Rating scales for cognition in Huntington's disease: Critique and recommendations

Cognitive impairment is one of the main features of Huntington's disease and is present across the disease spectrum. As part of the International Parkinson's Disease and Movement Disorder Society-sponsored project to review all clinical rating scales used in Huntington's disease, a systematic review of the literature was performed to identify cognitive scales used in Huntington's disease and make recommendations for their use. A total of 17 cognitive scales were identified and evaluated. None of the scales met criteria for a "recommended" status. For assessing severity of cognitive dysfunction, the Montreal Cognitive Assessment was "recommended with caveats." The UHDRS Cognitive Assessment, the UHDRS-For Advanced Patients cognitive section, the Alzheimer's Disease Assessment Scale-Cognitive Subscale, the Frontal Assessment Battery, the Mattis Dementia Rating Scale, the Mini-Mental State Examination, and the Repeatable Battery for the Assessment of Neuropsychological Status were "suggested" for evaluating severity of cognitive impairment. The MoCA was "suggested" as a screening tool for cognitive impairment. The major challenge in the assessment of cognition in Huntington's disease is the lack of a formal definition of dementia and/or mild cognitive impairment in this disease. The committee concluded that there is a need to further validate currently available cognitive scales in Huntington's disease, but that it is premature to recommend the development of new scales. Recently developed Huntington's disease-specific scales, such as the Huntington's Disease-Cognitive Assessment Battery, hold promise but require the completion of more comprehensive clinimetric development. © 2017 International Parkinson and Movement Disorder Society.

A randomized, double-blind, placebo-controlled trial of coenzyme Q10 in Huntington disease

OBJECTIVE

To test the hypothesis that chronic treatment of early-stage Huntington disease (HD) with high-dose coenzyme Q10 (CoQ) will slow the progressive functional decline of HD.

METHODS

We performed a multicenter randomized, double-blind, placebo-controlled trial. Patients with early-stage HD (n = 609) were enrolled at 48 sites in the United States, Canada, and Australia from 2008 to 2012. Patients were randomized to receive either CoQ 2,400 mg/d or matching placebo, then followed for 60 months. The primary outcome variable was the change from baseline to month 60 in Total Functional Capacity score (for patients who survived) combined with time to death (for patients who died) analyzed using a joint-rank analysis approach.

RESULTS

An interim analysis for futility revealed a conditional power of <5% for the primary analysis, prompting premature conclusion in July 2014. No statistically significant differences were seen between treatment groups for the primary or secondary outcome measures. CoQ was generally safe and well-tolerated throughout the study.

CONCLUSIONS

These data do not justify use of CoQ as a treatment to slow functional decline in HD.

CLINICALTRIALSGOV IDENTIFIER

NCT00608881.

CLASSIFICATION OF EVIDENCE

This article provides Class I evidence that CoQ does not slow the progressive functional decline of patients with HD.

Optimal Cutoff Scores for Alzheimer's Disease Using the Chinese Version of Mini-Mental State Examination Among Chinese Population Living in Rural Areas

To explore the optimal cutoff score for initial detection of Alzheimer's Disease (AD) through the Chinese version of Mini-Mental State Examination (CMMSE) in rural areas in China, we conducted a cross-sectional study within the Linxian General Population Nutritional Follow-up study. 16,488 eligible cohort members participated in the survey and 881 completed the CMMSE. Among 881 participants, the median age (Interquartile range) was 69.00 (10.00), 634 (71.92%) were female, 657 (74.57%) were illiterate, 35 (3.97%) had 6 years of education or higher, and 295 (33.48%) were diagnosed with AD. By reducing the CMMSE criteria for illiterate to 16 points, primary school to 19 points, and middle school or higher to 23 points, the efficiency of Chinese version of Mini-Mental State Examination can be significantly improved for initial detection of AD in rural areas in China, especially in those nutrition deficient areas.

Neurocognitive clinical outcome assessments for inborn errors of metabolism and other rare conditions

Well-defined and reliable clinical outcome assessments are essential for determining whether a drug provides clinically meaningful treatment benefit for patients. In 2015, FDA convened a workshop, "Assessing Neurocognitive Outcomes in Inborn Errors of Metabolism." Topics covered included special challenges of clinical studies of inborn errors of metabolism (IEMs) and other rare diseases; complexities of identifying treatment effects in the context of the dynamic processes of child development and disease progression; and the importance of natural history studies. Clinicians, parents/caregivers, and participants from industry, academia, and government discussed factors to consider when developing measures to assess treatment outcomes, as well as tools and methods that may contribute to standardizing measures. Many issues examined are relevant to the broader field of rare diseases in addition to specifics of IEMs.

Safety and tolerability of high-dosage coenzyme Q10 in Huntington's disease and healthy subjects

Coenzyme Q10 (CoQ(10)), a potential neuroprotective compound, was previously investigated at a dosage of 600 mg/day in Huntington's disease (HD) patients and demonstrated a trend toward slowing disease progression. Higher CoQ(10) dosages may prove beneficial. We investigated the tolerability and blood levels associated with 1,200, 2,400, and 3,600 mg/day of CoQ(10) in HD and healthy subjects. Twenty-eight subjects (20 HD, 8 healthy) enrolled in a 20-week open-label trial. Subjects started on 1,200 mg/day of CoQ(10), increasing every 4 weeks by 1,200 mg to a maximum dosage of 3,600 mg/day. Monthly evaluations included review of adverse events and CoQ(10) blood levels. Twenty-three subjects (82%) achieved the target dosage of 3,600 mg/day. Six subjects (2 healthy, 4 HD) withdrew prematurely (gastrointestinal (GI) symptoms in 3, worsening HD in 2, and 1 because of a fall). All three serious adverse events occurred in a single subject, and were deemed unrelated to CoQ(10). The most common adverse events seen were GI symptoms. Mean (± SD) CoQ10 blood levels achieved over the course of the trial were as follows: 1.26 ± 1.27 μg/mL (baseline, n = 28), 5.59 ± 2.24 μg/mL (1,200 mg/day, week 4, n = 26), 6.38 ± 3.25 μg/mL (2,400 mg/day, week 8, n = 25), 7.49 ± 4.09 μg/mL (3,600 mg/day, week 12, n = 23), and 6.78 ± 3.36 μg/mL (3,600 mg/day, week 20, n = 20). CoQ(10) was well tolerated with over 80% of subjects achieving the target dosage. Dosages of 2,400 mg/day may provide the best balance between tolerability and blood level achieved. Further studies examining the efficacy of 2,400 mg/day are planned.

Prevalence of dementia in rural China: impact of age, gender and education

OBJECTIVE

To determine the prevalence of dementia and Alzheimer's disease (AD) in rural China.

METHODS

A cross-sectional study was conducted within a cohort of adults older than 50 years of age in Linxian County, China. A Chinese version of the Mini-Mental State Examination (CMMSE) was used to screen cases of possible dementia. Three different cutoff points on CMMSE were applied depending on the participant's level of education. The participants then were given psychiatric interviews, medical and neurological examinations, and psychometric tests to ascertain the clinical diagnoses of dementia and AD.

RESULTS

Among the 16,095 participants, 5.26% were screened positive with 374 diagnosed as having dementia. Among them, AD accounted for 80.5%. The adjusted prevalence rates were 0.33%, 0.89%, 3.43%, and 8.19% in people in age groups 50-54, 55-64, 65-74, and 75 and above, respectively. The prevalence of AD correlated with the participant's level of education, and was 2.61%, 0.94%, and 0.56% in the illiterate group, in the primary school group, and in the middle school or higher group, respectively. Adjusted by education levels a higher prevalence in women was observed in the illiterate group.

CONCLUSIONS

The prevalence of dementia in this population is similar to that reported from other areas in mainland China and Taiwan with aging being a significant risk factor. After controlling for age, being a female and having received less number of years of education were associated with an higher prevalence of AD.

Dietary factors and smoking as risk factors for PD in a rural population in China: a nested case-control study

BACKGROUND

Dietary factors and history of smoking remain elusive in the pathogenesis of Parkinson's disease (PD).

OBJECTIVE

We investigated the association of environmental factors with PD in a rural population in China.

METHODS

Subjects were participants of a past nutritional intervention trial. Information on their characteristics was collected during the baseline interview of the trial. Control subjects were randomly selected from the same cohort and frequency matched for sex, age and residential area.

RESULTS AND CONCLUSION

Among 16,488 subjects surveyed, we diagnosed 464 subjects with PD. Then, four sex- and age-matched controls were paired with each definite PD case. A total of 85 cases and 340 controls were analyzed. Meat consumption and the body mass index (BMI) were inversely associated with PD. The PD risk declined with the increment of BMI. A history of gastric ulcer was associated with an increased risk of PD. As to smoking, there seemed an increased risk of PD among individuals who smoked regularly, non-significantly. However, a significantly increased risk of PD was found among those who smoked more than 30 pack-years.

Creatine in Huntington disease is safe, tolerable, bioavailable in brain and reduces serum 8OH2'dG

In a randomized, double-blind, placebo-controlled study in 64 subjects with Huntington disease (HD), 8 g/day of creatine administered for 16 weeks was well tolerated and safe. Serum and brain creatine concentrations increased in the creatine-treated group and returned to baseline after washout. Serum 8-hydroxy-2'-deoxyguanosine (8OH2'dG) levels, an indicator of oxidative injury to DNA, were markedly elevated in HD and reduced by creatine treatment.

Patient selection and assessment recommendations for deep brain stimulation in Tourette syndrome

In response to recent publicity regarding the potential use of deep brain stimulation (DBS) for reducing tic severity in Tourette's syndrome (TS), the Tourette Syndrome Association convened a group of TS and DBS experts to develop recommendations to guide the early use and potential clinical trials of DBS for TS and other tic disorders. The goals of these recommendations are to ensure that all surgical candidates are (1) fully informed about the risks, benefits, and alternative treatments available; (2) receive a comprehensive evaluation before surgery to ensure that DBS is clearly the appropriate clinical treatment choice; and (3) that early clinical experience will be documented publicly to facilitate rational decision-making for both clinical care and future clinical trials.

The prevalence of PD in a nutritionally deficient rural population in China

OBJECTIVES

In most reports, the prevalence of PD in mainland China is lower than in western populations. To estimate PD prevalence in China, we performed a cross-sectional study in a rural population in Linxian County, China.

PRIMARY OUTCOMES

Clinical diagnosis of PD.

RESULTS

Among the 16,488 participants examined, the overall age- and gender-adjusted prevalence rate of PD was 522/100,000 (95% CI: 477-567) assuming no cases of PD would be found among those younger than 50 years of age. The gender-adjusted prevalence rates were 103 (95% CI: 83-123), 621 (95% CI: 572-670), 902 (95% CI: 843-961), and 1744 (95% CI: 1662-1826) per 100,000 in age groups 50-59, 60-69, 70-79, and 80 and above, respectively.

CONCLUSIONS

The estimated prevalence of PD in Linxian, China is higher than most of those reported from other areas in China, and similar to those reported from non-Asian populations.

Predicting verbal memory decline following anterior temporal lobectomy (ATL)

OBJECTIVE

To develop a multivariate risk factor model for predicting postoperative verbal memory decline in an individual patient following dominant or nondominant anterior temporal lobectomy (ATL).

METHODS

The authors studied 132 consecutive ATL patients who 1). were older than 16 years at surgery, 2). had estimated preoperative Full Scale IQ score of >69, 3) had unilateral language dominance based on the intracarotid amobarbital procedure (IAP), and 4) underwent neuropsychological testing at baseline and >or=6 months postoperatively (mean 1.2 years). Five potential risk factors for postoperative verbal memory decline were selected a priori that reflect the functional adequacy of the to-be-resected temporal lobe. These were 1). resection in the dominant hemisphere, 2). MRI findings other than exclusively unilateral mesial temporal sclerosis, intact preoperative 3). immediate and 4). delayed verbal memory function, and 5). intact IAP memory performance following injection contralateral to the seizure focus. Verbal memory decline was defined using two verbal memory tests and published reliable change indices.

RESULTS

Thirty-eight percent of the sample declined reliably on one or both verbal memory measures. Logistic regression analysis demonstrated that all five risk factors were significantly and independently associated with outcome, with side of surgery having the strongest association (p < 0.0001) and preoperative immediate verbal memory the weakest (p < 0.05).

CONCLUSIONS

An individual patient's risk for postoperative verbal memory decline following dominant or nondominant ATL can be predicted using clinical data routinely available preoperatively (side of surgery, qualitative MRI, baseline memory testing, IAP performance). This information may be useful for preoperative patient counseling.

Relationship between blood pressure and Alzheimer's disease in Linxian County, China

To investigate the relationship between hypertension and Alzheimer's disease(AD) and the change of Alzheimer's patients' blood pressure(BP) before and after the onset of AD, we conducted this epidemiological study. Subjects for this study were individuals who participated in a large scale, randomized controlled trial of nutritional intervention from 1984 to 1991. Participants were initially screened for dementia using Chinese Mini-Mental State Examination (CMMS) and Activities of Daily Living (ADL). Positive subjects were subsequently administered a detailed neuropsychological and neurobehavioral examination. The diagnosis of AD was made by a consensus conference of psychiatrists using Diagnostic And Statistical Manual Of Mental Disorders-Fourth Edition(DSM-IV) criteria. 16488 subjects were examined and 301 were diagnosed as AD. We compared the prevalence of AD in different populations that were stratified with 1984's systolic or diastolic blood pressure(those four stratifications being high blood pressure, borderline blood pressure, normal, low blood pressure), and compared the change of blood pressure of 301 AD patients between 1984 and 1999-2000, which is before and after the onset of AD respectively. Multiple Logistic Regression (1:1 nested case-control study) was used to assess if hypertension is an independent risk factor for AD, and Trend test was used to assess the relationship between blood pressure and AD. Here we demonstrate that there was a significant difference in AD prevalence among different populations stratified by systolic or diastolic blood pressure (P < 0.01). The prevalence is highest in hypertension group, and lowest in hypotension group. Multiple Logistic Regression identified high blood pressure as a risk factor for AD (OR = 1.97, 95%CI:1.09-3.54, P = 0.02). Trend test showed that there is a significant dose-response relationship between blood pressure and AD (P < 0.0002). For hypertensive AD patients, there was no significant difference in systolic blood pressure(SBP) before and after the onset of AD, but diastolic blood pressure(DBP) decreased dramatically after the onset of AD (P < 0.01); however, the result also showed that DBP decrease occurred in the non-demented group. Based on this, we think the DBP decrease is not related to AD. We further investigated whether BP values differed crossed-sectionally between the AD-patients and non-demented individuals. We found that regardless of SBP or DBP, the BP values of the AD group were all significantly higher than that of non-demented. In summary, these data suggest there is a strong relationship between hypertension and AD; however, the mechanism remains to be studied.

Clinical markers of early disease in persons near onset of Huntington's disease

OBJECTIVE

There is increasing evidence that neuron loss precedes the phenotypic expression of Huntington's disease (HD). As genes for late-onset neurodegenerative diseases are identified, the need for accurate assessment of phenoconversion (i.e., the transition from health to the disease phenotype) will be important.

METHODS

Prospective longitudinal evaluation using the Unified Huntington's Disease Rating Scale (UHDRS) was conducted by Huntington Study Group members from 36 sites. There were 260 persons considered "at risk" for HD who initially did not have manifest disease and had at least one subsequent evaluation. Repeat UHDRS data, obtained an average of 2 years later, showed that 70 persons were given a diagnosis of definite HD based on the quantified neurologic examination.

RESULTS

Baseline cognitive performances were consistently worse for the at-risk group who demonstrated conversion to a definitive diagnosis compared with those who did not. Longitudinal change scores showed that the at-risk group who did not demonstrate manifest disease during the follow-up study period demonstrated improvements in all cognitive tests, whereas performances in the at-risk group demonstrating conversion to disease during the study declined across cognitive domains.

CONCLUSIONS

Neuropsychological measures show impairment 2 years before the development of more manifest motor disease. Findings suggest that these brief cognitive measures administered over time may capture early striatal neural loss in HD.

A controlled trial of remacemide hydrochloride in Huntington's disease

We conducted a randomized, double-blind, placebo-controlled tolerability study of a N-methyl-D-aspartate (NMDA) glutamate receptor ion-channel blocker, remacemide hydrochloride, in 31 independently ambulatory patients (18 men, 13 women) with Huntington's disease (HD). Subjects were randomized to receive either placebo or active remacemide at dosages of 200 mg/day or 600 mg/day. The primary outcome measure was the proportion of subjects able to complete the study with the assigned treatment. Remacemide was generally well tolerated, and no significant differences between the treatment arms were found in the primary outcome measure. A trend toward improvement in chorea was observed among subjects administered remacemide 200 mg/day. Based on the tolerability and safety demonstrated during this short-term trial, remacemide warrants more extended controlled investigation in patients with HD.

Assessment of coenzyme Q10 tolerability in Huntington's disease

We performed a 6-month open-label trial to evaluate the tolerability and efficacy of coenzyme Q10 (CoQ) in 10 patients with Huntington's disease (HD). Subjects were evaluated at baseline, 3 months, and 6 months using the HD Rating Scale (HDRS), the HD Functional Capacity Scale (HDFCS), and standardized neuropsychological measures. Adverse events (AEs) were assessed by telephone interview every month. CoQ doses ranged from 600 to 1,200 mg per day. All subjects completed the study, although four subjects reported mild AEs, including headache, heartburn, fatigue, and increased involuntary movements. There was no significant effect of the treatment on the clinical ratings. The good tolerability of CoQ suggests that it is a good candidate for evaluation in long-term clinical trials designed to slow the progression of HD.

A controlled trial of deprenyl in children with Tourette's syndrome and attention deficit hyperactivity disorder

We conducted a double-blind placebo-controlled crossover study to assess the efficacy of deprenyl for attention deficit hyperactivity disorder (ADHD) in children and adolescents with comorbid Tourette's syndrome (TS). Twenty-four subjects (21 boys, 3 girls; mean age 12 years) were enrolled at two sites (University of Rochester and Baylor College of Medicine). The design included two 8-week treatment periods separated by a 6-week washout period. The primary outcome measures for ADHD and tic severity were total scores on the DuPaul Attention Deficit Hyperactivity Scale (DADHS) and the Yale Global Tic Severity Scale (YGTSS). Fifteen subjects completed the study. The primary analysis revealed no statistically significant beneficial effect of deprenyl on the DADHS (mean improvement 1.3; 95% CI, -2.7 to 5.3; p = 0.50). Further post-hoc analyses revealed, however, that the effect of deprenyl in the first period was substantial (p = 0.02). There was a marginally statistically significant beneficial effect of deprenyl on the YGTSS total score (p = 0.06). Deprenyl may improve both ADHD and tics in children with TS and warrants further study.

Functional decline in Huntington's disease

We prospectively evaluated 129 patients with manifest Huntington's disease (HD) to determine the rate of illness progression and the clinical features that correlate with functional decline. A single examiner evaluated each patient using the HD Functional Capacity Scale. Standardized motor performance was also assessed in 94 of the patients (73%) using the HD Rating Scale. Total Functional Capacity declined at a rate of 0.63 +/- 0.75 U per year. As functional capacity worsened, chorea lessened, and dystonia intensified. There was no correlation between rate of functional decline and age at onset of HD, body weight, gender of affected parent, or history of neuroleptic use.

The effect of deprenyl and tocopherol on cognitive performance in early untreated Parkinson's disease. Parkinson Study Group

We conducted prospective cognitive assessments over 14 +/- 6 (mean +/- SD) months of observation as part of the multicenter trial Deprenyl and Tocopherol Antioxidative Therapy of Parkinsonism (DATATOP), which involved 800 patients with early untreated Parkinson's disease. We administered tests that measured memory, visuospatial, and frontal lobe functions. Subjects were randomly assigned to receive placebo, deprenyl (10 mg/d), tocopherol (2,000 IU/d), or both deprenyl and tocopherol. We analyzed treatment effects using annualized rates of cognitive change. We performed exploratory analyses to identify potential clinical and demographic correlates of cognitive performance. There was no significant effect of either deprenyl or tocopherol on cognitive test performance. In early untreated Parkinson's disease, cognitive performance appears to be stable and unrelated to either motor deterioration or treatment with deprenyl or tocopherol.

Preliminary examination of the comorbidity of anxiety and depression in Parkinson's disease

Significant anxiety in combination with depression may represent a specific depressive subtype in Parkinson's disease (PD). To ascertain the prevalence of this symptom complex, we administered a self-report survey and standardized psychological tests that measure anxiety and depression to 164 PD patients and 150 age-matched healthy spouse control subjects. The reporting of depression in combination with panic/anxiety best differentiated the two populations (38% vs. 8%). Depression and anxiety were highly correlated in relationship to clinical features of PD. Our findings suggest that clinically significant levels of depression and anxiety may frequently coexist in PD. The specific neuropathology of PD may predispose to this pattern of behavioral disturbance.

Segregation and linkage analyses of Tourette's syndrome and related disorders

Segregation and linkage analyses were performed with data from a large Tourette's syndrome (TS) multigenerational kindred. Results of segregation analyses were remarkably similar to some reported earlier and suggest that the mode of transmission is consistent with autosomal dominant inheritance. The analyses were done using three diagnostic schemes to specify affected family members (TS only; TS or chronic tics [CT]; and TS, CT or obsessive compulsive disorder [OCD]). The estimates of penetrance for the genotypes AA, Aa and aa (A denotes the susceptibility allele) in the analyses including relatives with TS, CT or OCD were 0.99, 0.99 and 0.00, respectively, for males and 0.70, 0.70 and 0.00 for females. Pairwise linkage analyses with 140 marker loci failed to identify a linked marker. However, approximately 30 percent of the genome was excluded as the site of the hypothesized locus for TS.

Transient tic disorder and the spectrum of Tourette's syndrome

Transient tic disorder (TTD) has not generally been considered part of the spectrum of Tourette's syndrome (TS). We studied a large kindred affected by TS and identified two family members with TTD who are very likely obligate carriers of the TS gene. Our observations indicate that TTD is a possible expression of the TS gene and that individuals with TTD may transmit TS to their offspring.

Drug-induced alzheimerism

A 74-year-old man with parkinsonism developed progressive cognitive and behavioral dysfunction suggesting coexistent Alzheimer's disease. The intellectual and behavioral disturbances were reversed following withdrawal of his anticholinergic antiparkinsonian medication. This case demonstrates that anticholinergic drugs used to treat parkinsonism may mimic or exacerbate the clinical signs of Alzheimer's disease and suggests that these medications should be withdrawn for all parkinsonian patients who develop significant impairments of cognition or behavior.

Hemoglobin Summer Hill beta 52(D3) Asp leads to His a new variant from Sydney, Australia

Hemoglobin Summer Hill was found in a Lebanese woman living in Sydney, New South Wales, Australia. Its structure was shown to be beta 52(D3) Asp leads to His. It is a stable hemoglobin which has no significant change in oxygen affinity or heme-cooperativity.