Symptom burden among individuals with Parkinson disease: A national survey

Fox Insight: Most Bothersome Symptoms in Early-Stage Parkinson's Disease

BACKGROUND

Limited evidence exists regarding the meaningfulness of symptoms experienced in early Parkinson's disease (PD).

OBJECTIVES

To identify the most bothersome symptoms experienced by people with early PD, leveraging data from the Parkinson's Disease Patient Report of Problems (PD-PROP) questionnaire within the Fox Insight Study.

METHODS

Individuals with a self-reported diagnosis of PD completed the PD-PROP questionnaire, reporting up to five most bothersome symptoms. Symptom types and frequencies were derived through a combination of human expertise and machine learning.

RESULTS

Participants (N = 8536) were 0.9 years since diagnosis, predominantly white (96%), male (53.3%), and with an average age of 64.6 years. Top most bothersome motor symptoms were tremor (55.9%) and gait issues (36.7%). Top most bothersome non-motor symptoms were pain/discomfort (33.1%) and physical fatigue (27.5%).

CONCLUSIONS

This study underscores the complexity of early PD symptomatology. Future consideration of diverse patient experiences is needed to improve therapeutic and outcome measurement strategies.

Home-Based Hypnosis: A Feasibility Study for End-of-Life Patients and Their Relatives

CONTEXT

Palliative care patients facing the end of their life often experience severe symptoms and seek complementary therapies for relief and improved well-being. Clinical hypnosis is a promising mind-body therapy in palliative settings, benefiting both patients and their relatives. Nevertheless, access at the end-of-life can be limited due to symptom severity and restricted mobility.

OBJECTIVES

This study aimed to assess the feasibility and acceptability of a home-based hypnosis intervention for end-of-life patients to alleviate symptoms and for their relatives to enhance coping resources.

METHODS

A mixed-method observational feasibility study was conducted from February 2022 to January 2023 in French-speaking Switzerland. Participants included 32 end-of-life patients and 14 relatives, receiving weekly 20-25-minute hypnosis sessions over four weeks. Quantitative data on symptom intensity and well-being were collected using numeric rating scales, while qualitative data were gathered through semi-structured interviews with those who completed the intervention.

RESULTS

Eighteen patients and eight relatives completed the four-sessions. Significant reductions were observed in patient anxiety (median 6.5-2.0, P=.001) and pain (median 5.0 to 3.0, P=.001). Patient well-being improved across all sessions (median 5-7, P=.001). Relatives reported increased well-being (median 5.0-8.0, P=.001), serenity (median 5.0-8.0, P=.001), and energy levels (median 5.0-7.5, P=.042). High levels of satisfaction and frequent use of self-hypnosis recordings were noted.

CONCLUSION

A home-based hypnosis intervention was feasible and seemed beneficial for both end-of-life patients and their relatives, reducing symptoms and enhancing coping resources. Future research should build upon these findings to further support the integration of complementary therapies into standard palliative care practices.

[Demographic and prevalence study of parkinsonism in the region of Murcia]

OBJECTIVES

To quantify parkinsonian patients in the Region of Murcia (RM), their health areas and zones, and find their prevalences and percentages.

MATERIAL AND METHODS

All RM patients registered in Primary Care of the Murcian Health Service with the CIAP-2 code N87 were included. We calculated number, prevalence and percentages by age and sex groups, means and age ranges and years of evolution. The study was carried out at the age of diagnosis and at the age of data collection, analyzing their differences.

RESULTS

We obtained 3050 parkinsonian patients (1476 men and 1574 women) with respective prevalences of 206.09 cases per 100,000 inhabitants (206.09/105), 199.06/105 and 213.15/105, not significant differences by sex or in number of patients (p=0.79) or in prevalence (P=.52). By age group, prevalences were higher in men (P<.05) between 50 and 99years of age (not between 90 and 94 and ≥100years). Of the 9 Health Areas, the highest prevalences were in areas IVNorthwest, with 322.31/105, and VAltiplano, with 304.30/105, and the lowest prevalence, of 171.13/105, was observed in Area VIIMurcia East (P<.05). Of the 85 Health Zones, the one with the highest prevalence was Lorca-La Paca, with 510.51/105, and the one with the lowest Murcia-Zarandona, with 78.48/105 (P<.05).

CONCLUSIONS

First demographic and detailed prevalence study of parkinsonism in the RM. The prevalence in RM was 206.09/105. By health areas, the highest prevalences were in the Northwest and Altiplano and by health areas a prevalence of 510.51/105 stood out. This work aims to be useful to facilitate resource planning, with consequent better health care.

The rise of Parkinson's disease is a global challenge, but efforts to tackle this must begin at a national level: a protocol for national digital screening and "eat, move, sleep" lifestyle interventions to prevent or slow the rise of non-communicable diseases in Thailand

The rising prevalence of Parkinson's disease (PD) globally presents a significant public health challenge for national healthcare systems, particularly in low-to-middle income countries, such as Thailand, which may have insufficient resources to meet these escalating healthcare needs. There are also many undiagnosed cases of early-stage PD, a period when therapeutic interventions would have the most value and least cost. The traditional "passive" approach, whereby clinicians wait for patients with symptomatic PD to seek treatment, is inadequate. Proactive, early identification of PD will allow timely therapeutic interventions, and digital health technologies can be scaled up in the identification and early diagnosis of cases. The Parkinson's disease risk survey (TCTR20231025005) aims to evaluate a digital population screening platform to identify undiagnosed PD cases in the Thai population. Recognizing the long prodromal phase of PD, the target demographic for screening is people aged ≥ 40 years, approximately 20 years before the usual emergence of motor symptoms. Thailand has a highly rated healthcare system with an established universal healthcare program for citizens, making it ideal for deploying a national screening program using digital technology. Designed by a multidisciplinary group of PD experts, the digital platform comprises a 20-item questionnaire about PD symptoms along with objective tests of eight digital markers: voice vowel, voice sentences, resting and postural tremor, alternate finger tapping, a "pinch-to-size" test, gait and balance, with performance recorded using a mobile application and smartphone's sensors. Machine learning tools use the collected data to identify subjects at risk of developing, or with early signs of, PD. This article describes the selection and validation of questionnaire items and digital markers, with results showing the chosen parameters and data analysis methods to be robust, reliable, and reproducible. This digital platform could serve as a model for similar screening strategies for other non-communicable diseases in Thailand.

Parkinson's disease: symptoms and medications at the end of life

OBJECTIVES

People with Parkinson's disease (PwP) have a high palliative symptom burden throughout their disease course, equivalent to advanced malignancy. We aim to establish trends in symptom frequency and prescribing in the 72 hours prior to death for PwP.

METHODS

Retrospective case note review of PwP who died between February 2019 and September 2020.

RESULTS

51 patients were included. 60.78% of patients (n=31) had agitation and 58.82% (n=30) had pain in the final 72 hours. Patients with cognitive impairment were 4.67 times more likely to experience agitation (p=0.035) compared with those without, with higher total midazolam doses (29.18 mg vs 11.4 mg, p=0.21). Terminal motor symptoms were recorded in three patients. 28.57% of patients received the recommended dose of rotigotine for dopaminergic therapy.

CONCLUSIONS

PwP have a significant symptom burden at the end of life (EOL) with levels of terminal agitation at the higher end of those expected in the general population. There was a trend towards higher doses of sedation, rather than analgesia, in people with coexistent cognitive impairment.Terminal stiffness, despite being seldom documented in the literature, is an important although infrequent symptom.Rotigotine use at EOL remains commonplace and better understanding of its effect and dosing is required.

U.S. Tax Credits to Promote Practical Proactive Preventative Care for Parkinson's Disease

Persons with Parkinson's disease (PD) and society at large can profit from a strategic investment into a forward leaning, practical, preventative, and proactive multidisciplinary care policy. The American healthcare system is not easily bent to accommodate this type of care, and thus a tax benefit is an attractive option. An individual federal income tax benefit of $6200 each year for every person residing in the US with a diagnosis of PD, could among other offerings provide monthly access to a licensed clinical social worker and access to mental health services. The implementation of more coordinated care has the potential reduce the burden of depression, anxiety, and demoralization. Personal training would also be covered and directed by physical and occupational therapists. The combination of home-based and telemedicine services would have the added benefit of improving access. The tax benefit would also provide access to a dietician. This type of care strategy could be designed to proactively identify early signs of aspiration and urinary tract infections to 'head off' significant morbidity. A $6200/year individual tax benefit for those diagnosed with PD will thus translate into more fall prevention, more care in the home setting, less hospitalizations, less depression, less anxiety, less demoralization, better diets, and less persons placed in nursing facilities. Additionally, this tax benefit will provide the potential for billions of dollars in savings to the healthcare system. A tax benefit for PD is a practical preventative and proactive strategy which can serve to advantage both this generation and the next.

Prevalence of hallucinations in Parkinson's patients: meta-analysis of International studies

BACKGROUND

Parkinson's disease (PD) is one of the common causes of disability in the elderly. This study aims to estimate the prevalence of hallucinations in Parkinson's patients in the world.

METHODS

A systematic review of PubMed/Medline, ISI Web of Knowledge, and Google Scholar was conducted from 2017 to 2022. This study investigated the prevalence of hallucinations in Parkinson's patients. Point prevalence was analyzed with a 95% confidence interval. The variances of each study were calculated using the binomial distribution formula The researcher used Cochrane Q-test with a significance level of less than 0.1 to check the heterogeneity between studies and the change index assigned to heterogeneity I2. Due to the heterogeneity between the studies, the random effects model was used to combine the results of the studies. All statistical analyses were performed by STATA version 14 software using meta-analysis commands.

RESULTS

Reports indicated that the prevalence of hallucinations in Parkinson's patients in 32 studies was 28% (0.22-0.34 = 95%CI). The highest prevalence was 34% and 95% CI = 0.07- 0.61 in developing countries and 27% with CI = 0.33-0.21 in developed countries. Reports showed the prevalence in men was 30% (CI = 0.22-0.38) and in women 23% (95% CI = 0.14-0.31).

CONCLUSIONS

Considering the relatively high prevalence of hallucinations in these patients, checking up for the presence of hallucinations on every visit of Parkinson's patients is recommended, and providing appropriate treatment for that is necessary.

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.

Palliative care to support the needs of adults with neurological disease

Neurological diseases cause physical, psychosocial, and spiritual or existential suffering from the time of their diagnosis. Palliative care focuses on improving quality of life for people with serious illness and their families by addressing this multidimensional suffering. Evidence from clinical trials supports the ability of palliative care to improve patient and caregiver outcomes by the use of outpatient or home-based palliative care interventions for people with motor neuron disease, multiple sclerosis, or Parkinson's disease; inpatient palliative care consultations for people with advanced dementia; telephone-based case management for people with dementia in the community; and nurse-led discussions with decision aids for people with advanced dementia in long-term care. Unfortunately, most people with neurological diseases do not get the support that they need for their palliative care under current standards of healthcare. Improving this situation requires the deployment of routine screening to identify individual palliative care needs, the integration of palliative care approaches into routine neurological care, and collaboration between neurologists and palliative care specialists. Research, education, and advocacy are also needed to raise standards of care.

Parkinson's disease therapy: what lies ahead?

The worldwide prevalence of Parkinson's disease (PD) has been constantly increasing in the last decades. With rising life expectancy, a longer disease duration in PD patients is observed, further increasing the need and socioeconomic importance of adequate PD treatment. Today, PD is exclusively treated symptomatically, mainly by dopaminergic stimulation, while efforts to modify disease progression could not yet be translated to the clinics. New formulations of approved drugs and treatment options of motor fluctuations in advanced stages accompanied by telehealth monitoring have improved PD patients care. In addition, continuous improvement in the understanding of PD disease mechanisms resulted in the identification of new pharmacological targets. Applying novel trial designs, targeting of pre-symptomatic disease stages, and the acknowledgment of PD heterogeneity raise hopes to overcome past failures in the development of drugs for disease modification. In this review, we address these recent developments and venture a glimpse into the future of PD therapy in the years to come.

Relative Meaningfulness and Impacts of Symptoms in People with Early-Stage Parkinson's Disease

BACKGROUND

Patient perspectives on meaningful symptoms and impacts in early Parkinson's disease (PD) are lacking and are urgently needed to clarify priority areas for monitoring, management, and new therapies.

OBJECTIVE

To examine experiences of people with early-stage PD, systematically describe meaningful symptoms and impacts, and determine which are most bothersome or important.

METHODS

Forty adults with early PD who participated in a study evaluating smartwatch and smartphone digital measures (WATCH-PD study) completed online interviews with symptom mapping to hierarchically delineate symptoms and impacts of disease from "Most bothersome" to "Not present," and to identify which of these were viewed as most important and why. Individual symptom maps were coded for types, frequencies, and bothersomeness of symptoms and their impacts, with thematic analysis of narratives to explore perceptions.

RESULTS

The three most bothersome and important symptoms were tremor, fine motor difficulties, and slow movements. Symptoms had the greatest impact on sleep, job functioning, exercise, communication, relationships, and self-concept- commonly expressed as a sense of being limited by PD. Thematically, most bothersome symptoms were those that were personally limiting with broadest negative impact on well-being and activities. However, symptoms could be important to patients even when not present or limiting (e.g., speech, cognition).

CONCLUSION

Meaningful symptoms of early PD can include symptoms that are present or anticipated future symptoms that are important to the individual. Systematic assessment of meaningful symptoms should aim to assess the extent to which symptoms are personally important, present, bothersome, and limiting.

A Retrospective Medical Record Review of Adults with Non-Cancer Diagnoses Prescribed Medicinal Cannabis

Research describing patients using medicinal cannabis and its effectiveness is lacking. We aimed to describe adults with non-cancer diagnoses who are prescribed medicinal cannabis via a retrospective medical record review and assess its effectiveness and safety. From 157 Australian records, most were female (63.7%; mean age 63.0 years). Most patients had neurological (58.0%) or musculoskeletal (24.8%) conditions. Medicinal cannabis was perceived beneficial by 53.5% of patients. Mixed-effects modelling and post hoc multiple comparisons analysis showed significant changes overtime for pain, bowel problems, fatigue, difficulty sleeping, mood, quality of life (all p < 0.0001), breathing problems (p = 0.0035), and appetite (p = 0.0465) Symptom Assessment Scale scores. For the conditions, neuropathic pain/peripheral neuropathy had the highest rate of perceived benefit (66.6%), followed by Parkinson's disease (60.9%), multiple sclerosis (60.0%), migraine (43.8%), chronic pain syndrome (42.1%), and spondylosis (40.0%). For the indications, medicinal cannabis had the greatest perceived effect on sleep (80.0%), followed by pain (51.5%), and muscle spasm (50%). Oral oil preparations of balanced delta-9-tetrahydrocannabinol/cannabidiol (average post-titration dose of 16.9 mg and 34.8 mg per day, respectively) were mainly prescribed. Somnolence was the most frequently reported side effect (21%). This study supports medicinal cannabis' potential to safely treat non-cancer chronic conditions and indications.

Palliative care in Parkinson disease and related disorders

Although neuropalliative care is a relatively new field, there is increasing evidence for its use among the degenerative parkinsonian syndromes, including idiopathic Parkinson disease, progressive supranuclear palsy, multiple system atrophy, dementia with Lewy bodies, and corticobasal syndrome. This chapter outlines the current state of evidence for palliative care among individuals with the degenerative parkinsonian syndromes with discussion surrounding: (1) disease burden and needs across the conditions; (2) utility, timing, and methods for advance care planning; (3) novel care models for the provision of palliative care; and 4) end-of-life care issues. We also discuss currently unmet needs and unanswered questions in the field, proposing priorities for research and the assessment of implemented care models.

Effects of Oral Levodopa on Balance in People with Idiopathic Parkinson's Disease

BACKGROUND

Balance impairment is a frequent cause of morbidity and mortality in people with Parkinson's disease (PD). As opposed to the effects of appendicular motor symptoms, the effects of Levodopa on balance impairment in idiopathic PD are less clear.

OBJECTIVE

To review the literature on the effects of oral Levodopa on clinical balance test performance, posturography, step initiation, and responses to perturbation in people with idiopathic PD (PwPD).

METHODS

A systematic search of three scientific databases (Pubmed, Embase, and Web of Science) was conducted in accordance with PRISMA guidelines. For the pilot meta-analysis, standardized mean differences with 95% confidence intervals were calculated using an inverse variance random effects model. Data not suitable for implementation in the meta-analysis (missing means or standard deviations, and non-independent outcomes) were analyzed narratively.

RESULTS

A total of 2772 unique studies were retrieved, of which 18 met the eligibility criteria and were analyzed, including data of 710 idiopathic PwPD. Levodopa had a significant positive effect on the Berg Balance Scale, the Push and Release test, and jerk and frequency parameters during posturography. In contrast, some significant negative effects on velocity-based sway parameters were found during posturography and step initiation. However, Levodopa had no significant effect on most step initiation- and all perturbation parameters.

CONCLUSION

The effects of Levodopa on balance in PwPD vary depending on the outcome parameters and patient inclusion criteria. A systematic approach with well-defined outcome parameters, and prespecified, sensitive and reliable tests is needed in future studies to unravel the effects of oral Levodopa on balance.

Education in neuropalliative care

The importance and value of providing palliative care for patients with neurologic disease is increasingly recognized. While palliative and neuropalliative specialists may be well-positioned to provide this care, there is a shortage of specialists to address these needs. As a result, much of the upfront palliative care will naturally be provided by the treating neurologist. It is imperative that all neurologists receive quality training in primary palliative care skills. As the subspecialty of neuropalliative care grows, the need for specialty neuropalliative education has arisen. This chapter reviews existing educational initiatives and common neuropalliative-oriented career tracks and identifies opportunities for growth along the continuum of medical education and beyond.

[Characteristics and treatment of pain in Parkinson's disease]

Pain is a representative non-motor symptom in patients with Parkinson's disease (PD). Pain is one of the most common symptoms that plague patients with PD regardless of the stage of the disease, also it can exacerbate other symptoms, such as depression, anxiety or sleep disturbance, and lead to impaired quality of life. However, pain is often not adequately evaluated and treated. PD patients complain of a wide variety of pain, including both PD-related pain which caused by PD-specific symptoms, for example, rigidity, bradykinesia or motor fluctuation, and PD-unrelated pain, and it can be divided into central and peripheral depending on the site of the disorder. In the medical care of the pain, it is important to evaluate the type and severity of the pain using PD-specific assessment scales such as King's PD pain scale and to consider the evidence-based treatment methods according to the pathophysiology of the pain.

Evaluating the effects of dance on motor outcomes, non-motor outcomes, and quality of life in people living with Parkinson's: a feasibility study

BACKGROUND

Community-based dance programs for people living with Parkinson's have grown in popularity over the past two decades. Studies investigating these programs have demonstrated multidimensional benefits in motor, non-motor, and quality of life related outcomes, yet there is a need to focus on the feasibility of larger trials. The primary objective of this study was to assess the feasibility and acceptability of conducting a trial investigating dance and Parkinson's in Northern Ireland. The secondary objectives were to conduct preliminary analyses of the classes' effects and to assess the appropriateness of outcome measures for a randomized controlled trial.

METHODS

Participants were recruited through the community, Parkinson's UK, and university contacts to participate in a 12-week dance intervention inspired by the Dance for PD® model. Pre- and post-intervention, participants completed the following outcomes: MDS-UPDRS III, TUG, DT-TUG, Sensory Organization Test, MoCA, Trail Making Tests A&B, Digit Symbol Substitution Test, Digit Span, PDQ-39, FOG-Q, PHQ-9, FES-I, and an exit questionnaire (post-test only). Data were analyzed using paired samples t tests or Wilcoxon signed ranked test.

RESULTS

Ten people living with Parkinson's participated. Running a larger trial was deemed infeasible in this setting due to recruitment issues; conversely, the dance intervention was accepted by participants with all but one completing the study. Functional mobility (TUG), symptoms of depression (PHQ-9), and bodily discomfort showed improvement. All other outcomes did not. The exit questionnaire revealed that the social aspect of classes was important, and improvements in mood or mental state were cited most frequently as perceived benefits. Outcome measures were feasible, with some changes suggested for future trials.

CONCLUSIONS

This study highlighted the infeasibility of running a larger trial using this design in this setting despite demonstrating the acceptability of implementing a dance program in Northern Ireland for people living with Parkinson's. The results support existing evidence demonstrating that dance may improve functional mobility and symptoms of depression in people living with Parkinson's, though the study design and small sample size prevent the generalizability of results. The findings also support the idea that dancing has the potential to support several aspects of physical, emotional, mental, and social health.

Approach to the Patient with Gait Disturbance

The assessment of patients presenting with disorders of gait can be a daunting task for neurologists given the broad potential localization and differential diagnosis. However, gait disorders are extremely common in outpatient neurology, and all neurologists should be comfortable with the assessment, triage, and management of patients presenting with difficulty walking. Here, we aim to present a manageable framework for neurologists to approach the assessment of patients presenting with gait dysfunction. We suggest a chief complaint-based phenomenological characterization of gait, using components of the neurological history and examination to guide testing and treatment. We present the framework to mirror the outpatient visit with the patient, highlighting (1) important features of the gait history, including the most common gait-related chief complaints and common secondary (medical) causes of gait dysfunction; (2) gait physiology and a systematic approach to the gait examination allowing appropriate characterization of gait phenomenology; (3) an algorithmic approach to ancillary testing for patients with gait dysfunction based on historical and examination features; and (4) definitive and supportive therapies for the management of patients presenting with common neurological disorders of gait.

What People with Parkinson's Disease Want

Parkinson’s disease is an incurable, progressive neurodegenerative disease. This condition is complicated by the varying symptoms in individuals who differ in age of onset, symptoms, progression of disease, response to treatment and prognosis. In this paper, we focus on quality of life achieved through a combination of comprehensive health care, continuous support, and self care. Determining what people with Parkinson’s disease want is like assembling multiple puzzles simultaneously. While we surmise that patient centered care, support programs, access to comprehensive health care, and relevant symptom control are pieces of this puzzle, more longitudinal studies— which are observational in nature and correlate the impact of symptoms with patients’ reported needs— are necessary.

The Experiences of Treatment Burden in People with Parkinson's Disease and Their Caregivers: A Systematic Review of Qualitative Studies

BackgroundHigh treatment burden is associated with poor adherence, wasted resources, poor quality of life and poor health outcomes. Identifying factors that impact treatment burden in Parkinson's disease can offer insights into strategies to mitigate them.ObjectiveTo explore the experiences of treatment burden among people with Parkinson's disease (PwP) and their caregivers.MethodsA systematic review of studies published from year 2006 was conducted. Qualitative and mixed-method studies with a qualitative component that relate to usual care in Parkinson's disease were included. Quantitative studies and grey literature were excluded. Data synthesis was conducted using framework synthesis.Results1757 articles were screened, and 39 articles included. Understanding treatment burden in PwP and caregivers was not the primary aim in any of the included studies. The main issues of treatment burden in Parkinson's disease are: 1) work and challenges of taking medication; 2) healthcare provider obstacles including lack of patient-centered care, poor patient-provider relationships, lack of care coordination, inflexible organizational structures, lack of access to services and issues in care home or hospital settings; and 3) learning about health and challenges with information provision. The treatment burden led to physical and mental exhaustion of self-care and limitations on the role and social activities of PwP and caregivers.Conclusion:There are potential strategies to improve the treatment burden in Parkinson's disease at an individual level such as patient-centered approach to care, and at system level by improving access and care coordination between services. Future research is needed to determine the modifiable factors of treatment burden in Parkinson's disease.

Elevated HDL Levels Linked to Poorer Cognitive Ability in Females With Parkinson's Disease

Introduction

Cholesterol levels have been associated with age-related cognitive decline, however, such an association has not been comprehensively explored in people with Parkinson's disease (PD). To address this uncertainty, the current cross-sectional study examined the cholesterol profile and cognitive performance in a cohort of PD patients.

Methods

Cognitive function was evaluated using two validated assessments (ACE-R and SCOPA-COG) in 182 people with PD from the Australian Parkinson's Disease Registry. Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and Triglyceride (TRG) levels were examined within this cohort. The influence of individual lipid subfractions on domain-specific cognitive performance was investigated using covariate-adjusted generalised linear models.

Results

Females with PD exhibited significantly higher lipid subfraction levels (TC, HDL, and LDL) when compared to male counterparts. While accounting for covariates, HDL levels were strongly associated with poorer performance across multiple cognitive domains in females but not males. Conversely, TC and LDL levels were not associated with cognitive status in people with PD.

Conclusion

Higher serum HDL associates with poorer cognitive function in females with PD and presents a sex-specific biomarker for cognitive impairment in PD.

Capturing Initial Understanding and Impressions of Surgical Therapy for Parkinson's Disease

Background: Deep Brain Stimulation (DBS) is an underutilized surgical therapy for Parkinson's Disease (PD). Both physician and patient hesitancies have been described as potential barriers to DBS, but the specifics of patient perceptions of DBS have not been well-characterized in the general PD population. Objective: To characterize the understanding and impressions of surgical therapy in PD patients prior to formal surgical evaluation. Methods: A 30-question survey assessing impressions of surgical therapy for PD and understanding of DBS for PD was administered to PD patients seen at an urban movement disorders clinic. Results: One hundred and two patients completed the survey. When asked if they would undergo a hypothetical risk-free, curative brain surgery for PD, 98 patients responded "yes." Patients were more agreeable to "reversible," "minimally-invasive," and "incisionless" surgery. 51.2% thought DBS is an "effective" treatment for PD, 76.6% thought it was "invasive," and 18.3% thought it was "reversible." 45.2% reported fear of being awake during DBS surgery. Regarding costs, 52.4% were concerned that DBS was "very expensive" or "not covered by insurance." Initial source of information and perceived treatment effectiveness were not associated with concerns about DBS effectiveness or threats to normality. Negative perceptions of past surgery were associated with concerns about DBS altering mood and personality. Conclusion: Overall, patients expressed concerns regarding procedural efficacy, invasiveness, cost, and irreversibility-independent of the original source of information. Future studies are required to allow us to better understand the impact of these initial findings on DBS hesitancy and underutilization.

Impact of pharmacists on outcomes for patients with psychiatric or neurologic disorders

INTRODUCTION

Psychiatric and neurologic illnesses are highly prevalent and are often suboptimally treated. A 2015 review highlighted the value of psychiatric pharmacists in improving medication-related outcomes. There is a need to describe areas of expansion and strengthened evidence regarding pharmacist practice and patient care impact in psychiatric and neurologic settings since 2015.

METHODS

A systematic search of literature published from January 2014 to June 2019 was conducted. Publications describing patient-level outcome results associated with pharmacist provision of care in a psychiatric/neurologic setting and/or in relation to central nervous system (CNS) medications were included.

RESULTS

A total of 64 publications were included. There was significant heterogeneity of published study methods and data, prohibiting meta-analysis. Pharmacists practicing across a wide variety of health care settings with focus on CNS medication management significantly improved patient-level outcomes, such as medication adherence, disease control, and avoidance of hospitalization. The most common practice approach associated with significant improvement in patient-level outcomes was incorporation of psychiatric pharmacist input into the interprofessional health care team.

DISCUSSION

Pharmacists who focus on psychiatric and neurologic disease improve outcomes for patients with these conditions. This is important in the current health care environment as most patients with psychiatric or neurologic conditions continue to have unmet needs. Additional studies designed to measure pharmacists' impact on patient-level outcomes are encouraged to strengthen these findings.

Palliative Care for Parkinson's Spectrum Disorders: an Emerging Approach

Parkinson's spectrum disorders (PSD) are neurodegenerative parkinsonian conditions that carry a tremendous symptom burden. Palliative care is an interdisciplinary medical specialty that focuses on improving quality of life for patients and caregivers affected by serious life-limiting illnesses, at any stage of disease. Research and clinical programs into this emerging therapeutic approach remain limited. This review focuses on the role of palliative care in the treatment of patients with PSD. Gaps in knowledge and recommendations for future research are discussed.

Pavlovian bias in Parkinson's disease: an objective marker of impulsivity that modulates with deep brain stimulation

Impulsivity is a common symptom in Parkinson's disease (PD). Adaptive behavior is influenced by prepotent action-reward and inaction-avoid loss Pavlovian biases. We aimed to assess the hypothesis that impulsivity in PD is associated with Pavlovian bias, and to assess whether dopaminergic medications and deep brain stimulation (DBS) influence Pavlovian bias. A PD DBS cohort (N = 37) completed a reward-based Go/No-Go task and bias measures were calculated. This DBS cohort completed the task under three conditions: on-med/pre-DBS, off-med/off-DBS, and on-med/on-DBS. Participants also completed self-reported measures of impulsivity. Dopaminergic medication was associated with lower action-reward bias while DBS was associated with higher action-reward bias. Impulsivity was associated with higher action-reward bias but not inaction-avoid loss bias. We furthermore replicated this association in an independent, non-DBS PD cohort (N = 88). Overall we establish an objective behavioral marker of impulsivity and show that DBS affects impulsivity by amplifying automated responding. Our results point to the importance of reward rather than punishment avoidance in driving impulsive behaviors. This work provides insight into the pathophysiological underpinnings of impulsivity and especially medication and DBS-associated impulsivity in PD.

Pharmacotherapy Use for Non-Motor Symptoms Among de novo Parkinson's Disease Parkinson's Progression Markers Initiative Participants

Parkinson's disease (PD) patients experience a range of non-motor symptoms that are believed to be related to disease pathophysiology, many of which are treatable by medications. Among newly-diagnosed PD participants in the Parkinson's Progression Markers Initiative study, we describe (1) the frequency of medication use for common non-motor symptoms, and (2) when non-motor symptomatic treatment was initiated relative to PD diagnosis. Non-motor medication use was reported by 73% of participants, most commonly for depression, constipation, and anxiety. Treatment of some non-motor symptoms, notably depression, antedated diagnosis. These data may be useful for studies of non-motor symptoms in PD.