Age-, and gender-specific incidence of vascular parkinsonism, progressive supranuclear palsy, and parkinsonian-type multiple system atrophy in North East Scotland: the PINE study

Prevalence of multiple system atrophy: A literature review

INTRODUCTION

This paper aims to provide a literature overview on multiple system atrophy (MSA) prevalence in European and other pan-European populations.

METHODS

A literature search (PubMed, EMBASE) was performed through 2022 to identify published studies on MSA prevalence in European countries. Of these search results, titles and abstracts were screened for relevance. A standardized assessment tool was used for systematically data extraction and comparison. For studies where only the incidence rate was reported, MSA prevalence was derived based on the incidence and duration of disease.

RESULTS

A total of 24 studies conducted in 14 countries and published between 1995 and 2022 were identified. The prevalence of MSA was reported in 18 (75%) studies and was derived from six (25%) incidence studies. These studies were mainly prospective population-based studies or multi-center studies from specific regions or specialty clinical settings. Two earlier studies in Germany and the Netherlands were conducted using door-to-door design. The time period of evaluation of prevalence ranged from 1990 to 2018. The crude prevalence of MSA ranged from 0.5/100,000 in Spain to 17/100,000 in Japan. Age-specific prevalence rates were provided in five studies, and the reported age ranges varied. The gender-specific crude prevalence was estimated as 2.75/100,000 for men and 1.19/100.000 for women. The derived prevalence was higher (ranging from 0.7-18.9/100,000) than studies where the prevalence was reported.

CONCLUSION

The variations observed in MSA prevalence may result from differences in age distributions of the study populations, study methodology, diagnostic criteria and case assessment strategies of MSA. Thus, the comparability of these studies is limited.

The prevalence and incidence of progressive supranuclear palsy and corticobasal syndrome: a systematic review and meta-analysis

INTRODUCTION

Progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) are progressive neurodegenerative syndromes characterised by Parkinsonism with additional features including cognitive dysfunction, falls, and oculomotor abnormalities. Understanding the epidemiology of these conditions is critical to planning for future service provision.

METHODS

We conducted a systematic review of studies reporting incidence and prevalence of CBS and PSP. A search of the PubMed and EMBASE data bases was conducted from their date of inception to 13th July 2021. Meta-analysis of studies sharing similar methodologies was carried out to generate estimated pooled prevalence and incidence.

RESULTS

We found 32 studies meeting our criteria for inclusion. There were 20 studies with data on prevalence and 12 with incidence data of PSP. Prevalence of CBS was reported in eight studies while seven studies reported incidence. Reported estimates of prevalence for PSP ranged from 1.00 (0.9-1.1) to 18 (8-28) per 100,000 while prevalence rates for CBS ranged from 0.83 (0.1-3.0) to 25 (0-59). Incidence rates for PSP and CBS respectively ranged from 0.16 (0.07-0.39) to 2.6 per 100,000 person-years and 0.03 (0-0.18) to 0.8 (0.4-1.3) per 100,000 person-years. A random effects model meta-analysis of studies with similar methodologies yielded a pooled prevalence estimate for PSP of 6.92 (4.33-11.06, I2 = 89%, τ2 = 0.3907) and 3.91 (2.03-7.51, I2 = 72%, τ2 = 0.2573) per 100,000 for CBS.

CONCLUSION

Studies of the epidemiology of PSP and CBS report highly heterogeneous findings. There is a need for further studies using rigorous phenotyping and the most recent diagnostic criteria to understand the true burden of these conditions.

The Neuroinflammatory Acute Phase Response in Parkinsonian-Related Disorders

BACKGROUND

Neuroinflammation is implicated in the pathophysiology of Parkinson's disease (PD) and related conditions, yet prior clinical biomarker data report mixed findings.

OBJECTIVES

The aim was to measure a panel of neuroinflammatory acute phase response (APR) proteins in the cerebrospinal fluid (CSF) of participants with PD and related disorders.

METHODS

Eleven APR proteins were measured in the CSF of 867 participants from the BioFINDER cohort who were healthy (612) or had a diagnosis of PD (155), multiple system atrophy (MSA) (26), progressive supranuclear palsy (PSP) (22), dementia with Lewy bodies (DLB) (23), or Parkinson's disease with dementia (PDD) (29).

RESULTS

CSF APR proteins were mostly unchanged in PD, with only haptoglobin and α1-antitrypsin significantly elevated compared to controls. These proteins were variably increased in the other disorders. Certain protein components yielded unique signatures according to diagnosis: ferritin and transthyretin were selectively elevated in MSA and discriminated these patients from all others. Haptoglobin was selectively increased in PSP, discriminating this disease from MSA when used in combination with ferritin and transthyretin. This panel of proteins did not correlate well with severity of motor impairment in any disease category, but several (particularly ceruloplasmin and ferritin) were associated with memory performance (Mini-Mental State Examination) in patients with DLB and PDD.

CONCLUSIONS

These findings provide new insights into inflammatory changes in PD and related disorders while also introducing biomarkers of potential clinical diagnostic utility. © 2022 International Parkinson and Movement Disorder Society.

Parkinsonism and cerebrovascular disease

The relationship between cerebrovascular disease and parkinsonism is commonly seen in everyday clinical practice but remains ill-defined and under-recognised with little guidance for the practising neurologist. We attempt to define this association and to illustrate key clinical, radiological and pathological features of the syndrome of Vascular Parkinsonism (VaP). VaP is a major cause of morbidity in the elderly associated with falls, hip fractures and cognitive impairment. Although acute parkinsonism is reported in the context of an acute cerebrovascular event, the vast majority of VaP presents as an insidious syndrome usually in the context of vascular risk factors and radiological evidence of small vessel disease. There may be an anatomic impact on basal ganglia neuronal networks, however the effect of small vessel disease (SVD) on these pathways is not clear. There are now established reporting standards for radiological features of SVD on MRI. White matter hyperintensities and lacunes have been thought to be the representative radiological features of SVD but other features such as the perivascular space are gaining more importance, especially in context of the glymphatic system. It is important to consider VaP in the differential diagnosis of Parkinson disease (PD) and in these situations, neuroimaging may offer diagnostic benefit especially in those patients with atypical presentations or refractoriness to levodopa. Proactive management of vascular risk factors, monitoring of bone density and an exercise program may offer easily attainable therapeutic targets in PD and VaP. Levodopa therapy should be considered in patients with VaP, however the dose and effect may be different from use in PD. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna.

Treatment Responsiveness of Motor Features in Parkinson's Disease: A Matched Case-Control Analysis

BACKGROUND

Treatment response in PD is important clinically and for research diagnostic criteria, but few objective data show treatment-responsiveness of PD motor features.

OBJECTIVES

To evaluate the treatment response of motor features to moderate treatment doses in a "real-world" PD cohort.

METHODS

We analyzed data from a community-based incident cohort of PD in North-East Scotland (PINE study). We assessed change in the UPDRS motor scale and its individual items over a period of up to 13 months comparing (1) patients with an increase of at least 300 mg of levodopa-equivalent dose (LED) and (2) patients without treatment change, matched for age, sex, and disease duration.

RESULTS

We identified 101 matched pairs of patients with and without a treatment increase. LED increases were mostly 300 to 375 mg/day. Forty-two percent with treatment increase had ≥30% improvement in overall UPDRS motor score, a further 35% had substantial subjective improvement, but only 1 had an objective excellent (>70%) treatment response. Women responded better than men by 5.4 points (95% confidence interval [CI]: 2.7-8.1). All motor features improved with treatment, but after adjustment for age, sex, and initial score, only rest tremor (P < 0.001), rigidity (P = 0.01), bradykinesia (<0.001), posture (P = 0.01), and gait (P = 0.03) had significant improvements, compared to those with no treatment change. Dopa-less-responsive motor items, taken together, had small statistically significant relative improvements (1.1-point difference [95% CI: 0.4-1.8]; P = 0.004).

CONCLUSIONS

Motor items sometimes previously considered dopa unresponsive have small improvements with moderate LED increases. Women respond better than men. Excellent treatment responses are uncommon. These data can inform clinical decisions about treatment.

Secondary parkinsonism due to drugs, vascular lesions, tumors, trauma, and other insults

In addition to neurodegenerative disorders, there are many secondary forms of parkinsonism. The most common cause for secondary parkinsonism is the intake of distinct drugs. Neuroleptics and calcium channel blockers have been mainly described to induce parkinsonism, but also other drugs were suspected to cause or worsen parkinsonism. Another common cause for secondary parkinsonism are vascular lesions (i.e. vascular parkinsonism). Furthermore, also brain tumors have been described as rare causes for parkinsonism. Moreover, parkinsonism can be caused by chronic traumatic encephalopathy, which is a special case, since secondary insults to the brain leads to the occurrence of a neuropathologically defined disease. Other rare causes for secondary parkinsonism are lesions caused by infectious or immunological diseases as well as toxins or street drugs.

Modifiable risk and protective factors in disease development, progression and clinical subtypes of Parkinson's disease: What do prospective studies suggest?

Parkinson's disease (PD) is a neurodegenerative disorder whose pathogenesis depends on a combination of genetic and environmental factors. The aim of the present review was to provide an updated description of the findings emerging from prospective longitudinal cohort studies on the possible risk/protective factors underlying the development, progression and clinical subtypes of PD. We reviewed all the environmental, lifestyle, dietary, comorbid and pharmacological factors that have been investigated as possible modifiable protective/risk factors for PD by longitudinal studies. Only a few factors have the epidemiological evidence and the biological plausibility to be considered risk (pesticides, dairy products, β2-adrenoreceptor antagonists) or protective (smoking, caffeine and tea intake, physical activity, gout, vitamin E intake, non-steroidal anti-inflammatory drugs and β2-adrenoreceptor agonists) factors for PD. Caffeine intake and physical activity also seem to slow down the progression of the disease, thus representing good candidates for primary prevention and disease modifying strategies in PD. Possible modifiable risk factors of PD subtypes is almost unknown and this might depend on the uncertain biological and neuropathological reliability of clinical subtypes. The results of the present review suggest that only eleven risk/protective factors may be associated with the risk of PD. It may be possible to target some of these factors for preventive interventions aimed at reducing the risk of developing and the rate of progression of PD.

Factors to Consider in the Selection of Dopamine Agonists for Older Persons with Parkinson's Disease

Dopamine agonists (DAs) are frequently used in the management of Parkinson's disease (PD), a complex multisystem disorder influenced substantially by age-related factors. Over 80% of PD patients present after age 60 years and may have clinical features exacerbated by age-related comorbidities or decline in physiological compensatory mechanisms. Pharmacotherapy for motor symptoms in older persons is more likely to involve exclusive use of levodopa combined with a peripheral decarboxylase inhibitor throughout the course of the illness. Non-ergot DAs, such as pramipexole, rotigotine and ropinirole, may be used as de novo monotherapy for the control of motor symptoms in older persons, although they are less efficacious than levodopa therapy. DAs may also be considered as adjunct therapy in older persons when motor symptoms are no longer adequately controlled by levodopa or when motor fluctuations and dyskinesia appear. DAs may be used cautiously in older persons with cognitive impairment and orthostatic hypotension but should be avoided when there is a history or risk of psychosis or impulse control disorders.

Development and validation of prognostic survival models in newly diagnosed Parkinson's disease

OBJECTIVE

The objective of this study was to develop valid prognostic models to predict mortality, dependency, and "death or dependency" for use in newly diagnosed Parkinson's disease (PD).

METHODS

The models were developed in the Parkinsonism Incidence in North-East Scotland study (UK, 198 patients) and validated in the ParkWest study (Norway, 192 patients), cohorts that attempted to identify and follow-up all new PD cases in the study area. Dependency was defined using the Schwab & England scale. We selected variables measured at time of diagnosis to include in the models. Internal validation and external validation were performed by calculating C-statistics (discrimination) and plotting observed versus predicted risk in quantiles of predicted risk (calibration).

RESULTS

Older age, male sex, increased severity of axial features, and Charlson comorbidity index were independent prognostic factors in the mortality model. Increasing age, higher smoking history, increased severity of axial features, and lower MMSE score were independent predictors in the models of dependency and "death or dependency." Each model had very good internal calibration and very good or good discrimination (internal and external C-statistics for the models were 0.73-0.75 and 0.68-0.78, respectively). Although each model clearly separated patients into groups according to risk, they tended to overestimate risk in ParkWest. The models were recalibrated to the baseline risk in the ParkWest study and then calibrated well in this cohort.

CONCLUSIONS

We have developed prognostic models for predicting medium-term risk of important clinical outcomes in newly diagnosed PD. These models have validity for use for stratification of randomization, confounder adjustment, and case-mix correction, but they are inadequate for individualized prognostication. © 2017. The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Predictors of functional dependency in Parkinson's disease

BACKGROUND

Functional dependency, the need for help in basic activities of daily living, is an important patient-oriented outcome. We aimed to describe the development of dependency in Parkinson's disease (PD) and identify independent prognostic factors for this outcome.

METHODS

We analyzed data from the Parkinsonism Incidence in North-East Scotland (PINE) study, a prospective, community-based incident cohort of PD with ongoing follow-up. We described the development of dependency defined by a Schwab & England score of < 80% and a Barthel Index of <19. We identified the baseline predictors of dependency using multivariable Cox regression.

RESULTS

In 198 patients with PD, the rate of development of dependency was 14 per 100 person years. Older age at diagnosis (hazard ratio for 10-year increase 2.23 [95% confidence interval 1.66-2.98]), greater smoking history (hazard ratio for 10-pack-year increase, 1.15 [1.04-1.26]), more severe axial impairment (hazard ratio for 5-point increase in sum of axial items from UPDRS scale, 1.78 [1.30-2.44]), and lower MMSE score (hazard ratio 0.88 [0.79-0.98]) were independently associated with a higher risk of dependency as defined by Schwab & England. Only older age (hazard ratio for 10-year increase 1.35 [1.04-1.76]) and severity of axial impairment (hazard ratio for 5-point increase 1.85 [1.31-2.62]) were associated with a higher risk of dependency as defined by the Barthel Index. Sex, deprivation, comorbidity, overall UPDRS motor score, and disease stage were not independently associated with dependency.

CONCLUSION

This is the first community-based study of dependency in PD. There was a high rate of dependency development. Older age, more smoking, more axial impairment, and poorer cognition were independent predictors. © 2016 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Gender differences in Parkinson's disease: A clinical perspective

Available data indicate that there are gender differences in many features of Parkinson's disease (PD). Precise identification of the gender differences is important to tailor treatment, predict outcomes, and meet other individual and social needs in women and men with PD. The aim of this study was to review the available clinical data on gender differences in PD. Original articles and meta-analyses published between 1990 and 2016 systematically exploring gender differences in PD were reviewed. There is slight male preponderance in incidence and prevalence of PD. PD starts earlier in men. Women tend to be more prone to develop tremor-dominant PD but are less rigid than men. Motor improvement after deep brain stimulation is equal in both sexes, but women tend to show better improvement in activities of daily living. Furthermore, women with PD show better results on tests for general cognitive abilities, outperform men in verbal cognitive tasks, show more pain symptoms, and score higher on depression scales. It seems, however, that the differences in cognition, mood, and pain perception are not disease specific as similar gender differences can be found in healthy subjects and in other neurological conditions. Despite PD being the most frequently studied movement disorder, studies investigating gender differences in PD are still scarce with most of the studies being cross-sectional. Good-quality, prospective, longitudinal studies analyzing gender differences in PD and comparing them to matched healthy controls are needed in order to properly address the issues of gender differences in PD.

Therapeutic Interventions for Vascular Parkinsonism: A Systematic Review and Meta-analysis

Background

Vascular parkinsonism (VP) is defined as the presence of parkinsonian syndrome, evidence of cerebrovascular disease, and an established relationship between the two disorders. However, the diagnosis of VP is problematic, particularly for the clinician confronted with moving from diagnosis to treatment. Given the different criteria used in the diagnosis of VP, the effectiveness of available therapeutic interventions for this disease are currently unknown.

Methods

To assess the clinical response of all published therapeutic interventions for VP that have been reported in the literature, we conducted a systematic review looking for VP subjects treated with any therapeutic intervention. To clarify the prevalence of responsiveness to levodopa among VP subjects, we conducted a meta-analysis of 17 observational studies retrieved with the search criteria of our review. Also, four studies were included in a second analysis to explore if nigrostriatal lesion affected the prevalence of levodopa response in VP subjects. Relevant articles were identified from MEDLINE, Scopus, and Web of Science published until June 2017.

Results

436 non-duplicate citations were identified for screening, 107 articles were assessed for eligibility, and only 23 observational studies were included in this review. No randomized clinical trials were found. Four different therapies were found in the literature; among them, levodopa was the only one repetitively reported. The calculated event rate of levodopa response in VP subjects was of 0.304 [95% confidence interval (CI) of 0.230–0.388]. The overall odds ratio for good response to levodopa in VP with lesion in the nigrostriatal pathway vs. no lesion in the nigrostriatal pathway was 15.15 (95% CI: 5.2–44.17).

Conclusion

Despite the lack of randomized controlled trials, results of this systematic review and meta-analysis show that VP subjects, as operationally defined here, have a low response rate to levodopa; nigrostriatal lesion could be used as a proxy predictor of levodopa response in VP subjects. Other therapies seem to be co-adjuvant. Randomized controlled trials with a clear definition of VP are necessary to be able to assign positive or negative predictive values to available treatments and to recommend any of the therapeutic interventions for these subjects.

Glitazone use associated with reduced risk of Parkinson's disease

Background

Whether antidiabetic glitazone drugs protect against Parkinson's disease remains controversial. Although a single clinical trial showed no evidence of disease modulation, retrospective studies suggest that a disease‐preventing effect may be plausible. The objective of this study was to examine if the use of glitazone drugs is associated with a lower incidence of PD among diabetic patients.

Methods

We compared the incidence of PD between individuals with diabetes who used glitazones, with or without metformin, and individuals using only metformin in the Norwegian Prescription Database. This database contains all prescription drugs dispensed for the entire Norwegian population. We identified 94,349 metformin users and 8396 glitazone users during a 10‐year period and compared the incidence of PD in the 2 groups using Cox regression survival analysis, with glitazone exposure as a time‐dependent covariate.

Results

Glitazone use was associated with a significantly lower incidence of PD compared with metformin‐only use (hazard ratio, 0.72; 95% confidence interval, 0.55‐0.94; P = 0.01).

Conclusions

The use of glitazones is associated with a decreased risk of incident PD in populations with diabetes. Further studies are warranted to confirm and understand the role of glitazones in neurodegeneration. © 2017 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society

Cognitive Impairment and Basal Ganglia Functional Connectivity in Vascular Parkinsonism

BACKGROUND AND PURPOSE

Patients with vascular parkinsonism have higher cognitive decline and more basal ganglia lesions. We aimed to evaluate the relationship of cognitive impairment with functional connectivity between the basal ganglia and cingulate cortex in vascular parkinsonism.

MATERIALS AND METHODS

Thirty patients (8 with vascular parkinsonism and 22 with Parkinson disease) and 23 controls were enrolled. The Mattis Dementia Rating Scale and the Stroop Task were used to assess cognitive decline. MR imaging examinations included T1-MPRAGE, FLAIR, and resting-state fMRI sequences. MPRAGE was segmented to obtain basal ganglia and cingulate cortex volumes. FLAIR was segmented to obtain white matter hyperintensity lesion volume. Resting-state fMRI sequences were used to compare basal ganglia functional connectivity with the cingulate cortex between patients and controls.

RESULTS

Patients with vascular parkinsonism exhibited impaired attention, resistance to interference, and inhibitory control and an increased number of errors on the Stroop Task. They also had higher caudate nucleus and white matter hyperintensity lesion volumes, which were positively correlated (ρ = 0.75, P < .0001). Caudate nucleus functional connectivity with the perigenual anterior cingulate cortex was increased in patients with vascular parkinsonism compared with controls and patients with Parkinson disease, and it was positively correlated with the caudate nucleus volume (ρ = 0.44, P = .016). Caudate nucleus functional connectivity with the posterior cingulate cortex was decreased in patients with vascular parkinsonism compared with controls and negatively correlated with the number of errors on the Stroop test (ρ = -0.51, P = .0003).

CONCLUSIONS

In patients with vascular parkinsonism, cognitive decline could be related to changes of caudate nucleus functional connectivity with the cingulate cortex at resting-state, which may be induced by ischemia-related remodelling.

Etiologic Framework for the Study of Neurodegenerative Disorders as Well as Vascular and Metabolic Comorbidities on the Grounds of Shared Epidemiologic and Biologic Features

Background: During the last two decades, protein aggregation at all organismal levels, from viruses to humans, has emerged from a neglected area of protein science to become a central issue in biology and biomedicine. This article constitutes a risk-based review aimed at supporting an etiologic scenario of selected, sporadic, protein-associated, i.e., conformational, neurodegenerative disorders (NDDs), and their vascular- and metabolic-associated ailments.

Methods: A rationale is adopted, to incorporate selected clinical data and results from animal-model research, complementing epidemiologic evidences reported in two prior articles.

Findings: Theory is formulated assuming an underlying conformational transmission mechanism, mediated either by horizontal transfer of mammalian genes coding for specific aggregation-prone proteins, or by xeno-templating between bacterial and host proteins. We build a few population-based and experimentally-testable hypotheses focusing on: (1) non-disposable surgical instruments for sporadic Creutzfeldt-Jakob disease (sCJD) and other rapid progressive neurodegenerative dementia (sRPNDd), multiple system atrophy (MSA), and motor neuron disease (MND); and (2) specific bacterial infections such as B. pertussis and E. coli for all forms, but particularly for late-life sporadic conformational, NDDs, type 2 diabetes mellitus (T2DM), and atherosclerosis where natural protein fibrils present in such organisms as a result of adaptation to the human host induce prion-like mechanisms.

Conclusion: Implications for cohort alignment and experimental animal research are discussed and research lines proposed.