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Jackowiak E, Szpara A, Kotagal V. Age and Life-Sustaining Treatment Preferences in Parkinson Disease. Neurol Clin Pract 2021; 11:e245-e250. [PMID: 34484898 DOI: 10.1212/cpj.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/18/2020] [Indexed: 11/15/2022]
Abstract
Objective Advance Care Planning (ACP) is one of 10 key elements in the American Academy of Neurology Parkinson disease (PD) clinical practice quality measures. We know little about how aging influences ACP views in people with PD. Methods We conducted a cross-sectional survey of 39 participants (mean age 70.3 years; range: 52-81) with PD to explore correlations between older age and life-sustaining treatment preferences while controlling for confounders including years of education, Montreal Cognitive Assessment score and Movement Disorders Society Unified Parkinson's disease Rating Scale motor score. Scenarios asked participants to choose their level of interest in pursuing life-sustaining measures in the setting of specific medical illnesses including stroke, metastatic cancer, severe heart attack, and dementia. All participants were men and were recruited from the Veterans Affairs Ann Arbor Healthcare System. Results In the hypothetical stroke, metastatic colon cancer, and dementia scenarios, older age correlated with more aggressive care goals related to the use cardiopulmonary resuscitation to treat cardiopulmonary arrest. Conclusions Advancing age in PD may correlate with paradoxically more aggressive goals as it relates to life-sustaining treatment preferences including cardiopulmonary resuscitation. This may reflect a response to heightened concern among older adults with PD about the potential for compromised autonomy in the setting of aging.
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Affiliation(s)
- Eric Jackowiak
- Department of Neurology (EJ, VK), University of Michigan; Veterans Affairs Ann Arbor Healthcare System (VAAAHS) (EJ, VK); and School of Public Health (AS), University of Michigan, Ann Arbor
| | - Ashley Szpara
- Department of Neurology (EJ, VK), University of Michigan; Veterans Affairs Ann Arbor Healthcare System (VAAAHS) (EJ, VK); and School of Public Health (AS), University of Michigan, Ann Arbor
| | - Vikas Kotagal
- Department of Neurology (EJ, VK), University of Michigan; Veterans Affairs Ann Arbor Healthcare System (VAAAHS) (EJ, VK); and School of Public Health (AS), University of Michigan, Ann Arbor
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Albin RL, Müller MLTM, Bohnen NI, Spino C, Sarter M, Koeppe RA, Szpara A, Kim K, Lustig C, Dauer WT. α4β2 * Nicotinic Cholinergic Receptor Target Engagement in Parkinson Disease Gait-Balance Disorders. Ann Neurol 2021; 90:130-142. [PMID: 33977560 DOI: 10.1002/ana.26102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Attentional deficits following degeneration of brain cholinergic systems contribute to gait-balance deficits in Parkinson disease (PD). As a step toward assessing whether α4β2* nicotinic acetylcholine receptor (nAChR) stimulation improves gait-balance function, we assessed target engagement of the α4β2* nAChR partial agonist varenicline. METHODS Nondemented PD participants with cholinergic deficits were identified with [18 F]fluoroethoxybenzovesamicol positron emission tomography (PET). α4β2* nAChR occupancy after subacute oral varenicline treatment was measured with [18 F]flubatine PET. With a dose selected from the nAChR occupancy experiment, varenicline effects on gait, balance, and cognition were assessed in a double-masked placebo-controlled crossover study. Primary endpoints were normal pace gait speed and a measure of postural stability. RESULTS Varenicline doses (0.25mg per day, 0.25mg twice daily [b.i.d.], 0.5mg b.i.d., and 1.0mg b.i.d.) produced 60 to 70% receptor occupancy. We selected 0.5mg orally b.i.d for the crossover study. Thirty-three participants completed the crossover study with excellent tolerability. Varenicline had no significant impact on the postural stability measure and caused slower normal pace gait speed. Varenicline narrowed the difference in normal pace gait speed between dual task and no dual task gait conditions, reduced dual task cost, and improved sustained attention test performance. We obtained identical conclusions in 28 participants with treatment compliance confirmed by plasma varenicline measurements. INTERPRETATION Varenicline occupied α4β2* nicotinic acetylcholine receptors, was tolerated well, enhanced attention, and altered gait performance. These results are consistent with target engagement. α4β2* agonists may be worth further evaluation for mitigation of gait and balance disorders in PD. ANN NEUROL 2021;90:130-142.
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Affiliation(s)
- Roger L Albin
- Neurology Service and GRECC, VAAAHS, Ann Arbor, MI.,Department of Neurology, University of Michigan, Ann Arbor, MI.,University of Michigan Morris K. Udall Parkinson's Disease Research Center of Excellence, Ann Arbor, MI.,University of Michigan Parkinson's Foundation Research Center of Excellence, Ann Arbor, MI
| | - Martijn L T M Müller
- University of Michigan Morris K. Udall Parkinson's Disease Research Center of Excellence, Ann Arbor, MI.,University of Michigan Parkinson's Foundation Research Center of Excellence, Ann Arbor, MI.,Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Nicolaas I Bohnen
- Neurology Service and GRECC, VAAAHS, Ann Arbor, MI.,Department of Neurology, University of Michigan, Ann Arbor, MI.,University of Michigan Morris K. Udall Parkinson's Disease Research Center of Excellence, Ann Arbor, MI.,University of Michigan Parkinson's Foundation Research Center of Excellence, Ann Arbor, MI.,Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Cathie Spino
- University of Michigan Morris K. Udall Parkinson's Disease Research Center of Excellence, Ann Arbor, MI.,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Martin Sarter
- University of Michigan Morris K. Udall Parkinson's Disease Research Center of Excellence, Ann Arbor, MI.,Department of Psychology, University of Michigan, Ann Arbor, MI
| | - Robert A Koeppe
- Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Ashley Szpara
- Department of Neurology, University of Michigan, Ann Arbor, MI.,University of Michigan Morris K. Udall Parkinson's Disease Research Center of Excellence, Ann Arbor, MI
| | - Kamin Kim
- Department of Psychology, University of Michigan, Ann Arbor, MI
| | - Cindy Lustig
- University of Michigan Parkinson's Foundation Research Center of Excellence, Ann Arbor, MI.,Department of Psychology, University of Michigan, Ann Arbor, MI
| | - William T Dauer
- Neurology Service and GRECC, VAAAHS, Ann Arbor, MI.,Department of Neurology, University of Michigan, Ann Arbor, MI.,University of Michigan Morris K. Udall Parkinson's Disease Research Center of Excellence, Ann Arbor, MI.,Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX.,Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX.,Peter J. O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX
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Abstract
BACKGROUND/OBJECTIVE Fatigue is a common debilitating symptom in Parkinson's disease (PD) of unclear etiology. Hypotension and blood pressure variability are common in PD though their relationship to other non-motor symptoms is less well understood. METHODS We conducted a cross-sectional study to explore differences in 24-hour ambulatory blood pressure measurements in PD subjects (n = 35) with and without fatigue. Subjects underwent hourly systolic (SBP) and diastolic (DBP) blood pressure testing in their home environment. The presence of fatigue was assessed using the Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part 1. We compared blood pressure measurements in fatigued vs. non-fatigued PD subjects, assessed over 4 epochs: overnight, morning, midday, and evening. RESULTS PD subjects with symptoms of fatigue demonstrated lower mean DBP, compared to those without fatigue (67.8±4.8 mmHg vs. 75.6±9.4 t = 2.57, p = 0.014). These intergroup differences were most notable in the morning. The two groups did not differ in scoring on the Survey of Autonomic Symptoms or on an office-based blood assessment of SBP or DBP performed on the day of 24-hour monitor initiation. CONCLUSIONS Fatigue in PD may be a clinical manifestation of low-grade systemic hypotension.
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Affiliation(s)
- Vikas Kotagal
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA
| | - Ashley Szpara
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA
| | - Roger L Albin
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA.,University of Michigan Morris K. Udall Center of Excellence for Parkinson's Disease Research, Ann Arbor, MI, USA
| | - Nicolaas I Bohnen
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA.,University of Michigan Morris K. Udall Center of Excellence for Parkinson's Disease Research, Ann Arbor, MI, USA.,Department of Radiology, Division of Nuclear Medicine, University of Michigan, Ann Arbor, MI, USA
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