Bradyphrenia and Tachyphrenia in Idiopathic Parkinsonism Appear, in Part, Iatrogenic: An Observational Study with Systematic Review Background

We question whether bradyphrenia, slowing of cognitive processing not explained by depression or a global cognitive assessment, is a nosological entity in idiopathic parkinsonism (IP). The time taken to break contact of an index finger with a touch-sensitive plate was measured, with and without a warning in the alerting signal as to which side the imperative would indicate, in 77 people diagnosed with IP and in 124 people without an IP diagnosis. The ability to utilise a warning, measured by the difference between loge-transformed reaction times (unwarned minus warned), was termed 'cognitive efficiency'. It was approximately normally distributed. A questionnaire on self- and partner perception of proband's bradyphrenia was applied. A multivariable model showed that those prescribed levodopa were less cognitively efficient (mean -5.2 (CI -9.5, -1.0)% per 300 mg/day, p = 0.02), but those prescribed the anti-muscarinic trihexyphenidyl were more efficient (14.7 (0.2, 31.3)% per 4 mg/day, p < 0.05) and those prescribed monoamine oxidase-B inhibitor (MAOBI) tended to be more efficient (8.3 (0.0, 17.4)%, p = 0.07). The variance in efficiency was greater within IP (F-test, p = 0.01 adjusted for any demographic covariates: coefficient of variation, with and without IP, 0.68 and 0.46, respectively), but not so after adjustment for anti-parkinsonian medication (p = 0.13: coefficient of variation 0.62). The within-participant follow-up time, a median of 4.8 (interquartile range 3.1, 5.5) years (101 participants), did not influence efficiency, irrespective of IP status. Perception of bradyphrenia did not usefully predict efficiency. We conclude that both bradyphrenia and 'tachyphrenia' in IP appear to have iatrogenic components, of clinically important size, related to the dose of antiparkinsonian medication. Levodopa is the most commonly prescribed first-line medication: co-prescribing a MAOBI may circumvent its associated bradyphrenia. The previously reported greater efficiency associated with (low-dose) anti-muscarinic was confirmed.

A randomized controlled trial study on effectiveness between tadalafil versus combination mirabegron and solifenacin on treatment of ureteral stent-related symptoms

Introduction

ureteral stents have common complications like ureteral stent-related symptoms (SRSs). This study investigated the effectiveness of tadalafil compared to mirabegron and solifenacin combination therapy in patients with ureteral SRSs after double-J (DJ) stent insertion.

Methods

this double-blind, randomized clinical trial used consecutive random sampling in participants with SRSs after double-J stent insertion. The study was conducted at four different hospitals in Makassar, Indonesia, from July to December 2020. Ureteral stent-related morbidity indices which analyzed include urinary symptoms, pain, general health, quality of work, and sex scores. All of the indices were measured by ureteral symptom score questionnaire for the first, second, third, and fourth weeks after drug consumption, either tadalafil 10 mg/day (group A, n=25) and a combination of mirabegron 25 mg/day and solifenacin 5 mg/day (group B, n=28).

Results

before the treatment procedure, the groups were comparable in age, gender, body mass index, DJ stent procedures, type, and indication. In general, the score in all parameters declined over the follow-up time for both groups. Group A had a lower urinary symptom score than group B at week III and week IV (all p-value < 0.001). In addition, group A had a lower pain score, general condition, work activity, and other complaints than group B at week II, week III, and week IV (all p-value <0.001). The sexual activity score is comparable between the group, except in week I.

Conclusion

according to our results, we suggest tadalafil to minimize stent-related urinary symptoms and improve general health in patients with double J stent.

Addition of zolpidem to combination therapy with atomoxetine-oxybutynin increases sleep efficiency and the respiratory arousal threshold in obstructive sleep apnoea: A randomized trial

BACKGROUND AND OBJECTIVE

Atomoxetine combined with oxybutynin (Ato-Oxy) has recently been shown to reduce obstructive sleep apnoea (OSA) severity by >60%. However, Ato-Oxy also modestly reduced the respiratory arousal threshold, which may decrease sleep quality/efficiency. We sought to investigate the additional effect of zolpidem with Ato-Oxy on sleep efficiency (primary outcome), the arousal threshold, OSA severity, other standard polysomnography (PSG) parameters, next-day sleepiness and alertness (secondary outcomes).

METHODS

Twelve participants with OSA received 10 mg zolpidem plus Ato-Oxy (80-5 mg, respectively) or Ato-Oxy plus placebo prior to overnight in-laboratory PSG according to a double-blind, randomized, crossover design (1-week washout). Participants were fitted with an epiglottic catheter, a nasal mask and pneumotachograph to quantify arousal threshold and airflow. Next-day sleepiness and alertness were assessed via the Karolinska Sleepiness Scale and a driving simulation task.

RESULTS

The addition of zolpidem increased sleep efficiency by 9% ± 13% (80.9% ± 16.9% vs. 88.2% ± 8.2%, p = 0.037) and the respiratory arousal threshold by 17% ± 18% (-26.6 ± 14.5 vs. -33.8 ± 20.3 cm H₂ O, p = 0.004) versus Ato-Oxy + placebo. Zolpidem did not systematically change OSA severity. Combination therapy was well tolerated, and zolpidem did not worsen next-day sleepiness. However, median steering deviation during the driving simulator task increased following the zolpidem combination.

CONCLUSION

Zolpidem improves sleep efficiency via an increase in the respiratory arousal threshold to counteract potential wake-promoting properties of atomoxetine in OSA. These changes occur without altering the rate of respiratory events or overnight hypoxaemia. However, while the addition of zolpidem does not increase next-day perceived sleepiness, caution is warranted given the potential impact on next-morning objective alertness.

Advances in pharmacotherapy for the treatment of overactive bladder

Purpose of review

To present the current literature on the pharmacologic management of overactive bladder, including combination therapies, agents still in clinical development, and special considerations related to individuals with cognitive decline, frailty and cardiovascular risk.

Recent Findings

Combination therapy is shown to be more effective than monotherapy, without additional side effects. Preliminary studies on novel treatment methods, including new medications, as well was novel use of established medications, demonstrates improved efficacy with a favorable side effect profile. Investigation into new target pathways may be an area for future pharmacologic development. Special consideration should be given when prescribing anti-muscarinic medication in the frail adult population. Overactive bladder has been associated with frailty and anti-muscarinic medications have been associated with the worsening cognitive decline.

Summary

Combination therapy is a safe and effective alternative to patients with refractory overactive bladder. Caution should be taken in prescribing medications for the frail older adult, and alternative first- and third-line treatments should be considered. Future studies should involve long term data on safety and outcomes stratified by age with objective measurements of cognition and frailty.

Symptom score change and patient versus doctor satisfaction in overactive bladder before and after anti-muscarinic treatment

AIMS

To evaluate voiding symptoms and questionnaire score change before and after anti-muscarinic treatment and evaluate the correlation of agreement in patient and doctor satisfaction after treatment.

METHODS

Forty women newly diagnosed with overactive bladder (OAB), attending the urogynecology clinic at Chulalongkorn Hospital during April-June 2011 were recruited. Tolterodine 4 mg orally once daily was given for 4 weeks. A voiding diary and Thai version of the OAB questionnaires eight-item Overactive Bladder awareness tool (OAB-v8), Overactive Bladder Symptoms Score (OABSS) and Overactive Bladder QOL (OABq) were completed before and at the end of treatment. At the end of the trial, self-report patient satisfaction, and doctor satisfaction (according to symptom improvement in the voiding diary) were assessed. Student's t-test and weighted kappa coefficients were used in statistical analysis. Sample size was calculated from an OAB questionnaire pilot study with 20% addition for loss to follow up.

RESULTS

All voiding parameters and questionnaire scores (OAB-v8, OABSS and OABq) were improved after treatment. Weighted kappa was only 0.06, between doctor and patient satisfaction.

CONCLUSION

OAB-v8 and OABSS questionnaires can be used as screening and follow-up tools. There is poor agreement between patient and doctor satisfaction. Satisfaction should therefore be measured from the patient's perspective.

Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review

OBJECTIVES

to determine the effect of drugs with anti-cholinergic properties on relevant health outcomes.

DESIGN

electronic published and unpublished literature/trial registries were systematically reviewed. Studies evaluating medications with anti-cholinergic activity on cognitive function, delirium, physical function or mortality were eligible.

RESULTS

forty-six studies including 60,944 participants were included. Seventy-seven percent of included studies evaluating cognitive function (n = 33) reported a significant decline in cognitive ability with increasing anti-cholinergic load (P < 0.05). Four of five included studies reported no association with delirium and increasing anti-cholinergic drug load (P > 0.05). Five of the eight included studies reported a decline in physical function in users of anti-cholinergics (P < 0.05). Three of nine studies evaluating mortality reported that the use of drugs with anti-cholinergic properties was associated with a trend towards increased mortality, but this was not statistically significant. The methodological quality of the evidence-base ranged from poor to very good.

CONCLUSION

medicines with anti-cholinergic properties have a significant adverse effect on cognitive and physical function, but limited evidence exists for delirium or mortality outcomes.