DBS amplitude setting can improve aspects of quality of life in patients with Parkinson’s disease

The DBS STN is a non-curative treatment; its effect on the patient’s quality of life (QoL) determines the therapeutic success of this procedure. We aimed to assess whether stimulation parameters setting may influence also some of the non-motor aspects of QoL. The QoL was assessed by PDQ-39 questionnaire. The questionnaire was administered to patients before and after the DBS surgery. A sham change of stimulation amplitude was performed before the actual increase. After the further amplitude increase in subgroup of patients (mean increase of amplitude of 0.35 V), there was a statistically significant additional improvement of total PDQ-39 score by another 22.9 %. In this group the emotions, stigma and communication subscales improved after the stimulation increase, without further change of UPDRS III. We were able to demonstrate that the increase of stimulation parameters (amplitude) has a potential to improve some non-motor functions and aspects of QoL and thus has an additional effect on quality of life in certain subset of PD patients. The meticulous observation of QoL should be a routine part of assessments before and after the DBS STN surgery, and can even aid during the parameter setting.     

A comprehensive model of health-related quality of life in Parkinson’s disease

BACKGROUND : Insight in how impairments and disabilities related to Parkinson's disease (PD) influence health-related quality of life (HRQoL) is required to review adequacy of current management strategies. METHODS : The Scales for Outcomes in Parkinson's disease (SCOPA) evaluation was used to assess impairments and disabilities. HRQoL was assessed with the EuroQol-5D Visual Analogue Scale. 378 patients with PD who participated in the SCOPA/PROPARK cohort were assessed while on their usual treatment. Multiple linear regression analysis and structural equation modelling were used to construct a model of factors that influence HRQoL. RESULTS : A model with good fit was constructed that identified various impairments and disabilities as important contributors to HRQoL in PD. Of the disabilities, psychosocial well-being had a larger impact on HRQoL than physical functioning. Of the impairments, depression had the largest contribution to HRQoL, followed by axial motor symptoms, gastrointestinal symptoms, and urinary symptoms. In addition, pain, psychiatric and motor complications, and daytime sleepiness had small but significant influences on HRQoL. CONCLUSION : Multiple factors, including disabilities, nonmotor symptoms and axial motor symptoms, affect HRQoL in patients with PD. In patients who are on symptomatic treatment aiming to alleviate mainly motor symptoms, there is a large impact on HRQoL of nonmotor and nondopaminergic symptoms. Research is warranted to develop and evaluate management strategies for the aspects that currently impact on HRQoL as psychosocial well-being, depressive symptoms, axial motor symptoms, gastrointestinal symptoms, and urinary symptoms. These findings call for a multidisciplinary approach in the care of these features.     

Psychiatric aspects of Parkinson’s disease

Abstract. In patients with Parkinsons disease (PD) disturbances of mental state constitute some of the most difficult treatment challenges of advanced disease, often limiting effective treatment of motor symptoms and leading to increased disability and poor quality of life. This article provides an update on the current knowledge of these complications and the use of old and new drugs in their management. Mental state alterations in PD include depression, anxiety, cognitive impairment, apathy, and treatment-related psychiatric symptoms. The latter range from vivid dreams and hallucinations to delusions, manic symptoms, hypersexuality, dopamine dysregulation syndrome and delirium. While some of these symptoms may be alleviated by anti-parkinsonian medication, especially if they are off-period related, treatment-related phenomena are usually exacerbated by increasing the number or dosage of antiparkinsonian drugs. Elimination of exacerbating factors and simplification of drug regimes are the first and most important steps in improvement of such symptoms. However, the advent of atypical antipsychotics such as clozapine has dramatically helped the management of treatment-related psychiatric complications in PD. In patients with dementia associated with PD cognitive functioning and behavioural problems appear to respond to cholinesterase inhibitors, such as rivastigmine or donepezil. Depression is a common problem in early as well as advanced PD, and selective serotonin reuptake inhibitors, reboxetine, and tricyclic antidepressants have been reported to be effective and well tolerated antidepressants. Randomised, controlled studies are required to assess the differential efficacy and tolerability of antidepressants in patients with PD, including the newer antidepressants with serotonergic and noradrenergic properties.     

Only physical aspects of quality of life are significantly improved by bilateral subthalamic stimulation in Parkinson’s disease

Background The well known global improvement of quality of life (QoL) after bilateral high frequency chronic deep brain stimulation of the subthalamic nucleus (STN DBS) in Parkinsons disease (PD) is in contrast to behavioral disturbances as observed after surgery. Indeed the impact of DBS on physical versus mental aspects of QoL in PD remains unknown. Objective To assess the influence of bilateral STN DBS on physical versus mental aspects of QoL in Parkinsons disease. Methods The results of 27 patients for the Unified Parkinsons disease Rating Scale (UPDRS), Parkinsons Disease Questionnaire 39 (PDQ39) and Short Form 36 health survey questionnaire (SF36) were compared before surgery and after 12 months of bilateral STN DBS. Results Comparing off–dopa conditions before versus 12 months after surgery, both UPDRS part II and part III significantly improved: 32.6% and 52%, respectively. UPDRS part I scores did not change significantly at 12 months. As for PDQ39, the global score significantly improved after surgery (21.1 %) as did four subscores: mobility (25.6 %), activity of daily living (34.5 %), stigma (40.1 %) and bodily discomfort (30 %). Three PDQ39 subscores, however, showed no significant changes: emotional well–being (10.7 %), social support (3.2%) and cognition (8.5 %) and one item even worsened: communication (–7.7 %). In SF36, only physical items significantly improved. Conclusion Using clinicians based rating scale, bilateral STN DBS showed significant improvement in PD patients at 12 month follow up. However, using patients self–assessment scales, the clinical benefit of STN DBS was more subtle: physical items of QoL significantly improved, whereas mental items such as emotional well–being, social support, cognition and communication showed no improvement. Our results are suggestive of a dissociation of motor and non–motor symptoms control after bilateral STN DBS in PD patients.     

Pallidotomy does not ameliorate abnormal intracortical inhibition in Parkinson’s disease

Motor cortex excitability was assessed in 12 patients with Parkinson’s disease (PD) using transcranial magnetic stimulation. Patients were studied when mobile and medicated (“ON”) and when immobile after medication withdrawal (“OFF”). Results were compared to eight age-matched and 11 young controls. Cortical excitability was assessed by measurement of resting motor threshold (RMT), intracortical inhibition and cortical silent period duration. In five patients, the studies included assessments following pallidotomy. Cortical excitability was abnormal in patients with PD with reduced RMT in “ON” and “OFF” states, and less effective intracortical inhibition. Pallidotomy did not affect cortical excitability in either “ON” or “OFF” states, indicating that enhanced motor cortex excitability in patients with PD is unaffected by pallidotomy despite clinical improvement in motor scores.     

Dance classes improve self-esteem and quality of life in persons with Parkinson’s disease

Journal of Neurology - Dance can reduce motor symptoms in persons with Parkinson’s disease (PD). However, the effect on psychosocial wellbeing, including self-esteem and quality of life is...     

The relationship between repetitive finger movement and quality of life in Parkinson’s disease

Background: Repetitive finger movement significantly impacts daily living activities, but there have been limited studies determining how repetitive finger movement impacts quality of life (QOL) in persons with Parkinson’s disease (PD). The purpose of this study was to determine the relationship between impairment in repetitive finger movement and QOL in persons with PD.

Methods: Eighty-four participants with PD completed a repetitive movement task and the Parkinson’s Disease Questionnaire (PDQ). Structural equation modeling was used to determine the relationship between repetitive finger movement outcome measures of amplitude and movement rate difference and the domains of the PDQ.

Results: Including all repetitive finger outcome measures with demographic variables produced the strongest model for predicting QOL.

Discussion: Repetitive finger movement is associated with QOL, but more research is needed to better understand the relationship between repetitive finger movement variables and each specific QOL domain.     

Quality of life and gender identity in Parkinson’s disease

Summary. We examined the correlation between gender identity (perception of masculinity or femininity) and quality of life (QoL) of 124 Parkinson’s disease (PD) patients without dementia (69 men, 55 women, mean age 65.8 ± 10.2 years, mean disease duration 8.5 ± 5.8 years, mean Hoehn and Yahr [H&Y] stage 2.7 ± 0.8). All patients underwent clinical examinations and completed the PDQ-39 and the quality of sexual life questionnaire. Their masculine or feminine stereotypes were determined by the Bem Sex Role Inventory (BSRI) modified by Dior. QoL was significantly correlated with disease duration (r = 0.262, p<0.01), H&Y staging (r = 0.330, p<0.001) and disease severity (UPDRS) (r = 0.432, p<0.001). The QoL of androgynous men and women (i.e., with strong feminine and masculine characteristics) was significantly (p<0.05) better than the other gender groups. A significant interaction was found between the sexes to gender identity (p<0.05). Conclusion: Androgynous PD patients cope better with their disease in terms of QoL parameters, especially androgynous women.     

Real life evaluation of safinamide effectiveness in Parkinson’s disease

In this retrospective study, we evaluated both efficacy and effectiveness of safinamide 50 and 100 mg in the treatment of motor fluctuations and disabling dyskinesias in a cohort of patients with idiopathic Parkinson’s disease (PD). Ninety-one PD patients were evaluated during the first year of commercialization of the drug, both prior to starting safinamide and at the last available follow-up. Evaluations were based on the Unified Parkinson’s Disease Scale part III (UPDRS III), Hoehn & Yahr (HY), Unified Dyskinesia Rating Scale (UDysRS) walking and balance item 9 score, daily time spent in OFF and in ON with disabling dyskinesias (1 week diary), mean daily dose of levodopa (LD), dopamine-agonists (DA), catechol-O-methyl transferase inhibitor (COMT-I), monoamine oxidase B inhibitor (MAOB-I), and their LD equivalent dose (LEDD). Eight patients withdrew safinamide within the first month for minor side effects. At the follow-up evaluation, after a mean time with safinamide of 7.5 months?±?3.4, all patients showed a significant improvement of all the scale scores, except for HY, and of the daily dosages of the drugs and the LEDD. The same results were shown by PD patients treated with safinamide 50 mg and patients who started safinamide without switching from a previous MAOBI. PD patients with safinamide 100 mg and patients who started safinamide switching from a previous MAOBI significantly improved in time spent in OFF and LEDD. In conclusion, safinamide is safe and effective in improving motor complications in patients with idiopathic PD and can be considered a useful levodopa sparing strategy.     

Effect of impulse control disorders on disability and quality of life in Parkinson’s disease patients

Impulse control and related disorders (ICRD) are not uncommon in patients with idiopathic Parkinson’s disease (PD). The present study aimed to investigate the effects of ICRD on quality of life (QoL) and disability in PD. From two movement disorder clinics in Sydney, Australia, 100 consecutive patients with PD were included in the trial. The Unified Parkinson’s Disease Rating Scale (UPDRS), Mini Mental State Examination and the Parkinson’s Disease Questionnaire-39 were used to measure disease severity, cognition and disease-specific QoL. The diagnosis of ICRD was based on face-to-face structured clinical interviews by three psychiatrists with experience in ICRD using the Expanded Structured Clinical Interview for the Diagnostic and Statistical Manual IV for Obsessive-Compulsive Disorder Related/Spectrum Disorders. ICRD were present in 15% of our patient population, and had a negative impact on QoL and Activity of Daily Living (ADL) scores. After adjusting for the presence of major depressive disorders and PD duration, the effect on emotional wellbeing remained statistically significant (p < 0.004). Disease duration also correlated with worse QoL and ADL scores. Major depression disorders reduced QoL but not ADL. Patients with ICRD tended to suffer more from depression than those without ICRD. There were no statistically significant differences in age, sex, major depressive disorders, PD duration, total levodopa equivalent daily dose, use of dopamine agonists, or UPDRS motor score between patients with and without ICDR.     

The impact of sleep and mood disorders on quality of life in Parkinson’s disease patients

Sleep disturbances are common and often severe in patients with Parkinson’s disease (PD) and their symptoms can be present at any time of day. The purpose of our study was to examine how excessive daytime sleepiness or poor nocturnal sleep quality and mood disorders influence the quality of life (QoL) in PD patients. Ninety-three PD patients from eastern Slovakia were recruited (49.5% males, mean age 68.0 ± 9.5 years, mean disease duration 6.1 ± 5.9 years). Sleep disturbances were measured using the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI); QoL with the Parkinson’s Disease Quality of Life Questionnaire (PDQ-39); depression and anxiety with the Hospital Anxiety and Depression Scale (HADS) and disease severity with the Unified Parkinson’s Disease Rating Scale (UPDRS). χ ² test, bivariate correlations and multiple linear regressions were performed. PSQI and ESS had significant correlations with worse QoL (p < 0.01, p < 0.05, respectively). HADS-D (p < 0.01), HADS-A (p < 0.01), UPDRS (p < 0.01) and disease duration (p < 0.05) were also significantly related to worse QoL. In the linear regression analysis, however, only PSQI (p < 0.01), anxiety (p < 0.001) and UPDRS (p < 0.001) remained significant. The model with PSQI explained 74% of the variance, and the model with ESS explained 63% of the variance in PDQ-39 when analyses were performed separately. In an overall model, however, only PSQI remained significant, accounting for 82% of the variance in PDQ-39. Nighttime poor sleep and anxiety are important contributors leading to a worse QoL. As these are treatable conditions, they should be recognized by clinicians and managed properly.     

Urological problems in Parkinson’s disease: clinical aspects

Bladder dysfunctions are quite common in Parkinson’s disease. They may occur at any stage of the illness and get worse with advancing and aggravating disease. The most prominent dysfunction is the so-called overactive bladder. Control of bladder function is part of a highly complex system subject to the interaction of predominantly the frontal and pontine micturition or continence center and the spinal cord. Besides there are some other anatomic structures involved in the complex control loop of bladder regulation. Regarding central regulation, dopamine is the essential neurotransmitter that inhibits bladder activity. All dopaminergic substances are capable of influencing automatic control systems. This also holds true for many other classes of other medications such as anticholinergics, antidepressants, and beta-blockers. The chief clinical problem of this patient consists in reduced inhibition with consequentially resulting overactivity of the detrusor muscle, meaning the urge to urinate in the absence of adequate bladder filling. The patients mostly complain of an imperative urge to urinate, of pollakisuria, nocturia and even incontinence of urine (urge incontinence). The objectives of diagnosis and therapy focus on controlled bladder evacuation and continence of urine. The most important diagnostic clues are provided by the patient’s medical history. Only in rare cases urodynamic studies are indicated as well. For treatment we can avail ourselves of a number of anticholinergic drugs. We must watch out though that the medication ordered is not going to impact on cognition.We recommend tolteradine, not passing the blood brain barrier, or M3-specific antimuscarinics such as solifenacin and darifenacin. Positive therapeutic outcomes are limited. A new alternative at hand, albeit not approved for the time being, is the local injection of botulinum toxin into the detrusor muscle.     

Diagnostic staging of Parkinson’s disease: conceptual aspects

Summary. Insidious onset of mild, unspecific, sensitive, vegetative, psychopathological, cognitive and perceptive disturbances, i.e. visual and olfactory dysfunction, with a resulting change of personal behaviour, i.e. reduced stress tolerance, precede the initially intermittendly occurring motor symptoms in patients with Parkinsons disease (PD). Novel neuropathological findings suggest an expansion pattern of the neurodegenerative process beyond the nigral dopaminergic neurons with the initial event located outside the brain. We related these clinical observations of premotor symptoms of PD to this novel neuropathological concept of emerging neurodegeneration, which starts in the enteric system and then rises via spinal cord and brainstem to nigral and subsequent cortical neurons. We describe an initial premotor phase, which starts in non dopaminergic areas, and subdivide it according to the onset of gastrointestinal and brainstem associated and sensory deficits. Then motor symptoms occur and increase in the further course of PD similar to the Hoehn and Yahr stages. Our proposed diagnostic concept aims to an earlier diagnosis of PD. In addition, attention should be given to diseases of the gastrointestinal tract and psychosomatic disorders, all of which, if not or ineffectively treated, may contribute to an enhanced vulnerability for PD. The concept takes into account, that an as far unknown pathogen, e.g. viral infection or nutritional component, that meets a genetically predisposed person with a long lasting disturbed enteric nervous system, may be at risk for PD. Earlier premotor diagnosis of PD will enable more convincing future results on the therapeutic efficacy of neuroprotective compounds.