A randomized, double-blind, placebo-controlled trial of subcutaneously injected apomorphine for parkinsonian off-state events

OBJECTIVE

To assess the safety and efficacy of subcutaneous apomorphine hydrochloride administration for off-state (poor motor function) periods in patients with Parkinson disease with motor fluctuations under both inpatient titration and outpatient therapeutic conditions.

PATIENTS AND METHODS

Twenty-nine patients had advanced Parkinson disease with 2 hours or more off time despite aggressive oral therapy. Patients randomly received titrated doses of subcutaneous apomorphine hydrochloride (2-10 mg, n = 20) or pH-matched vehicle placebo (n = 9) during an inpatient and 1-month outpatient phase. A change in the United Parkinson Disease Rating Scale motor score 20 minutes after inpatient dosing during a practically defined off-state event and the percentage of injections successfully aborting off-state events were the primary inpatient and outpatient efficacy factors.

RESULTS

The average (SEM) levodopa equivalent dose of apomorphine hydrochloride was 5.4 +/- 0.5 mg and the mean placebo dose was 1.0 mL. Mean inpatient United Parkinson Disease Rating Scale motor scores were reduced by 23.9 and 0.1 points (62% and 1%) by apomorphine treatment and placebo, respectively (P<.001). The mean percentage of outpatient injections resulting in successful abortion of off-state events was 95% for apomorphine and 23% for placebo (P<.001). Inpatient response was significantly correlated with and predictive of outpatient efficacy (P<.001). The levodopa dose was not predictive of the apomorphine dose requirement. Frequent adverse events included dyskinesia, yawning, and injection site reactions.

CONCLUSION

Apomorphine by intermittent subcutaneous injection is effective and safe for outpatient use to reverse off-state events that occur despite optimized oral therapy.

Transdermal dopaminergic D(2) receptor agonist therapy in Parkinson's disease with N-0923 TDS: a double-blind, placebo-controlled study

N-0923 is a non-ergot, dopaminergic D(2) agonist designed to be transdermally available. It has anti-parkinsonian effects when infused intravenously. An adhesive matrix patch was developed to deliver N-0923 transdermally (N-0923 TDS). In this phase II trial, we evaluated the effectiveness of various doses of N-0923 TDS at replacing levodopa. Eighty-five Parkinson's disease (PD) patients were randomized to placebo or one of four doses of N-0923 TDS for 21 days. Change in daily levodopa dose was the primary efficacy measure. Significantly greater reductions in levodopa dose were achieved as compared to placebo for the two highest doses of N-0923 TDS. Patients treated with 33.5 mg and 67 mg N-0923 TDS decreased levodopa use by 26% and 28%, vs. 7% for placebo. N-0923 TDS was safe and well tolerated.

Immediate-release and controlled-release carbidopa/levodopa in PD: a 5-year randomized multicenter study. Carbidopa/Levodopa Study Group

OBJECTIVE

To compare effects of immediate-release (IR) and sustained-release (CR) carbidopa/levodopa in levodopa-naive PD patients.

BACKGROUND

It was hypothesized that the long-acting preparation would be associated with fewer long-term complications.

METHODS

A total of 618 patients were studied in 36 centers worldwide in a blinded, randomized parallel study. Measures of efficacy and adverse reactions were recorded at 3-month intervals for 5 years. Motor fluctuations and dyskinesias were evaluated by a patient diary and a physician-recorded questionnaire. The Nottingham Health Profile (NHP) was used to evaluate quality of life.

RESULTS

Approximately 60% of patients completed the trial. After 5 years, the mean dose of IR was 426 mg/day, and the bioavailable dose of CR was 510 mg/day (mean dose, 736 mg/day). After 5 years, 20.6% of the IR group and 21.8% of the CR group had motor fluctuations or dyskinesia. Sixteen percent of both groups had changes in motor response by the questionnaire's definition. There was no significant difference between the two treatment groups. Disability scores and the motor score of the Unified Parkinson Disease Rating Scale (UPDRS) were highest at baseline, improved with therapy, and thereafter worsened over time to reach baseline scoring at the end of 5 years. The CR group was superior to IR for the Activities of Daily Living subsection of the UPDRS for all 5 years and for emotional reactivity and social isolation on the NHP; however, this may have resulted from higher doses of CR that were used.

CONCLUSION

Despite the progressive nature of PD, both the immediate-release and sustained-release carbidopa/levodopa formulations maintained a similar level of control in PD after 5 years compared with baseline. Additionally, the low incidence of motor fluctuations or dyskinesia was not significantly different between the treatment groups and may be partly attributed to the relatively low doses of levodopa used throughout the 5-year study.

Multicenter, placebo-controlled trial of cabergoline taken once daily in the treatment of Parkinson's disease

Cabergoline is a dopaminergic agonist relatively specific for the D2 receptor and much longer-acting than other dopamine agonists. We conducted a randomized, placebo-controlled, double-blind study of cabergoline in 188 levodopa/carbidopa-treated patients with suboptimally controlled Parkinson's disease (PD). The cabergoline patients had significantly better Activities of Daily Living (p = 0.032) and Motor Examination (p = 0.031) scores at the conclusion of the trial compared with the placebo group. The daily levodopa dose for the cabergoline patients decreased 18% compared with a 3% reduction for the placebo group (p < 0.001). The amount of time in the "on" state increased more in the cabergoline group (p = 0.022). The side-effect was similar to that seen with other dopamine agonists, and cabergoline was generally well tolerated. We conclude that cabergoline is an effective adjunct to levodopa for the treatment of PD.

Postural finger tremor exhibited by Parkinson patients and age-matched subjects

Physiological correlates of postural tremor of the finger seen in Parkinson's disease patients are different from those seen in age-matched control subjects. A significant correlation between the spectral peak of acceleration and the spectral peak of rectified electromyographic activity from the muscle responsible for finger extension was found in Parkinson's disease patients. This correlation was not seen in age-matched control subjects. Any neural drive imposed on the motoneuron pool from supraspinal levels would enhance the electromyographic activity. Likewise, any feedback effects via spinal stretch reflexes or supraspinal stretch responses would be mediated through the motoneuron pool and electromyographic activity. The results of this research support the theory that Parkinson tremor is a centrally driven rhythm that may be influenced by feedback effects, whereas physiological tremor is due to a complex interaction of central, feedback, and mechanical effects.

Assessment of intellectual functioning of patients with Parkinson's disease using the Satz-Mogel (1962) short form of the Wechsler Adult Intelligence Scale

The purpose of the present study was to compare the Satz-Mogel (S-M) short form of the Wechsler Adult Intelligence Scale--Revised (WAIS-R) with the full-scale WAIS-R to establish its utility in the assessment of intellectual functioning in patients with Parkinson's disease (PD). PD patients and elderly control subjects were administered a neuropsychological test battery that included the complete WAIS-R or the S-M. Results indicated that the S-M was a reliable measure of IQ. The PD subjects' Verbal, Performance, and Full-Scale IQ scores were inferior to that of controls, regardless of test form. Adjustments for depression and age did not alter these results. PD patients with more severe disease scored lower on some visual-spatial measures. Verbal decrements among PD patients may relate to problems in verbal fluency, categorical thinking, and impaired retrieval of verbal material. PD patients may experience patterns of subtle cognitive changes that include deterioration of some specific abilities as the disease progresses.

Contrast sensitivity dysfunction in Alzheimer's disease

We compared the spatial contrast sensitivity of six patients with mild to moderate Alzheimer's disease (AD) and six age-matched control subjects in a parametric design. Results demonstrate reduced contrast sensitivity in patients with AD at all but the lowest frequency tested. The results suggest that the effect of AD on spatial contrast sensitivity is stronger at higher frequencies and provide a rationale for complaints of poor vision in AD patients.

Levodopa improves spatial contrast sensitivity in Parkinson's disease

OBJECTIVE

To study the effect of levodopa on the visual contrast sensitivity of patients with Parkinson's disease.

DESIGN

Contrast sensitivity of patients was measured before and after levodopa administration. Patient contrast sensitivity was compared with that of normal controls by repeated-measures analyses of variance.

SETTING

Parkinson's disease research center associated with private neurology practice.

PATIENTS

Fifteen patients with idiopathic Parkinson's disease (eight men, seven women; mean age, 71.8 years) and 22 normal controls (10 men, 12 women; mean age, 68.0 years) volunteered for the study.

INTERVENTION

Levodopa/carbidopa (Sinemet).

MAIN OUTCOME MEASURE

Change in contrast sensitivity of parkinsonian patients.

RESULTS

Following levodopa treatment, the contrast sensitivity of parkinsonian patients improved significantly at the three lowest spatial frequencies tested (0.4, 1, and 2 cycles per degree).

CONCLUSIONS

Levodopa improves low-frequency contrast sensitivity in parkinsonian patients. Initially deficient contrast sensitivity in such patients may be restored to near normal levels by levodopa therapy.

Controlled study of the antiparkinsonian activity and tolerability of cabergoline

Cabergoline, a new ergoline derivative, is a D2-specific dopaminergic agonist that is more potent and longer-acting than other agonist agents. We conducted a randomized, double-blind study of increasing doses of cabergoline taken once a day. Twenty-five patients with Parkinson's disease taking stable doses of levodopa began cabergoline at 0.5 mg. The dose was escalated at weekly intervals to 1.0 mg in 19 patients, 1.5 mg in 14 patients, 2.0 mg in nine patients, and 2.5 mg in four patients. Treatment continued for 8 weeks after titration. Unified Parkinson's Disease Rating Scale scores, Hoehn and Yahr stage of disease, and computerized measures of motor performance improved significantly with cabergoline treatment. Dose-response effects were not significant. No serious adverse experiences occurred during the 13-week trial, and the side-effect profile mirrored other dopaminergic agonists. Cabergoline appears to be a promising agent in the treatment of Parkinson's disease.

Long-acting carbidopa-levodopa in the management of moderate and advanced Parkinson's disease

Parkinson's disease patients treated chronically with levodopa often develop fluctuations in motor response. Motor fluctuations can be attributed in part to oscillating plasma levodopa concentrations. A controlled-release formulation containing 200 mg of levodopa and 50 mg of carbidopa provides superior plasma levodopa profiles compared with the standard preparation. A multicenter, double-blind trial involving 202 patients with fluctuating motor response found controlled-release carbidopa-levodopa to be safe and tolerable, with improved efficacy compared with the standard formulation. Long-term exposure to the controlled-release formulation, at least for a period of 3 years, does not appear to be associated with any increase in the incidence of adverse side effects.

Long-term evaluation of Sinemet CR in parkinsonian patients with motor fluctuations

The safety and efficacy of Sinemet CR, a controlled-release formulation of carbidopa/levodopa, were investigated in a three year, open-label trial involving 18 parkinsonian patients with fluctuating motor response. The average daily levodopa dosing frequency did not change significantly during long-term treatment. Efficacy measures generally revealed a gradual progression of parkinsonian disability. Patient diaries of motor fluctuations revealed relative stability of time "on" but with a tendency toward increased time "on with dyskinesias" over the 36 month follow-up period. There were no adverse laboratory results deemed to be related to Sinemet CR and no unexpected side effects were observed.

Spatial contrast sensitivity is reduced in bilateral Parkinson's disease

We studied the contrast sensitivity functions of 41 patients with idiopathic Parkinson's disease (PD) with a wide range of parkinsonian symptomatology (Hoehn and Yahr stages 1 to 4) and 22 age-matched control subjects in a parametric design. Results demonstrated reduced contrast sensitivity in PD patients but only in those patients who had progressed beyond Hoehn and Yahr stage 1. Furthermore, there were deficits in contrast sensitivity related to the severity of PD.

Multicenter controlled study of Sinemet CR vs Sinemet (25/100) in advanced Parkinson's disease

Controlled-release carbidopa/levodopa 50/200 (Sinemet CR) and standard carbidopa/levodopa (Sinemet 25/100) were compared in a multicenter double-blind trial involving 202 patients with advanced Parkinson's disease and motor response fluctuations. Treatment with Sinemet CR significantly reduced daily "off" time. According to both physician and patient global ratings, patients showed significant improvements with Sinemet CR compared to treatment with standard Sinemet. Patients preferred Sinemet CR treatment by a ratio of approximately 2 to 1. Daily dosing frequency was 33% less with Sinemet CR, while daily intake of levodopa required was increased by 25%. The safety profiles of the 2 formulations were similar. We conclude that Sinemet CR is superior to standard Sinemet for many patients with advanced Parkinson's disease, although it does not solve the problem of fluctuating motor performance.

Changes in the performance of parkinsonian patients and normal aged on the Benton Visual Retention Test

Performance on the Benton Visual Retention Test was compared between those with Parkinson's disease (PD) and age-equivalent controls. The major difference between groups was that those with PD showed an increase in figural reproduction errors between test periods spaced six months apart, while controls showed little increase in errors over this time and made fewer errors at each time of testing. Age and IQ accounted for major proportions of variance in performance for both groups (about 50%), far more than that attributable to group membership. Within the PD group, however, age and disease onset were confounded (r = .92), indicating that age as a variable is quite when disease onset is considered. The results support the notion that PD is associated with change in visual-spatial memory, beyond that predicted by age per se.

Treatment of chronic Parkinson's disease with controlled-release carbidopa/levodopa

Controlled-release carbidopa/levodopa 50/200 (SINEMET CR) and standard carbidopa/levodopa (SINEMET 25/100) were compared in a double-blind, six-month, crossover study involving 21 patients with chronic Parkinson's disease and motor response fluctuations. Daily dosage frequency was significantly reduced with SINEMET CR compared with SINEMET 25/100, while the daily amount of levodopa required with SINEMET CR was significantly greater. No significant differences in disability ratings, motor response fluctuations, or safety were detected during double-blind conditions. In the open-label, dose-finding phase of the study, SINEMET CR was superior to standard SINEMET 25/100 in patient ratings of percent "on" time (good motor function), clinical assessments of motor function, and activities of daily living. This finding resulted from a depreciation of the value of the "old drug" rather than an overestimation of the value of the experimental drug. This double-blind study also suggested that elderly male patients with Parkinson's disease derived the greatest benefit from SINEMET CR.

Prolonged serum levodopa levels with controlled-release carbidopa-levodopa in the treatment of Parkinson's disease

Twenty parkinsonian patients (Hoehn and Yahr scale, I through III) were treated with controlled-release carbidopa-levodopa (CR-2 or CR-3) and standard carbidopa-levodopa (Sinemet, 25 mg/100 mg) in a double-blind, crossover pharmacokinetic and clinical efficacy study. The controlled-release agents had a slower rise to peak plasma values and flatter pharmacokinetic curves than did the standard. The area under the curve for CR-3 was significantly increased by 55.5% as compared with standard agent and by 84.2% as compared with CR-2. No differences in clinical efficacy were found between controlled-release agents and the standard agent for this group of parkinsonian patients with mild to moderate severity. The dissociation between the prolonged serum levodopa levels and unimproved clinical efficacy may have resulted from the absence of patients with prominent motor fluctuations and/or substantial serum levodopa variability that was especially prominent with CR-3.

Alzheimer's disease: evolving clinical concepts and management strategies

The prevalence of Alzheimer's disease is rising dramatically. This increase results from a "graying" of our population and a redefinition of the term Alzheimer's disease. Alzheimer's disease is recognized to be a progressive neurologic disorder of unknown cause but is not associated with any increased cerebral arteriosclerosis as compared to age-matched controls. The course of the illness on average is about ten years. A variety of inclusion and exclusion criteria, if used conservatively, can accurately predict the pathologic diagnosis of Alzheimer's disease. Whereas no specific cause or clearly effective treatment is currently available, care consists of pharmacologic therapy aimed at specific symptoms and measures designed to reduce patient confusion and care-giver burden. The physician can benefit the patient and care giver by providing an accurate diagnosis, providing therapy where available, counseling the family, and providing referrals to available community-support services.

Brain reactive antibodies and the blood-brain barrier: observations in aging rodents and the effects of peripheral kainic acid

This study was initiated to confirm the existence of brain-reactive autoantibodies and to determine if such antibodies have higher affinity for brain regions especially affected in Alzheimer's disease. Serum collected from 90, 300, and 600 day old mice was incubated against brain tissues from these same mice, followed by incubation with fluorescently tagged rabbit antimouse IgG. No antibodies were present in the youngest serum, but considerable antibodies were present at 300 and, especially, at 600 days. Such antibodies were present in the blood vessels, but not in the brains of older animals. These antibodies, applied exogenously, labeled cells equally in all three ages of brains including most cortical and many other neurons, indicating that they are not neurotransmitter specific. In a further study, kainic acid or saline was administered peripherally to 15-month old rats. Kainic acid damaged the blood brain barrier and allowed the CNS entry of brain-reactive antibodies, especially into the subregions of hippocampus most damaged in Alzheimer's.

A novel, adaptable and inexpensive computerized activity meter

A number of activity meters ranging from fully manual to fully automated have been described. A computerized activity meter, used primarily as a rotational activity chamber, is described. This inexpensive system is built around a Commodore 64 computer interfaced through a circuit board to the meters. Each computer can run four chambers and, as a rotometer, can distinguish quarter and full turns in either direction. The system is easily adapted to record data from various behavioral chambers, including an open field with photocell beams.

Abnormal ocular motor function predicts clinical diagnosis of familial ataxia

Ocular motor performance was significantly impaired in familial ataxia patients as compared with normal controls. Ataxic patients showed prolonged saccadic latencies, longer saccadic refixation times, reduced visual tracking performance, and increased hypermetria. Cutoff values were derived and applied to 15 subjects at risk for developing familial ataxia. Three of 15 showed abnormal values in three or more of four categories of ocular motor performance. Within 3 years, all three subjects were diagnosed on clinical grounds as having familial ataxia. We conclude that ocular motor performance is impaired in familial ataxia and may prove useful for earlier diagnosis.

Clinical neurophysiology of dementia

The role of EEG in the study of the dementias is to help in the differential diagnosis of the multiple causes of this syndrome. EEG is useful in differentiating early on between treatable and as of now untreatable forms of dementia. Space-occupying lesions that give rise to dementia are reliably detected by EEG. Infectious, toxic, and metabolic processes are associated with early and severe electroencephalographic abnormalities. The "slow virus" infections show characteristic electrical patterns that reliably distinguish them from the cortical or subcortical dementias. Finally, the EEG may contribute to distinguishing between Alzheimer's disease and MID, two commonly occurring forms of dementia. The paucity of substantial early EEG abnormalities in Alzheimer's disease, although helping to differentiate it from other dementias, leaves us without a currently available physiologic test that provides positive evidence for this condition. Recent studies of EPs, however, suggest that some intermediate latency VEP components may be delayed in patients with Alzheimer's disease when compared with normal subjects. This is encouraging, as latencies in VEPs are more reliable and less variable than amplitude that has previously been reported as "abnormal" in some early Alzheimer patients. Long latency ERPs and CNV also show early abnormalities in Alzheimer's disease. Tests of eye movements such as ERPs are psychophysiologic tests requiring some degree of patient cooperation. Performance on tests of ocular smooth pursuit correlate highly with severity of the dementia syndrome in Alzheimer's disease. In contrast, smooth pursuit testing is usually normal in elderly patients with pseudodementia of depression, suggesting this test may be of some value in differentiating these two clinical disorders. Some evidence exists that smooth pursuit eye movements are also normal, at least in the early and middle stages, in Pick's disease, again suggesting that eye movement testing may prove to have some utility in differentiating this form of dementia from Alzheimer's disease. Ocular scanpaths are abnormal in dementia. They typically are poorly organized and at times perseveratory. In addition, the average durations of eye fixations during directed visual search are altered in dementia as compared with normals. The average eye fixation durations are longer with Alzheimer's disease and briefer in patients with frontal lobe tumors as compared with elderly normal controls. These group differences suggest differing scanning strategies for these two forms of dementia.(ABSTRACT TRUNCATED AT 400 WORDS)

Families of Alzheimer's victims. Family support to the caregivers

This study examined the instrumental and social-emotional support provided by families to the primary caregivers of Alzheimer's patients. It was anticipated that the more adequate the support provided by the family, the less sense of burden and the better the coping effectiveness of the caregiver. Ratings of instrumental assistance, social-emotional support, adequacy of support, and coping effectiveness were made by trained raters from transcribed interviews with 23 primary caregivers. Also, a second family member who was usually next closest of kin to the caregiver was interviewed in order to provide another perspective of the support the family provided. While the major caregiving tasks were performed by the primary caregiver, the types of assistance from family that seemed most appreciated were visits and having persons stay with the patient so that the caregiver could take a trip, rest, run errands, or get out of the house for social activities. The majority of caregivers felt a high degree of support from their families and reported low levels of emotional upset resulting from family support efforts. The most common family problems reported were lack of visits, disagreement over level of patient's mental and physical functioning, and disagreement over the type of care required. The data confirmed the hypothesis that family support was positively associated with the caregiver's coping effectiveness. In addition, caregivers who did not receive enough support were most burdened; however, the group receiving the greatest amount of support was the next most burdened, a finding which was unanticipated.(ABSTRACT TRUNCATED AT 250 WORDS)

Lateral saccadic latencies and handedness

Lateral saccadic latencies were determined in 18 right-handers and 18 left-handers. Within the right-handed group the mean latency was significantly shorter when looking from the left to the right (242.7 msec) than from right to left (265.0 msec), whereas no significant directional difference was found in the left-handed group. An age effect was also found with longer latencies being associated with increased age. These findings agree with those of Pirozzolo and Rayner (Neuropsychologia 18, 225-229, 1980) and provide further evidence of the pervasiveness of functional asymmetry in the human brain. The present findings suggest that motoric or central integrative mechanisms may contribute more to saccadic directional asymmetries than do perceptual differences.

A case-control study of dementia of the Alzheimer type

A case-control study to assess factors of possible etiologic significance to dementia of the Alzheimer type was conducted with 78 male cases diagnosed in 1979-1982 at the Veterans Administration Medical Center in Minneapolis, Minnesota and age-race-sex-matched hospital and neighborhood controls (14 of 16 autopsied cases were histopathologically confirmed). Information was obtained on variables relevant to vital, genetic, and immunologic hypotheses, and on possible occupational and environmental exposures, drug use, psychologic stress, smoking, and alcohol consumption. The only major difference between patients with dementia of the Alzheimer type and controls was a significantly greater occurrence of antecedent head trauma in the patients (odds ratio = 4.50). This finding is consistent with the literature on posttraumatic dementia but its importance is presently unclear.

Head injury as a risk factor for Alzheimer's disease

A case-control study was performed in which the frequency of prior head injury was assessed in 78 patients with dementia of the Alzheimer type (DAT) and 124 control subjects matched for age, sex, and race. A history of head injury with loss of consciousness was reported in 25.6% of patients and 5.3% and 14.6% of hospital and neighborhood controls, respectively. Matched-pair analysis of patients and hospital controls yielded an odds ratio of 4.50, which was significant (p less than 0.01). The ranges of times of occurrence of head injuries were similar in patients and controls, spanning several decades. The findings suggest a possible etiologic role for head injury in DAT.

Role of the senile plaque in neuropeptide deficits of Alzheimer's disease

Senile plaques participate in a cropping of the dendritic tree of enkephalinergic dentate granule cells and hl and subicular pyramidal cells. Somatostatin-containing pyramidal neurons are lost in Alzheimer's disease, whereas nonpyramidal somatostatin neurons are less affected. Fibers containing somatostatin penetrate immature, but not end-stage senile plaques. The senile plaque may precipitate much of the hippocampal denervation seen in Alzheimer's disease.

Controlled-release carbidopa/levodopa in the treatment of Parkinsonism

Controlled release carbidopa/levodopa (CSR-1) was compared to standard carbidopa/levodopa in a double-blind, crossover study of 20 Parkinson's disease patients. The most consistent finding in a variety of clinical measurements was the superiority of standard carbidopa/levodopa to CSR-1. Increased dosages of CSR-1 resulted in reduced Parkinson symptoms, suggesting that a more potent controlled-release formulation might prove to be more efficacious than CSR-1.