Precued shifting of attention between cognitive sets in Parkinson patients

Systematic assessment of decision models in Parkinson's disease

OBJECTIVE

To give an insight into the structural and methodological approaches used in published decision-analytic models evaluating interventions in Parkinson's disease (PD) and to derive recommendations for future comprehensive PD decision models.

METHODS

A systematic literature review was performed to identify studies that evaluated PD interventions using mathematical decision models. Using a standardized assessment form, information on the study design, methodological framework, and data sources was extracted from each publication and systematically reported. Strengths and limitations were assessed.

RESULTS

We identified eight studies that used mathematical models to evaluate different pharmaceutical (n=7) and surgical (n=1) treatment options in PD. All models included economic evaluations. Modeling approaches comprised mathematical equations, decision trees, and Markov models with a time horizon ranging from 5 years to lifetime. All based progression on the evolution of clinical surrogate endpoints. Treatment effects were either modeled via reduction of symptomatic progression and/or initial symptomatic improvement or via reduction of adverse effect rates. No model is currently available that encompasses both the underlying biologic disease progression and the spectrum of all relevant complications and also links them to patient preferences and economic outcomes.

CONCLUSIONS

Models have been successfully applied to evaluate PD treatments. However, currently available models have substantial limitations. We recommend that a comprehensive, generic, and flexible decision model for PD that can be applied to different treatment strategies should consider a large spectrum of clinically relevant outcomes and complications of the disease during a sufficiently long time horizon, include PD-specific mortality, systematically evaluate uncertainty including heterogeneity effects, and should be validated by independent data or other models. Approaches to model treatment effects included reduction of symptomatic progression, initial symptomatic improvement, or reduction of adverse effects. We believe that structural bias could be avoided if underlying disease progression and treatment effects on symptoms are modeled separately.

The psychological refractory period in Parkinson's disease

The Psychological Refractory Period paradigm was used to investigate whether patients with Parkinson's disease showed disproportional deficits in regulating responses to two sequential presented stimuli. The first task required a speeded key-press response to an auditory stimulus, and the second task required a speeded key-press response to a visual stimulus. The stimulus onset asynchrony (SOA) between Task 1 and Task 2 was 50 msec., 150 msec., and 650 msec. According to the bottleneck model, the SOA manipulation should not affect performance on Task 1, but reaction time for Task 2 should increase as the SOA between the two tasks decreased. The increase in reaction time for Task 2 was referred to as the Psychological Refractory Period. In this study, both patients with Parkinson's disease and normal controls showed classical effects. More importantly, although the 22 patients with Parkinison's disease took longer to respond to both Tasks 1 and 2 than the 20 normal controls, the effects of the Psychological Refractory Period for the two groups were of the same magnitude. The results suggest that Parkinson's disease affects only the response-execution stages rather than the response-selection stages, based on the central bottleneck model.

Object-based and location-based shifting of attention in Parkinson's disease

Research into Parkinson's disease has made much use of the precuing paradigm developed by Posner to examine patients' ability to shift visuospatial attention. The majority of studies indicate that patients with Parkinson's disease have significantly reduced shift costs when compared with normal controls. This reduction in costs is ascribed to abnormal maintenance of attention resulting from Parkinson's disease. We know that visual attention is not directed to spatial locations alone but that it may also be directed to object representations. To date, however, it has not been clear whether the reduced shift costs apparent in Parkinson's disease patients are evident only on spatial locations or on both spatial locations and object representations. Therefore, in the current study we have adopted a new technique with a view to studying both location-based and object-based attentional components within the same paradigm. Our results with 17 patients with Parkinson's disease suggest, at least in the early stages, patients do not show deficits in maintenance of attention to the miscued source of stimulation as reflected in their normal magnitude of cuing effect related to shifting between locations and between objects. 14 normal persons were control subjects.