Contribution of neuropsychiatric symptoms in Parkinson's disease to different domains of caregiver burden.

INTRODUCTION: Caregiver burden is high among caregivers of PD patients (CPD). Neuropsychiatric symptoms are leading contributors to CPD burden, but whether different symptoms differentially impact domains of caregiver burden is not known. Our objective was to examine which neuropsychiatric symptoms and demographic factors contribute to different domains of caregiver burden in PD. METHODS: This was a cross-sectional online survey study. Participants were recruited from the Fox Insight (FI) study and were eligible if they identified themselves as a CPD. The primary outcome was the Caregiver Burden Inventory (CBI) total score and its 5 sub-domain scores. The Neuropsychiatric Inventory Questionnaire (NPI-Q) assessed caregiver-reported neuropsychiatric symptoms in the care recipient. Multivariable linear regression models were used to characterize the associations between NPI-Q symptom severity scores and CBI scores. Covariates were caregiver age, sex, education, and caregiving duration. RESULTS: The sample consisted of 450 CPD, mean age 65.87 (SD 10.39) years, 74% females. After adjusting for covariates, CBI total score was predicted by NPI-Q total score (ß = 1.96, p < 0.001); model adjusted R2 = 39.2%. Anxiety severity had the largest effect size [standardized ß (sß) = 0.224] on the time-dependency domain, which was also associated with female sex (sß = - 0.133) and age (sß = 0.088). Severity of disinhibition (sß = 0.218), agitation (sß = 0.199), and female sex (sß = 0.104) were associated with greater emotional burden. CONCLUSION: Our findings indicate that demographic characteristics and specific neuropsychiatric symptoms contribute differentially to domains of caregiver burden. Tailored interventions to support CPD are needed.

Basic clinical features do not predict dopamine transporter binding in idiopathic REM behavior disorder.

REM sleep behavior disorder (RBD) is strongly associated with development of Parkinson's Disease and other α-synuclein-related disorders. Dopamine transporter (DAT) binding deficit predicts conversion to α-synuclein-related disorders in individuals with RBD. In turn, identifying which individuals with RBD have the highest likelihood of having abnormal DAT binding would be useful. The objective of this analysis was to examine if there are basic clinical predictors of DAT deficit in RBD. Participants referred for inclusion in the RBD cohort of the Parkinson Progression Markers Initiative were included. Assessments at the screening visit including DAT SPECT imaging, physical examination, cognitive function screen, and questionnaire-based non-motor assessment. The group with DAT binding deficit (n = 49) was compared to those without (n = 26). There were no significant differences in demographic or clinical features between the two groups. When recruiting RBD cohorts enriched for high risk of neurodegenerative disorders, our data support the need for objective biomarker assessments.

Modifiable vascular risk factors, white matter disease and cognition in early Parkinson's disease.

BACKGROUND AND PURPOSE: Dementia in Parkinson's disease (PD) is common and disabling. Identification of modifiable risk factors for it is essential. Vascular risk factors (VRFs) may be associated with cognitive decline in early PD. Biomarkers that serve as surrogates of the long-term effect of VRFs on PD are needed. To that end, we aimed to quantitate white matter hyperintensities (WMH) in early PD, measure associations with VRFs and examine relationships between WMH and longitudinal cognition. METHODS: Participants in the Parkinson's Progression Markers Initiative study (141 patients with PD, 63 healthy controls) with adequate baseline structural brain magnetic resonance imaging data were included. Hypertension and diabetes history, and body mass index were combined to create a vascular risk score. WMH were quantitated via automated methods. Cognition was assessed annually with a comprehensive test battery. RESULTS: In the PD group, vascular risk score was associated with WMH for total brain (ß = 0.210; P = 0.021), total white matter (ß = 0.214; P = 0.013), frontal (ß = 0.220; P = 0.002) and temporal (ß = 0.212; P = 0.002) regions. Annual rate of change in global cognition was greater in those with higher vascular risk score (ß = -0.040; P = 0.007) and greater WMH (ß = -0.029; P = 0.049). Higher temporal WMH burden was associated with great decline over time in verbal memory (ß = -0.034; P = 0.031). CONCLUSIONS: In early PD, modifiable VRFs are associated with WMH on brain magnetic resonance imaging. Temporal WMH burden predicts decline in verbal memory. WMH may serve as a surrogate marker for the effect of VRFs on cognitive abilities in PD.

Portable objective assessment of upper extremity motor function in Parkinson's disease.

INTRODUCTION: Objective, portable measures of motor function for out-of-office assessments are needed in Parkinson's Disease (PD). This study had 3 objectives. First, to examine change in objective motor measurements in PD (as assessed with the Objective PD Measurement (OPDM) system). Second, to correlate objective measures with clinical features and putative PD cerebrospinal fluid (CSF) and dopaminergic imaging biomarkers. Third, to assess participant compliance with and perceptions of serial in-home motor assessments. METHODS: De novo PD subjects participating in this pilot study of the Parkinson Progression Markers Initiative (PPMI) completed OPDM assessments at home weekly for 3 months and in the clinic at baseline and 3-, 6-, and 12-months. Tasks included (i)digitography (ii)a repetitive hand tapping task and (iii)timed pegboard task. A global objective motor score (OMS) was derived from the latter three. MDS-UPDRS-III score was obtained at each time point, and CSF and dopamine transporter (DAT) SPECT at baseline. RESULTS: 27 participants, mean age 62.6 years, 19 male were included. A mean of 10.5 in-home assessments were completed. There was no significant change in in-home OMS over 12 weeks (p = 0.48). There was strong correlation between mean baseline OMS and MDS-UPDRS-III scores (spearman's rho = 0.60, p=<0.0001). Baseline OMS predicted 6-month MDS-UPDRS-III (ß = 0.80, p = 0.0002) but not change in MDS-UPDRS-III score, DAT SPECT, or putative CSF biomarkers. CONCLUSIONS: This study suggests that administration of in-home motor tasks as part of a large multi-center study is feasible and scores derived from these assessments may serve as surrogates of in-person clinician-assessed motor score.

Longitudinal changes in cognition in early Parkinson's disease patients with REM sleep behavior disorder.

INTRODUCTION: Cognitive decline is common in Parkinson's disease (PD), and identifying patients at highest risk for it is essential. We aimed to examine the effect of possible REM sleep behavior disorder (pRBD) on rate of cognitive decline in early PD, for both global cognition and in specific cognitive domains. METHODS: Parkinson's Progression Markers Initiative (PPMI) is a multi-site, international study of PD patients untreated at enrollment. pRBD was assessed with the REM sleep behavior disorder questionnaire (RBDSQ). Global cognition was assessed at baseline and annually using the Montreal Cognitive Assessment (MoCA) and a cognitive battery. Linear mixed effects models were used to examine the relationship between pRBD (RBDSQ≥6) and rate of change in cognitive variables. Age, sex, years of education, and baseline motor and cognitive scores were included as covariates. RESULTS: The baseline sample consisted of 423 individuals with PD, mean age 61.7 years and 65.5% male. Data was available on 389, 366, and 196 participants at 1-year, 2-year, and 3-year follow-up respectively. Possible RBD occurred in 108 (25.5%) at baseline. In multivariate analyses, baseline RBD was associated with greater annual rate of decline in MoCA score (ß = -0.34, 95%CI -0.54, -0.13, p < 0.001), Symbol Digit Modalities Test (ß = -0.69, 95%CI -1.3, -0.09, p = 0.024), and Hopkins Verbal Learning Test-Revised, delayed free recall (ß = -0.21, 95%CI -0.41, -0.013, p = 0.037). CONCLUSIONS: Possible RBD is common in early PD and predicts future cognitive decline, particularly in attention and memory domains.

Rasagiline in Parkinson's disease.

It has long been recognized that monoamine oxidase (MAO) inhibitors have a role in the management of Parkinson's disease (PD). The MAO-B inhibitor rasagiline has neuroprotective effects in animal models, mediated partly by its antiapoptotic activity. Rasagiline has been shown to be effective as monotherapy for early PD and as an adjunct to dopaminergic therapy. Clinical trials have also shown putative disease-modifying effects, though rasagiline's potential to alter the long-term course of PD remains controversial. Given the demonstrated benefits of rasagiline, along with its safety and tolerability profile, it has an important role to play in PD therapy.

Effects of STN DBS for Parkinson's disease on restless legs syndrome and other sleep-related measures.

Restless legs syndrome (RLS) and other sleep abnormalities are common in Parkinson's Disease (PD). We prospectively examined sleep measures in PD patients undergoing subthalamic nucleus (STN) deep brain stimulation (DBS). An RLS questionnaire, Epworth Sleepiness Scale (ESS), and Parkinson's Disease Sleep Scale (PDSS) were administered through telephone interviews preoperatively and postoperatively. Seventeen patients were included. Mean preoperative and 4 weeks postoperative ESS scores were 11.6 and 6.4 respectively (p < 0.001) and PDSS scores were 94.2 and 122.9 respectively (p < 0.001). The improvement was sustained at 6 months. Six patients were diagnosed with RLS preoperatively. Mean preoperative International Restless Legs Syndrome Study Group rating scale score was 23.0. Mean 4 week and 6 month postoperative IRLSSG rating scale scores were 14.8 and 13.8 respectively, significantly improved compared to preoperative scores (p = 0.027 and p = 0.037 respectively). No patients developed new-onset RLS postoperatively. STN DBS improves daytime sleepiness, sleep quality, and RLS.

Mental health care in Lebanon: policy, plans and programmes.

Lebanon is a developing country marred by several years of civil war and continuing political, social and economic instability. It has no mental health policy or plan. Through literature reviews, surveillance of current mental health services and interviews with primary care physicians and officials at the Ministry of Public Health and World Health Organization, we identified several barriers to the optimal delivery of mental health services in Lebanon. These include government-, physician-, and patient-related factors. New initiatives are necessary at several levels, particularly in the primary care setting. These are outlined in light of the 2001 WHO recommendations on mental health services.

Mental health care in Lebanon: policy, plans and programmes

Lebanon is a developing country marred by several years of civil war and continuing political, social and economic instability. It has no mental health policy or plan. Through literature reviews, surveillance of current mental health services and interviews with primary care physicians and officials at the Ministry of Public Health and World Health Organization, we identified several barriers to the optimal delivery of mental health services in Lebanon. These include government-, physician-, and patient-related factors. New initiatives are necessary at several levels, particularly in the primary care setting. These are outlined in light of the 2001 WHO recommendations on mental health services

Palliative care needs of patients with neurologic or neurosurgical conditions.

BACKGROUND AND PURPOSE: Many patients with non-cancer diagnoses utilize palliative services. There is little data on the palliative care needs of patients with neurologic and neurosurgical disorders. METHODS: Retrospective chart review. Log sheets which contain all patients seen between January 2004 and 2007 by palliative medicine (PM) were reviewed. Patients with neurologic or neurosurgical disorders were identified and their in-patient charts and electronic records reviewed. Patients with cancer were excluded. RESULTS: A total of 1429 cancer patients were seen by PM. Neurologic or neurosurgical diseases were the second most common in patients seen by the PM service, in 177 cases. Forty-seven patients were excluded. Complete data was collected on 129 patients. Mean age was 70. Seventy-one (55%) were female. The most common neurologic diagnosis was ischemic stroke in 33 (26%). Seventy-five (58%) had symptoms recorded. Reasons for PM consultation included 'comfort measures' in 40 (39%) and 'hospice candidacy' in 38 (37%). The most common recommendation made by the PM service was morphine in 44 (42%). Sixty-three (49%) were deemed hospice appropriate. CONCLUSIONS: Our findings support the need for PM services for patients with various neurologic and neurosurgical disorders. Understanding these needs will allow for the tailoring of palliative care services to such patients.

Older adult care in Lebanon: towards stronger and sustainable reforms.

We assessed elderly care in Lebanon through direct observation and review of the literature and legislation with the aim of drawing attention to the current situation and the need for improvement, and providing suggestions to address the problems. The weaknesses of elderly care in Lebanon and obstacles to reform include the stigma of age, an inefficient health care system, a lack of geriatric specialists and social/volunteer services, and inadequacies in nursing homes. Countering the negative perception of ageing, promoting social welfare, refurbishing nursing homes and empowering volunteer services are needed to improve the lives and care of the elderly. Sustained initiatives by governmental agencies, physicians, volunteer services and the community are essential. Adequate funding is also imperative.

Older adult care in Lebanon: towards stronger and sustainable reforms

We assessed elderly care in Lebanon through direct observation and review of the literature and legislation with the aim of drawing attention to the current situation and the need for improvement, and providing suggestions to address the problems. The weaknesses of elderly care in Lebanon and obstacles to reform include the stigma of age, an inefficient health care system, a lack of geriatric specialists and social/volunteer services, and inadequacies in nursing homes. Countering the negative perception of ageing, promoting social welfare, refurbishing nursing homes and empowering volunteer services are needed to improve the lives and care of the elderly. Sustained initiatives by governmental agencies, physicians, volunteer services and the community are essential. Adequate funding is also imperative

Familial mesial temporal lobe epilepsy maps to chromosome 4q13.2-q21.3.

PURPOSE: To report results of linkage analysis in a large family with autosomal dominant (AD) familial mesial temporal lobe epilepsy (FMTLE). BACKGROUND: Although FMTLE is a heterogeneous syndrome, one important subgroup is characterized by a relatively benign course, absence of antecedent febrile seizures, and absence of hippocampal sclerosis. These patients have predominantly simple partial seizures (SPS) and infrequent complex partial seizures (CPS), and intense and frequent déjà vu phenomenon may be the only manifestation of this epilepsy syndrome. No linkage has been described in this form of FMTLE. METHODS: We identified a four-generation kindred with several affected members meeting criteria for FMTLE and enrolled 21 individuals who gave informed consent. Every individual was personally interviewed and examined; EEG and MRI studies were performed on three affected subjects. DNA was extracted from every enrolled individual. We performed a genome-wide search using an 8 cM panel and fine mapping was performed in the regions with a multipoint lod score >1. We sequenced the highest priority candidate genes. RESULTS: Inheritance was consistent with AD mode with reduced penetrance. Eleven individuals were classified as affected with FMTLE and we also identified two living asymptomatic individuals who had affected offspring. Seizure semiologies included predominantly SPS with déjà vu feeling, infrequent CPS, and rare secondarily generalized tonic-clonic seizures. No structural abnormalities, including hippocampal sclerosis, were detected on MRI performed on three individuals. Genetic analysis detected a group of markers with lod score >3 on chromosome 4q13.2-q21.3 spanning a 7 cM region. No ion channel genes are predicted to be localized within this locus. We sequenced all coding exons of sodium bicarbonate cotransporter (SLC4A) gene, which plays an important role in tissue excitability, and cyclin I (CCNI), because of its role in the cell migration and possibility of subtle cortical abnormalities. No disease-causing mutations were identified in these genes. CONCLUSION: We report identification of a genetic locus for familial mesial temporal lobe epilepsy. The identification of a disease-causing gene will contribute to our understanding of the pathogenesis of temporal lobe epilepsies.

Dementia and depression among nursing home residents in Lebanon: a pilot study.

BACKGROUND: The proportion of elderly in the Lebanese population is 7.1% and this is expected to increase to 10.2% by the year 2025. The nursing home (NH) population in Lebanon has not been studied. The aim of this study was to investigate the prevalence of dementia and depression among a portion of nursing home residents (NHR) in Lebanon and describe the characteristics of NHR afflicted with dementia and depression. METHOD: Of 200 NHR from three NH in Lebanon, 117 were selected by random sampling. Data on demographics and medical history were collected. An Arabic version of the Mini-Mental Status Examination and Geriatric Depression Scale (GDS) were administered. RESULTS: Our final sample consisted of 102 NHR. Sixty-one (59.8%) had dementia of some kind. Seventeen (27.9%) had mild dementia, 14 (22.9%) had moderate dementia, and 30 (49.2%) had severe dementia. Forty-five (57.7%) of the NHR tested had depression as measured by a GDS score of more than 10. CONCLUSIONS: Dementia and depression were present in more than half of the NHR in our sample. Our results have important implications, being the first to be collected in the Lebanese community. Screening NHR for dementia and depression on admission and at regular time intervals is a must. More studies targeting all aspects of the elderly population in Lebanon are needed.

Hyperekplexia in Kurdish families: a possible GLRA1 founder mutation.

Autosomal recessive hyperekplexia is due to loss-of-function mutations in the GLRA1 gene. The authors describe six patients from two consanguineous families with a homozygous deletion of the first seven GLRA1 exons and provide evidence of a founder effect in Kurds from Turkey. Hyperekplexia may be misdiagnosed as epilepsy.

Du rire aux larmes: pathological laughing and crying in patients with traumatic brain injury and treatment with lamotrigine.

Pathologic laughter and crying (PLC) is the involuntary occurrence of laughter and crying in the absence of a corresponding change in affect. PLC resulting from structural brain damage in patients with traumatic brain injury can be the cause of substantial social dysfunction in these patients. The use of lamotrigine as an antiepileptic drug and mood stabilizer is well established; its use in PLC has been reported only once during treatment following a stroke. We present here four young patients with pathological laughter and/or pathological crying following traumatic brain injury who were successfully treated with lamotrigine. Data supporting the use of lamotrigine in the treatment of PLC following traumatic brain injury and the neuroanatomy of pathological laughing are briefly reviewed.

The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study.

This study measured the incidence of recurrent aphthous ulcers during the use of dentifrices with and without sodium lauryl sulfate (SLS). A single-blind, crossover design was used. A statistically significant reduction in recurrent aphthous ulcers was observed during 2 months' use of SLS-free dentifrice compared to 2 months' use of the SLS-containing dentifrice. These results support the results of an earlier independent study, and suggest that use of an SLS-free dentifrice should be considered for individuals suffering from recurrent aphthous ulcers.