECTIVE

The aim of this paper is to report an aspect of the management of a case of dissociative fugue.

CLINICAL PICTURE

A Vietnam veteran was suffering post-traumatic stress disorder.

TREATMENT

Treatment involved the provision of a locator beacon worn in a neck chain.

OUTCOME

This treatment resulted in the curtailment of the dissociative fugue episodes.

CONCLUSION

The locator device proved a useful component of a multimodal treatment regime.

Sport psychiatry

OBJECTIVE

The aim of this article is to provide an overview of the literature on psychiatry for elite athletes.

METHOD

Relevant literature was presented to the general psychiatrist.

RESULTS

The prevalence of drug misuse, eating disorders and brain injury in elite and professional athletes is stressed. The uniquely troublesome adverse effects of psychopharmacology in this group of subjects is commented upon.

CONCLUSIONS

Elite athletes may require competent and informed psychiatric opinion and management.

Methylphenidate in terminal depression

Major depressive disorder in 26 hospice inpatients was managed with a trial of methylphenidate (mean daily dosage, 17.7 mg). A therapeutic response was achieved in 46% of the sample. However, a significant response was obtained in only 7% of those patients who subsequently died of their terminal illness within 6 weeks. Higher dosage psychostimulants may be indicated in the last weeks of life of the terminally ill. Alternatively "vital exhaustion" may account for the poor response rate in the treatment of depression in patients with advanced malignancy.

Dysgraphia and terminal delirium

Delirium is a frequently encountered clinical condition in palliative medicine, but it is often unrecognized and misdiagnosed. The cardinal sign of delirium is that of impaired consciousness. Writing skills are reported to be a delicate indicator of consciousness impairment, and a too infrequently utilized clinical sign of delirium. Ten delirious hospice patients completed the Frenchay Aphasia Screening Test which showed that writing was the most impaired of the language dysfunctions assessed. The simple clinical task of a request to write 'name and address' revealed overt dysgraphic errors among delirious patients. This examination is clinically acceptable to hospice practice and may be an adequate and accurate bedside test of delirium.

The use of opioid medications in patients with chronic non-malignant pain who have drug dependence

The use of opioid medications in the management of painful medical conditions is currently being 'rediscovered'. However, although drug-dependent patients are likely to be over-represented in the chronic pain population and are also arguably less likely to respond to non-pharmacological interventions for chronic pain, opioid medications are considered to be relatively contraindicated for such a patient group. This paper explores, first, the background to this situation before proposing a set of interim guidelines for the use of opioid medications in the management of chronic pain in drug-dependent patients in order to protect access to this treatment strategy for this difficult patient group, while data from controlled studies are obtained for more definitive policy formation.

The reactivation of post-traumatic stress disorder in later life

Forty-five World War II veterans reporting recent reactivation of chronic post-traumatic stress disorder (PTSD) symptoms were clinically assessed in order to determine war pension disability. In the course of these examinations, factors implicated in the exacerbation of their re-experiencing and arousal symptoms were recorded. The most prominent of these factors was that of physical ill health. Retirement, loneliness, comorbid psychiatric illness, anniversaries, service reunions, and alcohol and psychotropic medication usage were other factors. The natural history of chronic PTSD was observed by reviewing the veterans' medical records, which had been commenced at enlistment, prior to active service. The masking of intrusive symptoms in mid-life was usual. A terminal phase of symptomatic reactivation in older age may occur. The indelibility of the memory of fear is demonstrated by these veterans. The reticence to retell the trauma story remains a major obstacle in the study of the mental health sequelae of warfare. War-related psychiatric disorder in the elderly male is easily missed. Direct questioning regarding military service is advisable. The ineffectiveness of the management strategies offered to World War II PTSD sufferers is clearly apparent.

Effective concentration 50 for propofol with and without 67% nitrous oxide

The Effective Blood Concentration (EC) of propofol required to prevent response to surgical incision was determined in 65 ASA I or II female patients breathing either 100% oxygen or 67% N2O in oxygen. Propofol was administered via a microcomputer-controlled infusion system programmed to maintain the blood propofol concentration at predetermined target values. The blood propofol concentrations predicted by the micro-computer were validated by measurement of whole blood propofol concentration. Predicted and measured concentrations differed during infusion of propofol, but became similar after discontinuing the infusion for at least 90 s, suggesting that equilibration within the central compartment was incomplete during infusion. The response to the initial incision was observed and probit analysis used to determine the predicted blood concentration at which 50% of patients responded. The predicted EC50 for propofol/N2O/O2 and propofol/O2 was 4.5 micrograms ml-1 and 6.0 micrograms ml-1 respectively, and the measured EC50 propofol/N2O/O2 and propofol/O2 was 5.36 micrograms ml-1 and 8.1 micrograms ml-1, 67% nitrous oxide in oxygen reducing the predicted EC50 by 25% and the measured EC50 of propofol by 33%. The predicted EC may be more representative of the equilibrated concentration in the central compartment and thus reflective of tissue propofol concentrations.

Posttraumatic stress disorder in World War Two veterans

The clinical presentations of chronic posttraumatic stress disorder of 18 world war two veterans are detailed. This psychiatric sequelae of trauma may be chronic and persistent, as demonstrated by the presence and severity of symptoms 45-50 years after the onset. Early treatment interventions would appear desirable even if not yet conclusively proven to be effective.

Comparison of two methods for predicting difficult intubation

Two methods of predicting difficult laryngoscopy were compared prospectively. Mallampati class and Wilson risk-sum were determined before operation and laryngeal view graded in 675 patients. Both tests identified five of 12 difficult laryngoscopies; twice as many patients were predicted to be difficult by Mallampati classification than by Wilson risk-sum. Inter-observer variation was minimal using Wilson risk-sum, but considerable for Mallampati classification. We prefer the Wilson risk-sum for assessment of the airway, while noting that both tests have poor sensitivities.

Respiratory depression and melancholia

Presented is the case of the fifty-six year-old asthmatic woman, with a six-month history of a Major Depressive Episode. Following an acute respiratory crisis, requiring assisted ventilation, the depressive symptomatology resolved. The historical administration of treatments of the mentally ill, incorporating acute physiological stress, are commented upon, and hypotheses discussed concerning the possible mechanisms of action of such treatments. The induction of a delirium may be the significant therapeutic event experienced by this patient, and the common event induced by physiologically stressful treatments administered by our psychiatric forebearers.

Self-neglect of spinal injured patients

Self-neglect is a recognised, but poorly emphasised, complication of spinal cord injury, with a prevalence in this study of 9% of a consecutive sample of 400 patients. Self-neglect may be the presenting symptom of problems related to adjustment to disability, a major depressive disorder (DSM III criteria), or a clear and rational wish to die (existential self-neglect). Management is discussed, emphasising the importance of respecting spinal injured patients' autonomy.

Calenture-missing at sea?

Calenture is a behavioural phenomenon, the predominant symptom being an irresistible impulse of sailors to jump into the sea from their vessels. The original description of this phenomenon was that of ancient Spanish sailors. Psychiatric descriptions of calenture appeared in the 18th and 19th centuries; subsequent psychiatric literature has, however, made no direct reference to calenture. This article describes calenture from a historical and clinical perspective, with discussion of the phenomenon in terms of modern psychological understanding. Some implications are considered, including the possible association with the nautical term 'missing at sea'.

Breath alcohol analysis in the Accident and Emergency Department

Breath alcohol analysis was undertaken in 1044 consecutive patients aged over 15 years attending the Accident and Emergency (A and E) Department of a rural district general hospital during a 50-day period. 16.5 per cent of all patients had the smell of alcohol on their breath, with 10.2 per cent of the patients recording a breath alcohol level equivalent to a blood level of 80 mg/100 ml or more. One-third of all patients attending between 9 pm and midnight, and almost two-thirds of patients attending between midnight and 3 am had positive breath tests. Positive breath tests were most likely in males, patients with head injuries, with overdoses, in victims of assault and in patients with a depressed conscious level, irrespective of cause. Clinical estimation of intoxication by alcohol may be accurate in the co-operative patient, but in the patient with a head injury or with a depressed conscious level from another cause, this is more difficult. Breath alcohol analysis is rapid, not-invasive, accurate and of clinical value in these and other high-risk patients attending hospital as emergencies.