Vestibulo-Ocular Reflex Suppression: Clinical Relevance and Assessment in the Digital Age

Background

Visual acuity and image stability are crucial for daily activities, particularly during head motion. The vestibulo-ocular reflex (VOR) and its suppression (VORS) support stable fixation of objects of interest. The VOR drives a reflexive eye movement to counter retinal slip of a stable target during head motion. In contrast, VORS inhibits this countermovement when the target stimulus is in motion. The VORS allows for object fixation when it aligns with the direction of the head's movement, or when an object within or outside the peripheral vision needs to be focused upon.

Summary

Deficits of the VORS have been linked to age-related diseases such as balance deficits associated with an increased fall risk. Therefore, the accurate assessment of the VORS is of particular clinical relevance. However, current clinical assessment methods for VORS are mainly qualitative and not sufficiently standardised. Recent advances in digital health technology, such as smartphone-based videooculography, offer a promising alternative for assessing VORS in a more accessible, efficient, and quantitative manner. Moreover, integrating mobile eye-tracking technology with virtual reality environments allows for the implementation of controlled VORS assessments with different visual inputs. These assessment approaches allow the extraction of novel parameters with potential pathomechanistic and clinical relevance.

Key Messages

We argue that researchers and clinicians can obtain a more nuanced understanding of this ocular stabilisation reflex and its associated pathologies by harnessing digital health technology for VORS assessment. Further research is warranted to explore the technologies' full potential and utility in clinical practice.

Nationwide Retrospective Analysis of Combinations of Advanced Therapies in Patients With Parkinson Disease

BACKGROUND AND OBJECTIVES

Advanced therapies (ATs; deep brain stimulation [DBS] or pump therapies: continuous subcutaneous apomorphine infusion [CSAI], levodopa/carbidopa intestinal gel [LCIG]) are used in later stages of Parkinson disease (PD). However, decreasing efficacy over time and/or side effects may require an AT change or combination in individual patients. Current knowledge about changing or combining ATs is limited to mostly retrospective and small-scale studies. The nationwide case collection Combinations of Advanced Therapies in PD assessed simultaneous or sequential AT combinations in Germany since 2005 to analyze their clinical outcome, their side effects, and the reasons for AT modifications.

METHODS

Data were acquired retrospectively by modular questionnaires in 22 PD centers throughout Germany based on clinical records and comprised general information about the centers/patients, clinical (Mini-Mental Status Test/Montréal Cognitive Assessment, Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale [MDS-UPDRS], side effects, reasons for AT modification), and therapeutical (ATs with specifications, oral medication) data. Data assessment started with initiation of the second AT.

RESULTS

A total of 148 AT modifications in 116 patients were associated with significantly improved objective (median decrease of MDS-UPDRS Part III 4.0 points [p < 0.001], of MDS-UPDRS Part IV 6.0 points [p < 0.001], of MDS-UPDRS Part IV-off-time item 1.0 points [p < 0.001]) and subjective clinical outcome and decreasing side effect rates. Main reasons for an AT modification were insufficient symptom control and side effects of the previous therapy. Subgroup analyses suggest addition of DBS in AT patients with leading dyskinesia, addition of LCIG for leading other cardinal motor symptoms, and addition of LCIG or CSAI for dominant off-time. The most long-lasting therapy-until requiring a modification-was DBS.

DISCUSSION

Changing or combining ATs may be beneficial when 1 AT is insufficient in efficacy or side effects. The outcome of an AT combination is comparable with the clinical benefit by introducing the first AT. The added AT should be chosen dependent on dominant clinical symptoms and adverse effects. Furthermore, prospective trials are needed to confirm the results of this exploratory case collection.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that, in patients with PD, changing or combining ATs is associated with an improvement in the MDS-UPDRS or subjective symptom reporting.

Application of single wrist-wearable accelerometry for objective motor diary assessment in fluctuating Parkinson's disease

Advanced Parkinson's disease (PD) is characterized by motor fluctuations including unpredictable oscillations remarkably impairing quality of life. Effective management and development of novel therapies for these response fluctuations largely depend on clinical rating instruments such as the widely-used PD home diary, which are associated with biases and errors. Recent advancements in digital health technologies provide user-friendly wearables that can be tailored for continuous monitoring of motor fluctuations. Their criterion validity under real-world conditions using clinical examination as the gold standard remains to be determined. We prospectively examined this validity of a wearable accelerometer-based digital Parkinson's Motor Diary (adPMD) using the Parkinson's Kinetigraph (PKG®) in an alternative application by converting its continuous data into one of the three motor categories of the PD home diary (Off, On and Dyskinetic state). Sixty-three out of 91 eligible participants with fluctuating PD (46% men, average age 66) had predefined sufficient adPMD datasets (>70% of half-hour periods) from 2 consecutive days. 92% of per-protocol assessments were completed. adPMD monitoring of daily times in motor states showed moderate validity for Off and Dyskinetic state (ICC = 0.43-0.51), while inter-rating methods agreements on half-hour-level can be characterized as poor (median Cohen's κ = 0.13-0.21). Individualization of adPMD thresholds for transferring accelerometer data into diary categories improved temporal agreements up to moderate level for Dyskinetic state detection (median Cohen's κ = 0.25-0.41). Here we report that adPMD real-world-monitoring captures daily times in Off and Dyskinetic state in advanced PD with moderate validities, while temporal agreement of adPMD and clinical observer diary data is limited.

Arm swing deviations in patients with Parkinson's disease at different gait velocities

Asymmetry of arm swing (AS) has been described as a characteristic of normal physiological gait. In patients with Parkinson's disease (PWPD), a one-sided reduction of AS can occur already as a prodromal symptom. There is limited evidence regarding AS in PWPD, but a growing interest in AS as a focus of exercise therapy. The differences of AS between 32 healthy subjects (HS) and 36 mildly-to-moderately impaired PWPD were assessed in overground walking at various gait speeds. Assessments were carried out with a sensor-based gait measurement system over a 40 m walk in very slow, slow, preferred, fast, and very fast gait speed. Longitudinal and AS kinematics were compared with ANOVA function and regression analysis. PWPD exhibited a one-sided reduction of AS compared to HS at normal, fast, and very fast walking. AS coordination, representing the timing of reciprocity of right and left AS, was reduced in PWPD in very slow and normal walking. With respect to leg movements, PWPD exhibited an increase in stride time variability in very slow gait. There were no group differences for cadence, stride length, and gait velocity. This study informs about the kinematics of AS at various gait velocities ranging from very slow to very fast in mildly-to-moderately impaired PWPD. Reduced one-sided AS can be considered as a very early sign of parkinsonian gait disturbance that precedes alterations of locomotive leg movements and improves at faster gait speeds.

Fear of Progression is Determined by Anxiety and Self-Efficacy but not Disease-Specific Parameters in Patients with Parkinson's Disease: Preliminary Data from a Multicenter Cross-Sectional Study

BACKGROUND

Fear of progression (FoP) is a reactive, conscious concern about chronic disease progression and its consequences which may limit quality of life substantially. Only one study has examined FoP in Parkinson's disease (PD), showing the second highest FoP scores among chronic diseases.

OBJECTIVE

To examine FoP prevalence and to exploratorily analyze determinants of FoP in PD.

METHODS

Within a multicenter cross-sectional study, 120 PD inpatients (age: 64.45±9.20; 60.8% male; UPDRS-III: 28.86±16.12) were examined with the FoP questionnaire (FoP-Q; max. 20 points). Stepwise multiple linear regression analysis examined sociodemographic, clinical, and (neuro-) psychological determinants of FoP.

RESULTS

With a mean FoP-Q score of 8.08±2.17, 63.0% of the patients were classified with moderate FoP and 17.6% with dysfunctional (i.e., severe) FoP. The highest scores were shown for the subscale 'loss of autonomy'. Increased levels of anxiety, less self-efficacy, female gender, current employment, and lower health literacy were identified as significant determinants associated with FoP.

CONCLUSION

With more than 80% of patients showing moderate to dysfunctional FoP, it must be regarded as a frequent symptom in PD, which needs to be further understood and addressed in clinical practice. Clinical parameters like PD duration and severity were no determinants for FoP, indicating that FoP awareness must be considered by professionals at all disease stages.

The safety/tolerability of opicapone when used early in Parkinson's disease patients with levodopa-induced motor fluctuations: A post-hoc analysis of BIPARK-I and II

Introduction

Post-hoc analyses of the BIPARK-I and II trials previously demonstrated that opicapone (OPC) 50 mg was efficacious over the whole trajectory of motor fluctuation evolution in patients with Parkinson's disease (PD) and end-of-dose motor fluctuations, with enhanced efficacy in patients who were earlier vs. later in their disease course and levodopa treatment pathway. Complementary post-hoc analyses were performed to evaluate the safety/tolerability of OPC following the same pre-defined segmentation of the wide spectrum of duration of both PD and levodopa therapy, as well as of motor fluctuation history, in this patient population.

Materials and methods

Data from matching treatment arms in BIPARK-I and II were combined for the placebo (PLC) and OPC 50 mg groups and exploratory post-hoc analyses were performed to investigate the safety/tolerability of OPC 50 mg and PLC in 22 subgroups of patients who were in “earlier” vs. “later” stages of both their disease course (e.g., duration of PD <6 years vs. ≥6 years) and levodopa treatment pathway (e.g., levodopa treatment duration <4 vs. ≥4 years). Safety/tolerability assessments included evaluation of treatment-emergent adverse events (TEAEs).

Results

The Safety Set included 522 patients (PLC, n = 257; OPC 50 mg, n = 265). For OPC 50 mg, incidences of TEAEs, related TEAEs, related serious TEAEs, and related TEAEs leading to discontinuation were lower for patients in earlier vs. later stages of their disease course and levodopa treatment pathway in 86.4, 86.4, 63.6, and 68.2% of the 22 pairwise comparisons conducted, respectively (compared with 63.6, 77.3, 18.2, and 45.5%, respectively, in the 22 corresponding PLC comparisons).

Conclusion

OPC 50 mg was generally well-tolerated when used to treat patients with PD with end-of-dose fluctuations, with an even more favorable tolerability profile in patients who were earlier, as opposed to later, in their disease course and levodopa treatment pathway, further supporting its use as an early adjunct to levodopa in PD.

Objective Observer vs. Patient Motor State Assessments Using the PD Home Diary in Advanced Parkinson's Disease

Background

The Parkinson Disease (PD) Home Diary (HD) is a commonly used clinical outcome measure, but it has not been extensively compared to direct assessments by experienced observers.

Objective

Validation of patient-reported HD by investigating the agreement between motor state assessments by patients and observers.

Methods

This observational study included patients with PD and motor fluctuations. Observers were physicians or research nurses. Patients completed a screening visit, one day of diary ratings at home, and then two days of ratings on-site during which patients and observers simultaneously judged the participants' motor state.

Results

Observers and 40 patients completed 1,288 pairs of half-hourly blinded motor state assessments. There were significant differences between observer and patient ratings (P &lt; 0.001) and the temporal agreement was poor (Cohen's κ = 0.358). The agreement between patient and observer ratings was 71.1% for observed “On without dyskinesia”, 57.3% for observed “Off”, and 49.4% for observed “On with dyskinesia”. Daily times spent in the three motor states as aggregated diary data showed fair to excellent reliability with intraclass coefficient values ranging from 0.45 to 0.52 for “On” and 0.77 for “Off”.

Conclusion

There were significant differences between observer and patient ratings. Patients and observers generally agreed on when the patients was in the “On” state (with or without dyskinesia). Patient ratings on the hour level seem to be influenced by other aspects of the patients' experience than the observed motor state, but assessment of daily time spent in the different motor state provides reasonable reliability.

Sexual Dysfunctions in Parkinson’s Disease and Their Influence on Partnership—Data of the PRISM Study

Background: Sexual dysfunctions (SD) are common but underreported in Parkinson’s disease (PD) and have negative impacts on the quality of life (QoL) and partnership. Methods: We analyzed the data set from the PRISM study for demographics of SD and their influence on quality of life and partnership. Results: 449/861 (52.1%) PD patients reported SD, with male patients being affected more often and having a longer course of disease. The most common SD in men was erectile dysfunction (ED) (n = 152), while women’s most frequent complaints were orgasm dysfunction (n = 84) and reduced libido (n = 81). Hypersexual SDs were reported significantly more often by men. Spousal caregivers of patients reporting inability to relax and enjoy sex and reduced libido indicated a negative influence on the relationship in general. Negative effects on the sexual relationship were reported significantly more often for patients with ED, difficulties with sexual arousal, inability to relax and enjoy sex, and reduced libido. Hypersexual dysfunctions showed no effect on the relationship. Conclusion: SD is a common but underreported problem in the treatment of patients with PD. Due to the negative influence on the relationship and QoL of patients and caregivers, SD should be assessed routinely.

[Development and content validation of a questionnaire for functional movement disorders]

Von Kriegszitterern zu Teenies mit TikTok-Tics – funktionelle Bewegungsstörungen galten lange als motorischer Ausdruck seelischer Turbulenzen. Tatsächlich werden psychodynamische Modelle jedoch zunehmend durch neurophysiologische Erkenntnisse ergänzt, sodass die Kombination von Psychotherapie mit spezialisierter Physiotherapie an Bedeutung gewinnt. Bislang existiert allerdings kein störungsspezifisches Ergebnismaß, welches patientenrelevante Aspekte dieser vielfältigen Störung adäquat abbildet. Ein erster derartiger Fragebogen wurde entwickelt und in einem mehrstufigen Entwicklungsprozess inhaltlich validiert. Relevanz und Verständlichkeit der Items wurden zuerst durch ein Expertengremium und anschließend durch betroffene Patienten evaluiert und entsprechend angepasst. Der so konstruierte Fragebogen erlaubt erstmals eine inhaltlich valide Quantifizierung der subjektiven Beschwerden und Auswirkungen funktioneller Bewegungsstörungen. Als Nächstes erfolgt eine multizentrische teststatistische Validierung.

The Added Benefit of Opicapone When Used Early in Parkinson's Disease Patients With Levodopa-Induced Motor Fluctuations: A Post-hoc Analysis of BIPARK-I and -II

Introduction: Opicapone (OPC) was efficacious in reducing OFF-time in two pivotal trials in patients with Parkinson's disease (PD) and end-of-dose motor fluctuations (BIPARK-I and -II). Post-hoc analyses of these trials evaluated the efficacy of OPC following pre-defined segmentation of the wide spectrum of motor fluctuations in PD.

Methods: Data from matching treatment arms in BIPARK-I and -II were combined for the placebo (PLC) and OPC 50-mg groups, and exploratory post-hoc analyses were performed to investigate the efficacy of OPC 50 mg vs. PLC in subgroups of patients who were in “earlier” vs. “later” stages of both their disease course (e.g., duration of PD <6 years vs. ≥6 years) and levodopa treatment pathway (e.g., number of daily levodopa intakes <4 vs. ≥4). Efficacy variables included changes from baseline in absolute OFF-time and total ON-time.

Results: The Full Analysis Set included 517 patients (PLC, n = 255; OPC 50 mg, n = 262). OPC 50 mg was significantly more effective than PLC in reducing OFF-time and increasing ON-time in the majority of subgroup analyses (p < 0.05). Moreover, patients in “earlier” stages of both their disease course and levodopa treatment pathway experienced numerically greater efficacy when using OPC 50 mg, in comparison with those in “later” stages.

Conclusion: OPC 50 mg was efficacious over the whole trajectory of motor fluctuation evolution in PD patients. There was also a signal for enhanced efficacy in patients who were earlier vs. later in their disease course and levodopa treatment pathway.

Endoscopic Characteristics of Dysphagia in Multiple System Atrophy Compared to Parkinson's Disease

BACKGROUND

Dysphagia is a major clinical concern in multiple system atrophy (MSA). A detailed evaluation of its major endoscopic features compared with Parkinson's disease (PD) is lacking.

OBJECTIVE

This study systematically assessed dysphagia in MSA compared with PD and correlated subjective dysphagia to objective endoscopic findings.

METHODS

Fifty-seven patients with MSA (median, 64 [interquartile range (IQR): 59-71] years; 35 women) underwent flexible endoscopic evaluation of swallowing using a specific MSA-flexible endoscopic evaluation of swallowing task protocol. Findings were compared with an age-matched cohort of 57 patients with PD (median, 67 [interquartile range: 60-73] years; 28 women). In a subcohort, subjective dysphagia was assessed using the Swallowing Disturbance Questionnaire and correlated to endoscopy findings.

RESULTS

Patients with MSA predominantly showed symptoms suggestive of oral-phase disturbance (premature spillage, 75.4%, piecemeal deglutition, 75.4%). Pharyngeal-phase symptoms occurred less often (pharyngeal residues, 50.9%; penetration/aspiration, 28.1%). In contrast, pharyngeal symptoms were the most common finding in PD (pharyngeal residues, 47.4%). Oral symptoms occurred less frequently in PD (premature spillage, 15.8%, P < 0.001; piecemeal deglutition, 1.8%, P < 0.01). Patients with MSA had a greater risk for oral-phase disturbances with increased disease severity (P < 0.05; odds ratio, 3.15). Patients with MSA showed a significantly higher intraindividual interswallow variability compared with PD. When correlating Swallowing Disturbance Questionnaire scores with endoscopy results, its cutoff, validated for PD, was not sensitive enough to identify patients with MSA with dysphagia. We developed a subscore for identifying dysphagia in MSA and calculated a new cutoff (sensitivity 85%, specificity 100%).

CONCLUSIONS

In contrast with patients with PD, patients with dysphagic MSA more frequently present with oral-phase symptoms and a significantly higher intraindividual interswallow variability. A novel Swallowing Disturbance Questionnaire MSA subscore may be a valuable tool to identify patients with MSA with early oropharyngeal dysphagia. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

The Power of Musification: Sensor-Based Music Feedback Improves Arm Swing in Parkinson's Disease

Background

Reduction of arm swing during gait is an early and common symptom in Parkinson's disease (PD). By using the technology of a mobile phone, acceleration of arm swing can be converted into a closed‐loop musical feedback (musification) to improve gait.

Objectives

To assess arm swing in healthy subjects and the effects of musification on arm swing amplitude and other gait parameters in patients with PD.

Methods

Gait kinematics were analyzed in 30 patients during a 320 m walk in 3 different conditions comprising (1) normal walking; (2) focused swinging of the more affected arm; and (3) with musification of arm swing provided by the iPhone application CuraSwing. The acceleration of arm swing was converted into musical feedback. Arm swing range of motion and further gait kinematics were analyzed. In addition, arm swing in patients was compared to 32 healthy subjects walking at normal, slow, and fast speeds.

Results

Musification led to a large and bilateral increase of arm swing range of motion in patients. The increase was greater on the more affected side of the patient (+529.5% compared to baseline). In addition, symmetry of arm swing, sternum rotation, and stride length increased. With musical feedback patients with PD reached arm swing movements within or above the range of healthy subjects.

Conclusions

Musification has an immediate effect on arm swing and other gait kinematics in PD. The results suggest that closed‐loop musical feedback is an effective technique to improve walking in patients with PD.

Subcutaneous Levodopa Infusion for Parkinson's Disease: 1-Year Data from the Open-Label BeyoND Study

BACKGROUND

Continuous, subcutaneous (SC) levodopa/carbidopa infusion with ND0612 is under development as a treatment for patients with Parkinson's disease (PD) and motor fluctuations.

OBJECTIVE

Evaluate 1-year safety data.

METHODS

BeyoND is an open-label study evaluating the long-term safety of two ND0612 dosing regimens.

RESULTS

Of the 214 enrolled patients (24-hour SC infusion: n = 90; 16-hour SC infusion: n = 124), 120 (56%) completed 12 months of treatment. Leading causes for study discontinuation were consent withdrawal (19.6%) and adverse events (17.3%). Rates of discontinuation were reduced from 49% to 29% after a protocol revision and retraining. Systemic safety was typical for PD patients treated with levodopa/carbidopa. Most patients experienced infusion site reactions, particularly nodules (30.8%) and hematoma (25.2%), which were judged mostly mild to moderate and led to discontinuation in only 10.3% of the participants.

CONCLUSIONS

Subcutaneous levodopa/carbidopa continuous infusion with ND0612 is generally safe, with typical infusion site reactions for SC delivery as the main adverse event. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

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.

Evaluation of Individualized Multi-Disciplinary Inpatient Treatment for Functional Movement Disorders

BACKGROUND

Functional movement disorders (FMD) are associated with considerable morbidity and impairment of quality of life. Specialized treatment is scarce and data on efficacy of different therapies are limited.

OBJECTIVE

To evaluate a multi-modal inpatient treatment program for patients with FMD.

METHODS

Thirty-one patients with FMD were analyzed before (t1) and after multi-modal inpatient treatment (t2) by a blinded video rating using the Psychogenic Movement Disorder Rating Scale (PMDRS), the simplified Functional Movement Disorder Rating Scale (S-FMDRS), and the Clinical Global Impression Scale of Severity (CGI-S), as well as patients' self-rating. In 23 out of 31 patients a 5 months follow-up investigation was performed (t3). Wilcoxon signed-rank test and Friedman test were used for rating scale and self-rating comparisons over time. Spearman correlation was used for correlation of symptom improvement and clinical characteristics.

RESULTS

Video rating revealed significant reduction of scores after therapy (median PMDRS t1 = 24, t2 = 8, P = 0.0006; S-FMDRS t1 = 11, t2 = 4, P = 0.008; CGI-S t1 = 4, t2 = 3, P = 0.000136) with sustained score decrease in follow-up evaluations (PMDRS t1 = 31, t2 = 8, t3 = 7, P = 0.000032; S-FMDRS t1 = 12, t2 = 4, t3 = 3, P = 0.000888; CGI-S t1 = 4, t2 = 3, t3 = 3, P = 0.000032). Patients reported a stable reduction of symptoms in the self-rating (CGI-S t1 = 5, t2 = 4, t3 = 4, P = 0.016). Age correlated with treatment response with older patients showing better improvement, but disease duration did not correlate with outcome. Patients who suffered from physical trauma, sexual or physical abuse had smaller score reductions.

CONCLUSION

Blinded video and self-rating assessment showed significant score reduction in patients with FMD after an individualized interdisciplinary inpatient intervention.

Laryngeal Movement Disorders in Multiple System Atrophy: A Diagnostic Biomarker?

Background

Multiple system atrophy (MSA) is a rare neurodegenerative disorder, and its parkinsonian variant can be difficult to delineate from Parkinson's disease (PD). Despite laryngeal dysfunction being associated with decreased life expectancy and quality of life, systematic assessments of laryngeal dysfunction in large cohorts are missing.

Objectives

The objective of this study was to systematically assess laryngeal dysfunction in MSA and PD and identify laryngeal symptoms that allow for differentiating MSA from PD.

Methods

Patients with probable or possible MSA underwent flexible endoscopic evaluation of swallowing performing a systematic task protocol. Findings were compared with an age‐matched PD cohort.

Results

A total of 57 patients with MSA (64 [59–71] years; 35 women) were included, and task assessments during endoscopic examination compared with 57 patients with PD (67 [60–73]; 28 women). Patients with MSA had a shorter disease duration (4 [3–5] years vs 7 [5–10]; P < 0.0001) and higher disease severity (Hoehn & Yahr stage 4 [3–4] vs 3 [2–4]; P < 0.0001). Of the patients with MSA, 43.9% showed clinically overt laryngeal dysfunction with inspiratory stridor. During endoscopic task assessment, however, 93% of patients with MSA demonstrated laryngeal dysfunction in contrast with only 1.8% of patients with PD (P < 0.0001). Irregular arytenoid cartilages movements were present in 91.2% of patients with MSA, but in no patients with PD (P < 0.0001). Further findings included vocal fold motion impairment (75.4%), paradoxical vocal fold motion (33.3%), and vocal fold fixation (19.3%). One patient with PD showed vocal fold motion impairment.

Conclusion

Laryngeal movement disorders are highly prevalent in patients with MSA when assessed by a specific task protocol despite the lack of overt clinical symptoms. Our data suggest that irregular arytenoid cartilage movements could be used as a clinical marker to delineate MSA from PD with a specificity of 1.0 and sensitivity 0.9. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Recommendations for the Organization of Multidisciplinary Clinical Care Teams in Parkinson's Disease

Background:

Optimal management in expert centers for Parkinson’s disease (PD) usually involves pharmacological and non-pharmacological interventions, delivered by a multidisciplinary approach. However, there is no guideline specifying how this model should be organized. Consequently, the nature of multidisciplinary care varies widely.

Objective:

To optimize care delivery, we aimed to provide recommendations for the organization of multidisciplinary care in PD.

Methods:

Twenty expert centers in the field of multidisciplinary PD care participated. Their leading neurologists completed a survey covering eight themes: elements for optimal multidisciplinary care; team members; role of patients and care partners; team coordination; team meetings; inpatient versus outpatient care; telehealth; and challenges towards multidisciplinary care. During a consensus meeting, outcomes were incorporated into concept recommendations that were reviewed by each center’s multidisciplinary team. Three patient organizations rated the recommendations according to patient priorities. Based on this feedback, a final set of recommendations (essential elements for delivery of multidisciplinary care) and considerations (desirable elements) was developed.

Results:

We developed 30 recommendations and 10 considerations. The patient organizations rated the following recommendations as most important: care is organized in a patient-centered way; every newly diagnosed patient has access to a core multidisciplinary team; and each team has a coordinator. A checklist was created to further facilitate its implementation.

Conclusion:

We provide a practical tool to improve multidisciplinary care for persons with PD at the organizational level. Future studies should focus on implementing these recommendations in clinical practice, evaluating their potential applicability and effectiveness, and comparing alternative models of PD care.

Diagnostic accuracy of a smartphone bedside test to assess the fixation suppression of the vestibulo-ocular reflex: when nothing else matters

OBJECTIVE

Validation of a bedside test to objectify the fixation suppression of the vestibulo-ocular reflex (FS-VOR) in patients with a cerebellar syndrome and healthy controls.

METHODS

The vestibulo-ocular reflex and its fixation suppression were assessed by video-nystagmography (VNG) in 20 healthy subjects (mean age 56 ± 15) and 19 patients with a cerebellar syndrome (mean age 70 ± 11). The statistical cutoff delineating normal from pathological FS-VOR was determined at the 2.5th percentile of the normal distribution of the healthy cohort. VNG was then compared to a bedside test, where eye movements were recorded with a smartphone while patients were rotated on a swivel chair at a defined speed and amplitude. These videos were rated as normal or pathological FS-VOR by six blinded raters, and results compared to VNG.

RESULTS

VNG in healthy controls showed FS-VOR with a reduction of nystagmus beats by 95.0% ± 7.2 (mean ± SD). The statistical cutoff was set at 80.6%. Cerebellar patients reduced nystagmus beats by only 26.3% ± 25.1. Inter-rater agreement of the smartphone video ratings was 85%. The sensitivity of the video ratings to detect an impaired FS-VOR was 99%, its specificity 92%. Inter-test agreement was 91%.

CONCLUSION

The smartphone bedside test is an easily performed, reliable, sensitive, specific, and inexpensive alternative for assessing FS-VOR.

[New Therapeutic Options for the Individualised Titration of Levodopa]

Levodopa is the most effective medication in the treatment of Parkinson's disease. In the course of the disease the storage facility of dopaminergic neurones deteriorates, so that the duration of the half-life period likewise converges. This results in fluctuations in performance, and also in dyskinesias as a further consequence of the narrowing therapeutic window. Therapeutically, this in turn leads to further fractioning of the levodopa dosage and a reduction of single-dose levels. There is, however, only limited scope for doing this with the conventional levodopa formulations. For this reason, the introduction of water-soluble microtablets à 5 / 1.25 mg levodopa / carbidopa can be regarded as a beneficial extension permitting for fine titration of the dopaminergic stimulation. Here we present this new therapeutic principle, the available data and concepts for clinical use.

Neurogeriatrics-a vision for improved care and research for geriatric patients with predominating neurological disabilities

Geriatric medicine is a rapidly evolving field that addresses diagnostic, therapeutic and care aspects of older adults. Some disabilities and disorders affecting cognition (e.g. dementia), motor function (e.g. stroke, Parkinson’s disease, neuropathies), mood (e.g. depression), behavior (e.g. delirium) and chronic pain disorders are particularly frequent in old subjects. As knowledge about these age-associated conditions and disabilities is steadily increasing, the integral implementation of neurogeriatric knowledge in geriatric medicine and specific neurogeriatric research is essential to develop the field. This article discusses how neurological know-how could be integrated in academic geriatric medicine to improve care of neurogeriatric patients, to foster neurogeriatric research and training concepts and to provide innovative care concepts for geriatric patients with predominant neurological conditions and disabilities.

[Delirium in idiopathic Parkinson's disease]

BACKGROUND

The development of delirium in patients with idiopathic Parkinson's disease (IPD) is a feared complication, which is often associated with sustained worsening of motor symptoms and psychopathological sequelae. Little is known regarding the prevalence and incidence rates, course and prognosis. Clinical studies from which recommendations for evidence-based management of delirium in IPD can be derived are lacking.

OBJECTIVE

To summarize the state of the art regarding epidemiological and clinical features of delirium in IPD. Discussion of prevention strategies and non-pharmacological and pharmacological treatment options.

METHODS

A literature search was carried out in PubMed.

RESULTS

The IPD is an independent risk factor for the development of delirium. Patients with IPD show poorer clinical outcome frequently with cognitive worsening and motor complications following development of delirium.

CONCLUSION

So far no validated rating scales for recognition and course evaluation of delirium in IPD are available. Preventive strategies and non-pharmacological measures should be consistently implemented to improve management. There are insufficient data concerning pharmacotherapy with quetiapine and clozapine, whereas other neuroleptics are contraindicated for delirium in IPD due to antidopaminergic side effects.

Evidence for the use of cannabinoids in Parkinson's disease

Cannabis and synthetic cannabinoid formulations have now been legally approved in several countries for treatment of patients with Parkinson's disease (PD). Hence, PD patients consult physicians more frequently for prescription of cannabinoids to alleviate symptoms that might not respond well to dopaminergic treatment. Despite the increasing volume of research generated in the field of cannabinoids and their effect on Parkinson's disease, there is still paucity of sufficient clinical data about the efficacy and safety in PD patients. There is increasing understanding of the endocannabinoid system, and the distribution of cannabinoid receptors in basal ganglia structures might suggest potential benefit on parkinsonian symptoms. Concerning clinical research, only one of to date four conducted randomized placebo-controlled trials showed an effect on motor symptoms with alleviation of levodopa-induced dyskinesia. There are a growing number of uncontrolled trials and case reports that suggest beneficial effects of cannabinoids in PD patients. However, the variety of substances investigated, the varying routes of intake, differing doses and time courses make it difficult to compare data. We here provide an overview of the current literature in this field and discuss a pragmatic approach for the clinical use of cannabinoids in PD.

The Shaking Palsy of the Larynx-Potential Biomarker for Multiple System Atrophy: A Pilot Study and Literature Review

In its early stages multiple system atrophy (MSA), a neurodegenerative movement disorder, can be difficult to differentiate from idiopathic Parkinson's disease (PD), and emphasis has been put on identifying premotor symptoms to allow for its early identification. The occurrence of vegetative symptoms in addition to motor impairment, such as orthostatic hypotension and neurogenic bladder dysfunction, enable the clinical diagnosis in the advanced stages of the disease. Usually with further disease progression, laryngeal abnormalities become clinically evident and can manifest in laryngeal stridor due to impaired vocal fold motion, such as vocal fold abduction restriction, mostly referred to as vocal fold paresis, or paradoxical vocal fold adduction during inspiration. While the pathogenesis of laryngeal stridor is discussed controversially, its occurrence is clearly associated with reduced life expectancy. Before the clinical manifestation of laryngeal dysfunction however, abnormal vocal fold motion can already be seen in patients that might not yet fulfill the diagnostic criteria of MSA. In this article we summarize the current literature on pharyngolaryngeal findings in MSA and report preliminary findings from a pilot study investigating eight consecutive MSA patients. Patients showed varying speech abnormalities. Only 2/8 patients exhibited laryngeal stridor. However, during FEES, all patients presented with irregular arytenoid cartilages movements and vocal fold abduction restriction. 3/8 showed vocal fold fixation and 1/8 paradoxical vocal fold motion. All patients presented with oropharyngeal dysphagia, 5/8 with penetration or aspiration events. We suggest that specific abnormal vocal fold motion can help identifying MSA patients and may allow for delimiting this disorder from idiopathic PD. These findings therefore may serve as a novel clinical biomarker for MSA. Based on the available data and our preliminary clinical experience we developed a standardized easy-to-implement task-protocol to be performed during flexible endoscopic evaluation of swallowing (FEES) for detection of MSA-related pharyngolaryngeal movement disorders. Furthermore, we initiated a prospective study to evaluate the diagnostic utility of this protocol.

Dynamics of Parkinson's Disease Multimodal Complex Treatment in Germany from 2010⁻2016: Patient Characteristics, Access to Treatment, and Formation of Regional Centers

Parkinson's disease (PD) is currently the world's fastest-growing neurological disorder. It is characterized by motor and non-motor symptoms which progressively lead to significant clinical impairment, causing a high burden of disease. In addition to pharmacological therapies, various non-pharmacological treatment options are available. A well established and frequently used multiprofessional inpatient treatment concept in Germany is "Parkinson's disease multimodal complex treatment" (PD-MCT) which involves physiotherapists, occupational therapists, speech therapists, and other specializations for the optimization of treatment in PD (ICD G20) and other Parkinsonian syndromes (ICD G21 and G23). In this study we analyze the PD-MCT characteristics of 55,141 PD inpatients who have been integrated into this therapy concept in Germany in the years 2010⁻2016. We demonstrate that PD-MCT is increasingly applied over this time period. Predominately, PD patients with advanced disease stage and motor fluctuations in age groups between 45 and 69 years were hospitalized. In terms of gender, more male than female patients were treated. PD-MCT is provided primarily in specialized hospitals with high patient numbers but a minor part of all therapies is performed in a rather large number of hospitals with each one treating only a few patients. Access to PD-MCT differs widely across regions, leading to significant migration of patients from underserved areas to PD-MCT centers ⁻ a development that should be considered when implementing such therapies in other countries. Furthermore, our data imply that despite the overall increase in PD-MCT treatments during the observational period, the restricted treatment accessibility may not adequately satisfy current patient´s need.

EuroInf 2: Subthalamic stimulation, apomorphine, and levodopa infusion in Parkinson's disease

OBJECTIVE

Real-life observational report of clinical efficacy of bilateral subthalamic stimulation (STN-DBS), apomorphine (APO), and intrajejunal levodopa infusion (IJLI) on quality of life, motor, and nonmotor symptoms (NMS) in Parkinson's disease (PD).

METHODS

In this prospective, multicenter, international, real-life cohort observation study of 173 PD patients undergoing STN-DBS (n = 101), IJLI (n = 33), or APO (n = 39) were followed-up using PDQuestionnaire-8, NMSScale (NMSS), Unified PD Rating Scale (UPDRS)-III, UPDRS-IV, and levodopa equivalent daily dose (LEDD) before and 6 months after intervention. Outcome changes were analyzed with Wilcoxon signed-rank or paired t test when parametric tests were applicable. Multiple comparisons were corrected (multiple treatments/scales). Effect strengths were quantified with relative changes, effect size, and number needed to treat. Analyses were computed before and after propensity score matching, balancing demographic and clinical characteristics.

RESULTS

In all groups, PDQuestionnaire-8, UPDRS-IV, and NMSS total scores improved significantly at follow-up. Levodopa equivalent daily dose was significantly reduced after STN-DBS. Explorative NMSS domain analyses resulted in distinct profiles: STN-DBS improved urinary/sexual functions, mood/cognition, sleep/fatigue, and the miscellaneous domain. IJLI improved the 3 latter domains and gastrointestinal symptoms. APO improved mood/cognition, perceptual problems/hallucinations, attention/memory, and the miscellaneous domain. Overall, STN-DBS and IJLI seemed favorable for NMSS total score, and APO favorable for neuropsychological/neuropsychiatric NMS and PDQuestionnaire-8 outcome.

CONCLUSIONS

This is the first comparison of quality of life, nonmotor. and motor outcomes in PD patients undergoing STN-DBS, IJLI, and APO in a real-life cohort. Distinct effect profiles were identified for each treatment option. Our results highlight the importance of holistic nonmotor and motor symptoms assessments to personalize treatment choices. © 2019 International Parkinson and Movement Disorder Society.

Do We Need to Rethink the Epidemiology and Healthcare Utilization of Parkinson's Disease in Germany?

Epidemiological aspects of Parkinson's disease (PD), co-occurring diseases and medical healthcare utilization of PD patients are still largely elusive. Based on claims data of 3.7 million statutory insurance members in Germany in 2015 the prevalence and incidence of PD was determined. PD cases had at least one main hospital discharge diagnosis of PD, or one physician diagnosis confirmed by a subsequent or independent diagnosis or by PD medication in 2015. Prevalence of (co-)occurring diseases, mortality, and healthcare measures in PD cases and matched controls were compared. In 2015, 21,714 prevalent PD cases (standardized prevalence: 511.4/100,000 persons) and 3,541 incident PD cases (standardized incidence: 84.1/100,000 persons) were identified. Prevalence of several (co-)occurring diseases/complications, e.g., dementia (PD/controls: 39/13%), depression (45/22%), bladder dysfunction (46/22%), and diabetes (35/31%), as well as mortality (10.7/5.8%) differed between PD cases and controls. The annual healthcare utilization was increased in PD cases compared to controls, e.g., regarding mean ± SD physician contacts (15.2 ± 7.6/12.2 ± 7.3), hospitalizations (1.3 ± 1.8/0.7 ± 1.4), drug prescriptions (overall: 37.7 ± 24.2/21.7 ± 19.6; anti-PD medication: 7.4 ± 7.4/0.1 ± 0.7), assistive/therapeutic devices (47/30%), and therapeutic remedies (57/16%). The standardized prevalence and incidence of PD in Germany as well as mortality in PD may be substantially higher than reported previously. While frequently diagnosed with co-occurring diseases/complications, such as dementia, depression, bladder dysfunction and diabetes, the degree of healthcare utilization shows large variability between PD patients. These findings encourage a rethinking of the epidemiology and healthcare utilization in PD, at least in Germany. Longitudinal studies of insurance claims data should further investigate the individual and epidemiological progression and healthcare demands in PD.

Cannabinoide in der Behandlung der Parkinson-Erkrankung

Aufgrund der Legalisierung von medizinischem Cannabis und Derivaten in zahlreichen Ländern gelangt diese Behandlungsoption zunehmend in die wissenschaftliche und öffentliche Debatte. Zunehmend häufig werden Behandler von Patienten mit idiopathischer Parkinson-Erkrankung mit der Frage nach Cannabis als Behandlungsalternative insbesondere bei Levodopa-resistenten Symptomen konfrontiert. Im Gegensatz zu zahlreichen positiven Einzelfallberichten und Fallserien bieten die wenigen Placebo-kontrollierten Studien nur wenige Hinweise auf eine positive Wirkung von Cannabinoiden auf Parkinson-Symptome. Lediglich in einer Arbeit konnte eine leichte Reduktion von Levodopa-induzierten Dyskinesien nachgewiesen werden, die drei anderen Arbeiten zeigen keinen Effekt auf motorische Symptome. Diese Arbeit soll einen Überblick über die Wirkungsweise von Cannabis und Forschungsergebnisse zu Cannabinoiden in der Behandlung der idiopathischen Parkinson-Erkrankung geben.

Halluzinationen und Psychose bei der Parkinson-Erkrankung

Psychotische Symptome sind eine häufige Komplikation der Parkinson-Erkrankung und treten oft im Zusammenhang mit der Parkinson-Demenz und der Demenz mit Lewy- Körperchen auf. Da Halluzinationen bei Parkinson-Syndromen ohne Lewy-Körperchen wie der Multisystematrophie oder der progressiven Blickparese selten vorkommen, hat das Auftreten von Halluzination auch eine Wertigkeit für die Differenzialdiagnose.

Präsenzgefühle, illusionäre Verkennungen und visuelle Pseudohalluzinationen mit erhaltener Einsicht werden zunächst von vielen Betroffenen als wenig belastend erlebt. Da derartige „benigne“ Wahrnehmungsstörungen bei der Parkinson-Erkrankung allerdings mit einer hohen Inzidenz schwerer psychotischer Störungen im weiteren Krankheitsverlauf assoziiert sind, sollte frühzeitig eine medikamentöse Therapie in Betracht gezogen werden. Neben Clozapin können in Abhängigkeit von den Begleitumständen auch Quetiapin, Benzodiazepine und Cholinesterase-Inhibitoren zur Behandlung von Halluzinationen in Frage kommen.

[Nonpharmacological treatment procedures for Parkinson's disease]

Nonpharmacological treatment strategies in Parkinson' disease include heterogeneous treatment modalities, such as physiotherapy, occupational therapy, speech therapy, cognitive training and deep brain stimulation as well as noninvasive brain stimulation strategies. Even in the early stages of Parkinson's disease nonpharmacological interventions, such as active exercise therapy and speech therapy can be indicated taking the individual symptoms of a patient into account. Mild cognitive deficits are frequently detected in the course of the disease and progression of these disorders to dementia in the advanced stages of the disease is not uncommon. The starting point for a cognitive training, training strategy and training frequency is unknown and currently under investigation. Deep brain stimulation is an established treatment modality, which should be considered when motor fluctuations cannot be adequately controlled by pharmacological treatment. This therapeutic option depends on patient-specific needs and has to be managed by a multiprofessional team. Non-invasive neurostimulation techniques, such as transcranial magnetic stimulation and transcranial direct current stimulation are experimental tools and cannot currently be recommended for general use.

[Practical Use of the Levodopa Pump]

Patients with advanced Parkinson's disease and motor complications undergoing optimized oral therapy can significantly benefit from continuous intrajejunal levodopa/carbidopa infusion applied by means of a medication pump. However, this requires a correctly positioned PEG-J tube and finely adjusted pump settings. Although this method is a routine procedure in specialist centers, no standard procedure has been defined up to now. For this reason, an expert recommendation regarding the practical application has been developed in order to standardize the procedure and facilitate patient access to this treatment option.

Nonpharmacological treatments for patients with Parkinson's disease

Since 2013, a number of studies have enhanced the literature and have guided clinicians on viable treatment interventions outside of pharmacotherapy and surgery. Thirty-three randomized controlled trials and one large observational study on exercise and physiotherapy were published in this period. Four randomized controlled trials focused on dance interventions, eight on treatment of cognition and behavior, two on occupational therapy, and two on speech and language therapy (the latter two specifically addressed dysphagia). Three randomized controlled trials focused on multidisciplinary care models, one study on telemedicine, and four studies on alternative interventions, including music therapy and mindfulness. These studies attest to the marked interest in these therapeutic approaches and the increasing evidence base that places nonpharmacological treatments firmly within the integrated repertoire of treatment options in Parkinson's disease.