Immediate inflammatory response to mechanical circulatory support in a porcine model of severe cardiogenic shock

BACKGROUND

In selected cases of cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is combined with trans valvular micro axial flow pumps (ECMELLA). Observational studies indicate that ECMELLA may reduce mortality but exposing the patient to two advanced mechanical support devices may affect the early inflammatory response. We aimed to explore inflammatory biomarkers in a porcine cardiogenic shock model managed with V-A ECMO or ECMELLA.

METHODS

Fourteen landrace pigs had acute myocardial infarction-induced cardiogenic shock with minimal arterial pulsatility by microsphere embolization and were afterwards managed 1:1 with either V-A ECMO or ECMELLA for 4 h. Serial blood samples were drawn hourly and analyzed for serum concentrations of interleukin 6 (IL-6), IL-8, tumor necrosis factor alpha, and serum amyloid A (SAA).

RESULTS

An increase in IL-6, IL-8, and SAA levels was observed during the experiment for both groups. At 2-4 h of support, IL-6 levels were higher in ECMELLA compared to V-A ECMO animals (difference: 1416 pg/ml, 1278 pg/ml, and 1030 pg/ml). SAA levels were higher in ECMELLA animals after 3 and 4 h of support (difference: 401 ng/ml and 524 ng/ml) and a significant treatment-by-time effect of ECMELLA on SAA was identified (p = 0.04). No statistical significant between-group differences were observed in carotid artery blood flow, urine output, and lactate levels.

CONCLUSIONS

Left ventricular unloading with Impella during V-A ECMO resulted in a more extensive inflammatory reaction despite similar end-organ perfusion.

Haemodynamic implications of VA-ECMO vs. VA-ECMO plus Impella CP for cardiogenic shock in a large animal model

AIMS

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with profound left ventricular (LV) failure is associated with inadequate LV emptying. To unload the LV, VA-ECMO can be combined with Impella CP (ECMELLA). We hypothesized that ECMELLA improves cardiac energetics compared with VA-ECMO in a porcine model of cardiogenic shock (CS).

METHODS AND RESULTS

Land-race pigs (weight 70 kg) were instrumented, including a LV conductance catheter and a carotid artery Doppler flow probe. CS was induced with embolization in the left main coronary artery. CS was defined as reduction of ≥50% in cardiac output or mixed oxygen saturation (SvO2) or a SvO2 < 30%. At CS VA-ECMO was initiated and embolization was continued until arterial pulse pressure was <10 mmHg. At this point, Impella CP was placed in the ECMELLA arm. Support was maintained for 4 h. CS was induced in 15 pigs (VA-ECMO n = 7, ECMELLA n = 8). At time of CS MAP was <45 mmHg in both groups, with no difference at 4 h (VA-ECMO 64 mmHg ± 11 vs. ECMELLA 55 mmHg ± 21, P = 0.08). Carotid blood flow and arterial lactate increased from CS and was similar in VA-ECMO and ECMELLA [239 mL/min ± 97 vs. 213 mL/min ± 133 (P = 0.6) and 5.2 ± 3.3 vs. 4.2 ± 2.9 mmol/ (P = 0.5)]. Pressure-volume area (PVA) was significantly higher with VA-ECMO compared with ECMELLA (9567 ± 1733 vs. 6921 ± 5036 mmHg × mL/min × 10-3, P = 0.014). Total diureses was found to be lower in VA-ECMO compared with ECMELLA [248 mL (179-930) vs. 506 mL (418-2190); P = 0.005].

CONCLUSIONS

In a porcine model of CS, we found lower PVA, with the ECMELLA configuration compared with VA-ECMO, indicating better cardiac energetics without compromising systemic perfusion.

A 12-year population-based study of freezing of gait in Parkinson's disease

INTRODUCTION

Freezing of gait (FOG) is a potentially disabling motor problem in Parkinson's disease (PD) with uncertain etiology. Longitudinal studies of FOG in PD are scarce. We determined the prevalence, incidence, and associated clinical risk factors and concomitants of FOG during prospective long-term follow-up of a population-based PD cohort.

METHODS

A community-based prevalent cohort of 232 PD patients was followed prospectively over 12 years. Reassessments were conducted at 4 and 8 years, and then annually. FOG, as well as severity of parkinsonism, motor complications, and psychotic symptoms were assessed by the Unified PD Rating Scale, and cognitive impairment by the Mini-Mental State Examination. Generalized estimating equations were applied to investigate baseline risk factors and concomitants of FOG over time.

RESULTS

The point prevalence of FOG at baseline was 27% (95% confidence interval (95%-CI) 22-33%). By study end, 63% (95%-CI 56-69%) of patients had developed FOG. The incidence rate of FOG was 124.2 (95%-CI 101.5-152.1) per 1000 person-years. Motor fluctuations (odds ratio (OR) 3.45; p = 0.036) and higher levodopa dose (OR 1.30/100 mg, p = 0.009) at baseline were independent risk factors of incident FOG. Prevalent FOG over time was additionally associated with features thought to reflect extrastrial, non-dopaminergic pathologies, including PIGD (postural instability/gait difficulty, OR 6.30/10 points, p < 0.001) and psychosis (OR 1.85; p = 0.016).

CONCLUSION

These findings demonstrate that FOG affects the majority of patients in the general PD population and provide support to the hypothesis that alterations in both basal ganglia and extrastriatal brain areas are involved in the pathogenesis of FOG in PD.

Parkinson disease: associated disorders in the Norwegian population based incident ParkWest study

Parkinson's disease (PD) may be associated with a number of different diseases due to common risk factors or overlapping symptomatology. We have asked for possible associated disorders in a Norwegian population of incident PD patients and controls, the Norwegian ParkWest study. The patients were diagnosed according to the Gelb criteria. 212 incident PD patients and 175 age and gender matched controls were included. PD patients and controls were asked for information on earlier medical history and family history. PD patients had a higher frequency of self-reported symptoms of depression (p = 0.003) and anxiety disorders (p = 0.004) before baseline. They tended to have a higher frequency of diabetes (p = 0.09) and had a higher frequency of prior stroke or TIA (p = 0.004).

Frequencies of falls and associated features at different stages of Parkinson's disease

BACKGROUND AND PURPOSE

To examine the frequencies and clinical characteristics of fallers and non-fallers at different stages of Parkinson's disease (PD).

METHODS

The sample consisted of 232 patients in an unselected cross-sectional cohort of patients with PD, 207 newly diagnosed and drug naive patients and 175 controls. The examinations included the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr, Schwab and England, and Mini-Mental State Examination. According to item 13 of the UPDRS, the participants were classified as fallers, rare-fallers and non-fallers.

RESULTS

In the cross-sectional study cohort, 19% of the patients were classified as fallers and 25% as rare-fallers. Higher scores on activity of daily living (UPDRS ADL score) and motor complications (UPDRS complication of therapy score) were significantly and independently associated with falling. In the cohort of newly diagnosed patients with PD 2% were classified as fallers and 15% as rare-fallers. In the age- and sex-matched control group, none were fallers, and only 2% were rare-fallers. Patients with tremor-dominated PD subtype in both study populations did not fall.

CONCLUSIONS

Falls are a markedly increasing problem in patients with PD as the disease progresses. Healthcare workers should ask patients about falling, and specially focus on patients with motor complications or postural instability and gait disability-dominated subtype of parkinsonism.

Subjective sleep problems in patients with early Parkinson's disease

BACKGROUND AND OBJECTIVE

Sleep problems are common in Parkinson's disease (PD) and increasingly so with disease progression. The frequency of these problems and the influence of dopaminergic treatment on sleep in early stages of PD remain unclear. We have therefore in this study examined the subjective experience of sleep problems in drug-naïve patients with early PD and how these problems developed after 1 year on dopaminergic treatment using the Parkinson's Disease Sleep Scale (PDSS).

METHODS

In all, 138 drug-naïve patients with early PD derived from a population-based incident cohort and 138 age- and gender-matched control subjects were thoroughly assessed for Parkinsonism, cognition, depressive symptoms and sleep by structured interviews and clinical examination at the time of diagnosis and 1 year later on medication. Sleep problems were assessed using the PDSS.

RESULTS

The total PDSS score for patients with PD was lower compared with controls, 119 vs. 127 (P < 0.05) at baseline and 121 vs. 128 (P < 0.005) after 1 year on drugs. Analyses of PDSS subdomains showed more nocturnal motor off symptoms both at baseline and after 1 year (P < 0.005) and increased daytime somnolence in patients compared with control subjects (P < 0.005 at baseline and P < 0.05 after 1 year). Only minor changes in sleep scores were seen after the introduction of dopaminergic treatment.

CONCLUSION

Patients with early PD report only modestly increased subjective sleep problems at the time of diagnosis compared with control subjects and dopaminergic treatment during the first year in general only slightly changed the experienced sleep problems.

Fatigue in early Parkinson's disease. Minor inconvenience or major distress?

BACKGROUND AND PURPOSE

  Although fatigue is recognized as a common and debilitating symptom in patients with Parkinson's disease (PD), little is known on how and when this symptom emerges during disease progression. The aim of the study was to explore the presence and severity of fatigue in patients with PD at the time of diagnosis, before dopaminergic treatment has been instituted.

METHODS

  The present study is part of the Norwegian ParkWest project, a large cohort study of patients with incident PD in Norway. PD was diagnosed according to the Gelb criteria. The study population comprised 199 patients with untreated, newly diagnosed PD and 172 control subjects, matched for gender and age. Fatigue was measured by the Fatigue Severity Scale (FSS).

RESULTS

  Fifty-five percent of the patients with PD had clinical significant fatigue (FSS > 4), compared with about 20% of the controls (RR = 2.9). The mean score in patients on the FSS was 4.4 (SD 1.7) and in controls 3.1 (SD 1.3). In addition, there were highly significant differences between patients and controls in each of the nine FSS items. In a regression analysis, only the Montgomery and Åsberg Depression Rating Scale and Unified Parkinson's Disease Rating Scale-Activities of Daily Living scores were significantly associated with fatigue. There was no correlation between fatigue and cognitive impairment and hypersomnia.

CONCLUSION

  Fatigue is a common symptom in PD, also in patients with early, untreated disease, and it has a negative impact on these patients' activity of daily living. Also in early PD, fatigue is an important consideration in the management of patients with the disease.

Increased risk of leg motor restlessness but not RLS in early Parkinson disease

OBJECTIVE

This study explores the risk and correlates of leg restlessness in drug-naive patients with Parkinson disease (PD) as compared to control subjects matched for age and gender.

METHODS

A total of 200 drug-naive patients with early, unmedicated PD derived from a population-based incident cohort and 173 age- and gender-matched control subjects were assessed for leg restlessness by structured interviews, clinical examination, and blood samples. All subjects were Caucasian. Restless legs syndrome (RLS) was diagnosed according to the essential diagnostic criteria.

RESULTS

More patients (81 of 200, 40.5%) than controls (31 of 173, 17.9%) reported leg restlessness (p < 0.001). Thirty-one (15.5%) of these patients with PD and 16 (9.2%) control subjects met RLS criteria (p = 0.07). A total of 21 (12.5%) patients and 12 (6.9%) controls with RLS remained after the exclusion of potential RLS mimics and 26 patients vs 10 control subjects with leg motor restlessness (LMR), leading to a relative risk for RLS of 1.76 (95% confidence interval [CI] 0.90-3.43, p = 0.089) and 2.84 for LMR (95% CI 1.43-5.61, p = 0.001) in PD. Except for increased sleep disturbances in patients with RLS and increased Montgomery and Åsberg Depression Rating Scale scores for patients with RLS or LMR there were no other major differences in relevant blood tests, motor or cognitive function between PD with and without RLS or LMR.

CONCLUSION

LMR and not RLS occurs with a near 3-fold higher risk as compared to controls in early PD. The findings underline a need for more accurate assessments of RLS in PD and support the notion that RLS and PD are different entities.

Choice of psychological coping in laryngectomized, head and neck squamous cell carcinoma patients versus multiple sclerosis patients

To be treated for cancer must be a frightening experience. Yet quality of life (QoL) of successfully treated cancer patients seems to be relatively similar in comparison with QoL of a general population, with psychological coping partly responsible for this finding. When measuring choice of coping, the nature of coping score levels constituting appropriate scores, and whether score levels rely on the context of the disease has not been settled. We have studied the COPE coping responses as related to disease in successfully treated head and neck squamous cell carcinoma (HNSCC) patient groups (general and laryngectomized), as well as compared to multiple sclerosis (MS) patients. The COPE response patterns have also been compared to the Beck depression inventory (BDI) scores. Age and gender of patients were not directly associated with choice of coping. Within the problem-focused coping indexes, the coping index "active coping" was reported to be most utilized among HNSCC patients, whereas "coping by suppression" and "coping by social support" were most utilized among MS patients. Emotional-focused coping was most prevalent among HNSCC patients and lowest among the MS patients. Level of avoidance coping was similar between the groups. The coping of the general HNSCC patients differed most from the MS patients. An association was shown between increased coping efforts and lowered mood. In particular, avoidance coping was associated with lowered mood. These associations were stronger among the MS patients than HNSCC patients. Drinking to cope was most prevalent among the laryngectomized group, and was correlated with BDI scores in all groups. Furthermore, adequate coping seems to be to limit avoidance coping and promote coping by acceptance. The response pattern of the COPE inventory seems to be valid among HNSCC and MS patients.

Are dysautonomic and sensory symptoms present in early Parkinson's disease?

Parkinson's disease (PD) occurs with an annual incidence of 13/100.000, is slightly more frequent in men and is characterized by the motor symptoms tremor, rigidity, bradykinesia and postural instability. In addition, non-motor symptoms have been increasingly connected to the disease although already described in James Parkinson's 'Essay on the shaking palsy' from 1817. The motor symptoms in PD are related to the degeneration of dopaminergic cells in the substantia nigra (SN). These symptoms respond well to dopaminergic substitution. It is much more unclear whether non-motor symptoms like dysautonomia, insomnia, day-time sleepiness, fatigue, pain and neuropsychiatric symptoms respond to levodopa. Autonomic symptoms include dizziness because of orthostatic hypotension, constipation, nausea, voiding symptoms and increased sweating. Such symptoms as well as sensory symptoms like hyposmia and pain are very frequently reported in PD and seem to occur early in the disease process. Braak proposed a sequential model of neuropathology in PD starting with affection of the olfactory bulb and the autonomic innervation of the heart and gut. Affection of SN is seen from Braak stage 3, and limbic and cortical structures are affected in the later stages of the disease. Currently, the evidence for sensory and autonomic involvement in PD is reviewed with special focus on the early phase of the disease.

Caregiver distress associated with neuropsychiatric problems in patients with early Parkinson's disease: the Norwegian ParkWest study

OBJECTIVES

We investigated caregiver distress associated with neuropsychiatric problems in patients with newly diagnosed Parkinson's disease (PD).

MATERIALS AND METHODS

Persons who were next of kins of 198 patients and 168 healthy individuals completed the Neuropsychiatric Inventory Caregiver Distress Scale.

RESULTS

Even at the time of diagnosis PD has a considerable impact on the next of kins' experience of distress. Nearly 50% reported distress, significantly more than in the control group, and more than one-quarter reported moderate severe distress. Except the more rarely reported neuropsychiatric symptoms, apathy was the symptom that most frequently caused caregiver distress in PD patient's next of kin (94.5%), followed by depression (88.2%), anxiety (86.2%) and irritability (83.3%).

CONCLUSIONS

The study underlines the importance of focusing on neuropsychiatric aspects in patients and associated caregiver distress even in early PD management.

The role of APOE alleles in incident Parkinson's disease. The Norwegian ParkWest Study

OBJECTIVES

Apolipoprotein E (APOE) gene alleles have been associated with various neurodegenerative disorders. However, there have been conflicting reports on associations between APOE alleles and Parkinson's disease (PD) and age at onset in PD. There exist no data on APOE alleles in an unselected cohort of patients with incident PD.

PATIENTS AND METHODS

To determine the role of APOE alleles in PD and age of onset in PD at time of diagnosis, 203 patients with incident PD and 187 healthy control subjects from Western and Southern Norway were investigated according to their APOE allele status.

RESULTS

No association was observed between any APOE alleles and susceptibility to PD or age at onset in PD.

CONCLUSION

In our cohort of unselected, incident PD patients APOE alleles do not seem to play a role for development of PD. Prospective, long-term follow-up may still reveal associations between APOE alleles and clinical and neuropsychological progression in PD.

Coping with multiple sclerosis: a 5-year follow-up study

OBJECTIVES

To examine how coping styles among patients with multiple sclerosis (MS) change over time and how patients' coping styles after 5 years are associated with disability pension.

MATERIALS AND METHODS

Seventy-six MS patients and 94 healthy controls were included in this study. The patients were examined at baseline and 5 years later. This included a neurological examination and information on disability pension and a questionnaire assessing coping (the COPE scale). Controls were registered at baseline only.

RESULTS

Compared to healthy controls, MS patients were more passive in coping with disease related distress. This was even more pronounced 5 years later. Disability pensioned patients employed more social support, venting of emotions and behavioural disengagement at follow-up.

CONCLUSION

This study shows that patients with MS employ coping styles that may be inadequate and this is not improved by adaption over time. Although patients also use strategies to enhance their lives, these findings suggest that there may be a potential for improving the lives of patients with MS through interventions that may enhance adequate coping with the disease.

Mild cognitive impairment in Parkinson disease: a multicenter pooled analysis

BACKGROUND

In studies of mild cognitive impairment (MCI) in Parkinson disease (PD), patients without dementia have reported variable prevalences and profiles of MCI, likely to be due to methodologic differences between the studies.

OBJECTIVE

The objective of this study was to determine frequency and the profile of MCI in a large, multicenter cohort of well-defined patients with PD using a standardized analytic method and a common definition of MCI.

METHODS

A total of 1,346 patients with PD from 8 different cohorts were included. Standardized analysis of verbal memory, visuospatial, and attentional/executive abilities was performed. Subjects were classified as having MCI if their age- and education-corrected z score on one or more cognitive domains was at least 1.5 standard deviations below the mean of either control subjects or normative data.

RESULTS

A total of 25.8% of subjects (95% confidence interval [CI] 23.5-28.2) were classified as having MCI. Memory impairment was most common (13.3%; 11.6-15.3), followed by visuospatial (11.0%; 9.4-13.0) and attention/executive ability impairment (10.1%; 8.6-11.9). Regarding cognitive profiles, 11.3% (9.7-13.1) were classified as nonamnestic single-domain MCI, 8.9% (7.0-9.9) as amnestic single-domain, 4.8% (3.8-6.1) as amnestic multiple-domain, and 1.3% (0.9-2.1) as nonamnestic multiple-domain MCI. Having MCI was associated with older age at assessment and at disease onset, male gender, depression, more severe motor symptoms, and advanced disease stage.

CONCLUSIONS

MCI is common in patients with PD without dementia, affecting a range of cognitive domains, including memory, visual-spatial, and attention/executive abilities. Future studies of patients with PD with MCI need to determine risk factors for ongoing cognitive decline and assess interventions at a predementia stage.

The effect of statin therapy on the progression of carotid artery stenosis in relation to stenosis severity

OBJECTIVES

To examine the effect of early statin treatment on progression of arteriosclerosis in internal carotid arteries (ICA); to compare the progression of arteriosclerosis in ICA of patients treated with a statin to the progression seen in drug-naïve patients.

PATIENTS AND METHODS

We performed repetitive Doppler scans of 363 carotid arteries with ICA stenosis > or =40% in 254 patients over time. Information on statin therapy and other risk factors for stroke were correlated with the annual change in degree of ICA stenosis.

RESULTS

In statin-treated patients, 19% of ICA stenosis showed a progression while 74% showed a regression of stenosis. In statin-naïve patients, 63% of stenotic arteries showed a progression, while a reduction could be observed in 28%. Decrease of ICA stenosis was most accentuated in patients with a mild stenosis and was independent of serum cholesterol levels.

CONCLUSION

Treatment with statins already in early stages of ICA stenosis might delay the progression and even reverse the degree of stenosis.

Parkinson's disease and hospital admissions: frequencies, diagnoses and costs

OBJECTIVE

To evaluate the frequencies, causes and costs related to hospital admissions for patients with Parkinson's disease (PD) and controls.

METHODS

In a prospective cohort study, 108 patients with PD from a population-based prevalence study and 854 age- and sex-matched controls were followed regarding admissions to the Stavanger University Hospital over a period of 12 years.

RESULTS

There was no significant difference regarding the number of patients admitted, number of admissions or length of stay between the two cohorts. Based on 2005 prices, the costs per person year of survival were EUR 3288 for patients with PD and EUR 2466 for control individual with incremental costs of EUR 822. However, the difference in costs was not statistically significant. The two cohorts had a different distribution of diagnoses causing hospital admissions. Patients with PD were more often admitted for PD-related symptoms and falls, while vascular disorders and cancer were substantially more common in control individuals.

CONCLUSION

Hospitalization in PD does not induce incremental costs. The diagnoses causing hospital admissions were different in patients with PD as compared with controls. Our results indicate that cancer and vascular diseases might be less common in patients with PD than in the general population.

Is there a need for long-term follow-up in chronic idiopathic polyneuropathy?

OBJECTIVE

To evaluate the long-term functional status and well-being in patients with chronic idiopathic polyneuropathy (CIP) in comparison to Guillain-Barré syndrome (GBS) and healthy controls.

MATERIALS AND METHODS

Forty-two CIP and 42 GBS-patients were examined at median 5 and 6 years after disease onset and were compared with 50 healthy controls. The Fatigue Severity Scale (FSS), Visual Analogue Scale for pain (VAS), Disability Rating Index (DRI) and Medical Outcome Study 36-item short-form health status scale (SF-36) were used. Variables at onset and symptoms at follow-up were correlated with outcome measurements in GBS.

RESULTS

Patients with CIP and GBS had more pain and disability than healthy controls. Additionally, CIP-patients were more fatigued than healthy controls. Patients with CIP were more fatigued [FSS 4.9 (SD 1.6) vs 3.8 (SD 1.8); P < 0.01] and disabled [DRI 4.1 (SD 2.3) vs 2.5 (SD 2.1); P = 0.05] than those with GBS. Physical functioning on the SF-36 was more impaired in CIP than GBS, compared with healthy controls.

CONCLUSIONS

Patients with CIP and GBS seem to develop persistent impairment on long-term functional status and well-being, more clearly in CIP, reflecting the importance of long-term follow-up in further disease management.

Occurrence and risk factors for apathy in Parkinson disease: a 4-year prospective longitudinal study

BACKGROUND

Apathy is a common but under-recognised behavioural disorder associated with depression and cognitive impairment in patients with Parkinson disease (PD). However, the longitudinal course of apathy in PD has not been studied.

OBJECTIVE

To examine the occurrence of and risk factors for apathy over time in a representative sample of patients with PD.

METHODS

A sample of 139 patients was drawn from a population-based prevalence study of PD in Rogaland County, Western Norway. Apathy was measured with the Neuropsychiatric Inventory, using a composite score >or=4 to indicate clinically significant apathy. Additional measurements included standardised rating scales for parkinsonism, depression and cognitive impairment. A follow-up evaluation was carried out in 79 patients (78.2% of the survivors) 4 years later.

RESULTS

Of the 79 patients included in this study, 29 patients (36.7%) had never had apathy, 11 (13.9%) had persistent apathy, and a further 39 (49.4%) developed apathy during follow-up. At follow-up, patients with apathy were more frequently depressed and demented than never-apathetic patients. Dementia at baseline and a more rapid decline in speech and axial impairment during follow-up were independent risk factors for incident apathy.

CONCLUSIONS

Apathy is a persistent behavioural feature in PD with a high incidence and prevalence over time. Progression of motor signs predominantly mediated by non-dopaminergic systems may be a useful preclinical marker for incident apathy in PD.

Incidence of Parkinson's disease in Norway: the Norwegian ParkWest study

OBJECTIVE

To present the incidence of Parkinson's disease (PD) in Norway and to explore gender influences on incidence and age at onset, as well as severity and pattern of parkinsonism at the time of diagnosis in a representative drug naïve cohort with newly diagnosed PD.

METHODS

In four Norwegian counties comprising a base population of 1 052 075 inhabitants, multiple sources of case ascertainment and a four step diagnostic procedure were used to establish a representative cohort of patients with incident PD at a high level of diagnostic accuracy. Of a total of 604 subjects referred to the study, 265 individuals fulfilled the clinical research criteria of PD at their latest clinical visit, at a mean 28 months after identification.

RESULTS

The incidence of PD in the study area, age standardised to the 1991 European standard population, was 12.6/10(5yr-1) (95% CI 11.1 to 14.2). The overall age standardised male to female ratio was 1.58 (95% CI 1.22 to 2.06), with a consistent male preponderance throughout all age groups. Clinical onset of PD was later in women than in men (68.6 vs 66.3 years; p = 0.062) whereas severity and pattern of parkinsonism in drug naïve patients was not different between genders at the time of diagnosis.

CONCLUSION

Incidence rates of PD in Norway are similar to those in other Western European and American countries. Female gender was associated with a considerably lower risk of PD and slightly delayed motor onset but had no impact on severity of parkinsonism or clinical phenotype in incident drug naïve PD, suggesting that the female gender influences on the nigrostriatal system are most pronounced in the preclinical phase of the disease.

The spectrum of neuropsychiatric symptoms in patients with early untreated Parkinson's disease

BACKGROUND

Neuropsychiatric symptoms are common in Parkinson's disease (PD) and have important clinical consequences for patients, caregivers and society. Few studies of neuropsychiatric symptoms in early untreated PD exist.

OBJECTIVE

To explore the range, clustering and correlates of neuropsychiatric symptoms in an incidence cohort of untreated subjects with PD.

METHODS

All cases with incident PD identified during a 22 month period in four counties of Western and Southern Norway were included. Standardised criteria were used to diagnose PD. The Neuropsychiatric Inventory (NPI) was administered to 175 PD and 166 healthy control subjects with similar age and sex distributions. Cluster analysis was used to investigate the interrelationship of NPI items.

RESULTS

The proportion with any NPI symptoms was higher in PD (56%) than in controls (22%) (p<0.001). Depression (37%), apathy (27%), sleep disturbance (18%) and anxiety (17%) were the most common symptoms. Clinically significant symptoms occurred in 27% of the PD group compared with only 3% in the control group (p<.001). Subjects with clinically significant neuropsychiatric symptoms had more severe parkinsonism than those without. Two neuropsychiatric clusters were identified, one characterised by mood symptoms and one by apathy.

CONCLUSIONS

Although the majority of patients with early untreated PD do not have clinical significant neuropsychiatric symptoms, these symptoms are more common in patients than in people without PD. Both psychological stress and brain changes associated with PD are likely to contribute to the higher frequencies.

Depressive symptoms and coping in newly diagnosed patients with multiple sclerosis

Background

Multiple sclerosis (MS) is a chronic disease with unclear etiology, unpredictable clinical course, and no cure. Patients’ ability to cope with MS moderates the adaptation to the disease.

Objectives

To compare coping in patients recently diagnosed with MS and healthy controls and to study the association between depressive symptoms and patients' coping styles.

Methods

A sample of 86 recently diagnosed patients with definite or probable MS and 93 healthy population controls completed questionnaires assessing coping styles and depressive symptoms.

Results

Compared with healthy controls, patients with MS used significantly less the problem focused strategies including planning, restraint coping, and seeking social support for instrumental reasons, and they used less the emotion-focused strategies seeking social support for emotional reasons, focusing on and venting of emotions, and positive reinterpretation and growth. The mean Beck Depressive symptoms Inventory scores were 10.8 and 4.7 in patients and controls, respectively. In stress situations connected to MS, depressive symptoms in these patients were related to the problem-focused strategies of restraint coping and planning, the emotion-focused strategy of focusing on and venting of emotions, and the avoidance strategies of behavioral- and mental disengagements, and denial.

Relationship of cognitive impairment to psychiatric symptoms in multiple sclerosis

Psychiatric and cognitive changes are common in patients with multiple sclerosis (MS), but their relationship has not received much attention. We studied the relationship between psychiatric symptoms and verbal memory, working memory, and mental speed in 78 patients with MS and 40 healthy control subjects using linear regression analyses. The MS group exhibited impaired performance on all cognitive tests. Apathy was associated with intrusions and depression with impaired memory and mental speed. The association between apathy and intrusions supports the hypothesis that lesions in frontal areas or frontal connections contribute to a specific neuropsychiatric syndrome in patients with MS.

Occurrence and clinical correlates of REM sleep behaviour disorder in patients with Parkinson's disease over time

OBJECTIVE

To examine the occurrence and clinical and demographic correlates of REM sleep behaviour disorder (RBD) in patients with Parkinson's disease (PD) in a community-based cohort over 8 years.

METHODS

231 patients with PD were included in a population-based prevalence study in 1993. Patients were then followed prospectively and reexamined after 4 and 8 years. Semi-structured interviews for information on clinical and demographic data were applied at all study visits. Standardised rating scales of parkinsonism, depression and cognitive impairment were used. The diagnosis of probable RBD (pRBD) was based on a sleep questionnaire. Proportional-odds ordinal logistic regression models for clustered data were used to study the relationship between pRBD and various demographic and clinical variables.

RESULTS

231 patients were evaluated for RBD in 1993 and, after 4 and 8 years, 142 and 89 patients, respectively, were available for re-evaluation. The frequency of pRBD varied from 14.6% to 27% during the study period. Probable RBD was related to male gender, higher dopaminergic treatment and less severe parkinsonism.

CONCLUSION

We found that the frequency of pRBD varied over time and that it is associated with male gender, less parkinsonism and higher levodopa equivalent dose. Our findings indicate that dopaminergic therapy may contribute to the expression of RBD and that RBD is symptomatic in earlier stages of PD.

Insomnia in Parkinson's disease: frequency and progression over time

OBJECTIVES

To examine the development of nocturnal sleeping problems in patients with Parkinson's disease (PD) over an 8-year period and to study the clinical and demographic correlates of insomnia.

METHODS

231 patients were included in a population-based prevalence study in 1993, and re-examined in 1997 and 2001. At all study visits, we applied semi-structured interviews to obtain information on clinical and demographic data, as well as on nocturnal sleeping problems. Standardised rating scales of parkinsonism, depression and cognitive impairment were used. The relationship between insomnia and demographic and clinical variables was analysed using population-averaged logistic regression models for correlated data. 231 patients were included at baseline, 142 were available for re-evaluation in 1997 and 89 patients in 2001.

RESULTS

Most nocturnal sleeping problems varied little in prevalence over time, whereas problems related to turning in bed and vivid dreaming or nightmares increased. Insomnia was present in 54-60% of the patients at each of the three study visits and varied considerably in individual patients over time. The presence of insomnia was closely related to disease duration, higher Montgomery-Asberg Depression Rating Scale scores and female sex.

CONCLUSION

Insomnia is a highly frequent complaint in patients with PD. It fluctuates over time in individual patients, and its origin seems to be multifactorial. Physicians should be aware of the high prevalence of insomnia in patients with PD and should examine their patients for a possible coexisting depression.

The effect of age of onset of PD on risk of dementia

BACKGROUND

Dementia occurs in the majority of patients with Parkinson's disease (PD). Late onset of PD has been reported to be associated with a higher risk for dementia. However, age at onset (AAO) and age at baseline assessment are often correlated. The aim of this study was to explore whether AAO of PD symptoms is a risk factor for dementia independent of the general effect of age.

METHODS

Two community-based studies of PD in New York (n=281) and Rogaland county, Norway (n=227) and two population-based groups of healthy elderly from New York (n=180) and Odense, Denmark (n=2414) were followed prospectively for 3-4 years and assessed for dementia according to DSM-IIIR. All PD and control cases underwent neurological examination and were followed with neurological and neuropsychological assessments. We used Cox proportional hazards regression based on three different time scales to explore the effect of AAO of PD on risk of dementia, adjusting for age at baseline and other demographic and clinical variables.

FINDINGS

In both PD groups and in the pooled analyses, there was a significant effect of age at baseline assessment on the time to develop dementia, but there was no effect of AAO independent of age itself. Consistent with these results, there was no increased relative effect of age on the time to develop dementia in PD cases compared with controls.

INTERPRETATION

This study shows that it is the general effect of age, rather than AAO that is associated with incident dementia in subjects with PD.

Patient information and coping styles in multiple sclerosis

Background Patients with multiple sclerose (MS) live with their disease for many years. The cause of the disease is unknown and there are no curative therapies. Patients' adaption to chronic disease is dependent on the effectiveness of coping behaviour.

Objectives To explore the correlation between the quality of perceived disease information and to estimate the correspondance between the quality of perceived disease information and later coping styles applied by MS-patients in stress situations related to their disease.

Methods Of a total of 108 patients recently diagnosed with MS, 93 agreed to participate in the study and 86 of these completed two different questionnaires, one assessing quality of the perceived information and the other asessing coping styles (the COPE scale).

Results 43.2% of the patients were dissatisfied or very dissatisfied with the information by the time of diagnosis. MS-related coping styles were influenced by general coping styles and the most frequently employed strategies were `positive reinterpretation and growth', `planning' and `restraint coping' while `denial' was the most infrequently employed strategy. Patients who were satisfied with the information employed avoidance coping to a lesser extent and more actively both plan and seek information about the situation.

Conclusion Optimizing the information process in the early phase of the disease may induce coping styles that produce a better adaption to living with MS. Multiple Sclerosis 2007; 13: 792-799. http:// msj.sagepub.com

Differences in neuropathologic characteristics across the Lewy body dementia spectrum

BACKGROUND

The objective of this comparative neuropathologic study was to determine the extent to which dementia with Lewy bodies (DLB) and Parkinson disease dementia (PDD) are distinct entities or part of a continuum with respect to the duration of parkinsonism.

METHODS

We evaluated the relationship between cortical alpha-synuclein pathology, plaques (Consortium to Establish a Registry for Alzheimer's Disease [CERAD]), tangles (Braak staging), and cholinergic deficits (choline acetyltransferase in temporal cortex) in 57 prospectively assessed patients (29 DLB, 28 PDD), confirmed at autopsy. The PDD group was divided according to the median duration of parkinsonism prior to dementia.

RESULTS

There was an association between longer duration of parkinsonism prior to dementia and less severe cortical alpha-synuclein pathology (chi(2) 10.4, df 2, p = 0.006) and lower CERAD plaque scores (chi(2) 26.6, df 9, p = 0.002), but not Braak staging. These findings were confirmed in a further correlation analysis, which also identified an unexpected correlation between more pronounced cortical cholinergic deficits and longer duration of parkinsonism prior to dementia (R = -0.37, p = 0.04).

CONCLUSION

While there is a clear relationship between the duration of Parkinson disease prior to the onset of dementia and key neuropathologic and neurochemical characteristics, there is a gradation of these differences across the dementia with Lewy bodies/Parkinson disease dementia spectrum and the findings do not support an arbitrary cut-off between the two disorders.

Review of the therapeutic management of Parkinson's disease. Report of a joint task force of the European Federation of Neurological Societies and the Movement Disorder Society-European Section. Part I: early (uncomplicated) Parkinson's disease

The aim of the study was to provide evidence-based recommendations for the management of early (uncomplicated) Parkinson's disease (PD), based on a review of the literature. Uncomplicated PD refers to patients suffering from the classical motor syndrome of PD only, without treatment-induced motor complications and without neuropsychiatric or autonomic problems. MEDLINE, Cochrane Library and International Network of Agencies for Health Technology Assessment (INAHTA) database literature searches were conducted. National guidelines were requested from all European Federation of Neurological Societies (EFNS) societies. Non-European guidelines were searched for using MEDLINE. Part I of the guidelines deals with prevention of disease progression, symptomatic treatment of motor features (parkinsonism), and prevention of motor and neuropsychiatric complications of therapy. For each topic, a list of therapeutic interventions is provided, including classification of evidence. Following this, recommendations for management are given, alongside ratings of efficacy. Classifications of evidence and ratings of efficacy are made according to EFNS guidance. In cases where there is insufficient scientific evidence, a consensus statement (good practice point) is made.

Review of the therapeutic management of Parkinson's disease. Report of a joint task force of the European Federation of Neurological Societies (EFNS) and the Movement Disorder Society-European Section (MDS-ES). Part II: late (complicated) Parkinson's disease

To provide evidence-based recommendations for the management of late (complicated) Parkinson's disease (PD), based on a review of the literature. Complicated PD refers to patients suffering from the classical motor syndrome of PD along with other motor or non-motor complications, either disease-related (e.g. freezing) or treatment-related (e.g. dyskinesias or hallucinations). MEDLINE, Cochrane Library and INAHTA database literature searches were conducted. National guidelines were requested from all EFNS societies. Non-European guidelines were searched for using MEDLINE. Part II of the guidelines deals with treatment of motor and neuropsychiatric complications and autonomic disturbances. For each topic, a list of therapeutic interventions is provided, including classification of evidence. Following this, recommendations for management are given, alongside ratings of efficacy. Classifications of evidence and ratings of efficacy are made according to EFNS guidance. In cases where there is insufficient scientific evidence, a consensus statement ('good practice point') is made.

Excessive daytime sleepiness in Parkinson disease: is it the drugs or the disease?

OBJECTIVE

To examine associated demographic and clinical correlates and the development of excessive daytime sleepiness (EDS) over 8 years in a community-based cohort of patients with Parkinson disease (PD).

METHODS

A total of 232 patients with PD were included in a population-based prevalence study in 1993. Patients were followed prospectively and reexamined after 4 and 8 years. At all study visits, the authors administered semistructured interviews to obtain information on clinical and demographic variables. Standardized rating scales of parkinsonism, depression, and cognitive impairment were used. The diagnosis of EDS was based on a sleep questionnaire and in 2001 also on the Epworth Sleepiness Scale. Population-averaged logistic regression models for correlated data were performed to study the relationship between EDS and various demographic and clinical variables.

RESULTS

Of the 232 patients included at baseline, 138 were available for re-evaluation after 4 years and 89 patients after 8 years. Frequency rates of EDS increased from 5.6% in 1993 to 22.5% in 1997 and 40.8% in 2001, with an 8-year prevalence of 54.2%. In the majority of patients, EDS was a persistent feature. In the logistic regression model, EDS was related to age, gender, and use of dopamine agonists. In those never having used dopamine agonists, hypersomnia was associated with the Hoehn and Yahr stage only.

CONCLUSION

Excessive daytime sleepiness is a frequent and highly persistent feature in Parkinson disease, with multifactorial underlying pathophysiology. The authors' findings indicate that both age and disease related disturbances of the sleep-wake regulation contribute to hypersomnia in PD. Treatment with dopamine agonists also contributed to excessive daytime sleepiness in our patients.

Drug costs for patients with Parkinson's disease in two different European countries

OBJECTIVE

To examine factors that influence drug costs in patients with Parkinson's disease (PD) and to compare the costs in two different countries.

METHODS

We examined drug costs among 438 patients with PD (286 from Germany and 152 from Norway) and collected information on the patients' age, medication, disease duration, and Hoehn & Yahr stage.

RESULTS

Drug expenses rose with increasing severity and duration of the disease. This increase differed somewhat between the two countries. Mean drug costs per day and patient in the German group was Euro 5.78 while it was Euro 3.92 in the Norwegian group. A higher proportion of the German patients were treated with two or more drugs, and the switch from mono- to multi-drug therapy was done earlier in the course of the disease. Dopamine agonists caused 44% of total drug costs in both countries.

CONCLUSION

Different management strategies of PD have a great impact on drug costs. Surveillance of prescription habits and careful cost/benefit analyses are therefore important.

Parkin gene variations in late-onset Parkinson's disease: comparison between Norwegian and German cohorts

OBJECTIVES

Mutations in the Parkin gene can cause autosomal recessive early-onset Parkinson's disease (PD). Recently, Parkin mutations were also suggested to play a role in the commoner late-onset forms of PD.

METHODS

We compared a German cohort of PD patients (95) with a Norwegian cohort of PD patients (96). Both cohorts have predominant late-onset form of PD. Mutation and polymorphism frequencies were compared via single-strand conformation polymorphism and sequence analyses.

RESULTS

Three heterozygous missense mutations (Arg256Cys, Arg402Cys and Thr240Met) were found in late-onset PD patients in the German patient cohort (1.6%). A missense mutation (Arg402Cys) was also found in one of 149 healthy control subjects (0.3%). Only one heterozygous missense mutation (Arg256Cys) was identified in a Norwegian patient suffering from late-onset PD (0.5%). The frequencies of four known single nucleotide polymorphisms significantly differ between the two distant European populations.

CONCLUSION

The results support the hypothesis that heterozygous mutations in the Parkin gene may act as susceptibility alleles for late-onset forms of PD in rare cases.

Neuropsychiatric symptoms in patients with multiple sclerosis

OBJECTIVE

To explore the range of psychiatric symptoms in patients with multiple sclerosis (MS) and their association with neurological disability.

METHOD

Patients diagnosed with MS during 1998-2000 in Rogaland and Hordaland counties, western Norway, were included. Psychiatric symptoms were assessed by the Neuropsychiatric Inventory (NPI). Patients with systemic lupus erythematosus (SLE) served as controls.

RESULTS

Eighty-six of 93 eligible MS patients were included, and 80% showed at least one psychiatric symptom. The most frequent symptoms were depression (59%), sleep disturbance (48%), irritability/emotional lability (42%), and apathy (31%). Depression was associated with higher disability score. MS patients showed significantly higher NPI irritability score (P = 0.002), appetite disturbance score (P < 0.001), and apathy score (P = 0.01) than SLE patients.

CONCLUSION

Neuropsychiatric symptoms occur frequently in patients with MS. Irritability and apathy are independent of disability and chronic disease and represent unique disease manifestations.

The influence of cerebrovascular risk factors on incident dementia in patients with Parkinson's disease

OBJECTIVE

To examine if risk factors for cerebrovascular disease would increase the risk for dementia in patients with Parkinson's disease (PD).

METHODS

Non-demented patients were recruited from an epidemiological study of PD in the county of Rogaland, Norway. PD and dementia were diagnosed according to strict diagnostic criteria. Established cerebrovascular risk factors were recorded at baseline, and their influence on incident dementia was assessed 4 years later using logistic regression analysis.

RESULTS

A total of 171 non-demented PD patients constituted the at-risk population. Seventy-two (55%) had at least one cerebrovascular risk factor. A total of 130 subjects (96% of survivors) completed the follow-up examination. Forty-three (33%) new cases of dementia were found. Twenty-five of the 72 (35%) patients with and 18 of the 58 (31%) subjects without any risk factor developed dementia (ns). A significant association with dementia was found for a diagnosis of heart failure in the univariate analyses. However, in the logistic regression analysis none of the cerebrovascular risk factors were significantly associated with incident dementia.

CONCLUSIONS

In this large and representative cohort of patients with PD cerebrovascular risk factors were not associated with incident dementia, indicating that the disease-related degenerative brain changes are the main causes of dementia in PD.

Neuropsychiatric disturbances in Parkinson's disease clusters in five groups with different prevalence of dementia

OBJECTIVE

To investigate the inter-relationship of neuropsychiatric disturbances in Parkinson's disease (PD) by cluster analysis and describe the properties of the clusters.

METHOD

A total of 139 patients were assessed using the neuropsychiatric inventory (NPI). A cluster-analysis was used to investigate the inter-relationship of NPI items. The clusters were profiled regarding dementia (PDD) and major depression.

RESULTS

A total of 39 patients showed no neuropsychiatric symptoms. The remaining 100 patients (43% PDD) were divided in to five clusters. The largest group (42, 31% PDD) showed symptoms of mild depression, followed by a group (29, 79.3% PDD) with hallucinations and mild other symptoms. The third group (14, 7.1% PDD) had sleep disturbances exclusively. The fourth group (8, 25% PDD) showed apathy, anxiety and depression. The smallest group (7, 57.1% PDD) had high scores on several NPI items.

CONCLUSION

Our PD sample can be divided in to clusters based on the NPI, with different prevalence of dementia and depression.

IL-10 promoter haplotype influence on interferon treatment response in multiple sclerosis

The level of interleukin-10 (IL-10) expression is related to polymorphisms -1082 (G/A), -819 (T/C) and -592 (A/C) in the promoter region of the IL-10 gene, which constitute three haplotypes, GCC, ATA, and ACC. The ATA (a non-GCC) haplotype, which is associated with low IL-10 expression, has been shown to improve interferon (IFN) treatment response in hepatitis C. We analysed the distribution of IL-10 promoter haplotype combinations to determine whether they could influence initial IFN treatment response in 63 patients with relapsing-remitting multiple sclerosis (MS). The patients were grouped into non-GCC or GCC haplotypes, and the clinical and magnetic resonance imaging (MRI) disease activity was compared in the two groups. During the first 6 months of treatment, MS patients with non-GCC haplotypes experienced fewer new MRI T1-contrast enhancing lesions [0.77+/-0.36 (SEM)] than patients with the GCC haplotype (2.45+/-0.57) (P=0.05, Mann-Whitney U test). No differences were detected on clinical disease activity. The results suggest an influence of IL-10 promoter polymorphisms on IFN treatment response in MS.

Is fatigue an independent and persistent symptom in patients with Parkinson disease?

OBJECTIVE

To evaluate if mental fatigue is a symptom that appears independently from other clinical features in patients with Parkinson disease (PD), and to study if fatigue is persistent over time in these patients.

METHODS

In 1993, 233 patients with PD were included in a community-based study of fatigue and followed prospectively over 8 years. Fatigue was measured by a combination of a seven-point scale and parts of the Nottingham Health Profile (NHP) at baseline and after 4 and 8 years. In addition, the Fatigue Severity Scale (FSS) was used to evaluate fatigue in 2001. Population-averaged logistic regression models for correlated data were performed to study the relationship between fatigue and various demographic and clinical variables.

RESULTS

In patients who were followed throughout the 8-year study period, fatigue increased from 35.7% in 1993 to 42.9% in 1997 and 55.7% in 2001. Fatigue was related to disease progression, depression, and excessive daytime sleepiness (EDS). However, the prevalence of fatigue in patients without depression and EDS remained high and increased from 32.1% to 38.9% during the study period. For about 44% of the patients with fatigue the presence of this symptom varied during the study period, as it was persistent in 56% of the patients with fatigue.

CONCLUSIONS

The authors confirmed the high prevalence of mental fatigue in patients with Parkinson disease (PD). Fatigue is related to other non-motor features such as depression and excessive daytime sleepiness, but cannot be explained by this comorbidity alone. In more than half of the patients mental fatigue is persistent and seems to be an independent symptom that develops parallel to the progressive neurodegenerative disorder of PD.

Cognitive, psychiatric and motor response to galantamine in Parkinson's disease with dementia

BACKGROUND

Cholinesterase inhibitors with additional nicotinic activity, such as galantamine, may be useful in PD patients with dementia (PDD) since stimulation of nicotinic receptors may prevent the down-regulation that is likely to accompany cholinesterase inhibition and facilitate dopamine release in the striatum.

METHODS

Sixteen PDD patients (six female) with onset of cognitive impairment after at least one year with parkinsonism participated in this open-label trial of galantamine. Cognitive, psychiatric, and motor symptoms were assessed before and after 8 weeks of treatment with galantamine using unstructured clinical assessment as well as rating scales including the Mini-Mental State Examination (MMSE), clock drawing test, verbal fluency and selected items from the Neuropsychiatric Inventory (NPI).

RESULTS

Age (mean, SD) was 75.6 (5.2) years, duration of PD 13.4 (5.9), duration of dementia 2.1 (1.7) years, Hoehn and Yahr score was 3.8 (0.8) and baseline MMSE score was 17.7 (6.7). Side-effects caused discontinuation in three patients, but were rare and mild in the remaining 13. Improvement of global mental symptoms was noted in eight patients, whereas worsening was reported in four. Hallucinations improved in seven of the nine patients with hallucinations before treatment. Parkinsonism improved in six patients, but a mild worsening of tremor was noted in three. Clock-drawing improved (p=0.016), and trends towards improvement on MMSE (p=0.09) and verbal fluency (p=0.16) were found.

CONCLUSIONS

Although controlled trials are needed, the findings suggest that galantamine is useful in patients with PDD.

Performance on the dementia rating scale in Parkinson's disease with dementia and dementia with Lewy bodies: comparison with progressive supranuclear palsy and Alzheimer's disease

BACKGROUND

The relation between dementia with Lewy bodies (DLB) and Parkinson's disease with dementia (PDD) is unknown.

OBJECTIVES

To compare the cognitive profiles of patients with DLB and PDD, and compare those with the performance of patients with a subcortical dementia (progressive supranuclear palsy) and a cortical dementia (Alzheimer's disease).

DESIGN

Survey of cognitive features.

SETTING

General community in Rogaland county, Norway, and a university dementia and movement disorder research centre in the USA.

PATIENTS

60 patients with DLB, 35 with PDD, 49 with progressive supranuclear palsy, and 29 with Alzheimer's disease, diagnosed by either standardised clinical procedures and criteria (all PDD and Alzheimer cases and 76% of cases of progressive supranuclear palsy), or necropsy (all DLB cases and 24% of cases of progressive supranuclear palsy). Level of dementia severity was matched using the total score on the dementia rating scale adjusted for age and education.

MAIN OUTCOME MEASURES

Dementia rating scale subscores corrected for age.

RESULTS

No significant differences between the dementia rating scale subscores in the PDD and DLB groups were found in the severely demented patients; in patients with mild to moderate dementia the conceptualisation subscore was higher in PDD than in DLB (p = 0.03). Compared with Alzheimer's disease, PDD and DLB had higher memory subscores (p < 0.001) but lower initiation and perseveration (p = 0.008 and p=0.021) and construction subscores (p = 0.009 and p = 0.001). DLB patients had a lower conceptualisation subscore (p = 0.004). Compared with progressive supranuclear palsy, PDD and DLB patients had lower memory subscores (p < 0.001).

CONCLUSIONS

The cognitive profiles of patients with DLB and PDD were similar, but they differed from those of patients with Alzheimer's disease and progressive supranuclear palsy. The cognitive pattern in DLB and PDD probably reflects the superimposition of subcortical deficits upon deficits typically associated with Alzheimer's disease.

The tolerability and efficacy of entacapone over 3 years in patients with Parkinson's disease

The long-term safety and efficacy of the catechol-O-methyltransferase (COMT) inhibitor entacapone was investigated in a 3-year open-label extension of the 6-month double-blind placebo-controlled Nordic (NOMECOMT) study. After a wash-out following this study, 132 patients with Parkinson's disease (PD) experiencing motor fluctuations treated with levodopa/dopa decarboxylase (DDC) inhibitor received additional therapy with entacapone 200 mg, administered with each dose of levodopa. The most common adverse events (AEs) were insomnia (30%), dizziness (20%), nausea (20%), aggravated parkinsonism (17%) and hallucinations (14%). Only 19 (14%) patients discontinued because of AEs. Most dopaminergic AEs occurred shortly after initiation of entacapone, and these could be managed by levodopa down-adjustment. The mean duration of benefit of a single dose of levodopa increased significantly from 2.1 to 2.8 h (P < 0.01) at 3 months and remained prolonged for the whole study. At the end of the study, the mean daily dose of levodopa was significantly decreased from baseline (from 737 to 696 mg; P < 0.05). The patients' global assessment indicated that 69% of patients improved when given entacapone and this proportion was maintained until the end of the study (64%). There was a significant worsening of disability upon withdrawal of entacapone. In conclusion, entacapone given in combination with levodopa, has a good long-term safety profile and a sustained beneficial effect in patients with PD with motor fluctuations.

Familial Parkinson's disease: a community-based study

Genetic factors seem to be important in the pathogenesis of Parkinson's disease (PD). It is however, still controversial whether these factors also are reflected in a familial aggregation of PD. The aim of this study was to investigate the frequency of PD patients with a positive PD family history compared with two control groups. The included 245 PD patients were examined by neurologists and information was obtained through a semi-structured interview. The patients and the control groups were examined for the frequency of PD and dementia in their families. The 245 patients with PD were included in this study. A positive PD-family history could be obtained in 53 (21.6%) patients. The frequency was three- and four-fold increased as compared with the control groups (P < 0.001). Age at onset of disease was not different among patients with and without PD in the family. The frequency of dementia did not differ in the family of individuals with and without PD (P > 0.1). As a conclusion our study of PD in a community based population supports previous reports of a three- to fourfold increased risk for PD in the families of patients with the disease. Our results indicate that the familial aggregation of the disease is independent of the age of the proband.

The influence of fatigue on health-related quality of life in patients with Parkinson's disease

OBJECTIVE

To examine the correlation between fatigue and health-related quality of life (HRQL) in patients with Parkinson's disease (PD).

PATIENTS AND METHODS

Sixty-six patients with idiopathic PD. The patients did not have a depressive mood disorder or cognitive impairment. Fatigue was measured by the Fatigue Severity Scale (FSS). HRQL was measured by the Parkinson's Disease Questionnaire (PDQ-39) and the Short-Form 36 (SF-36).

RESULTS

Thirty-three (50%) of the patients had significant fatigue. Patients with fatigue had a more advanced disease than those without fatigue, measured by the UPDRS scale, including a higher Hoehn and Yahr stage and lower Schwab and England score. Patients with fatigue reported more distress in the dimensions of emotional well-being and mobility (PDQ-39) and also had a significantly higher PDQ summary index. On the SF-36 patients with fatigue reported more problems in the areas of physical functioning, role limitation (physical), social functioning and vitality. Correlations between the FSS and the HRQL scales were highest for the summary index of PDQ-39 and in the dimensions of ADL, mobility and emotional well-being (PDQ-39) and physical functioning, role limitation (physical), social functioning, general health and vitality (SF-36).

CONCLUSIONS

PD has a substantial negative impact on HRQL. We found a strong correlation between fatigue and high distress scores on HRQL scales in a population of patients with PD who were not depressed or demented. The diversity of symptoms and high prevalence of non-motor features, including fatigue, is important to take into account in our efforts to optimize treatment and care for this patient group.

Measuring fatigue in patients with Parkinson's disease - the Fatigue Severity Scale

The objective was to compare the prevalence and severity of fatigue in patients with Parkinson's disease (PD) with that in two control groups, one consisting of randomly chosen control subjects of the same age and sex distribution and the other consisting of patients with coxarthrosis waiting to receive total hip replacement. We also explored the possible correlation of demographic and clinical data to the presence and severity of fatigue. Sixty-six patients with PD, 131 randomly chosen controls and 79 patients with coxarthrosis, waiting to receive total hip replacement, were evaluated for fatigue. Patients and controls with a depressive mood disorder or cognitive impairment had been excluded from the study. Fatigue was measured by the Fatigue Severity Scale (FSS). For the patients with PD the mean total FSS score was 4.1, compared with 2.7 amongst the randomly chosen control group and 2.9 in the group consisting of patients with coxarthrosis. Fifty per cent of the patients with PD had a mean total FSS score of 4 or higher, compared with 25% in both of the two control groups. There was no correlation between pain, presence of self-reported nocturnal sleep disorders or duration of PD and fatigue. The patients with fatigue did have a more advanced disease, measured both by Unified Parkinson's Disease Rating Scale score and Hoehn and Yahr stage. Although the univariate analyses indicated that more severe parkinsonism was correlated to the symptom, the multivariate analysis showed that none of the studied variables were significant explanatory factors for fatigue. Fatigue is a common symptom in patients with PD without depression or dementia. The study indicates that fatigue is an independent symptom of the disease without relation to other motor or non-motor symptoms.

Donepezil for cognitive impairment in Parkinson's disease: a randomised controlled study

OBJECTIVE

To study the safety and efficacy of the cholinesterase inhibitor donepezil in patients with Parkinson's disease (PD) and cognitive impairment.

METHODS

This was a double blind, randomised and placebo controlled, crossover study in which 14 patients with PD and cognitive impairment received donepezil (5 or 10 mg per day) or matching placebo during two sequential periods lasting 10 weeks each. The primary outcome measures were the mini mental state examination (MMSE) score, the clinician's interview based impression of change plus caregiver input (CIBIC+) score, and the motor subscale of the unified Parkinson's disease rating scale (UPDRS).

RESULTS

Two patients on donepezil (14%) dropped out after one and four weeks of the first treatment period because of peripheral cholinergic side effects, otherwise the adverse effects were few and not severe. Carryover or residual effects were not observed. Parkinsonism did not increase during donepezil treatment. After 10 weeks of treatment, the mean MMSE score was increased by 2.1(SD 2.7) points on donepezil and 0.3 (SD 3.2) points on placebo, and the CIBIC+ score was 3.3 (SD 0.9) on donepezil and 4.1 (SD 0.8) on placebo. Statistical analysis of the repeated measurements and crossover study design showed significant effects of donepezil compared with placebo for MMSE (p=0.013) and CIBIC+ (p=0.034). Five (42%) patients on donepezil and two (17%) on placebo were rated as improved on the basis of the CIBIC+ score.

CONCLUSIONS

Donepezil improves cognition, and seems to be well tolerated and not to worsen parkinsonism in patients with cognitive impairment.

Development of daytime somnolence over time in Parkinson's disease

The authors examined the development over time of excessive daytime sleepiness (EDS) in patients with PD by evaluating EDS among 142 patients in 1993 and 4 years later. Eleven patients were diagnosed with EDS in 1993. In all of these patients, EDS persisted 4 years later. During follow-up, 30 new patients had EDS (6% new patients per year). In 1997, 29% of the patients with PD had EDS. The development of EDS correlated with more advanced disease and dementia.

Comparison of extrapyramidal signs in dementia with Lewy bodies and Parkinson's disease

Extrapyramidal signs (EPS) were compared in 98 dementia with Lewy bodies (DLB) and 130 medication-responsive Parkinson's disease (PD) patients. DLB patients were older at assessment and at disease onset, were cognitively more impaired, and had a shorter duration of disease than PD patients. Sixty-seven DLB patients (68%) showed EPS. The 58 DLB patients with complete data had more severe action tremor, body bradykinesia, difficulty arising from a chair, and facial expression, gait, and rigidity symptoms than PD patients (all P<0.001). Abnormal posture and tremor at rest did not differ. Severity of EPS correlated with age, duration of disease, and cognitive impairment in PD patients but not in DLB patients. Studies of the clinical significance and management of EPS in DLB patients are needed.

Sleep disorders in patients with Parkinson's disease: epidemiology and management

Patients with Parkinson's disease can experience a number of sleep disorders, including insomnia, parasomnias and daytime somnolence [specifically, excessive daytime sleepiness (EDS) and sleep attacks]. Insomnia is a frequent and important complaint of patients with the disease. Both the pathology of Parkinson's disease and dopaminergic drugs may contribute to the much higher than expected frequency of sleep fragmentation and disrupted sleep among these patients. In addition, coexisting depression seems to be a major and frequent risk factor for insomnia in Parkinson's disease. After recognising a sleep problem, the first step in management is to examine and diagnose the type of insomnia and possible medical or psychological factors that may disturb nocturnal sleep. The next step is to give the patient appropriate advice on sleep hygiene. Increasing the dosage of dopaminergic drug treatment will often increase sleep disruption and should be avoided unless the patient's sleep is primarily disturbed by the motor manifestations of parkinsonism during the night. Depression should be looked for and if appropriate be treated in any patients with insomnia. If it becomes necessary to treat the patient with an hypnosedative agent, it is important to use a drug with a short half-life and that manifests as few adverse effects as possible the next morning. Up-to-date guidelines for the use of hypnosedatives should be followed. Patients with Parkinson's disease experience a wide range of parasomnias. The majority of behaviours may be related to rapid eye movement (REM) sleep behaviour disorder (RBD) or to a spectrum of symptoms ranging from vivid dreaming to psychosis. RBD is effectively treated with clonazepam. In addition, the atypical antipsychotics have given physicians new and better treatment options for psychotic symptoms in individuals with Parkinson's disease. EDS is common in Parkinson's disease, while sleep attacks seem to be rare manifestations of the disease or its treatment. Significant EDS is found in 15% of patients with Parkinson's disease compared with in 1% of healthy elderly people. Sleep attacks are observed in patients treated with all dopaminergic medications but have recently been brought to prominence because of their association with the newer dopamine agonists ropinirole and pramipexole. Patients with Parkinson's disease should be informed about the possibility of developing sleep problems during the day when prescribed new drugs. Appropriate actions with regard to driving must be taken if significant and persistent daytime somnolence or sleep attacks appear.

Neuropsychiatric symptoms of patients with progressive supranuclear palsy and Parkinson's disease

Neuropsychiatric symptoms are common in basal ganglia disorders and may have severe clinical consequences. The authors compared the neuropsychiatric manifestations of patients with Parkinson's disease (PD) and progressive supranuclear palsy (PSP). All 103 PD patients and 27 of the 61 PSP patients were taking dopaminergic agents. PSP patients showed significantly more apathy and disinhibition. Patients with PD had higher frequency of hallucinations, delusions, and depression. These results suggest that PSP patients show symptoms compatible with lesioned orbitofrontal and medial frontal circuits, such as disinhibition and apathy, whereas PD patients show symptoms associated with monoaminergic disturbances, such as psychosis and depression.

A comparative study of psychiatric symptoms in dementia with Lewy bodies and Parkinson's disease with and without dementia

OBJECTIVES

To compare the frequency and clinical correlates of neuropsychiatric symptoms in patients with Parkinson's disease (PD) with and without dementia and in those with dementia with Lewy bodies (DLB).

METHODS

Neuropsychiatric symptoms during the month prior to assessment were assessed in clinically diagnosed PD patients with dementia (PDD; n = 48) and without dementia (PDND; n = 83) and in 98 DLB patients (33% autopsy confirmed) using standardized instruments.

RESULTS

Delusions and hallucinations were significantly more common in DLB (57% and 76%) than PDD (29% and 54%) and PDND (7% and 14%) patients (p < 0.001). In all groups, auditory and visual hallucinations and paranoid and phantom boarder delusions were the most common psychotic symptoms. Frequency of major depression and less than major depression did not differ significantly between the three groups. Clinical correlates of hallucinations in PD were dementia (odds ratio (OR) = 3.9; 95% confidence interval (CI) 1.5-10.4) and Hoehn-Yahr stage 3 or more (OR 3.4; 95% CI 1.0-12.0), whereas no significant clinical correlates of hallucinations were found in DLB patients.

CONCLUSIONS

Delusions and hallucinations occur with increasing frequency in PDND, PDD and DLB patients, but the presentation of these symptoms is similar. These findings support the hypothesis that psychiatric symptoms are associated with cortical Lewy bodies or cholinergic deficits in the two disorders.