Impact of Sex on the Nonmotor Symptoms and the Health-Related Quality of Life in Parkinson's Disease

Health-related quality of life in Parkinson's disease: systematic review and meta-analysis of EuroQol (EQ-5D) utility scores

INTRODUCTION

Evaluating the Health-related quality of life (HRQoL) of individuals with Parkinson's disease (PD) holds significant importance in clinical and research settings. The EQ-5D is a widely recognized tool for comprehensive measurement of HRQoL using utility values. This study aims to systematically review and synthesize EQ-5D utility values from existing literature on patients with PD and their caregivers.

METHODS

We conducted a systematic search for studies that provided EQ-5D utility scores for patients with PD, using PubMed-Medline, Scopus, and Embase and selected the studies. The selected studies underwent systematic review, including an assessment of their quality. We performed a meta-analysis using a random-effect model and conducted a meta-regression analysis to investigate sources of heterogeneity among the studies.

RESULTS

The search result of 13,417 articles that were reviewed, 130 studies with 33,914 participants were selected for systematic review, and 79 studies were included for meta-analysis. The pooled EQ-5D utility values and visual analog score (VAS) among PD were 62.72% (60.53-64.93, I2 = 99.56%) and 0.60 (0.55-0.65, I2 = 99.81%), respectively. The pooled scores for caregivers' EQ-VAS and EQ-5D utility were 70.10% (63.99-76.20, I2 = 98.25%) and 0.71 (0.61-0.81, I2 = 94.88%), respectively. Disease duration (P < 0.05) showed a negative correlation with EQ-5D utility values on meta-regression.

CONCLUSION

The pooled utility values of PD and their caregivers help to understand their HRQoL and aid in conducting health economics research. The negative association between disease duration and utility values highlights the evolving nature of HRQoL challenges, suggesting the need for appropriate long-term disease management.

Age and gender differences in non-motor symptoms in people with Parkinson's disease

Background

Non-motor symptoms of Parkinson's disease (PD) are highly prevalent and heterogenic. Previous studies aimed to gain more insight on this heterogeneity by investigating age and gender differences in non-motor symptom severity, but findings were inconsistent. Furthermore, besides examining the single effects of age and gender, the interaction between them in relation to non-motor functioning has -as far as we know- not been investigated before.

Objectives

To investigate the association of age and gender identity -as well as the interaction between age and gender identity- with non-motor symptoms and their impact on quality of life.

Methods

We combined three large and independent studies. This approach resulted in a total number of unique participants of 1,509. We used linear regression models to assess the association of age and gender identity, and their interaction, with non-motor symptoms and their impact on quality of life.

Results

Older people with PD generally had worse cognitive functioning, worse autonomic functioning and worse quality of life. Women with PD generally experienced more anxiety, worse autonomic functioning and worse quality of life compared to men with PD, whereas men with PD generally had worse cognitive functioning. In interaction analyses by age and gender identity, depressive symptoms and anxiety were disproportionally worse with increasing age in women compared to men.

Conclusion

Our findings indicate that both age and gender -as well as their interaction- are differentially associated with non-motor symptoms of PD. Both research and clinical practice should pay more attention to demographic subgroups differences and possible different treatment approaches with respect to age and gender. We showed how combining datasets is of added value in this kind of analyses and encourage others to use similar approaches.

Gender discrepancies and differences in motor and non-motor symptoms, cognition, and psychological outcomes in the treatment of Parkinson's disease with subthalamic deep brain stimulation

Available data suggest that there may be gender differences in the effect of STN-DBS in the treatment of Parkinson's disease (PD). The aim of this study was to review data on gender discrepancies and gender differences in clinical outcomes in PD patients treated with deep brain stimulation of the subthalamic nucleus (STN-DBS). Included were original studies that specifically examined gender discrepancies or gender differences in PD patients with STN-DBS. Men receive more DBS than women, for various indications. The decision-making process for DBS in women compared to men is more influenced by personal preferences and external factors. Motor symptoms improve in both genders, but bradykinesia improves more in men. The postoperative reduction of the levodopa equivalent daily dose seems to be more pronounced in men. Men show more cognitive deterioration and less improvement than women after STN-DBS. Women show more depressive symptoms before surgery, but they improve similarly to men. Men show more improvement in impulsivity and less decrease in impulsive behaviour symptoms than women. Anxiety and personality traits remain unchanged in both genders. Voice quality improves more in men and deteriorates less often than in women. Men gain fat-free mass and fat mass, but women only gain fat mass. Regarding sexual function the evidence is inconsistent. More urinary symptoms improve in women than in men. Pain and restless leg syndrome seems to improve more in men. Regarding quality of life, the evidence seems to be inconsistent, and activities of daily living seems to improve in both genders. Better prospective controlled studies, focusing directly on gender differences in PD patients treated with STN-DBS, are needed to better explain gender differences in STN-DBS for PD.

Sex-dependent neuronal effects of α-synuclein reveal that GABAergic transmission is neuroprotective of sleep-controlling neurons

BACKGROUND

Sleep disorders (SDs) are a symptom of the prodromal phase of neurodegenerative disorders that are mechanistically linked to the protein α-synuclein (α-syn) including Parkinson's disease (PD). SDs during the prodromal phase could result from neurodegeneration induced in state-controlling neurons by accumulation of α-syn predominant early in the disease, and consistent with this, we reported the monomeric form of α-syn (monomeric α-syn; α-synM) caused cell death in the laterodorsal tegmental nucleus (LDT), which controls arousal as well as the sleep and wakefulness state. However, we only examined the male LDT, and since sex is considered a risk factor for the development of α-syn-related diseases including prodromal SDs, the possibility exists of sex-based differences in α-synM effects. Accordingly, we examined the hypothesis that α-synM exerts differential effects on membrane excitability, intracellular calcium, and cell viability in the LDT of females compared to males.

METHODS

Patch clamp electrophysiology, bulk load calcium imaging, and cell death histochemistry were used in LDT brain slices to monitor responses to α-synM and effects of GABA receptor acting agents.

RESULTS

Consistent with our hypothesis, we found differing effects of α-synM on female LDT neurons when compared to male. In females, α-synM induced a decrease in membrane excitability and heightened reductions in intracellular calcium, which were reliant on functional inhibitory acid transmission, as well as decreased the amplitude and frequency of spontaneous excitatory postsynaptic currents (sEPSCs) with a concurrent reduction in action potential firing rate. Cell viability studies showed higher α-synM-mediated neurodegeneration in males compared to females that depended on inhibitory amino acid transmission. Further, presence of GABA receptor agonists was associated with reduced cell death in males.

CONCLUSIONS

When taken together, we conclude that α-synM induces a sex-dependent effect on LDT neurons involving a GABA receptor-mediated mechanism that is neuroprotective. Understanding the potential sex differences in neurodegenerative processes, especially those occurring early in the disease, could enable implementation of sex-based strategies to identify prodromal PD cases, and promote efforts to illuminate new directions for tailored treatment and management of PD.

Sex differences in alpha-synucleinopathies: a systematic review

Background

Past research indicates a higher prevalence, incidence, and severe clinical manifestations of alpha-synucleinopathies in men, leading to a suggestion of neuroprotective properties of female sex hormones (especially estrogen). The potential pathomechanisms of any such effect on alpha-synucleinopathies, however, are far from understood. With that aim, we undertook to systematically review, and to critically assess, contemporary evidence on sex and gender differences in alpha-synucleinopathies using a bench-to-bedside approach.

Methods

In this systematic review, studies investigating sex and gender differences in alpha-synucleinopathies (Rapid Eye Movement (REM) Behavior Disorder (RBD), Parkinson's Disease (PD), Dementia with Lewy Bodies (DLB), Multiple System Atrophy (MSA)) from 2012 to 2022 were identified using electronic database searches of PubMed, Embase and Ovid.

Results

One hundred sixty-two studies were included; 5 RBD, 6 MSA, 20 DLB and 131 PD studies. Overall, there is conclusive evidence to suggest sex-and gender-specific manifestation in demographics, biomarkers, genetics, clinical features, interventions, and quality of life in alpha-synucleinopathies. Only limited data exists on the effects of distinct sex hormones, with majority of studies concentrating on estrogen and its speculated neuroprotective effects.

Conclusion

Future studies disentangling the underlying sex-specific mechanisms of alpha-synucleinopathies are urgently needed in order to enable novel sex-specific therapeutics.

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

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

Demographic Influences on the Relationship Between Fatigue and Quality of Life in Parkinson's Disease

Background

Fatigue has a major impact on health-related quality of life (HR-QOL) in Parkinson's disease (PD).

Objectives

To determine whether demographic characteristics modify the relationship between fatigue and HR-QOL.

Methods

Patients with PD in the Fox Insight study completed the Parkinson Fatigue Scale (PFS-16) and Geriatric Depression Scale (GDS-15). Linear regression examined the relationship between the PFS-16 and Parkinson Disease Quality of Life, as modified by age, sex, and GDS-15.

Results

A total of 1029 participants (44% female, mean age 67.4 years, and mean disease duration 4.6 years) were included in this analysis. Multivariable regression modeling demonstrated a negative effect modification for age (β = -0.07, P < 0.001) and a positive effect modification for the GDS-15 (β = 0.057, P = 0.002), but not for sex (β = -0.021, P = 0.231).

Conclusion

The association between fatigue and worse HR-QOL is greater at younger ages and in individuals with more depressive symptoms. Targeted therapeutics for these individuals may provide the greatest impact on fatigue in PD.

Sex effects on clinical features in LRRK2 G2385R carriers and non-carriers in Parkinson's disease

BACKGROUND

Differences of genotypes between male and female have been studied in Parkinson's disease (PD), but limited research has focused on the comparison between sexes with LRRK2 G2385 variant.

OBJECTIVE

The aim of this study was to explore sex effects in the same genetic subtype and role of leucine-rich repeat kinase 2 (LRRK2) G2385R variants in the same sex in PD.

METHODS

613 PD patients were recruited from the Movement Disorders Clinic in Ruijin Hospital. We did not include healthy controls in this study. The data collected includes demographic information, disease history, scores of motor and non-motor symptoms scales, midbrain transcranial sonography and DNA. Binary logistic regression analysis was performed to evaluate the association between clinical features and sex in LRRK2 G2385R carriers and non-carriers, as well as the association between the clinical features and LRRK2 G2385R variants in male and female sex.

RESULTS

Sex distribution is similar in LRRK2 G2385R carriers and non-carriers. In male sex, LRRK2 G2385R carriers showed lower risk in cognitive impairment compared with non-carriers (OR = 0.301, p = 0.003, 95%CI 0.135-0.668). In female sex, LRRK2 G2385R carriers showed lower risk in autonomic dysfunction compared with non-carrier (OR = 0.401, p = 0.040, 95%CI 0.167-0.960). In LRRK2 G2385R non-carriers, female sex showed lower risk of impairment in activity of daily living (OR = 0.610, p = 0.021, 95%CI 0.400-0.928), excessive daytime sleepiness (OR = 0.555, p = 0.007, 95%CI 0.361-0.853), substantia nigra hyperechogenicity (OR = 0.448, p = 0.019, 95%CI 0.228-0.878), autonomic dysfunction frequency (OR = 0.626, p = 0.016, 95%CI 0.428-0.917) and higher risk in mood disorders (OR = 1.691, p = 0.022, 95%CI 1.078-2.654) compared with male. In LRRK2 G2385R carriers, female sex showed a lower risk of autonomic dysfunction (OR = 0.294, p = 0.024, 95%CI 0.102-0.849) compared with male.

CONCLUSION

In contrast to male PD patients, a more benign disease course was observed in female in both LRRK2 G2385R carriers and non-carriers. However, sex differences were less notable in PD with LRRK2 G2385R variants.

The Impact of Trimetazidine on Disease Severity and Quality of Life in Parkinson's Disease

Trimetazidine is contraindicated in movement disorders, however, a not negligible part of trimetazidine users is still patients with Parkinson’s disease (PD). The present study aimed to objectively determine the impact of trimetazidine on the severity of symptoms and the health-related quality of life of patients with PD by measuring changes after its withdrawal. A consecutive series of 42 patients with PD using trimetazidine underwent detailed neurological and neuropsychological assessments at baseline and three months after the discontinuation of trimetazidine. Clinically relevant improvements were achieved with discontinuation of trimetazidine according to changes in scores of each part of the Movement Disorder Society-sponsored Unified Parkinson’s Disease Rating Scale (Part I: −25.7%, p < 0.001; Part II: −23.8%, p < 0.001; Part III: −28.5%, p < 0.001; Part IV: −30.1%, p = 0.004) and total scores of the Non-Motor Symptoms Scale (−25.6%, p = 0.004) and the Montgomery-Asberg-Depression Rating Scale (−20.1%, p = 0.001). Benefits resulting from the withdrawal of the drug also manifested in the improvement of the health-related quality of life based on changes in the summary index of the 39-item Parkinson’s Disease Questionnaire (−18.2%, p = 0.031). Our results provide clinical rationale for strictly avoiding the use of trimetazidine in PD. Discontinuation of trimetazidin results in clinically relevant improvements in Parkinsonian symptoms.

Sex differences in movement disorders

In a range of neurological conditions, including movement disorders, sex-related differences are emerging not only in brain anatomy and function, but also in pathogenesis, clinical features and response to treatment. In Parkinson disease (PD), for example, oestrogens can influence the severity of motor symptoms, whereas elevation of androgens can exacerbate tic disorders. Nevertheless, the real impact of sex differences in movement disorders remains under-recognized. In this article, we provide an up-to-date review of sex-related differences in PD and the most common hyperkinetic movement disorders, namely, essential tremor, dystonia, Huntington disease and other chorea syndromes, and Tourette syndrome and other chronic tic disorders. We highlight the most relevant clinical aspects of movement disorders that differ between men and women. Increased recognition of these differences and their impact on patient care could aid the development of tailored approaches to the management of movement disorders and enable the optimization of preclinical research and clinical studies.

The Parkinson's Disease Composite Scale Is Adequately Responsive to Acute Levodopa Challenge

Background

The Parkinson's Disease Composite Scale (PDCS) is a recently developed easy-to-use tool enabling a timely but comprehensive assessment of Parkinson's disease (PD)-related symptoms. Although the PDCS has been extensively validated, its responsiveness to acute levodopa challenge has not been demonstrated yet.

Objective

To investigate the correlation between changes in the motor examination part of the Movement Disorder Society-sponsored Unified Parkinson's Disease Rating Scale (MDS-UPDRS) and the PDCS motor scores during acute levodopa challenge and calculate a cutoff range on the PDCS indicating clinically relevant improvement.

Methods

A consecutive series of 100 patients with parkinsonism were assessed using the motor examination sections of the MDS-UPDRS and the PDCS at least 12 hours after the last levodopa dose and after the administration of a single dose of a suprathreshold immediate formulation of levodopa/benserazide reaching the "best ON." Results. There was a high correlation between changes in the MDS-UPDRS and the PDCS motor scores (Spearman's rho = 0.73, p < 0.001). Receiver operating characteristic analysis revealed that a 14.6%-18.5% improvement in the PDCS motor scores corresponds to a 20-30% improvement in the MDS-UPDRS motor examination.

Conclusions

The PDCS can reliably and adequately respond to an acute levodopa challenge. Any improvements in PDCS motor scores exceeding the 14.6-18.5% threshold could represent a clinically relevant response to levodopa.

Profile of Nonmotor Symptoms and the Association with the Quality of Life of Parkinson's Disease Patients in Nigeria

CONTEXT

Parkinson's disease (PD) is the second most common neurodegenerative disorder. Several nonmotor symptoms (NMS) are associated with the condition, affecting multiple body systems in addition to the nervous system.

AIMS

The aim of the study is to describe the profile of NMS and the factors related to their severity as well as their association with the quality of life (QoL) among patients with PD in a Nigerian neurology clinic.

METHODS

A total of 105 patients with PD and 105 healthy controls were assessed for various NMS using a validated NMS assessment scale. A validated PD-specific QoL assessment tool, the PD Questionnaire-39 was also administered to the study patients with PD. Analyses for correlation and difference were performed to determine the associated factors of NMS severity and their association with QoL.

RESULTS

The most common NMS in the PD patients were in the domains of sleep/fatigue and mood/cognition. The total NMS score were significantly higher in patients compared to controls (median [interquartile range] 42 [13-72] vs. 20 [14-29], P < 0.001). There was a significantly higher score in the advanced Hoehn and Yahr stages (P < 0.001). The duration of PD had a positive correlation with the NMS scores (rs= 0.207, P = 0.034. The total NMS score had a strong positive correlation with the QoL (rs= 0.851, P < 0.001).

CONCLUSION

PD is associated with significant NMS and worsens with the progression of the disease and the duration of illness. These NMS have a significant association with the QoL, necessitating the need for detailed and prompt evaluation and management.

Sex-Specific Patient Journeys in Early Parkinson's Disease in the Netherlands

Objective: To reconstruct a sex-specific patient journey for Dutch persons with Parkinson's disease (PD) during the first 5 years after diagnosis.

Method: We analyzed a national administrative medical claims database containing data of all patients newly diagnosed with PD between 2012 and 2016 in the Netherlands. We performed time-to-event analysis to identify the moments when patients received care from neurologists, allied healthcare therapists or general practitioners. We also extracted relevant clinical milestones: unexpected hospitalization for PD, pneumonia, orthopedic injuries, nursing home admission, and death. Using these data, we constructed the patient journey stratified for sex.

Results: We included claims data of 13,518 men and 8,775 women with newly diagnosed PD in the Netherlands. While we found little difference in neurologist consultations, women visited general practitioners and physiotherapists significantly earlier and more often (all p-values < 0.001). After 5 years, 37.9% (n = 3,326) of women had visited an occupational therapist and 18.5% (n = 1,623) a speech and language therapist at least once. This was 33.1% (n = 4,474) and 23.7% (n = 3,204) for men. Approximately 2 years after diagnosis, PD-related complications (pneumonia, orthopedic injuries, and PD-related hospitalization) occurred for the first time (women: 1.8 years; men: 2.3 years), and after 5 years, 72.9% (n = 6,397) of women, and 68.7% (n = 9,287) of men had experienced at least one.

Discussion: Considering the strengths and limitations of our methods, our findings suggest that women experience complications and access most healthcare services sooner after diagnosis and more frequently than men. The identified sex differences extend the debate about phenotypical differences in PD between men and women.

Comorbid Depression and Psychosis in Parkinson's Disease: A Report of 62,783 Hospitalizations in the United States

Background

Depression and psychosis are common comorbidities that significantly affects the quality of life and disease outcomes in Parkinson’s disease (PD) patients.

Objective

The aim of this study was to analyze and discern the differences in the hospitalization outcomes, comorbidities, and utilization of deep brain stimulation (DBS) in PD patients with comorbid depression and comorbid psychosis.

Methods

We used the Nationwide Inpatient Sample (2010-2014) and identified PD as a primary diagnosis (N = 62,783), and depression (N = 11,358) and psychosis (N = 2,475) as co-diagnosis using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Pearson’s chi-square test and independent-sample t-test were used for categorical data and continuous data, respectively.

Results

White male, older age, and comorbid psychosis were significantly associated with higher odds of having major severity of illness in PD inpatients. The mean length of stay (LOS) was higher in PD patients with psychosis compared to PD with depression (7.32 days vs. 4.23 days; P < 0.001), though the mean total charges of hospitalization were lower in psychosis ($31,240 vs. $38,581; P < 0.001). Utilization of DBS was lower in PD patients with psychosis versus with depression (3.9% vs. 24.3%; P < 0.001).

Conclusion

Psychiatric comorbidities are prevalent in PD patients and are associated with more disease severity, impaired quality of life, and increased use of healthcare resources (higher LOS and cost). They should be considered an integral part of the disease, and a multidisciplinary approach to managing this disease is crucial to improve the health-related quality of life of PD patients.

EQ-5D studies in nervous system diseases in eight Central and East European countries: a systematic literature review

BACKROUND

Guidelines for economic analyses of health care technologies require local input data for reimbursement decisions in the countries of Central and Eastern Europe (CEE). The aim of this study was to systematically review and analyse the available empirical studies using the EQ-5D instrument as a measure of the health-related quality of life (HRQoL) in patients with neurological diseases.

METHODS

A systematic literature search was performed up to 1st April 2018 to identify relevant studies in eight selected CEE countries. Original articles reporting on studies of neurological diseases using the EQ-5D instrument were analysed.

RESULTS

Thirty-six articles, describing the results of 38 samples of patients and a total of 13,005 patients were included in the review. Most studies were from Hungary (44.4%) and none from Romania or Slovakia. EQ-5D utility scores were reported in 33 (91.7%) articles. In multiple sclerosis (MS) being the most represented disease, the average utility scores ranged from 0.49 in Austria to 0.80 in Poland with a weighted average of 0.69. EQ VAS scores for MS ranged from 39 in Czech Republic to 72.0 in Poland, with weighted average of 59.1. MS patients, together with epilepsy and essential tremor patients, estimated their HRQoL among the highest.

CONCLUSIONS

EQ-5D research activity in neurology has been increasing through the years in studied CEE countries. There are clinical areas with the significant social burden, such as a migraine or meningitis, that are completely lacking data, other areas, such as stroke or epilepsy, with very scarce data.

Screening for Problematic Internet Use May Help Identify Impulse Control Disorders in Parkinson's Disease

Background

Impulse control disorders in Parkinson's disease (PD) represent emerging problems with potentially devastating consequences. The standard screening methods for impulse control disorders are clinically imperfect. Although it is rarely reported, many patients utilize the Internet to fulfill their compulsive behaviors because of its easy accessibility. We designed a study to test the hypothesis that an active screening for excessive Internet use and Internet addiction might improve the sensitivity of identification of impulse control disorders.

Methods

The standard screening method included the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease and the modified Minnesota Impulsive Disorders Interview. In the second round, the Problematic Internet Use Questionnaire was also assessed for detecting excessive Internet use.

Results

While the standard approach identified 19 patients out of 106 (17.9%) with any type of impulse control disorders, screening for the problematic Internet use detected 29 patients with impulse control disorders (27.4%) having significantly better efficacy over the standard method (p = 0.004, the McNemar test).

Conclusions

Our study suggests that the screening for problematic Internet use by the Problematic Internet Use Questionnaire is an effective, feasible, and easy-to-use add-on method for identifying PD patients with impulse control disorders more efficiently and probably at earlier stages.

Relationship of Nocturnal Sleep Dysfunction and Pain Subtypes in Parkinson's Disease

Background

Little research has been conducted regarding the relationship between sleep disorders and different pain types in Parkinson's disease (PD).

Objective

To explore the influence of the various pain subtypes experienced by PD patients on sleep.

Methods

Three hundred consecutive PD patients were assessed with the PD Sleep Scale-Version 2 (PDSS-2), King's PD Pain Scale (KPPS), King's PD Pain Questionnaire (KPPQ), Visual Analog Scales for Pain (VAS-Pain), and Hospital Anxiety and Depression Scale.

Results

According to the PDSS-2, 99.3% of our sample suffered from at least one sleep issue. Those who reported experiencing any modality of pain suffered significantly more from sleep disorders than those who did not (all, P < 0.003). The PDSS-2 showed moderate-to-high correlations with the KPPS (r_S = 0.57), KPPQ (0.57), and VAS-Pain (0.35). When PDSS-2 items 10 to 12 (pain-related) were excluded, the correlation values decreased to 0.50, 0.51, and 0.28, respectively, while these items showed moderate-to-high correlations with KPPS (0.56), KPPQ (0.54), and VAS-Pain (0.42). Among the variables analyzed, multiple linear regression models suggested that KPPS and KPPQ were the most relevant predictors of sleep disorders (as per the PDSS-2), although following exclusion of PDSS-2 pain items, depression was the relevant predictor. Depression and anxiety were the most relevant predictors in the analysis involving the VAS-Pain. Regression analysis, considering only the KPPS domains, showed that nocturnal and musculoskeletal pains were the best predictors of overall nocturnal sleep disorder.

Conclusions

Pain showed a moderate association with nocturnal sleep dysfunction in PD. Some pain subtypes had a greater effect on sleep than others.

Comparing Sensitivity and Specificity of Addenbrooke's Cognitive Examination-I, III and Mini-Addenbrooke's Cognitive Examination in Parkinson's Disease

Background

Parkinson's disease (PD) is the second most common neurodegenerative disorder characterized by numerous motor and nonmotor symptoms. Neurocognitive disorders (NCD) are one of the most troublesome problems and their diagnosis is often challenging.

Methods

We compared the sensitivity and specificity of several versions of Addenbrooke Cognitive Examination (ACE, ACE-III, and Mini-ACE) on 552 subjects with PD. Normal cognition, mild and major NCD were judged in accordance with the respective criteria of the Diagnostic and Statistical Manual of Mental Disorders 5^th edition. Subsequently, we applied the receiver operation characteristic (ROC) analysis in comparison of different education levels.

Results

For subjects with education level 0–8 and 9–12 years, the ACE-III had the best discriminating capabilities for mild NCD (cut-off scores: 83.5 and 85.5 points, respectively), while Mini-ACE was the best for subjects having education > 12 years (cut-off score: 25.5 points). For detecting major NCD, ACE-III had the best diagnostic accuracy in all levels of education (cut-off scores: 70.5, 77.5, and 78.5 points for subjects having education level 0–8, 9–12, and >12 years, respectively).

Conclusion

ACE-III and its nested version, the Mini-ACE, had the best screening abilities for detecting mild and major NCD in PD.

Health-Related Quality of Life Subdomains in Patients with Parkinson's Disease: The Role of Gender

The most frequently used instrument to assess health-related quality of life (HrQoL) in Parkinson's disease (PD) is the Parkinson's Disease Questionnaire 39 (PDQ-39). However, both the dimensionality of the eight PDQ-39 subscales and their summary score recently faced criticism. Furthermore, data on disease-related and neuropsychological determinants and the role of gender on HrQoL in PD are inconclusive yet. Therefore, our aim was to reevaluate the PDQ-39 structure and to further explore determinants of HrQoL in PD. 245 PD patients (age: M = 69.64, SD = 8.43; 62.9% male; H&Y: Md = 3.00; cognitive assessment with PANDA: M = 24.82, SD = 3.57) from the baseline database of the Cologne Parkinson Network were used to reevaluate the dimensionality of the PDQ-39 with a principal component analysis (PCA). Multiple regression analyses were conducted to clarify general and domain-specific relationships between clinical, (neuro)psychological, and sociodemographic variables, gender in particular, and HrQoL. The PCA identified three HrQoL domains: physical-functioning, cognition, and socioemotional HrQoL. Depressive symptoms were identified as the most important determinant of HrQoL across all models. Disease-related HrQoL determinants (UPDRS-III, H&Y stage, and LEDD) were less strong and consistent HrQoL determinants than nonmotor symptoms. Analyses did not reveal a global gender effect; however, female gender was a negative predictor for physical-functioning and socioemotional HrQoL, whereas male gender was a negative predictor for cognition HrQoL. Our analyses suggest the consideration of a reevaluation of the PDQ-39. Only the full understanding of HrQoL, its determinants, and their interrelationships will allow the development of PD intervention strategies focusing on what matters the most for patients' HrQoL. Gender is one relevant variable that should be considered in this context.

Stool Immune Profiles Evince Gastrointestinal Inflammation in Parkinson's Disease

BACKGROUND

Gastrointestinal symptoms are common in Parkinson's disease and frequently precede the development of motor impairments. Intestinal inflammation has been proposed as a driver of disease pathology, and evaluation of inflammatory mediators in stool could possibly identify valuable early-stage biomarkers. We measured immune- and angiogenesis-related proteins in human stool to examine inflammatory profiles associated with Parkinson's disease.

METHODS

Stool samples and subjects' self-reported metadata were obtained from 156 individuals with Parkinson's disease and 110 without, including spouse and nonhousehold controls. Metadata were probed for disease-associated differences, and levels of 37 immune and angiogenesis factors in stool homogenates were measured by multiplexed immunoassay and compared across experimental groups.

RESULTS

Parkinson's disease patients reported greater incidence of intestinal disease and digestive problems than controls. Direct comparison of levels of stool analytes in patients and controls revealed elevated vascular endothelial growth factor receptor 1, interleukin-1α, and CXCL8 in patients' stool. Paired comparison of patients and spouses suggested higher levels of multiple factors in patients, but this was complicated by sex differences. Sex, body mass index, a history of smoking, and use of probiotics were found to strongly influence levels of stool analytes. Multivariate analysis accounting for these and other potential confounders confirmed elevated levels of interleukin-1α and CXCL8 and also revealed increased interleukin-1β and C-reactive protein in stool in Parkinson's disease. These differences were not dependent on subject age or disease duration.

CONCLUSIONS

Levels of stool immune factors indicate that intestinal inflammation is present in patients with Parkinson's disease. © 2018 International Parkinson and Movement Disorder Society.

Prevalence of Anxiety among Hungarian Subjects with Parkinson's Disease

Although anxiety is one of the most frequent symptoms of Parkinson's disease (PD), only a few clinical tools can efficiently and reliably detect its presence. The aim of the present study was to validate the Hungarian patient-rated version of Parkinson Anxiety Scale (PAS). A total of 190 PD patients were enrolled into the clinimetric validation phase of the study and another 590 participated in the cross-sectional screening phase. The presence of anxiety disorder was diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders criteria. The cutoff value for PAS which best discriminated the presence of anxiety from the absence was 12.5 points (sensitivity of 88.6%, specificity of 79.9). The area under the curve was 0.847 whereas the ROC analysis yielded the statistical significance level (p < 0.001). The optimal threshold values for mild (Hoehn and Yahr Stage, HYS 1 and 2), moderate (HYS 3), and severe (HYS 4 and 5) disease stages were 10.5, 12.5, and 13.5 points, respectively. Based on the general threshold anxiety occurred in 35.8% of the patients (persistent anxiety: 29.2%, episodic anxiety: 20.7%, and avoidant anxiety disorder: 16.8%). We demonstrate that the PAS is a valid, highly reliable, and sensitive tool for assessing anxiety.

Neuropathology of Nonmotor Symptoms of Parkinson's Disease

Parkinson's disease (PD), a multiorgan neurodegenerative disorder associated with α-synuclein deposits throughout the nervous system and many organs, is clinically characterized by motor and nonmotor features, many of the latter antedating motor dysfunctions by 20 or more years. The causes of the nonmotor manifestations such as olfactory, autonomic, sensory, neuropsychiatric, visuospatial, sleep, and other disorders are unlikely to be related to single lesions. They are mediated by the involvement of both dopaminergic and nondopaminergic systems, and diverse structures outside the nigrostriatal system that is mainly responsible for the motor features of PD. The nonmotor alterations appear in early/prodromal stages of the disease and its further progression, suggesting a topographical and chronological spread of the lesions. This lends further support for the notion that PD is a multiorgan proteinopathy, although the exact relationship between presymptomatic and later developing nonmotor features of PD and neuropathology awaits further elucidation.

Clinical Determinants of Parkinson's Disease-associated Pain Using the King's Parkinson's Disease Pain Scale

Background

Pain is a frequent feature in Parkinson's disease (PD). Current knowledge on pain and its associated factors in PD has been obtained using nondisease-specific tools. Recently, the King's Parkinson's Disease Pain Scale (KPPS) was published as the first disease-specific scale. The aim of this study was to assess PD-associated pain and its main determinants using the KPPS.

Methods

A cross-sectional study was carried out. Consecutive patients with PD were recruited from a movement disorders clinic. Clinical and demographical data were collected. The KPPS, the Movement Disorders Society Unified Parkinson's Disease Rating Scale, and the Non-Motor Symptoms Scale were used to assess all participants.

Results

In total, 314 patients were included. Overall, 88.6% of the sample reported at least 1 type of pain. The mean ± standard KPPS score was 18.8 ± 19.5. Factors associated with higher KPSS scores were female sex (P < 0.001), levodopa treatment (P < 0.001), the presence of depressed mood (P < 0.001), wearing off (P = 0.003), and dyskinesia (P = 0.005). Participants who had postural instability and gait difficulty motor subtypes had higher KPPS scores compared with those who had other subtypes. Multivariate regression analysis showed that only sex, motor subtype, depressed mood, and Non-Motor Symptoms Scale sleep/fatigue domain scores achieved statistical significance as determinants (all P < 0.01).

Conclusion

PD-associated pain is a frequent symptom that tends to increase in both frequency and severity as disease progresses. Risk factors for increased burden include female gender, postural instability and gait difficulty motor subtypes, mood alterations, and sleep/fatigue disturbances.

Sexual dimorphism in Parkinson's disease: differences in clinical manifestations, quality of life and psychosocial functioning between males and females

INTRODUCTION

Sex-related differences in clinical manifestations and consequences of Parkinson's disease (PD) have been poorly explored. Better understanding of sexual dimorphism in neurologic diseases such as PD has been announced as a research priority. The aim of our study was to determine independent sex differences in clinical manifestations and subtypes, psychosocial functioning, quality of life (QoL) and its domains between male and female individuals with PD.

PATIENTS AND METHODS

A comprehensive list of demographics, motor symptoms and subtypes, nonmotor features, health-related quality of life (HRQoL), psychosocial functioning and general aspects of daily life was assessed in 157 individuals (108 males and 49 females) with idiopathic PD. In order to control for potential confounding variables, we applied Orthogonal Partial Least Squares - Discriminant Analysis (OPLS-DA) to explore the strength of each feature to discriminate male and female patients with PD.

RESULTS

While no sex difference was found in the total Unified Parkinson's Disease Rating Scale (UPDRS) score and cumulative daily dose of levodopa, females had significantly more severe anxiety (mean difference =2.2 [95% confidence interval, CI: 0.5-4.0], P=0.011), worse nutritional status (23.8 [standard deviation, SD =4.2] vs 25.8 [SD =2.6], P=0.003) and poorer QoL (28.3 [SD =15.7] vs 17.9 [SD =14.2], P<0.001). Based on multivariate discriminant analysis, emotional well-being, bodily discomfort, social support, mobility and communication domains of HRQoL, together with anxiety, depression and psychosocial functioning, were the strongest features with more severe/worse status in females after adjustment for potential statistical confounders.

CONCLUSION

Our study provides a comprehensive understanding of sexual dimorphism in PD. Anxiety, depression, specific domains of HRQoL (mobility, emotional well-being, social support and bodily discomfort) and psychosocial functioning were significantly worse in female individuals with PD. Sexual dimorphism in PD highlights the features that are more likely to be affected in each sex and should be specifically targeted when managing male and female individuals with PD.