Prevalence and age of onset of Parkinson's disease in Cardiff: a community based cross sectional study and meta-analysis

Associations of dual-task walking costs with cognition in Parkinson's disease

BACKGROUND

Gait and cognition are closely associated in Parkinson's disease (PD), with specific cognitive domains being associated with different motor symptoms. By identifying gait parameters affected by cognition, clinicians can develop targeted interventions that address cognitive impairment, improve gait, and reduce the risk of injury in PD patients.

RESEARCH QUESTION

What gait parameters are affected by cognition in PD patients during dual-task walking, and how are these parameters related to cognitive function as measured by the Montreal Cognitive Assessment (MoCA)?

METHODS

36 patients with available gait data and cognitive assessments were enrolled. Gait data of usual and dual-task walking sessions were recorded using lightweight wireless wearable sensors attached to trunk, lower, and upper extremities. Dual-task costs were calculated from usual and dual-task measures. Statistical analysis included non-parametric tests, Wilcoxon signed-rank test, Spearman's correlation, and stepwise linear regression models.

RESULTS

Walking speed, cadence, asymmetry in arm swing (ASA), between arms' amplitude symmetry (BAS), average stride time, and jerk of the acceleration movement of the legs were found to be affected during the dual-task walking session (P<0.05). Spearman's correlation showed significant correlations between MoCA scores and ASA (ρ=-0.469, P=0.036) and BAS (ρ=-0.448, P=0.036) costs. Stepwise linear regression models found that MoCA scores were significant predictors of BAS and ASA costs (P<0.05).

SIGNIFICANCE

This study found a significant association between global cognitive ability and several gait parameters costs under cognitive load caused by dual-task walking in PD patients. The study identified the gait parameters that were affected by cognitive load and found that MoCA scores were significant predictors of those gait parameters. Identifying gait parameters affected by cognition can lead to more targeted interventions for improving gait and reducing injury risk in PD patients.

Age Cutoff for Early-Onset Parkinson's Disease: Recommendations from the International Parkinson and Movement Disorder Society Task Force on Early Onset Parkinson's Disease

Background

Early-onset Parkinson's disease (EOPD)/young-onset Parkinson's disease (YOPD) is defined as Parkinson's disease (PD) with an age at onset (AAO) after age 21 years but before the usual AAO for PD. Consensus is lacking, and the reported maximal age for EOPD/YOPD has varied from 40 to 60 years, leading to a lack of uniformity in published studies and difficulty in harmonization of data. EOPD and YOPD have both been used in the literature, somewhat interchangeably.

Objective

To define the nomenclature and AAO cutoff for EOPD/YOPD.

Methods

An extensive review of the literature and task force meetings were conducted. Conclusions were reached by consensus.

Results

First, the literature has seen a shift from the use of YOPD toward EOPD. This seems motivated by an attempt to avoid age-related stigmatization of patients. Second, in defining EOPD, 56% of the countries use 50 or 51 years as the cutoff age. Third, the majority of international genetic studies in PD use an age cutoff of younger than 50 years to define EOPD. Fourth, many studies suggest that changes in the estrogen level can affect the predisposition to develop PD, making the average age at menopause of 50 years an important factor to consider when defining EOPD. Fifth, considering the differential impact of the AAO of PD on professional and social life, using 50 years as the upper cutoff for the definition of EOPD seems reasonable.

Conclusions

This task force recommends the use of EOPD rather than YOPD. It defines EOPD as PD with AAO after 21 years but before 50 years.

Blood based biomarkers for movement disorders

Movement disorders have been carefully clinically defined, based on clinico-pathological series; however there is often diagnostic and prognostic uncertainty, especially in early stage disease. Blood-based biomarkers for Alzheimer's disease (AD), particularly p-tau181 and p-tau217, may be useful in the movement disorder clinic, especially in identifying corticobasal syndrome due to AD pathology and in identifying Parkinson's disease (PD) patients at high risk for the future development of dementia. Serum or plasma neurofilament light (NfL) may be useful in separating Parkinson's plus syndromes (progressive supranuclear palsy-PSP, multiple system atrophy - MSA, and corticobasal syndrome-CBS) from PD. NfL is also a prognostic biomarker, in that the level of baseline or cross-sectional plasma/serum NfL is associated with a worse prognosis in PD and PSP. The development of protein aggregation assays in cerebrospinal fluid and multiplex assays which can measure 100 s-1000s of proteins in blood will provide new tools and insights for movement disorders for clinicians and researchers. The challenge is in efficiently integrating these tools into clinical practice and multi-modal approaches, where biomarkers are combined with clinical, genetic, and imaging data may guide the future use of these technologies.

A genetic analysis of Chinese patients with early-onset Parkinson' s disease

Genetic factors play an important role in early-onset Parkinson's disease (EOPD). The genetic spectrum of patients with EOPD varies widely among different ethnicities, with extensive investigations having been performed in Caucasian populations; however, research in Chinese populations remains limited. In this study, we performed multiplex ligation-dependent probe amplification assay and whole-exome sequencing in 15 unrelated Chinese EOPD patients with age of onset before 40 years. Among them, a patient carried compound heterozygous exon duplications in Parkin (exon 3 duplication and exon 4 duplication) (6.67%) and two patients carried the homozygous pathogenic variant (p.D331Y) in PLA2G6 (13.33%). Three novel variants in EIF4G1 (p.P1043S, p.R1505Q, and p.P266A) were identified and classified as uncertain significance. Additionally, a risk variant in GBA (p.L483P) was detected in one patient (6.67%). PLA2G6 (13.33%) was the most common causative gene among our EOPD patients. Furthermore, detailed clinical features were presented. Our results broaden the genetic spectrum and clinical phenotypic spectrum of EOPD patients.

Effect of virtual reality rehabilitation on functional outcomes for return-to-work patients with Parkinson's disease: An umbrella review of systematic reviews

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disease characterized by loss of substantia nigra neurons with deficiency of dopamine. The main symptoms are tremor, rigidity and bradykinesia. Rehabilitation has an important role in the treatment of this condition and virtual reality (VR) is one of the most recent tools.

OBJECTIVE

The purpose of this umbrella review is to evaluate the effectiveness of VR systems on gait control for return to work in patients with PD.

METHODS

The electronic search, for reviews and meta-analysis studies that investigated the effectiveness of VR on gait control in PD patients, was performed through December 2021 using the following databases: PubMed, Scopus, PEDro, and Google Scholar. Mesh terms used were: Job integration/reintegration OR return-to-work AND Parkinson's disease AND virtual reality OR exergame. No limit on the year of publication of the article was used.

CONCLUSIONS

A total of 14 articles were included in our analysis. The included evidence shows a stride length improvement in patients treated with VR compared to conventional active treatments. No difference was found in walking speed. Also, the included articles show an improvement on various measures of balance, motor function and severity of PD motor symptoms. In addition, the literature shows an improvement in the quality of life and neuropsychiatric symptoms in patients undergoing VR rehabilitation training.

RESULTS

he results of our study suggest that VR rehabilitation improves gait performance, particularly stride length, thus being able to provide an improvement in the quality of life and a more effective return to work training in patients with PD.

Change in the incidence of Parkinson's disease in a large UK primary care database

Parkinson's disease (PD) has the fastest rising prevalence of all neurodegenerative diseases worldwide. However, it is unclear whether its incidence has increased after accounting for age and changes in diagnostic patterns in the same population. We conducted a cohort study in individuals aged ≥50 years within a large UK primary care database between January 2006 and December 2016. To account for possible changes in diagnostic patterns, we calculated the incidence of PD using four case definitions with different stringency derived from the combination of PD diagnosis, symptoms, and treatment. Using the broadest case definition, the incidence rate (IR) per 100,000 person years at risk (PYAR) was 149 (95% CI 143.3-155.4) in 2006 and 144 (95% CI 136.9-150.7) in 2016. In conclusion, the incidence of PD in the UK remained stable between 2006 and 2016, when accounting for age and diagnostic patterns, suggesting no major change in underlying risk factors for PD during this time period in the UK.

ADHD and Neurodegenerative Disease Risk: A Critical Examination of the Evidence

In this review, we undertake a critical appraisal of eight published studies providing first evidence that a history of attention-deficit/hyperactivity disorder (ADHD) may increase risk for the later-life development of a neurodegenerative disease, in particular Lewy body diseases (LBD), by up to five-fold. Most of these studies have used data linked to health records in large population registers and include impressive sample sizes and adequate follow-up periods. We identify a number of methodological limitations as well, including potential diagnostic inaccuracies arising from the use of electronic health records, biases in the measurement of ADHD status and symptoms, and concerns surrounding the representativeness of ADHD and LBD cohorts. Consequently, previously reported risk associations may have been underestimated due to the high likelihood of potentially missed ADHD cases in groups used as “controls”, or alternatively previous estimates may be inflated due to the inclusion of confounding comorbidities or non-ADHD cases within “exposed” groups that may have better accounted for dementia risk. Prospective longitudinal studies involving well-characterized cases and controls are recommended to provide some reassurance about the validity of neurodegenerative risk estimates in ADHD.

Effect of onset age on the levodopa threshold dosage for dyskinesia in Parkinson's disease

INTRODUCTION

With the levodopa threshold effect for dyskinesia observed, threshold dosage of levodopa was identified in the general Parkinson's disease (PD) population. While early-onset PD (EOPD) and late-onset PD (LOPD) differ in the pathogenesis and clinical manifestations, threshold dosage of levodopa for individualized treatment remains unestablished. The objective of this study was to propose threshold dosage of levodopa in EOPD and LOPD patients, respectively.

METHODS

Data on demographic and clinical and treatment measures were collected in 539 PD patients. Patients were divided into different onset groups using 50 as the cut-off age. We used univariable and multivariable analysis to screen for risk factors for dyskinesia. Receiver operating characteristic curve was used to determine the levodopa threshold dosages for dyskinesia.

RESULTS

The prevalence of dyskinesia was 47.7% (53/111) in the EOPD group and 24.1% (103/428) in the LOPD group. Risk factors identified for dyskinesia include high levodopa daily dose and levodopa responsiveness for EOPD patients and high levodopa daily dose, long levodopa treatment duration, low body weight, use of entacapone, and high Hoehn-Yahr stage in off state for LOPD patients. The daily levodopa threshold dosages were 400 mg or 5.9 mg/kg for EOPD and 450 mg or 7.2 mg/kg for LOPD.

CONCLUSION

EOPD patients had lower levodopa threshold dosage comparing with LOPD patients. Treatment of EOPD requires stricter levodopa dose control to delay the onset of dyskinesia.

Personalized Care Management for Persons with Parkinson's Disease

There is a growing awareness that delivery of integrated and personalized care is necessary to meet the needs of persons living with Parkinson's disease. In other chronic diseases than Parkinson's disease, care management models have been deployed to deliver integrated and personalized care, yielding positive effects on patients' health outcomes, quality of life and health care utilization. However, care management models have been highly heterogeneous, as there is currently no clear operationalization of its core elements. In addition, most care management models are disease-specific and not tailored to the individual needs and preferences of a patient. In this viewpoint we present an integrated and personalized care management model for persons with Parkinson's disease costing of five core elements: (1) care coordination, (2) patient navigation, (3) information provision, (4) early detection of signs and symptoms through proactive monitoring and (5) process monitoring. Following the description of each core element, implications for implementing the model into practice are discussed. Finally, we provide clinical and methodological considerations on the evaluation of care management models.

Neuroprotective Activities of Boophone haemanthoides (Amaryllidaceae) Extract and Its Chemical Constituents

Parkinson’s disease (PD) is a neurodegenerative condition that progresses as age increases, and some of its major symptoms include tremor and postural and movement-related difficulties. To date, the treatment of PD remains a challenge because available drugs only treat the symptoms of the disease or possess serious side effects. In light of this, new treatment options are needed; hence, this study investigates the neuroprotective effects of an organic Boophone haemanthoides extract (BHE) and its bioactive compounds using an in vitro model of PD involving the toxin 1-methyl-4-phenylpyridinium (MPP⁺) and SH-SY5Y neuroblastoma cells. A total of seven compounds were isolated from BHE, viz distichamine (1), 1α,3α-diacetylnerbowdine (2), hippadine (3), stigmast-4-ene-3,6-dione (4), cholest-4-en-3-one (5), tyrosol (6), and 3-hydroxy-1-(4′-hydroxyphenyl)-1-propanone (7). Six compounds (1, 2, 4, 5, 6 and 7) were investigated, and five showed neuroprotection alongside the BHE. This study gives insight into the bioactivity of the non-alkaloidal constituents of Amaryllidaceae, since the isolated compounds and the BHE showed improved cell viability, increased ATP generation in the cells as well as inhibition of MPP⁺-induced apoptosis. Together, these findings support the claim that the Amaryllidaceae plant family could be a potential reserve of bioactive compounds for the discovery of neuroprotective agents.

Safinamide as an adjunct therapy in older patients with Parkinson's disease: a retrospective study

BACKGROUND

Safinamide, as a levodopa adjunct, is effective in reducing motor fluctuations in Parkinson's disease (PD) patients; however, scarce evidence is available regarding its use in older PD patients.

AIM

To evaluate the safety and tolerability of safinamide as an adjunct therapy in patients aged ≥ 60 years with advanced PD.

METHODS

A retrospective study including 203 PD patients admitted to a geriatric day hospital, who were evaluated following an extensive clinical protocol. Safinamide use was categorized as never used, ongoing, and withdrawn. Potential correlations of Safinamide withdrawal were investigated in stepwise backward logistic regression models.

RESULTS

A total of 44 out of 203 participants were current or former users of Safinamide. Overall, 14 (32%) patients discontinued due to treatment-emergent adverse events (TEAEs). Withdrawal was not associated with older age.

CONCLUSIONS

Safinamide as an adjunct therapy in patients aged ≥ 60 years with advanced PD was found to be safe and well-tolerated in older patients. There were no specific demographic or clinical characteristics associated with suspension.

Genetic analysis of Mendelian mutations in a large UK population-based Parkinson's disease study

Our objective was to define the prevalence and clinical features of genetic Parkinson’s disease in a large UK population-based cohort, the largest multicentre prospective clinico-genetic incident study in the world. We collected demographic data, Movement Disorder Society Unified Parkinson’s Disease Rating Scale scores, and Montreal Cognitive Assessment scores. We analysed mutations in PRKN (parkin), PINK1, LRRK2 and SNCA in relation to age at symptom onset, family history and clinical features. Of the 2262 participants recruited to the Tracking Parkinson’s study, 424 had young-onset Parkinson’s disease (age at onset ≤ 50) and 1799 had late onset Parkinson’s disease. A range of methods were used to genotype 2005 patients: 302 young-onset patients were fully genotyped with multiplex ligation-dependent probe amplification and either Sanger and/or exome sequencing; and 1701 late-onset patients were genotyped with the LRRK2 ‘Kompetitive’ allele-specific polymerase chain reaction assay and/or exome sequencing (two patients had missing age at onset). We identified 29 (1.4%) patients carrying pathogenic mutations. Eighteen patients carried the G2019S or R1441C mutations in LRRK2, and one patient carried a heterozygous duplication in SNCA. In PRKN, we identified patients carrying deletions of exons 1, 4 and 5, and P113Xfs, R275W, G430D and R33X. In PINK1, two patients carried deletions in exon 1 and 5, and the W90Xfs point mutation. Eighteen per cent of patients with age at onset ≤30 and 7.4% of patients from large dominant families carried pathogenic Mendelian gene mutations. Of all young-onset patients, 10 (3.3%) carried biallelic mutations in PRKN or PINK1. Across the whole cohort, 18 patients (0.9%) carried pathogenic LRRK2 mutations and one (0.05%) carried an SNCA duplication. There is a significant burden of LRRK2 G2019S in patients with both apparently sporadic and familial disease. In young-onset patients, dominant and recessive mutations were equally common. There were no differences in clinical features between LRRK2 carriers and non-carriers. However, we did find that PRKN and PINK1 mutation carriers have distinctive clinical features compared to young-onset non-carriers, with more postural symptoms at diagnosis and less cognitive impairment, after adjusting for age and disease duration. This supports the idea that there is a distinct clinical profile of PRKN and PINK1-related Parkinson’s disease. We estimate that there are approaching 1000 patients with a known genetic aetiology in the UK Parkinson’s disease population. A small but significant number of patients carry causal variants in LRRK2, SNCA, PRKN and PINK1 that could potentially be targeted by new therapies, such as LRRK2 inhibitors.

Saccadic Eye Movements in Young-Onset Parkinson's Disease - A BOLD fMRI Study

The objective of the present study was to understand control of saccadic eye movements in patients with young onset Parkinson's disease (YOPD) where onset of disease symptoms appears early in life (<40 years of age). Functional magnetic resonance imaging (fMRI) was performed in patients with YOPD and control subjects while they performed saccadic tasks, which consisted of a reflexive task and another task that required inhibitory control of eye movements (Go-NoGo task). Functional imaging related to saccadic eye movements in this group of patients has not been widely reported. A 1.5T MR scanner was used for structural and functional imaging. Analysis of blood-oxygen-level-dependent (BOLD) fMRI was performed using Statistical Parametric Mapping (SPM) software and compared in patients and controls. In patients with YOPD greater activation was seen significantly in the middle frontal gyrus, medial frontal gyrus, angular gyrus, cingulate gyrus, precuneus and cerebellum, when compared with the control group, during the saccadic tasks. Gap and overlap protocols revealed differential activation patterns. The abnormal activation during reflexive saccades was observed in the overlap condition, while during Go-NoGo saccades in the gap condition. The results suggest that impaired circuitry in patients with YOPD results in recruitment of more cortical areas. This increased frontal and parietal cortical activity possibly reflects compensatory mechanisms for impaired cognitive and saccadic circuitry.

Effects of Parkinson's on employment, cost of care, and quality of life of people with condition and family caregivers in the UK: a systematic literature review

Background

Parkinson’s is an incurable, neuro-degenerative condition with multiple symptoms substantially impacting on living conditions and quality of life (QoL) for people with Parkinson’s (PwP), most whom are older adults, and their families. The study aimed to undertake a literature review of studies conducted in the UK that quantify the direct or indirect impact of Parkinson’s on people with the condition, their families, and society in terms of out-of-pocket payments and financial consequences.

Methods

Literature was searched for Parkinson’s-related terms plus condition impact (eg, financial, employment, pension, housing, health care costs, and QoL) in the UK setting. The strategy probed several electronic databases with all retrieved papers screened for relevancy. The instruments used to measure patient-related outcomes were then examined for their relevancy in justifying the results.

Results

The initial search retrieved 2,143 papers of which 79 were shortlisted through title and abstract screening. A full-text reading indicated 38 papers met the inclusion and quality criteria. Summary data extracted from the articles on focus, design, sample size, and questionnaires/instruments used were presented in four themes: (a) QoL and wellbeing of PwP, (b) QoL and wellbeing of caregivers and family members, (c) employment and living conditions, and (d) direct and indirect health care and societal cost.

Conclusion

UK results substantiated global evidence regarding the deterioration of QoL of PwP as the condition progressed, utilizing numerous measures to demonstrate change. Many spouses and family accept care responsibilities, affecting their QoL and finances too. The review highlighted increased health care and privately borne costs with condition progression, although UK evidence was limited on societal costs of Parkinson’s in terms of loss of employment, reduced work hours, premature retirement of PwP and caregivers that directly affected their household budget.

Mitochondria function associated genes contribute to Parkinson's Disease risk and later age at onset

Mitochondrial dysfunction has been implicated in the etiology of monogenic Parkinson's disease (PD). Yet the role that mitochondrial processes play in the most common form of the disease; sporadic PD, is yet to be fully established. Here, we comprehensively assessed the role of mitochondrial function-associated genes in sporadic PD by leveraging improvements in the scale and analysis of PD GWAS data with recent advances in our understanding of the genetics of mitochondrial disease. We calculated a mitochondrial-specific polygenic risk score (PRS) and showed that cumulative small effect variants within both our primary and secondary gene lists are significantly associated with increased PD risk. We further reported that the PRS of the secondary mitochondrial gene list was significantly associated with later age at onset. Finally, to identify possible functional genomic associations we implemented Mendelian randomization, which showed that 14 of these mitochondrial function-associated genes showed functional consequence associated with PD risk. Further analysis suggested that the 14 identified genes are not only involved in mitophagy, but implicate new mitochondrial processes. Our data suggests that therapeutics targeting mitochondrial bioenergetics and proteostasis pathways distinct from mitophagy could be beneficial to treating the early stage of PD.

An Exploratory Survey of the Employment Concerns and Experiences of People With Parkinson's Disease: Implications for Rehabilitation Research, Policy, and Education

Purpose

Little is known about the employment-related decisions made by people with Parkinson's disease (PD). This study investigated the extent to which individuals diagnosed with PD would prefer to continue working or, if currently unemployed, reenter the workforce.

Method

This quantitative survey research design consisted of a purposive sample of people with PD. A total of 80 surveys were completed and returned and, after eliminating those not meeting the inclusion criteria, 58 usable surveys were included in the final analysis.

Results

Over 82% of participants reported leaving work as a direct result of symptoms associated with PD, with the most common being inability to keep up with the physical demands (17.9%), fatigue (12.5%), psychological or cognitive issues (10.7%), and tremors (7.1%). The majority of respondents (64.3%) responded that they were moderately-to-very interested in returning to work if given the right conditions and supports.

Conclusions

The results indicated that individuals with PD would, in the right situation, prefer to reenter the workforce. Rehabilitation counselors need to be adequately equipped with information and resources to assist those with PD in determining potential employment options and ensuring that acceptable accommodations are provided. Implications for rehabilitation counseling practice, research, policy, and education are presented.

[Trends in the Prevalence of Dementia and Parkinson's Disease: An Analysis Based on Health Claims Data from all German Statutory Health Insurance Funds for Persons aged 65+in Germany 2009-2012]

OBJECTIVES

There will be an increase in the number of people with dementia (DEM) and Parkinson's disease (PD) with the ageing of the population. The aim of the study was to calculate prevalences and trends of prevalences for DEM and PD in Germany to enable reliable public health planning.

METHODS

For the years 2009-2012, sex-specific period prevalences of DEM and PD for 5-year age-groups based on health claims data from all German statutory health insurance funds were calculated. Time trends were estimated using a negative binomial regression.

RESULTS

In 2012 and for persons aged 65 or older, the crude prevalence was 7.9% for DEM and 2.2% for PD. Between 2009 and 2012, a mean decrease of the DEM prevalence by 1.2% per year was found for women and men above age 65. For PD we found constant rates between 2009-2012 among men and an annual mean decrease of PD prevalence of 0.5% among women.

CONCLUSION

A reduction of the DEM prevalence by 1.2% per year could partially counterbalance the increase of people with dementia resulting from ageing population. For PD we found decreasing prevalences only among women.

Reduced workforce participation 5 years prior to first Parkinson's disease sick-leave

The importance of understanding the prodromal phase of Parkinson’s disease (PD) by systematic recording of prediagnostic symptoms and reductions in body functions has been highlighted. The aim of this study was to investigate whether persons later diagnosed with PD exhibit increased physician-certified sickness absence 1, 2, and 5 years prior to a first sick-leave episode attributed to PD. A case-control study was performed to analyze data from all nontrivial (exceeding 14 days) sick-leave episodes in Sweden between 2008 and 2014. The 537 incident PD sick-leave episodes were identified as PD sick-leave cases and compared to 537 sick-leave controls identified by matching age, sex, and date of the first day of the sick-leave episode. The total sickness absence and sickness absence due to musculoskeletal diagnoses were found to be increased among the PD sick-leave cases from 5 years prior to the first sick-leave episode ascribed to PD when compared to the controls. No differences between PD sick-leave cases and sick-leave controls were found with regard to mental and behavioral diagnoses. We conclude that the capacity to participate in working life is reduced already at the early prediagnostic stages of PD. This finding can be used as a basis for further research into the process of identifying individuals at risk for developing PD, particularly in combination with further investigation into biochemical, genetic, and imaging biomarkers.

A Swedish study shows that Parkinson’s disease (PD) patients had more sick-leave episodes in the years before diagnosis than matched controls not diagnosed with PD. There is growing evidence that prior PD diagnosis, patients experience a variety of nonmotor symptoms and subtle motor signs. Further understanding these symptoms could prompt earlier therapeutic intervention and increase the likelihood of slowing down or even halting disease progression. A study led by Jonathan Timpka at Lund University examined the sickness leave history of 537 workers 1, 2 and 5 years before a first sick-leave episode due to PD. These workers took more sick-leave due to musculoskeletal symptoms, but not due to mental or behavioral issues, than the control group. These findings highlight a potential effect of preclinical PD on patients’ ability to work.

Non-motor features of Parkinson's disease in a nested case-control study of US men

BACKGROUND

Several non-motor features may individually contribute to identify prodromal Parkinson's disease (PD), but little is known on how they interact.

METHODS

We conducted a case-control study nested within the Health Professionals Follow-up Study in a large cohort of men age 40-75 at recruitment in 1986. Cases (n=120) had confirmed PD, were<85 in January 2012, returned a 2012 questionnaire with questions on probable rapid eye movement sleep behaviour disorder (RBD) and constipation sent to all cohort participants and completed in 2014 the Brief Smell Identification Test and a questionnaire assessing parkinsonism and other non-motor PD features (including depressive symptoms, excessive daytime sleepiness, impaired colour vision and body pain). Controls (n=6479) met the same criteria as cases, except for the PD diagnosis.

RESULTS

Concurrent constipation, probable RBD and hyposmia were present in 29.3% of cases and 1.1% of controls, yielding an age-adjusted OR of 160(95%CI 72.8to353) for three features versus none. The odds of PD increased exponentially with additional non-motor features (OR for 6-7 features versus none: 1325; 95%CI333to5279). Among men without PD, the number of non-motor features was associated with odds of parkinsonism (OR for 6-7 features versus none: 89; 95%CI21.2to375). We estimated that in a population with a prodromal PD prevalence of 2%, concurrent constipation, probable RBD and hyposmia would have a maximum sensitivity of 29% and a positive predictive value (PPV) of 35%. The PPV could increase up to 70% by including additional features, but with sharply decreased sensitivity.

CONCLUSIONS

Concurrent constipation, probable RBD and hyposmia are strongly associated with PD. Because these features often precede motor symptoms and their co-occurrence could provide an efficient method for early PD identification.

Movement Disorders Related to Gluten Sensitivity: A Systematic Review

Gluten related disorders (GRD) represent a wide spectrum of clinical manifestations that are triggered by the ingestion of gluten. Coeliac disease (CD) or gluten sensitive enteropathy is the most widely recognised, but extra-intestinal manifestations have also been increasingly identified and reported. Such manifestations may exist in the absence of enteropathy. Gluten sensitivity (GS) is another term that has been used to include all GRD, including those where there is serological positivity for GS related antibodies in the absence of an enteropathy. Gluten ataxia (GA) is the commonest extraintestinal neurological manifestation and it has been the subject of many publications. Other movement disorders (MDs) have also been reported in the context of GS. The aim of this review was to assess the current available medical literature concerning MDs and GS with and without enteropathy. A systematic search was performed while using PubMed database. A total of 48 articles met the inclusion criteria and were included in the present review. This review highlights that the phenomenology of gluten related MDs is broader than GA and demonstrates that gluten-free diet (GFD) is beneficial in a great percentage of such cases.

Familial aggregation of Parkinson's disease and coaggregation with neuropsychiatric diseases: a population-based cohort study

Background

Individuals with a family history of Parkinson's disease (PD) appear to have a higher risk of developing PD and other neuropsychiatric diseases. However, estimates of the relative risks (RRs) of PD and the roles of genetic and environmental factors in PD susceptibility are unclear. The aim of this study was to examine familial aggregation and genetic contributions to PD and the RRs of other neuropsychiatric diseases in relatives of PD patients.

Methods

In this population-based family cohort study, the records of all individuals actively registered in the Taiwan National Health Insurance Research Database in 2015 were queried (N=24,349,599). In total, 149,187 individuals with a PD-affected parent, 3,698 with an affected offspring, 3,495 with an affected sibling, and 15 with an affected twin were identified. Diagnoses of PD were ascertained between January 1, 1999, and December 31, 2015. The prevalence and RRs of PD and other neuropsychiatric diseases in individuals with first-degree relatives with PD, as well as the contributions of heritability and environmental factors to PD susceptibility were investigated.

Results

The prevalence of PD was 0.46% in the general population and 0.52% in individuals with first-degree relatives with PD. The RR (95% CI) for PD was 2.20 (1.41-3.45) for siblings, 1.59 (1.47-1.73) for parents, 1.86 (1.63-2.11) for offspring, 63.12 (16.45-242.16) for twins, and 1.46 (1.41-1.52) for spouses. The RR (95% CI) in individuals with first-degree relatives with PD was 1.66 (1.57-1.76) for essential tremor, 1.68 (1.61-1.75) for schizophrenia, and 1.20 (1.12-1.28) for Alzheimer's disease. The estimated contribution to the phenotypic variance of PD was 11.0% for heritability, 9.1% for shared environmental factors, and 79.9% for non-shared environmental factors.

Conclusion

First-degree relatives of PD patients are more likely to develop PD and other neuropsychiatric diseases. Environmental factors account for a high proportion of the phenotypic variance of PD.

Clinical Profile of Parkinson's Disease: Experience of Niger

Background:

Parkinson's disease (PD) is a chronic neurodegenerative pathology with unknown etiology. It is characterized clinically by the classic triad that associated tremors, bradykinesia, and rigidity. In Niger, there are no data on PD.

Aims:

We aimed to provide the demographic and clinical profile of PD in patients from Niger to create a database on PD in Niger.

Patients and Methods:

We conducted a retrospective study at the Neurology Outpatient Clinic of the Hôpital National de Niamey (HNN, Niger) over a period of 4.42 years from February 2009 to July 2013 collecting all cases of PD. The demographic and clinical features of all patients were collected and analyzed.

Results:

During the period of the study, 1695 patients consulted at the Neurology Outpatient Clinic of the HNN, among which 76 patients (4.48%) had secondary parkinsonism and 25 patients (1.47%) had features compatible with PD. Only patients with PD were included in this study. The mean age at onset of symptoms was 58 years (range: 42–74 years). The male sex was predominant (60%) with a sex ratio of 1.5. The mean time interval from the onset of symptoms to diagnosis of PD was 1.8 years (range: 1–5 years). The tremor was the most common symptom (84%). Bradykinesia represented 64% of the symptoms and rigidity 20%. At the time of the diagnosis of PD, 8 patients (32%) were in Stage I of the classification of Hoehn and Yahr, 16 patients (64%) in Stage II, and 1 patient (4%) in Stage III. The levodopa/carbidopa combination was the most used antiparkinsonian drug in our patients (88%). The mean time of follow-up of the patients was 2.5 years (range: 1–4.42 years). During the course of the disease, 9 patients (36%) were in Stage II of the classification of Hoehn and Yahr, 13 patients (52%) in Stage III, and 3 patients (12%) in Stage IV.

Conclusion:

Our study provides demographic and clinical data of PD in patients from Niger and shows that the hospital frequency of this disease is low (1.47%). The demographic and clinical features of our patients are similar to those of the patients of the prior studies reported in sub-Saharan Africa.

Epidemiology of Parkinson's Disease-East Versus West

Background

The cause of PD at present remains unknown. A number of epidemiological studies have been conducted across the globe to ascertain the disease burden and the possible risk factors. In this review, we analyze the various studies from East and West with an aim to observe the important similarities and differences in the disease occurrence and risk factor profile.

Methods

A comprehensive search of descriptive and analytical epidemiological studies was undertaken. The descriptive studies and meta-analysis providing the standardised population rates were selected. The demographics, ethnicity and geographical differences between East and West were analysed. In analytical epidemiology, more established and well-studied non-genetic risk factors for PD were reviewed utilising the prospective cohort studies, case control studies and meta-analysis where available.

Results and Conclusion

PD is more common with increasing age and shows male predominance, which is more obvious in Western studies. The PD prevalence and incidence rates are slightly lower in the East compared to the West. Incidence studies on different ethnic populations in the same country have also found a lower occurrence of PD amongst Easterners compared to Westerners. Setting methodological differences aside, studies from East and West suggest a role for both environmental and genetic risk factors in PD causation. Smoking, caffeine intake and pesticide exposure are well-established risk factors across regions. There is a robust data for dairy product consumption, urate levels and physical activity in the West while studies on certain risk factors like head injury and alcohol show conflicting and mixed results.

Population Base Rates and Disease Course of Common Psychiatric and Neurodegenerative Disorders

Knowledge of population base rates of neurological and psychiatric disorders is fundamental for diagnostic decision making. Consideration of relevant probabilistic information can improve diagnostic efficiency and accuracy. However, such data continue to be misused or underutilized, which can lead to misdiagnoses and negative patient outcomes. The aim of the current review is to create an easily accessible and comprehensive reference of existing age of onset as well as prevalence and incidence data for common neurodegenerative and psychiatric disorders in adults. Relevant epidemiological data were compiled from well-respected and frequently-cited textbooks and scholarly studies. Reviews were collected from PubMed, and publicly-available sources were gathered from Google Scholar. Results are organized and presented in several tables and a figure, which can be used as a diagnostic guide for students and clinicians across healthcare disciplines.

Prevalence, Duration and Severity of Parkinson's Disease in Germany: A Combined Meta-Analysis from Literature Data and Outpatient Samples

BACKGROUND

Epidemiological data on the prevalence of Parkinson's disease (PD) in Germany are limited. The aims of this study were to estimate the age- and gender-specific prevalence of PD in Germany as well as the severity and illness duration.

SUMMARY

A systematic literature search was performed in 5 different databases. European studies were included if they reported age- and gender-specific numbers of prevalence rates of PD. Meta-analytic approaches were applied to derive age- and gender-specific pooled prevalence estimates. Data of 4 German outpatient samples were incorporated to calculate the proportion of patients with PD in Germany grouped by Hoehn and Yahr (HY) stages and disease duration. In the German population, 178,169 cases of PD were estimated (prevalence: 217.22/100,000). The estimated relative illness duration was 40% with less than 5 years, 31% with 5-9 years, and 29% with more than 9 years. The proportions for different HY stages were estimated at 13% (I), 30% (II), 35% (III), 17% (IV), and 4% (V), respectively. Key Message: We provide an up-to-date estimation of age- and gender-specific as well as severity-based prevalence figures for PD in Germany. Further community studies are needed to estimate population-based severity distributions and distributions of non-motor symptoms in PD.

Feasibility of a randomized single-blind crossover trial to assess the effects of the second-generation slow-release dopamine agonists pramipexole and ropinirole on cued recall memory in idiopathic mild or moderate Parkinson's disease without cognitive impairment

Background

The aim was to assess the feasibility of a single-centre, single-blind, randomized, crossover design to explore the effects of two slow-release dopamine agonists, ropinirole and pramipexole, on cued recall in Parkinson’s disease.

As the design required a switch from the prescribed agonist (pramipexole-to-ropinirole, or ropinirole-to-pramipexole), the primary objectives were to (a) examine the efficacy of processes and procedures used to manage symptoms during the washout period and (b) to use cued recall estimates to inform a power calculation for a definitive trial.

Secondary objectives were to assess consent and missing data rates, acceptability of clinical support for the OFF sessions, experience of the OFF sessions and of agonist switching, barriers-to-participation for patients and informal caregivers.

Methods

Patients were randomized in a 1:1 ratio to two treatment arms and stabilized on each agonist for 6 weeks. The arms differed only in the sequence in which the agonists were administered. Cued recall was assessed ON medication and, following a washout period resulting in 93.75% agonist elimination, OFF medication.

Results

A total of 220 patients were screened: 145 were excluded and 75 invitations to participate were sent to eligible patients. Fifty-three patients declined, 22 consented and 16 completed the study.

There were no serious adverse events, and rates of non-serious adverse events were equivalent between the agonists.

Using the largest standard deviation (SD) of the ON–OFF difference cued recall score (inflated by ~25% to give a conservative estimate of the SD in a definitive trial) and assuming an effect of at least 10% of the observed range of OFF medication cued recall scores for either agonist to be clinically important, a main trial requires a sample size of just under 150 patients.

The consent and missing data rates were 29 and 27% respectively. The washout period and the preparation for the OFF sessions were acceptable, and the sessions were manageable. The experience of switching was also manageable. Barriers to participation included concerns about disease stability, side effects, research process, carer workload and accessibility of the information sheet.

Conclusions

This study presented challenges to recruitment both in design and execution, and while it was a major aim of the study to assess this, evaluation of these challenges provided the opportunity to explore how they could be overcome for future studies.

Trial registration

EudraCT 2012-000801-64

Parkinson Disease: An Evolutionary Perspective

There are two central premises to this evolutionary view of Parkinson disease (PD). First, PD is a specific human disease. Second, the prevalence of PD has increased over the course of human history. Several lines of evidence may explain why PD appears to be restricted to the human species. The major manifestations of PD are the consequence of degeneration in the dopamine-synthesizing neurons of the mesostriatal neuronal pathway. It is of note the enormous expansion of the human dopamine mesencephalic neurons onto the striatum compared with other mammals. Hence, an evolutionary bottle neck was reached with the expansion of the massive nigrostriatal axonal arborization. This peculiar nigral overload may partly explain the selective fragility of the human dopaminergic mesencephalic neurotransmission and the unique presence of PD in humans. On the other hand, several facts may explain the increasing prevalence of PD over the centuries. The apparently low prevalence of PD before the twentieth century may be related to the shorter life expectancy and survival compared to present times. In addition, changes in lifestyle over the course of human history might also account for the increasing burden of PD. Our hunter-gatherers ancestors invested large energy expenditure on a daily basis, a prototypical physical way of life for which our genome remains adapted. Technological advances have led to a dramatic reduction of physical exercise. Since the brain release of neurotrophic factors (including brain-derived neurotrophic factor) is partially exercise related, the marked reduction in exercise may contribute to the increasing prevalence of PD.

A population-based epidemiologic study of adult neuromuscular disease in the Republic of Ireland

Objective:

To estimate the prevalence rates (PRs) of acquired and inherited neuromuscular diseases (NMD) in the adult Irish population, reflecting the burden of these conditions in a single country.

Methods:

This population-based study was performed in the Republic of Ireland (RoI), with a PR estimated for December 2013. Multiple case ascertainment sources were utilized. Demographic and clinical information and relevant diagnostic results were registered.

Results:

A total of 2,641 adults were identified, giving a PR of 62.6/100,000 (95% confidence interval [CI] 59.95–65.24) for all NMD in RoI. Disease-specific PR include chronic inflammatory demyelinating polyradiculoneuropathy 5.87/100,000 (95% CI 5.06–6.68), Charcot-Marie-Tooth 10.52/100,000 (95% CI 9.44–11.61), hereditary neuropathy with liability to pressure palsies 0.84/100,000 (95% CI 0.54–1.15), myotonic dystrophy type I 6.75/100,000 (95% CI 5.88–7.61), Duchenne muscular dystrophy 3.0/100,000 (95% CI 2.33–3.70), Becker muscular dystrophy 2.2/100,000 (95% CI 1.64–2.88), facioscapulohumeral dystrophy 2.59/100,000 (95% CI 2.05–3.13), limb-girdle muscular dystrophy 2.88/100,000 (95% CI 2.31–3.45), periodic paralysis 1.72/100,000 (95% CI 1.28–2.15), myotonia congenita 0.32/100,000 (95% CI 0.18–0.56), paramyotonia congenita 0.15/100,000 (95% CI 0.06–0.34), Kennedy disease 0.83/100,000 (95% CI 0.40–1.27), Lambert-Eaton myasthenic syndrome 0.29/100,000 (95% CI 0.11–0.47), myasthenia gravis 15.12/100,000 (95% CI 13.82–16.42), and sporadic inclusion body myositis 11.7/100,000 (95% CI 9.82–13.58). PR for amyotrophic lateral sclerosis was established from an existing Register as 7.20/100,000 (95% CI 6.34–8.15).

Conclusions:

The PR of all adult NMD in RoI is relatively high when compared with other chronic neurologic disorders, although some figures may be an underestimate of the true prevalence. The data provide a framework for international comparison and service planning.

Trends in the Incidence of Parkinson Disease in the General Population: The Rotterdam Study

We investigated trends in the incidence of parkinsonism and Parkinson disease (PD) by comparing data from the first 2 subcohorts of the Rotterdam Study, a prospective, population-based cohort study (first subcohort: baseline 1990 with 10 years of follow-up; second subcohort, baseline 2000 with 10 years of follow-up). From the baseline years, we observed differences in the second subcohort that were associated with a lower risk of PD for some but not all baseline risk factors. Participants in both subcohorts were followed for a maximum of 10 years and monitored for the onset of parkinsonism, the onset of dementia, or death, until January 1, 2011. We used Poisson regression models to compare the incidences of parkinsonism, both overall and by cause (PD and secondary causes), and competitive events (incident dementia and death) as well as the mortality of parkinsonism patients in the 2 subcohorts. In the 1990 subcohort, there were 182 cases of parkinsonism (84 of which were PD) during 57,052 person-years. In the 2000 subcohort, we observed 28 cases of parkinsonism (10 with PD) during 22,307 person-years. The overall age- and sex-adjusted incidence of parkinsonism was lower in the 2000 subcohort (incidence rate ratio = 0.55, 95% confidence interval: 0.36, 0.81), and PD incidence declined sharply (incidence rate ratio = 0.39, 95% confidence interval: 0.19, 0.72). Competitive event rates were lower in the 2000 subcohort, and mortality rates among persons with parkinsonism remained stable. These findings suggest that the incidence of parkinsonism in general, and of PD in particular, decreased between 1990 and 2011.

Age at onset and Parkinson disease phenotype

OBJECTIVE

To explore clinical phenotype and characteristics of Parkinson disease (PD) at different ages at onset in recently diagnosed patients with untreated PD.

METHODS

We have analyzed baseline data from the Parkinson's Progression Markers Initiative database. Four hundred twenty-two patients with a diagnosis of PD confirmed by DaTSCAN imaging were divided into 4 groups according to age at onset (onset younger than 50 years, 50-59 years, 60-69 years, and 70 years or older) and investigated for differences in side, type and localization of symptoms, occurrence/severity of motor and nonmotor features, nigrostriatal function, and CSF biomarkers.

RESULTS

Older age at onset was associated with a more severe motor and nonmotor phenotype, a greater dopaminergic dysfunction on DaTSCAN, and reduction of CSF α-synuclein and total tau. The most common presentation was the combination of 2 or 3 motor symptoms (bradykinesia, resting tremor, and rigidity) with rigidity being more common in the young-onset group. In about 80% of the patients with localized onset, the arm was the most affected part of the body, with no difference across subgroups.

CONCLUSIONS

Although the presentation of PD symptoms is similar across age subgroups, the severity of motor and nonmotor features, the impairment of striatal binding, and the levels of CSF biomarkers increase with age at onset. The variability of imaging and nonimaging biomarkers in patients with PD at different ages could hamper the results of future clinical trials.

Does HIV Infection Alter Parkinson Disease?

OBJECTIVE

To describe the clinical features, treatment(s), and outcomes of 15 HIV-infected patients with idiopathic Parkinson disease (PD) and sustained virus suppression and immunologic reconstitution, from a reference cohort of 9847 persons living with HIV (PLH).

METHODS

This retrospective, single-center matched case-control 1:2 study included PLH-PD patients evaluated over a 12-year period (2002-2013) with mean follow-up of 6.5 years. PD clinical features and dopamine replacement therapy (DRT) were compared, and biologically relevant HIV data were assessed.

RESULTS

PD prevalence in PLH was similar to that of the general population. At onset, clinical presentations and therapeutic management were similar for both groups. Rapidly effective DRT was well tolerated without combined antiretroviral therapy interactions or virus escape. At the end of the follow-up, compared with HIV-negative PD, PLH had a significantly lower median Unified Parkinson's Disease Rating Scale motor score (4 vs 14; P < 0.001), median Hoehn and Yahr stage (1 vs 2; P = 0.0005), and median Handipark scale score (2 vs 3; P = 0.0036) under the same daily DRT. One PLH underwent highly successful deep brain stimulation of the subthalamic nucleus.

CONCLUSIONS

HIV-associated PD is similar to idiopathic PD with some features suggesting an HIV-induced functional adaptation of dopaminergic neurons that might counterbalance the PD-induced neuronal loss. Concurrent HIV infection does not compromise the outcome of idiopathic PD.

Burden among Parkinson's disease care givers for a community based study from India

Aim was to analyze predictors of burden among primary caregivers (CGs) of Indian Parkinson's disease (PD) patients. 150 PD patients were administered using Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr Scale (H&Y), Montgomery Asberg Depression Rating Score (MADRS) and Mini Mental State Examination (MMSE) in this cross-sectional evaluation study. CG burden was assessed by Caregiver's Burden Scale (CBS), Hospital Anxiety and Depression Scale (HADS), SF-36 and 20-item Burden Assessment Schedule (BAS). Linear regression methods were used to evaluate factors contributing to burden and stress. Mean age of CG was 50.38±16.04 (range: 25-83 yrs). Marital status of CGs was noted to have significant relationship with CBS score (F=9.525, P<0.0001). Siblings (brother/sister) reported the highest CBS score while the wives reported the least. Correlations were strong between CBS and HADS anxiety (r=0.228, P=0.0048) and HADS depression (r=0.2172, P=0.0076). High correlations were found in caregiving duration, patients' stage of illness and motor disability among all the scales (CBS, HADS, SF36) determined. Step-wise regression analysis showed UPDRS (beta=1.364-0.202 ranging among all scales) and H&Y stages (beta=2.786-7.257) to have the strongest influence on CGs. CGs of patients with depression (MADRS: P=0.007 (SF36 mental) and dementia (MMSE: P=0.01) experienced greater stress. Social and financial status was disrupted in ~60% to 80% of the CGs. Motor imbalances with disability of PD patients and severity of disease are the main factors contributing to burden and stress in CGs.

Time trends in the prevalence and incidence of Parkinson's disease in Taiwan: A nationwide, population-based study

BACKGROUND/PURPOSE

Identifying trends in the prevalence and incidence of Parkinson's disease (PD) may yield information that supports public health goals. Our aim was to evaluate time-trend changes in the prevalence and incidence of PD in Taiwan between 2004 and 2011.

METHODS

This retrospective, nationwide, longitudinal study used the Taiwan National Health Insurance Research Database to identify patients with PD from 2004 to 2011 based on having ICD-9-CM diagnostic codes, which were assigned by neurologists, and being prescribed PD medication. Annual incidence and prevalence were calculated, and time-trend analyses were estimated assuming a Poisson distribution.

RESULTS

Over the study period, 19,302 patients in 2004 and 41,606 patients in 2011 fulfilling the study criteria for PD were included in the analysis. The average age-standardized prevalence of PD per 100,000 of population was 84.8 in 2004 and 147.7 in 2011, with a 7.9% yearly increase. Increasing prevalence trends of PD were statistically significant (p < 0.001) in all age groups, with the steepest rate among those aged ≥ 80 years. In contrast, the average age-standardized incidence of PD decreased steadily from 35.3 per 100,000 in 2005 to 28.8 per 100,000 in 2011. The incidence rate was higher in men than in women, and increased with age.

CONCLUSION

We identified an increasing trend in the annual prevalence rates of PD from 2004 to 2011; however, the substantial decline in the incidence of PD suggests that some major environmental risk factors for PD were removed from this population during this time period.

Later age at onset in Parkinson's disease over twenty years in an Italian tertiary clinic

BACKGROUND

Age is considered an important risk factor for Parkinson's disease (PD). However, although life-expectancy has increased considerably, incidence rates of PD appeared to be stable over the last two decades. Accordingly, an increase in mean age at onset over time could be expected. We investigated the changes in age at onset in PD over the last two decades.

METHODS

All consecutive PD patients assessed over a 18-year period (1995-2013) in a single tertiary outpatient clinic were included in the present retrospective cohort study.

RESULTS

After adjusting for several confounders (gender, positive family history for PD, education, smoking at onset and past exposure to environmental/occupational pollutants), 5-year cohorts of year of disease onset were associated with increasing age at onset in both prevalent (N = 6996) and incident (N = 4172) cases (for trend, P < 0.001). From 1995-2000 to 2010-2013 there was an increase in predicted age of 4.1 years (95% CI, 3.0-5.2) and 3.9 years (95% CI, 2.7-5.1) in prevalent and incident cases, respectively. However, the change in predicted age at PD onset, across cohorts of year at onset, showed a steeper increase than the corresponding sex and cohort-matched mean age from the official Italian statistics.

CONCLUSIONS

Over the last two decades, age at onset of PD appeared to shift progressively towards more advanced age. However, sequential, high-quality population-based incidence studies are required. To establish whether there is a trend towards increase in age at onset over and above general population ageing and to assess whether the increase is associated with improved medical and socio-economic conditions.

Gender-related protection from or vulnerability to severe CNS diseases: gonado-structural and/or gonado-activational? A meta-analysis of relevant epidemiological studies

BACKGROUND

A vast scientific literature has dealt with gender-specific risk for brain disorder. That field is evolving toward a consensus to the effect that the estrogen hormone family is outstandingly and uniquely neuroprotective. However, the epidemiology relevant to this general outlook remains piecemeal.

METHOD

The present investigation strategically formats the relevant epidemiological findings around the world in order to quantitatively meta-analyze gender ratio of risk for a variety of relevant severe central nervous system (CNS) diseases at all three gonadal stages of the life cycle, pre pubertal, post adolescent/pre menopausal, and post menopausal.

RESULTS

The data quantitatively establish that (1) no single epidemiological study should be cited as evidence of gender-specific neuroprotection against the most common severe CNS diseases because the gender-specific risk ratios are contradictory from one study to the other; (2) risk for severe CNS disease is indeed significantly gender-specific, but either gender can be protected: it depends on the disease, not at all on the age bracket.

CONCLUSION

Our assay of gender-specific risk for severe brain disease around the world has not been able to support the idea according to which any one gender-prevalent gonadal steroid hormone dominates as a neuroprotective agent at natural concentrations.

Morbidity in early Parkinson's disease and prior to diagnosis

BACKGROUND

Nonmotor symptoms are probably present prior to, early on, and following, a diagnosis of Parkinson's disease. Nonmotor symptoms may hold important information about the progression of Parkinson's disease.

OBJECTIVE

To evaluated the total early and prediagnostic morbidities in the 3 years before a hospital contact leading to a diagnosis of Parkinson's disease.

METHODS

Retrospective morbidity data from Danish National Patient Registry records (1997-2007) of 10,490 adult patients with a secondary care diagnosis of Parkinson's disease were compared with 42,505 control cases.

RESULTS

Parkinson's disease was associated with significantly higher morbidity rates associated with conditions in the following categories: mental and psychiatric, nervous system, gastrointestinal, musculoskeletal system and connective tissue, genitourinary, abnormal clinical and laboratory findings, injury, poisoning and certain other external causes, and other factors influencing health status and contact with health services. It was negatively associated with neoplasm, cardiovascular, and respiratory diseases.

CONCLUSIONS

Patients with a diagnosis of Parkinson's disease present significant differences in morbidities early on, following, and prior to, their diagnosis, compared with healthy controls.

Time to redefine PD? Introductory statement of the MDS Task Force on the definition of Parkinson's disease

With advances in knowledge disease, boundaries may change. Occasionally, these changes are of such a magnitude that they require redefinition of the disease. In recognition of the profound changes in our understanding of Parkinson's disease (PD), the International Parkinson and Movement Disorders Society (MDS) commissioned a task force to consider a redefinition of PD. This review is a discussion article, intended as the introductory statement of the task force. Several critical issues were identified that challenge current PD definitions. First, new findings challenge the central role of the classical pathologic criteria as the arbiter of diagnosis, notably genetic cases without synuclein deposition, the high prevalence of incidental Lewy body (LB) deposition, and the nonmotor prodrome of PD. It remains unclear, however, whether these challenges merit a change in the pathologic gold standard, especially considering the limitations of alternate gold standards. Second, the increasing recognition of dementia in PD challenges the distinction between diffuse LB disease and PD. Consideration might be given to removing dementia as an exclusion criterion for PD diagnosis. Third, there is increasing recognition of disease heterogeneity, suggesting that PD subtypes should be formally identified; however, current subtype classifications may not be sufficiently robust to warrant formal delineation. Fourth, the recognition of a nonmotor prodrome of PD requires that new diagnostic criteria for early-stage and prodromal PD should be created; here, essential features of these criteria are proposed. Finally, there is a need to create new MDS diagnostic criteria that take these changes in disease definition into consideration.

Comparing clinical features of young onset, middle onset and late onset Parkinson's disease

BACKGROUND

Parkinson's disease (PD) affects 1-2% of the population over 65 years. There is evidence that the clinical features differ with age at symptom onset, but published information is scarce.

METHODS

We reviewed the charts of 593 PD patients and divided them into young onset (≤49 years), middle onset (50-69 years) and late onset (≥70 years) groups. Data collected included age at symptom onset, year of onset, family history of Parkinson's disease in first and second degree relatives, predominant first symptom, first anti parkinsonian medication prescribed, frequency of levodopa-induced dyskinesia, therapy related dystonia, therapy related gastrointestinal side effects, hallucination, dementia, depression and apathy.

RESULTS

The middle onset was the largest group (51%), followed by the late onset (39%) and the young onset (10%) groups. Young onset patients had a more frequent family history of Parkinson's disease and a longer survival. Symptoms other than tremor were more frequent as the initial symptom of the young onset group, and the frequency of tremor as the first symptom increased with advancing age at onset. Depression was more frequent in the young onset group. The frequency of treatment related dyskinesia or dystonia decreased with advancing age at onset.

CONCLUSION

We have identified specific clinical differences in Parkinson's disease related to the patient's age at onset and added to the existing knowledge of the variability of disease presentation. We suggest an age of onset of 49 years or less for the definition of young onset PD.

The cost-effectiveness of deep brain stimulation in combination with best medical therapy, versus best medical therapy alone, in advanced Parkinson's disease

Parkinson’s disease (PD) is a complex progressive movement disorder leading to motor and non-motor symptoms that become increasingly debilitating as the disease advances, considerably reducing quality of life. Advanced treatment options include deep brain stimulation (DBS). While clinical effectiveness of DBS has been demonstrated in a number of randomised controlled trials (RCT), evidence on cost-effectiveness is limited. The cost-effectiveness of DBS combined with BMT, versus BMT alone, was evaluated from a UK payer perspective. Individual patient-level data on the effect of DBS on PD symptom progression from a large 6-month RCT were used to develop a Markov model representing clinical progression and capture treatment effect and costs. A 5-year time horizon was used, and an incremental cost-effectiveness ratio (ICER) was calculated in terms of cost per quality-adjusted life-years (QALY) and uncertainty assessed in deterministic sensitivity analyses. Total discounted costs in the DBS and BMT groups over 5 years were £68,970 and £48,243, respectively, with QALYs of 2.21 and 1.21, giving an incremental cost-effectiveness ratio of £20,678 per QALY gained. Utility weights in each health state and costs of on-going medication appear to be the key drivers of uncertainty in the model. The results suggest that DBS is a cost-effective intervention in patients with advanced PD who are eligible for surgery, providing good value for money to health care payers.

Parkinson's disease: how is employment affected?

BACKGROUND

Rates of unemployment and early retirement are increased in Parkinson's disease (PD) and contribute to disease burden.

AIMS

To investigate time to loss of employment from PD onset and predictors of continued employment; to identify common issues and possible interventions in the workplace.

METHODS

Eighty-eight patients with PD diagnosed at age≤65 years took part in a retrospective cohort study. Veterans RAND Short Form-36 and an employment survey were administered.

RESULTS

Unemployment rates for males were increased compared to the general Irish population (standardized ratio of 1.6, 95% CI 1.2-2.2, P<0.05). There was no significant difference for females. Median retirement age was 58 years for males and 61 years for females compared to 63.5 and 65 years, respectively, in the general population. In survival analysis, median time to loss of employment was 7 years (95% CI 4.8-9.2). After 5 years, 40% remained working and 14% after 10 years. Early age of PD onset (P<0.001), early diagnosis (P<0.002) and high scores in vitality (P<0.005) were associated with prolonged employment. There was no association with sex, education, type or hours of work. Slowness, fatigue and tremor were the most challenging symptoms at work. Changes in work schedule and type of work were suggested helpful adjustments.

CONCLUSION

Loss of employment places a significant socioeconomic burden on young PD patients. More detailed examination of specific issues and reasonable adjustments is needed, along with patient and employer education.