Prevalence of Spasticity in Nursing Home Residents

OBJECTIVES

To determine the prevalence, rate of underdiagnosis and undertreatment, and association with activities of daily living dependency of spasticity in a nursing home setting.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

This study is an analysis of a deidentified data set generated by a prior quality improvement project at a 240-bed nursing home for residents receiving long-term care or skilled nursing care services.

METHODS

Each resident was examined by a movement disorders specialist neurologist to determine whether spasticity was present and, if so, the total number of spastic postures present in upper and lower limbs was recorded. Medical records, including the Minimum Data Set, were reviewed for neurologic diagnoses associated with spasticity, activities of daily living (ADL) dependency, and prior documentation of diagnosis and past or current treatments. Ordinary least squares linear regression models were used to evaluate the association between spasticity and ADL dependency.

RESULTS

Two hundred nine residents (154 women, 81.9 ± 10.9 years) were included in this analysis. Spasticity was present in 22% (45/209) of residents examined by the neurologist. Only 11% of residents (5/45) had a prior diagnosis of spasticity and were receiving treatment. Presence of spasticity was associated with greater ADL dependency (χ² = 51.72, P < .001), which was driven by lower limb spasticity (χ² = 14.56, P = .006).

CONCLUSIONS AND IMPLICATIONS

These results suggest that spasticity (1) is common in nursing homes (1 of 5 residents), (2) is often not diagnosed or adequately treated, and (3) is associated with worse ADL dependency. Further research is needed to enhance the rates of diagnosis and treatment of spasticity in long-term care facilities.

Clinical Features of Tourette Syndrome

Tourette syndrome is a multifaceted disorder characterized by multiple motor and at least one vocal tics that start in childhood, persist for at least 1 year, and cannot be attributed to another medical condition or exposure to medications/drugs. Clinical diagnostic criteria are available, and identification of tics is typically straightforward based on characteristic appearance and features. Diagnostic uncertainty can rarely arise in cases of mild tics, atypical features, certain psychiatric comorbidities, and other non-tic movement disorders. Comorbid psychopathology, including attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive behaviors/obsessive-compulsive disorder, affects the majority of patients and is correlated with disease severity and the presence of additional psychiatric behaviors. The severity of tics often improves after adolescence, whereas psychiatric symptoms typically persist. The subset of patients in whom tics persist into adulthood experience higher rates of anxiety, and lower self-esteem, socioeconomic status, and quality of life; the relative contribution of motor tics and psychopathology is not fully understood. This article summarizes the clinical features of Tourette syndrome, including major diagnostic criteria, unique features of tics, and key aspects that differentiate tics from common mimics and chameleons. Comorbid psychiatric conditions and their impact on phenotype and quality of life are described. Finally, current understanding of the natural history is summarized, including limited research in adults with Tourette syndrome.

Postseizure aphasia in Wernicke's encephalopathy: a case report and review of literature

This case discusses the course of a woman with a history of epilepsy, alcohol use disorder, herpes simplex virus (HSV) encephalitis, and Wernicke encephalopathy (WE) who presented with altered mental status following approximately 48 hours of vomiting. After experiencing a tonic-clonic seizure in the emergency department, she developed a fluent aphasia. Aphasias are ordinarily attributed to structural changes in the brain parenchyma, often from stroke, neoplasm, or infection. When the magnetic resonance imaging of brain failed to show changes that could explain her fluent aphasia, the neurology team consulted psychiatry to workup psychogenic aphasia. During an admission 9 months earlier, she had been diagnosed with HSV encephalitis and possible WE. There was a high degree of suspicion for recurrent HSV infection, intermittent focal seizure activity, postictal psychosis, pseudobulbar affect, or a vascular cause of her fluent aphasia. After 3 days of treatment with levetiracetam, high-dose intravenous thiamine, and aripiprazole, the patient's fluent aphasia reversed. The authors conclude that the patient's reversible fluent aphasia was not psychiatric in etiology but likely caused by her seizures, the result of subtherapeutic phenytoin levels; her electroencephalogram showed focal seizure activity in the temporal lobes, possibly affecting her language centers. Language-related neurological conditions, or aphasias, can mimic psychiatric conditions such as conversion disorder or psychosis. In patients with substance use disorders, the line between psychiatric and neurological conditions becomes even more difficult to distinguish. The paper also discusses how unique aspects of her medications - levetiracetam conferring neuron membrane fluidity; aripiprazole, a drug shown to halt brain atrophy in mouse models; and parenteral thiamine to address her deficiency and WE - have aided in the reversal of the fluent aphasia. Levetiracetam should be considered in WE and the rare occurrence of aphasia after seizures.

Pilot study assessing the feasibility of applying bilateral subthalamic nucleus deep brain stimulation in very early stage Parkinson's disease: study design and rationale

BACKGROUND

Deep brain stimulation provides significant symptomatic benefit for people with advanced Parkinson's disease whose symptoms are no longer adequately controlled with medication. Preliminary evidence suggests that subthalamic nucleus stimulation may also be efficacious in early Parkinson's disease, and results of animal studies suggest that it may spare dopaminergic neurons in the substantia nigra.

OBJECTIVE

We report the methodology and design of a novel Phase I clinical trial testing the safety and tolerability of deep brain stimulation in early Parkinson's disease and discuss previous failed attempts at neuroprotection.

METHODS

We recently conducted a prospective, randomized, parallel-group, single-blind pilot clinical trial of deep brain stimulation in early Parkinson's disease. Subjects were randomized to receive either optimal drug therapy or deep brain stimulation plus optimal drug therapy. Follow-up visits occurred every six months for a period of two years and included week-long therapy washouts.

RESULTS

Thirty subjects with Hoehn & Yahr Stage II idiopathic Parkinson's disease were enrolled over a period of 32 months. Twenty-nine subjects completed all follow-up visits; one patient in the optimal drug therapy group withdrew from the study after baseline. Baseline characteristics for all thirty patients were not significantly different.

CONCLUSIONS

This study demonstrates that it is possible to recruit and retain subjects in a clinical trial testing deep brain stimulation in early Parkinson's disease. The results of this trial will be used to support the design of a Phase III, multicenter trial investigating the efficacy of deep brain stimulation in early Parkinson's disease.

Subthalamic nucleus deep brain stimulation in early stage Parkinson's disease

BACKGROUND

Deep brain stimulation (DBS) is an effective and approved therapy for advanced Parkinson's disease (PD), and a recent study suggests efficacy in mid-stage disease. This manuscript reports the results of a pilot trial investigating preliminary safety and tolerability of DBS in early PD.

METHODS

Thirty subjects with idiopathic PD (Hoehn & Yahr Stage II off medication), age 50-75, on medication ≥6 months but ≤4 years, and without motor fluctuations or dyskinesias were randomized to optimal drug therapy (ODT) (n = 15) or DBS + ODT (n = 15). Co-primary endpoints were the time to reach a 4-point worsening from baseline in the UPDRS-III off therapy and the change in levodopa equivalent daily dose from baseline to 24 months.

RESULTS

As hypothesized, the mean UPDRS total and part III scores were not significantly different on or off therapy at 24 months. Medication requirements in the DBS + ODT group were lower at all time points with a maximal difference at 18 months. With a few exceptions, differences in neuropsychological functioning were not significant. Two subjects in the DBS + ODT group suffered serious adverse events; remaining adverse events were mild or transient.

CONCLUSIONS

This study demonstrates that subjects with early stage PD will enroll in and complete trials testing invasive therapies and provides preliminary evidence that DBS is well tolerated in early PD. The results of this trial provide the data necessary to design a large, phase III, double-blind, multicenter trial investigating the safety and efficacy of DBS in early PD.

Methods for Surgical Targeting of the STN in Early-Stage Parkinson's Disease

Patients with Parkinson's disease (PD) experience progressive neurological decline, and future interventional therapies are thought to show most promise in early stages of the disease. There is much interest in therapies that target the subthalamic nucleus (STN) with surgical access. While locating STN in advanced disease patients (Hoehn-Yahr Stage III or IV) is well understood and routinely performed at many centers in the context of deep brain stimulation surgery, the ability to identify this nucleus in early-stage patients has not previously been explored in a sizeable cohort. We report surgical methods used to target the STN in 15 patients with early PD (Hoehn-Yahr Stage II), using a combination of image guided surgery, microelectrode recordings, and clinical responses to macrostimulation of the region surrounding the STN. Measures of electrophysiology (firing rates and root mean squared activity) have previously been found to be lower than in later-stage patients, however, the patterns of electrophysiology seen and dopamimetic macrostimulation effects are qualitatively similar to those seen in advanced stages. Our experience with surgical implantation of Parkinson's patients with minimal motor symptoms suggest that it remains possible to accurately target the STN in early-stage PD using traditional methods.

Potential subjects' responses to an ethics questionnaire in a phase I study of deep brain stimulation in early Parkinson's disease

BACKGROUND

Central to ethically justified clinical trial design is the need for an informed consent process responsive to how potential subjects actually comprehend study participation, especially study goals, risks, and potential benefits. This will be particularly challenging when studying deep brain stimulation and whether it impedes symptom progression in Parkinson's disease, since potential subjects will be Parkinson's patients for whom deep brain stimulation will likely have therapeutic value in the future as their disease progresses.

METHOD

As part of an expanded informed consent process for a pilot Phase I study of deep brain stimulation in early stage Parkinson's disease, an ethics questionnaire composed of 13 open-ended questions was distributed to potential subjects. The questionnaire was designed to guide potential subjects in thinking about their potential participation.

RESULTS

While the purpose of the study (safety and tolerability) was extensively presented during the informed consent process, in returned responses 70 percent focused on effectiveness and 91 percent included personal benefit as poten- tial benefit from enrolling. However, 91 percent also indicated helping other Parkinson's patients as motivation when considering whether or not to enroll.

CONCLUSIONS

This combination of responses highlights two issues to which investigators need to pay close attention in future trial designs: (1) how, and in what ways, informed consent processes reinforce potential subjects' preconceived understandings of benefit, and (2) that potential subjects see themselves as part of a community of Parkinson's sufferers with responsibilities extending beyond self-interest. More importantly, it invites speculation that a different paradigm for informed consent may be needed.

Deep brain stimulation in early Parkinson's disease: enrollment experience from a pilot trial

BACKGROUND

Deep brain stimulation (DBS) of the subthalamic nucleus is an accepted therapy for advanced Parkinson's disease (PD). In animal models, pharmacologic ablation and stimulation of the subthalamic nucleus have resulted in clinical improvement and, in some cases, improved survival of dopaminergic neurons. DBS has not been studied in the early stages of PD, but early application should be explored to evaluate safety, efficacy, and the potential to alter disease progression.

METHODS

We are conducting a prospective, randomized, single-blind clinical trial of optimal drug therapy (ODT) compared to medication plus DBS (ODT + DBS) in subjects with Hoehn & Yahr Stage II idiopathic PD who are without motor fluctuations or dementia. We report here subject screening, enrollment, baseline characteristics, and adverse events.

RESULTS

30 subjects (average age 60 ± 6.9 years, average duration of medicine 2.1 ± 1.3 years, average UPDRS-III scores 14.9 on medication and 27.0 off medication) are enrolled in the ongoing study. Twelve of 15 subjects randomized to DBS experienced perioperative adverse events, the majority of which were related to the procedure or device and resolved without sequelae. Frequently reported adverse events included wound healing problems, headache, edema, and confusion.

CONCLUSION

This report demonstrates that subjects with early stage PD can be successfully recruited, consented and retained in a long-term clinical trial of DBS. Our ongoing pilot investigation will provide important preliminary safety and tolerability data concerning the application of DBS in early stage PD.

Deep brain stimulation for early-stage Parkinson's disease: an illustrative case

OBJECTIVES

Subthalamic nucleus (STN) deep brain stimulation (DBS) is an effective intervention in advanced Parkinson's disease (PD), but its efficacy and safety in early PD are unknown. We are conducting a randomized pilot trial investigating DBS in early PD. This report describes one participant who received bilateral STN-DBS.

MATERIALS AND METHODS

Thirty subjects have been randomized to either optimal drug therapy (ODT) or DBS + ODT. Microelectrode recordings from the STN and substantia nigra are collected at implantation. The Unified Parkinson's Disease Rating Scale Motor Subscale (UPDRS-III) is administered in the ON and OFF states semi-annually and neuropsychological function and quality of life are assessed annually. We describe a 54-year-old man with a two-year history of PD who was randomized to DBS + ODT and followed for two years.

RESULTS

The subject showed a lower STN to substantia nigra ratio of neuronal activity than advanced PD patients, and higher firing rate than non-PD patients. The subject's total UPDRS and UPDRS-III scores improved during the two-year follow-up, while his OFF UPDRS-III score and levodopa equivalent daily dose increased. Quality of life, verbal fluency, and verbal learning improved. He did not experience any serious adverse events.

CONCLUSIONS

This report details the first successful application of bilateral STN-DBS for early-stage PD during a clinical trial.

Discordance in informed consent response on the basis of demographic factors: brief report

During an outcomes study of spasticity treatment at a developmental center for 62 residents with profound intellectual disabilities, either botulinum toxin A (BTX-A), intrathecal baclofen (ITB), or both were recommended with physical and occupational therapy. Conservators consented to BTX-A more than ITB (p = .021). Court-appointed conservators were more likely to provide consent for treatment than family members (p = .026). Nonparents consented more than parents (p = .009). Finally, Caucasian conservators were more likely to consent to treatment than African American conservators (p = .036), but ethnicity of the resident did not influence consent. Gender of resident or conservator did not influence rate of consent. This report highlights disparities in surrogate consent giving for individuals with intellectual disabilities and indicates a need for more research to ensure that this vulnerable population has access to appropriate treatments.

Neurotoxin injection for movement disorders

The therapeutic use of botulinum neurotoxin has exploded since the first US Food and Drug Administration indication was obtained in 1989, and today it represents the first-line therapy for several hyperkinetic movement disorders. Of the seven serotypes (A to G), types A and B have been approved for use in the United States. Two type A toxins, onabotulinumtoxinA (Botox) and abobotulinumtoxinA (Dysport), are available, and one type B toxin, rimabotulinumtoxinB (Myobloc) is available. The commercially available toxins differ by protein target, duration of action, and adverse event profile; no formula exists for interconversion. The clinical development of the toxin is outlined and methods for muscle targeting are compared. Treatment regimens should be designed to achieve a specific care or functional goal by interdisciplinary teams consisting of physicians, patients, caregivers, and therapists, when appropriate. We discuss dosing considerations and safety profiles in the context of hyperkinetic movement disorders commonly encountered by neurologists, including cervical dystonia, spasticity, pediatric spasticity, blepharospasm, focal limb dystonias, and essential tremor. Finally, the multiple illustrative cases sprinkled throughout the chapter demonstrate the highly individualized, goal-focused nature of treatment with neurotoxins.

Testing for HIV-1 infection in a public developmental center

The discovery of human immunodeficiency virus type 1 (HIV) infection in an individual who recently moved from a developmental center prompted the center to offer HIV testing to current and former residents. The guardians of 199 (93 percent) of the Center's current residents consented to testing. The remaining 14 current residents (seven percent) were not tested because informed consent for testing was not received. Consent for testing of 41 former residents was also obtained. All people who underwent testing were seronegative. Whether former residents who were not included in the present analysis received testing from other sources is not known.

Comparison of botulinum neurotoxin preparations for the treatment of cervical dystonia

BACKGROUND

Comparative studies of botulinum neurotoxin preparations to date have generally examined 2 preparations at prespecified dose ratios in relatively homogeneous groups of patients under controlled study conditions. It is unclear whether the differences in adverse-event rates that have been noted under these controlled conditions can be generalized to the broader population of cervical dystonia patients, who are treated with a wider range of doses in a variety of settings.

OBJECTIVE

We conducted a systematic review and analysis of the published literature to compare rates of dysphagia and dry mouth in studies of botulinum neurotoxin products.

METHODS

We searched the MEDLINE, EMBASE, Biosis, SciSearch, JICST (Japan Science and Technology Center), and Pascal databases from 1985 through 2006 using the terms cervical dystonia, spasmodic torticollis, and botulinum toxin for original English-language studies of Botox, Dysport, or Myobloc in the treatment of cervical dystonia (or spasmodic torticollis) that documented adverse events by treatment or patient. Studies that involved patients with various types of dystonias or movement disorders were included as long as adverse events were reported separately for those with cervical dystonia. Rates of dysphagia with the original preparation of Botox were considered separately from those with the current preparation of Botox.

RESULTS

Seventy published articles were included in the analysis (30 Botox, 24 Dysport, 3 Botox + Dysport, 11 Myobloc, 2 Botox + Myobloc). Mean total doses per treatment ranged from 60 to 374 U for Botox, 125 to 1200 U for Dysport, and 579 to 19,853 U for Myobloc. Botox was associated with a significantly lower rate of dysphagia than Dysport, with mean dysphagia rates of 10.5% for original Botox, 8.9% for current Botox, and 26.8% for Dysport (both, P < 0.05). Myobloc was associated with dry mouth (3.2%-90.0%) in 9 of 13 studies, but this adverse event was not reported in a sufficient number of studies of botulinum toxin type A preparations (Botox, n = 2; Dysport, n = 6) to permit statistical comparison. In the weighted analysis, the duration of effect differed between botulinum neurotoxin products (current Botox > Myobloc > original Botox > Dysport; all, P < 0.001), but only 43 (61.4%) of the 70 studies reported duration, and the definitions varied.

CONCLUSION

The results of this analysis indicate differences in adverse-event rates between botulinum neurotoxin preparations, suggesting that use of these products should be based on their individual dosing, efficacy, and safety profiles.

Combined treatment with BTX-A and ITB for spasticity: case report

One woman with profound mental retardation and spasticity living in a public residential developmental center was treated with intrathecal baclofen therapy and botulinum toxin type A injections. After one year of regular injections, extension across the right elbow increased 49 degrees. After one year of ITB, range of motion for left hip abduction increased 28 degrees; right hip abduction 9 degrees; left hip flexion 3 degrees; right hip flexion 1 degree; right knee flexion 31 degrees. Our case demonstrates the importance of a multidisciplinary approach in order to ease care and prevent complications. Expanded investigations should be carried out to evaluate the efficacy of combined therapy in patients with mental retardation.

Deep brain stimulation for Parkinson's disease: the Vanderbilt University Medical Center experience, 1998-2004

Deep brain stimulation (DBS) has become increasingly popular to treat the symptoms of Parkinson's disease (PD) that are no longer adequately controlled by oral medications. This report summarizes safety and efficacy outcomes for 72 patients who underwent DBS surgery at Vanderbilt University Medical Center between September 1998 and December 2004. Efficacy was measured by reduction in anti-PD medications; patients saved an average of $2,292 per year after surgery. The most common adverse event was intracranial hemorrhage (12.5 percent), which led to permanent deficits in one patient (1.4 percent) and transient deficits in five patients (6.9 percent). The next most common event was DBS lead infection in seven patients (9.7 percent). Our experience provides further evidence that DBS is one of the safest and most effective treatments for PD patients suffering from motor complications.

Depression and intelligence in patients with Parkinson's disease and deep-brain stimulation

The goal of this study is to examine the association of depression with intelligence and education in patients with Parkinson's disease treated with bilateral subthalamic nucleus stimulation (STN-DBS). The literature has been contradictory concerning depression in Parkinson's disease patients. Some studies have shown less depression in Parkinson's disease patients with more education not treated with STN-DBS. Other recently published studies indicate that STN-DBS improves the depression associated with Parkinson's disease. No studies have examined the correlation of these factors with depression in Parkinson's disease patients treated with STN-DBS. We administered the Beck Depression Inventory (BDI) pre- and postoperatively to 21 Parkinson's disease patients (seven women, 14 men, ages 49-75) who underwent STN-DBS. The postoperative scores of the lower 50th percentile (n=8) of the Verbal Comprehensive Index of the Wechsler Adult Intelligence Scale (WAIS-III) decreased significantly (P=0.036), while the upper 50th percentile (n=13) remained nearly constant (P=0.802). Furthermore, as the education increased from highschool to graduate level, patients demonstrated less improvement in depressive symptoms postoperatively. These findings suggest that Parkinson's disease patients with lower intelligence test scores and less education benefit more with regards to depressive symptomatology after STN-DBS than patients with higher scores and education.

Difficulty in securing treatment for degenerative hip disease in a patient with Down syndrome: the gap remains open

In 2002, the office of the U.S. surgeon general published a report detailing the discrepancies between the quality of healthcare afforded to persons with and without mental retardation. This article examines the case of a female resident of a developmental center with profound mental retardation due to Down syndrome and degenerative hip disease. Although she was in urgent need of a total hip replacement, the operation was denied or delayed by several different surgeons. Using a survey of physician attitudes, we examine several possible motivations behind the surgeons' reluctance to perform the procedure and conclude that these reasons were not appropriate in this case. Finally, we reiterate the surgeon general's call to eradicate preconceptions held in the medical community about the population of persons with mental retardation that result in similar failures to provide adequate care.

Deep brain stimulation of the subthalamic nucleus reduces antiparkinsonian medication costs

This study reports a retrospective analysis of 16 patients to determine changes in medication costs associated with deep brain stimulation of the bilateral subthalamic nucleus (DBS B-STN). Antiparkinsonian medication (APMED) costs were evaluated pre- and post-operatively at 1 and 2 years, based on prescribed dosages. After treatment with DBS, patients experienced a 32% reduction in APMED costs after 1 year and a 39% reduction after 2 years. Hypothetical projections of total potential savings are presented, accounting for increasingly complex medication regimens and medication cost inflation. DBS patients may experience a significant long-term reduction in the cost of their pharmacologic treatment.

Bilateral globus pallidus internus deep brain stimulation therapy for primary generalized dystonia

Primary generalized dystonia (PGD) associated with the early-onset generalized dystonia gene (DYT1) can cause severe disability, compromising an individual's ability to perform activities of daily living. Pharmacological treatment has been inadequate in alleviating the motor dysfunctions. Deep brain stimulation of the bilateral globus pallidus internus (DBS B-GPi) has been documented to reduce these debilitating motor abnormalities. This report details the successful treatment of a DYT1-positive 13 year-old boy suffering from PGD.

Botulinum toxin type A therapy during pregnancy

Injection with botulinum toxin type A (Botox) is a safe and efficacious treatment for idiopathic cervical dystonia. We present the first case report of clinical Botox treatment during pregnancy. This patient underwent four apparently uncomplicated full-term pregnancies while receiving regular Botox treatments.

Occurrence of depressive symptoms in Shy-Drager syndrome

We investigated the frequency and severity of depressive symptoms among patients with Shy-Drager Syndrome (SDS) and correlated depression with the extent of the patients' disability. Data were collected from 15 patients and their spouse caregivers through a mailed questionnaire. The patients were asked to complete the Beck Depression Inventory (BDI) questionnaire, while caregivers were asked to complete the self-assessment Parkinson's Disease Disability Scale and The Northwestern University Disability Scale for Parkinson's Disease. Data were statistically analyzed using descriptive statistics and Pearson-Product moment correlations. The prevalence of depressive symptoms was 85.7%; 28.6% of SDS patients scored in the moderately to severely depressed range. There was no significant correlation between the severity of depressive symptoms and disability (r = 0.02, p = 0.94) and the ability to perform activities of daily living (r = 0.0, p = 1.0). The prevalence of depressive symptoms in patients with SDS is common. The patient's level of depression does not correlate with physical disability. Pharmacologic management and interventions aimed at increasing active coping methods should improve quality of life.

Podiatric medical education. A view into the next century

The authors examine the future of podiatric medicine through an analysis of the characteristics of students presently enrolled in the colleges of podiatric medicine and the characteristics of college graduates from 1990 to 1995. Specific attention is also given to a number of critical issues surrounding graduate podiatric medical education. The authors conclude that despite a growing number of challenges awaiting podiatric medical education, the present complement of students and graduates of the colleges of podiatric medicine appear to offer the public reasonable expectations for quality foot care.

Oxprenolol plus ethanol causes no central nervous system depression--a comparison with lorazepam plus ethanol

Oxprenolol, a fat-soluble beta-adrenergic blocker, promoted as an anxiolytic agent to alleviate peripheral symptoms associated with anxiety, and lorazepam, a 1,4-benzodiazepine anxiolytic drug, may both depress central nervous system (CNS) function. It is generally accepted that ethanol, when concurrently ingested, potentiates the CNS-depressant effects of drugs. The effects on CNS function of oxprenolol, lorazepam and placebo alone and in combination with ethanol were determined by a Leeds Psychomotor Tester and we concluded that oxprenolol in combination with ethanol is less hazardous to people operating power tools/machines or driving motor vehicles than the combination of lorazepam with ethanol.