Clozapine as a potential treatment for refractory impulsive, compulsive, and punding behaviors in Parkinson's disease.

There have been emerging cases of medication refractory obsessions, impulsivity, compulsivity, and/or punding in Parkinson's disease. These cases have proven difficult to treat, even for the experienced clinician. We report several medication refractory cases with a positive response to treatment with clozapine.

Usefulness of screening tools for predicting driving performance in people with Parkinson's disease.

OBJECTIVE: We used screening tests administered by a certified driving rehabilitation specialist and by Parkinson's disease (PD) specialty neurologists to develop a model to predict on-road outcomes for patients with PD. METHOD: We administered a battery of screening tests to 41 patients with PD and 41 age-matched control participants before on-road testing. We used statistical models to predict actual on-road performance. RESULTS: The PD group had a higher failure rate, indicating more on-road errors. For the PD participants, the Useful Field of View (UFOV) Subtest 2 and Rapid Pace Walk were responsible for most of the variance in the on-road test. The model accurately categorized pass-fail outcomes for 81% of PD patients. CONCLUSION: Clinical screening batteries may be predictive of driving performance in PD. The UFOV Subtest 2, administered in approximately 15 min, may be the single most useful clinical test for such predictions.

Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial.

OBJECTIVE: Dysphagia is the main cause of aspiration pneumonia and death in Parkinson disease (PD) with no established restorative behavioral treatment to date. Reduced swallow safety may be related to decreased elevation and excursion of the hyolaryngeal complex. Increased submental muscle force generation has been associated with expiratory muscle strength training (EMST) and subsequent increases in hyolaryngeal complex movement provide a strong rationale for its use as a dysphagia treatment. The current study's objective was to test the treatment outcome of a 4-week device-driven EMST program on swallow safety and define the physiologic mechanisms through measures of swallow timing and hyoid displacement. METHODS: This was a randomized, blinded, sham-controlled EMST trial performed at an academic center. Sixty participants with PD completed EMST, 4 weeks, 5 days per week, for 20 minutes per day, using a calibrated or sham, handheld device. Measures of swallow function including judgments of swallow safety (penetration-aspiration [PA] scale scores), swallow timing, and hyoid movement were made from videofluoroscopic images. RESULTS: No pretreatment group differences existed. The active treatment (EMST) group demonstrated improved swallow safety compared to the sham group as evidenced by improved PA scores. The EMST group demonstrated improvement of hyolaryngeal function during swallowing, findings not evident for the sham group. CONCLUSIONS: EMST may be a restorative treatment for dysphagia in those with PD. The mechanism may be explained by improved hyolaryngeal complex movement. CLASSIFICATION OF EVIDENCE: This intervention study provides Class I evidence that swallow safety as defined by PA score improved post EMST.

Useful field of view as a reliable screening measure of driving performance in people with Parkinson's disease: results of a pilot study.

PURPOSE: To determine the correlations of the Useful Field of View (UFOV), compared to other clinical tests of Parkinson's disease (PD); vision; and cognition with measures of on-road driving assessments and to quantify the UFOV's ability to indicate passing/failing an on-road test in people with PD. METHODS: Nineteen randomly selected people with idiopathic PD, mean age = 74.8 (6.1), 14 (73.7%) men, 18 (94.7%) Caucasians, were age-matched to 104 controls without PD. The controls had a mean age of 75.4 (6.4), 59 (56.7%) men, 96 (92.3%) Caucasians. Both groups were referred for a driving evaluation after institutional review board approval. RESULTS: Compared to neuropsychological and clinical tests of vision and cognition, the UFOV showed the strongest correlations (r > .75, p < 0.05) with measures of failing a standardized road test and number of driving errors. Among PD patients, the UFOV Risk Index score of 3 (range 1-5) was established as the optimal cutoff value for passing the on-road test, with sensitivity 87 percent and specificity 82 percent, AUC = 92 percent (SE 0.61, p = .002). Similarly, the UFOV 2 (divided attention) optimum cutoff value is 223 ms (range 16-500 ms), sensitivity 87.5 percent, specificity 81.8 percent, AUC = 91 percent (SE 0.73, p = .003). The UFOV 3 (selected attention) optimal cutoff value is 273 ms (range 16-500 ms), sensitivity 75 percent, specificity 72.7 percent, AUC = 87 percent (SE 0.81, p = .007). CONCLUSION: In this pilot study among PD patients, the UFOV may be a superior screening measure (compared to other measures of disease, cognition, and vision) for predicting on-road driving performance but its rigor must be verified in a larger sample of people with PD.

Development and initial validation of a screening tool for Parkinson disease surgical candidates.

As there is currently no standardized assessment tool for evaluating Parkinson disease (PD) patients for deep brain stimulation (DBS), the authors developed the Florida Surgical Questionnaire for Parkinson Disease (FLASQ-PD). Part I of the study was a retrospective analysis of 174 patients presenting for a surgical screening. Part II was a multicenter study to assess the correlation of FLASQ-PD scores. The results of this study suggest that the FLASQ-PD may be a useful triage tool for screening PD patients for DBS surgery.