Depression and anxiety related subtypes in Parkinson's disease.

BACKGROUND: Depression and anxiety are common in Parkinson's disease (PD) and although clinically important remain poorly understood and managed. To date, research has tended to treat depression and anxiety as distinct phenomena. There is growing evidence for heterogeneity in PD in the motor and cognitive domains, with implications for pathophysiology and outcome. Similar heterogeneity may exist in the domain of depression and anxiety. OBJECTIVE: To identify the main anxiety and depression related subtype(s) in PD and their associated demographic and clinical features. METHODS: A sample of 513 patients with PD received a detailed assessment of depression and anxiety related symptomatology. Latent Class Analysis (LCA) was used to identify putative depression and anxiety related subtypes. Results LCA identified four classes, two interpretable as 'anxiety related': one anxiety alone (22.0%) and the other anxiety coexisting with prominent depressive symptoms (8.6%). A third subtype (9%) showed a prominent depressive profile only without significant anxiety. The final class (60.4%) showed a low probability of prominent affective symptoms. The validity of the four classes was supported by distinct patterns of association with important demographic and clinical variables. CONCLUSION: Depression in PD may manifest in two clinical phenotypes, one 'anxious-depressed' and the other 'depressed'. However, a further large proportion of patients can have relatively isolated anxiety. Further study of these putative phenotypes may identify important differences in pathophysiology and other aetiologically important factors and focus research on developing more targeted and effective treatment.

Circadian rest-activity rhythm is altered in Parkinson's disease patients with hallucinations.

The sleep-wake cycle in Parkinson's Disease (PD) is profoundly disrupted, but less is known about circadian rhythm in PD and its relationship to other important clinical features. This study compared rest-activity rhythms in healthy older adults and PD patients with and without hallucinations. Twenty-nine older adults and 50 PD patients (27 with hallucinations, 23 without) were assessed using wrist-worn actigraphy for 5 days. Disease-related and cognitive data were also collected. PD patients demonstrated reduced amplitude of activity (F = 12.719, P < 0.01) and increased intradaily variability (F = 22.005, P < 0.001), compared to healthy older adults, independently of age, and cognitive status. Hallucinators showed lower interdaily stability (F = 7.493, P < 0.01) significantly greater activity during "night-time" (F = 6.080, P < 0.05) and significantly reduced relative amplitude of activity (F = 5.804, P < 0.05) compared to nonhallucinators, independently of clinical factors including motor fluctuations. PD patients with hallucinations display altered rest-activity rhythm characterized by an unpredictable circadian pattern across days, likely arising from damage to brainstem and hypothalamic sleep centers. Treatment of sleep and rest-activity rhythm disturbance is an important target in Parkinson's Disease.

Why do doctors choose a career in geriatric medicine?

Reforms to postgraduate training in the U.K. may affect recruitment to geriatric medicine. In 2005, a questionnaire survey was undertaken to determine the factors favouring geriatric medicine as a career choice and whether these might be used to influence recruitment. In all, 1036 responses to the questionnaire were received (response rate 56.4%); 4% of the respondents decided to specialise in geriatric medicine as students, 3.8% of consultants and 8.6% of registrars decided as pre-registration house officers while 39% of consultants and 7% of registrars chose geriatric medicine while a middle grade in another specialty. The strongest influences on choice were clinical aspects of the specialty (34.1%) and inspirational seniors (26.2%). However, 9.2% of consultants and 10.1% of registrars subsequently regretted their career decision. Geriatric medicine seems to be a career choice for doctors of increasing maturity and including more posts in foundation programmes may not improve recruitment as anticipated. Although a small number of doctors regretted choosing geriatric medicine as a career, this was rarely to do with core aspects of the specialty.

Dementia with Lewy bodies.

Dementia with Lewy bodies (DLB) is the second commonest cause of neurodegenerative dementia in older people. It is part of the range of clinical presentations that share a neuritic pathology based on abnormal aggregation of the synaptic protein alpha-synuclein. DLB has many of the clinical and pathological characteristics of the dementia that occurs during the course of Parkinson's disease. Here we review the current state of scientific knowledge on DLB. Accurate identification of patients is important because they have specific symptoms, impairments, and functional disabilities that differ from those of other common types of dementia. Severe neuroleptic sensitivity reactions are associated with significantly increased morbidity and mortality. Treatment with cholinesterase inhibitors is well tolerated by most patients and substantially improves cognitive and neuropsychiatric symptoms. Clear guidance on the management of DLB is urgently needed. Virtually unrecognised 20 years ago, DLB could within this decade be one of the most treatable neurodegenerative disorders of late life.

Direct economic impact of Parkinson's disease: a research survey in the United Kingdom.

The direct costs of care were evaluated prospectively in a sample of people with Parkinson's disease (PD) in the United Kingdom in 1998. The subjects were drawn from a random sample of general practitioner practices within a representative sample of 36 Regional Health Authorities and the equivalent. A total of 444 resource use questionnaires with usable data were returned (response rate, 59%). The total mean annual cost of care per patient for all patients by age was 5,993 pounds (9,554 euro, n = 432). Hoehn and Yahr stage significantly (P < 0.001) influenced expenditure by stage as follows: 0 and I, 2,971 pounds (4,736 euro, n = 110); II, pound 3,065 (4,886 euro, n = 89); III, 6,183 pounds (9,857 euro, n = 120); IV, 10,134 pounds (euro;16,155, n = 87); V, 18,358 pounds (29,265 euro, n = 17). National Health Service costs accounted for approximately 38% and social services for 34% of the direct costs of care. Drug expenditure accounted for 24% of overall costs in the <65 years age group and 10% in patients aged >85 years. A move from home to residential care was associated with an approximately 500% cost increase. In conclusion, PD imposes significant direct costs on public services and on individuals. These costs should be taken into account when allocating public funds.

The incidence of oral Gram-negative bacteria in patients with Parkinson's disease.

Background: Parkinson's disease is a common neurodegenerative disorder that affects an increasing number of older people every year. Dysphagia is not only a common feature, but one that results in poor nutrition and an increased risk of bronchopneumonia. Previous work has suggested that the oral flora is altered in patients with oral pathology. Methods: Fifty patients were assessed to quantify the incidence of oral Gram-negative bacteria. Results: Sixteen of the patients with Parkinson's disease were found to have six different Gram-negative bacilli in their oral cavities. The 20 different Gram-negative bacteria present were Escherichia coli (n=7), Klebsiella spp. (n=3), Kluyvera spp. (n=3), Serratia spp. (n=3), Proteus spp. (n=2) and Enterobacter spp. (n=2). We found that the oral cavity of 16 (32%) of the patients with Parkinson's disease was abnormally colonised with Gram-negative bacteria and that Gram-negative bacteria were more likely to occur in those patients in whom oromuscular dysfunction was present (88% vs. 21%; p<0.05). Conclusion: Further work is required to determine the association between oral flora and the pathogenic organisms found in aspiration pneumonia as well as work on innovative treatments to reduce oral Gram-negative bacteria in those patients at particular risk of aspiration pneumonia.

Assessing caregiving distress: a conceptual analysis and a brief scale.

OBJECTIVES: Although it is well known that informal caregiving can have negative outcomes, and is an important factor in institutionalization, there is currently no common model to assess psychological distress in caregivers. In this study, we considered the conceptualization of caregiving distress, and present a five-dimension, 17-item Caregiving Distress Scale (CDS). DESIGN: The CDS was developed by administering several scales from the caregiving literature to a sample of 80 Parkinson's disease caregivers longitudinally. METHOD: A total of 58 items from published questionnaires were reduced initially by a hierarchical cluster analysis, then by factor analysis. RESULTS: This procedure produced five distinctive subscales - relationship distress, emotional burden, care-receiver demands, social impact, and personal cost - that also had high internal reliability. CONCLUSION: The CDS is quick to administer and score, and has the potential to be used to profile an individual caregiving situation. Of critical importance for the application of findings from the caregiving literature, the scale can be used to target the type of intervention for the amelioration of caregiving distress.