Swallowing Characteristics and Water Swallow Capacity in Patients with Parkinsonism.

Prevalence and characteristics of dysphagia (including aspiration) in patients with parkinsonism is variable, depending on type of assessment, diagnosis, disease stage and duration. The aim of this study was to further evaluate dysphagia characteristics in patients with different types of parkinsonism with both instrumental (Flexible Endoscopic Evaluation of Swallowing, FEES) and non-instrumental (Timed Water Swallow Test, TWST) assessments. Swallowing characteristics in 74 patients with parkinsonism were prospectively assessed using FEES and TWST. Statistics employed were (a) Spearman rank correlation to measure correlation between dysphagia results and Parkinson subtypes, disease severity and duration and (b) the non-parametric tests Mann Whitney U and Kruskal Wallis to measure difference between groups. Dysphagia was common, with 50 (67.6%) of the patients demonstrating a mild-severe Dysphagia Outcome Severity Scale (DOSS, level 1-5). During FEES, 42% aspirated and 68% of these had silent aspiration. Aspiration was seen more frequently with increased disease severity as per Hoehn and Yahr (H&Y) (r = .459, p = < 0.001) and disease duration (r = .269, p = .021). Thin liquid (IDDSI level 0) was the most common consistency to aspirate, and the frequency of aspiration decreased with thicker liquids. Dysphagia and aspiration are common in all subgroups of parkinsonism and seen in early stages of H&Y and within the first year of disease duration. Hence, it is recommended that these patients are evaluated early for optimal management and to avoid aspiration-related complications.

Gender differences in diagnostic tools, medication, time to medication, and nonmotor symptoms in Parkinsonian patients.

BACKGROUND: Swedish National Quality Registers (NQRs) play an important role in collecting large amounts of diagnosis-specific data, symptoms, and treatments. The subset of data, Parkinson's Registry, has been in use for more than 20 years and represents all counties and hospitals in Sweden where neurological care is provided. OBJECTIVE: To study the differences between genders regarding diagnostic tools, pharmacological interventions, and self-reported symptoms in patients with symptoms originating from basal ganglia disease, either idiopathic or secondary Parkinsonism (PD). METHODS: PD-diagnosed patients from a mix of urban and rural locations were chosen from the NQR and sorted by gender. Self-reported, first-experienced PD-related symptoms defined the debut point of PD. RESULTS: In all, data from 1,217 patients were analyzed: 502 (41%) females/715 (59%) males. A total of 493 imaging investigations were performed, where of 239 (48% females/52% males) had a CT scan performed, 120 (24% females/29% males) had a dopamine transporter scans, and 134 (23% females/26% males) had a magnetic resonance imaging performed (Fisher's exact test, P = 0.19). The average time in years from symptom onset to start of first treatment, and from first to second added treatment was 2;7/2;9 (females) and 5;1/5;2 (males). Nonmotor symptoms were more prominent among males, especially in memory and gastrointestinal domains, including drooling and obstipation. Significantly more sexual problems were reported from males; 26% versus 7% (Fisher's exact test, P < 0.0001). CONCLUSIONS: Differences between genders were identified in this study. Sexual problems and cognitive decline were more frequent among males. More advanced diagnostic imaging techniques were performed among males. The time point for a second added medication was earlier for males than females.

Mobile Geriatric Teams - A Cost-Effective Way Of Improving Patient Safety And Reducing Traditional Healthcare Utilization Among The Frail Elderly? A Randomized Controlled Trial.

BACKGROUND: Demographic changes combined with costly technological progress put a financial strain on the healthcare sector in the industrialized world. Hence, there is a constant need to develop new cost-effective treatment procedures in order to optimize the use of available resources. As a response, the concept of a Mobile Geriatric Team (MGT) has emerged not only nationally but also internationally during the last decade; however, scientific evaluation of this initiative has been very scarce. Thus, the objective of this study was to perform a mixed methods analysis, including a prospective, controlled and randomized quantitative evaluation, in combination with an interview-based qualitative assessment, to measure the effectiveness and user satisfaction of MGT. MATERIALS AND METHODS: Community-dwelling, frail elderly people were randomized to an intervention group (n=31, mean age 84) and a control group (n=31, mean age 86). A two-year retrospective quantitative data collection and a prospective one-year follow-up on healthcare utilization were combined with qualitative interviews. Non-parametric statistics and difference-in-difference (DiD) analyses were applied to the quantitative data. Qualitative data were analyzed using content analysis. RESULTS: No significant group differences in healthcare utilization were found before inclusion. Post intervention, primary care contact (including MGTs) increased for the MGT group. Inpatient care decreased dramatically for both groups. Hence, the increase in primary care contact for MGT patients was not accompanied by a reduction in inpatient care compared to the control group. Utilization of non-primary care was lower (p< 0.01) post-intervention in both groups. CONCLUSION: There appears to be a "natural" variation in healthcare needs over time among frail elderly people. Hence, it is vital to perform open, controlled clinical studies in tandem with the implementation of new caregiving strategies. The MGT initiative was clearly appreciated but did not fully achieve the desired reduction in healthcare utilization in this study. TRIAL REGISTRATION: Retrospectively registered 09/10/2018, ClinicalTrials.gov ID NCT03662945.

Dyskinesia and FAB score predict future falling in Parkinson's disease.

A growing body of research highlights the importance of cognition for prediction of falls in Parkinson's disease (PD). However, a previously proposed prediction model for future near falls and falls in PD, which includes history of near falls, tandem gait, and retropulsion, was developed without considering cognitive impairment. Therefore, by using a sample of 64 individuals with relatively mild PD and not excluding those with impaired cognition we aimed to externally validate the previously proposed model as well as to explore the value of additional predictors that also consider cognitive impairment. Since this validation study failed to support the proposed model in a PD sample including individuals with impaired global cognition, extended analyses generated a new model including dyskinesia (item 32 of Unified PD Rating Scale) and frontal lobe impairment (Frontal Assessment Battery-FAB) as significant independent predictors for future near falls and falls in PD. The discriminant ability of this new model was acceptable (AUC, 0. 80; 95% CI 0.68-0.91). Replacing the continuous FAB scores by a dichotomized version of FAB with a cut-off score ≤14 yielded slightly lower but still acceptable discriminant ability (AUC, 0. 79; 95% CI 0.68-0.91). Further studies are needed to test our new model and the proposed cut-off score of FAB in additional samples. Taken together, our observations suggest potentially important additions to the evidence base for clinical fall prediction in PD with concomitant cognitive impairment.

Distribution of non-motor symptoms in idiopathic Parkinson's disease and secondary Parkinsonism.

BACKGROUND: Non-motor symptoms (NMS) are frequent in patients with idiopathic Parkinson's disease (IPD). Clinical expressions, postulated pathophysiological mechanisms, and responsiveness to antiparkinson medication represent differences between IPD and secondary Parkinsonism (SP). OBJECTIVE: To evaluate NMS expressions in IPD, SP, and a matched control group. METHODS: The accepted criteria for IPD and SP were controlled for the participants who were consecutively recruited at two outdoor patient clinics. The Well-Being Map™ was used as the evaluation instrument. These were completed by the participants before their visit. The controls consisted of non-Parkinsonian individuals who were matched by age and gender. RESULTS: A total of 185 participants participated in the study, IPD/SP/controls; n=73/53 and 59, respectively. The mean age was 74 years, and the median duration of disease was 6/3 years. Differences were shown between the combined IPD/SP groups and the controls. Limited differences between the IPD and SP groups could be demonstrated. Symptoms such as pain, decreased taste, as well as sleep and bladder disturbances were more frequent in the IPD group. When more than minor problems with moving were reported, disturbances in sleep and digestion were also noted to a large extent. CONCLUSION: Despite differences in the pathophysiological mechanisms between IPD and SP, the study showed only minor differences in the expression of NMS. IPD and SP reported statistically more significant problems in all items compared to the controls. Sleeping problems were strongly associated with symptoms from the gastrointestinal tract, but sleep was only affected by longer disease duration to a minor extent. Motor symptoms, such as morning stiffness, were common in all three groups. Neurodegenerative diseases might have more complex expressions in common than what we have known before and it is certainly not a part of normal aging.

Evolution of Orofacial Symptoms and Disease Progression in Idiopathic Parkinson's Disease: Longitudinal Data from the Jönköping Parkinson Registry.

BACKGROUND: Orofacial symptoms are common in Parkinson's disease (PD) both as initial manifestations and late markers of disease complications. We aimed to investigate the evolution of orofacial manifestations and their prognostic value throughout PD progression. METHODS: Data was obtained from "Jönköping Parkinson Registry" database on routine care visits of 314 people with idiopathic PD in southern Sweden. Information on baseline symptomatology, orofacial features, UPDRS, and medications was recorded at baseline and during each follow-up visit within an average of 4.2 (range: 1-12) years. RESULTS: Hypomimia, affected speech, drooling, and impaired swallowing were present in 37.3%/91.6%, 14.1%/65.5%, 11.7%/55.3%, and 10.2%/34.5% at baseline/follow-up, respectively. Male sex [OR = 2.4 (95% CI: 1.0-5.9)], UPDRS motor scores [OR = 1.2 (95% CI: 1.1-1.3)], dominant rigidity [OR = 5.2 (95% CI: 1.4-19.1)], and autonomic disturbance [OR = 3.4 (95% CI: 1.1-10.9)] were risk factors for drooling. Individuals with more severe orofacial burden at baseline had shorter median time to develop UPDRS-Part III > 28 [3rd tertile = 4.7 yr, 2nd tertile = 6.2 yr, and 1st tertile = 7.8 yr; p = 0.014]. CONCLUSIONS: Majority of people with PD manifest orofacial manifestations at either early or late stages of the disease. PD severity, symmetry of motor disturbances, and autonomic disorders correlate with orofacial symptoms. Individuals with more severe orofacial burden at baseline progressed faster to more advanced stages.

Pain management in patients with Parkinson's disease: challenges and solutions.

This review focuses on the diagnosis and management of Parkinson-related pain which is one of the more frequently reported nonmotor symptoms in Parkinson's disease (PD), which is the second most common neurodegenerative disease after Alzheimer's disease. Pain is ranked high by patients as a troublesome symptom in all stages of the disease. In early-stage PD, pain is rated as the most bothersome symptom. Knowledge of the correct diagnosis of pain origin and possible methods of treatments for pain relief in PD is of great importance. The symptoms have a great negative impact on health-related quality of life. Separating PD-related pain from pain of other origins is an important challenge and can be characterized as "many syndromes under the same umbrella". Among the different forms of PD-related pain, musculoskeletal pain is the most common form, accounting for 40%-90% of reported pain in PD patients. Augmentation by pathophysiological pathways other than those secondary to rigidity, tremor, or any of the other motor manifestations of the disease seems most probable. In PD, the basal ganglia process somatosensory information differently, and increased subjective pain sensitivity with lower electrical and heat-pain thresholds has been reported in PD patients. The mechanism is assumed to be diminished activity of the descending inhibitory control system of the basal ganglia. PD pain, like many of the nonmotor symptoms, remains underdiagnosed and, thus, poorly managed. A systematic collection of patient descriptions of type, quality, and duration of pain is, therefore, of utmost importance. Recent studies have validated new and more specific and dedicated pain scales for PD-related symptoms. Symptomatic treatments based on clinical pain classification include not only pharmacological but also nonpharmacological methods and, to some degree, invasive approaches. In the clinic, pharmacological and nonpharmacological interventions can be effective to varying degrees - as single therapies or in combination - and should be employed, because no therapeutic strategies have been validated to date for managing PD pain. Multimodal approaches should always be considered, dopamine replacement therapies should be adjusted, and analgesics and/or antidepressants should be considered, including the use of different forms of complementary therapies.

Short- and long-term effects of tactile massage on salivary cortisol concentrations in Parkinson's disease: a randomised controlled pilot study.

BACKGROUND: Parkinson's disease (PD) is a chronic neurodegenerative disorder with limited knowledge about the normal function and effects of non-pharmacological therapies on the hypothalamic-pituitary-adrenal (HPA) axis. The aim of the study was to analyse the basal diurnal and total secretion of salivary cortisol in short- and long-term aspects of tactile massage (TM). DESIGN: Prospective, Controlled and Randomised Multicentre Trial. SETTING AND INTERVENTIONS: Forty-five women and men, aged 50-79 years, were recruited. Twenty-nine of them were blindly randomised to tactile massage (TM) and 16 of them to the control group, rest to music (RTM). Ten interventions were given during 8 weeks followed by a 26 weeks of follow up. Salivary cortisol was collected at 8 am, 1 pm, 8 pm, and 8 am the next day, on five occasions. With the first and eighth interventions, it was collected immediately before and after intervention. MAIN OUTCOME MEASURES: The primary aim was to assess and compare cortisol concentrations before and immediately after intervention and also during the follow-up period. The secondary aim was to assess the impact of age, gender, body mass index (BMI), duration and severity of PD, effects of interventional time-point of the day, and levodopa doses on cortisol concentration. RESULTS: The median cortisol concentrations for all participants were 16.0, 5.8, 2.8, and 14.0 nmol/L at baseline, later reproduced four times without significant differences. Cortisol concentrations decreased significantly after TM intervention but no change in diurnal salivary cortisol pattern was found. The findings of reduced salivary cortisol concentrations immediately after the interventions are in agreement with previous studies. However, there was no significant difference between the TM and control groups. There were no significant correlations between cortisol concentrations and age, gender, BMI, time-point for intervention, time interval between anti-parkinson pharmacy intake and sampling, levodopa doses, duration, or severity of PD. CONCLUSIONS: Diurnal salivary cortisol rhythm was normal. Salivary cortisol concentrations were significantly reduced after the TM intervention and after RTM, but there were no significant differences between the groups and no sustained long-term effect. No associations were seen between salivary cortisol concentration and clinical and/or pharmacological characteristics. TRIAL REGISTRATION: ClinicalTrial.gov, NCT01734876 and FoU Sweden 108881.

Found in transcription: accurate Parkinson's disease classification in peripheral blood.

BACKGROUND: A blood-based test for the early detection of Parkinson's disease (PD) would be an important diagnostic tool and useful for patient selection when developing novel drugs or treatments for the disease. OBJECTIVE: Here, we aimed to identify potential biomarkers associated with PD. METHODS: We applied gene expression profiling to the study of peripheral blood from 75 healthy control subjects and 79 PD patients at different stages of the disease. Healthy control subjects were matched for age and gender with PD subjects, and the diagnosis of patients was based on clinical evaluation by specialists in movement disorders. RNA was extracted from the blood samples and the gene expressions were measured using the Illumina HumanHT-12 v4.0 Expression BeadChip. RESULTS: Our results support previous studies that gene expression in blood may be instrumental in the search for molecular biomarkers for PD. Single cross-validation results show that PD can be correctly classified from healthy controls with an agreement of 88% to clinical diagnosis. De novo PD patients are classified with a sensitivity of 87%, which is close to what was achieved for the patients having a confirmed PD diagnosis with disease duration <5 and >5 years (93% and 88%). A double cross-validation procedure showed that using a selected set of around 650 informative genes, similar results are achieved. Functional analysis of the selected genes showed genes significantly associated to mitochondrial dysfunction, protein ubiquitination, gene expression and cell death. CONCLUSIONS: PD affects gene expression in blood, suggesting the potential for the development of a blood-based gene expression test.

National surveys: a way to manage treatment strategies in Parkinson's disease? Pharmaceutical prescribing patterns and patient experiences of symptom control and their impact on disease.

BACKGROUND: The purpose of this study was to draw conclusions from patient-reported experiences in two national surveys from Scandinavia with the intention of comparing treatment strategies and increasing our knowledge of factors that affect the experiences of patients with Parkinson's disease (PD). METHODS: A total of 2000 individuals in Sweden and 1300 in Norway were invited to complete postal surveys covering PD-related issues. Patient experiences of diagnostic procedures, symptom control, and follow-up in PD and the effects on symptom-related quality of life were collected. Pharmaceutical prescription data on anti-PD drugs and administrative data were collected from national registries. RESULTS: The surveys were completed by 1553 (78%) of the Swedish cohort and 1244 (96%) of the Norwegian cohort. Only small differences were seen in disease duration and age distribution. Statistically as well as clinically significant differences in symptom control, diagnostic, and follow-up procedures, as well as in pharmacological treatment and impact on quality of life, were found between the national cohorts independent of disease duration. CONCLUSION: Information from separate national surveys has the potential to increase our knowledge of patient experiences in PD and can be used to compare, evaluate, educate, and guide health care staff and administrators in optimizing health care for patients with the disease.

Parkinson's disease patients' subjective descriptions of characteristics of chronic pain, sleeping patterns and health-related quality of life.

OBJECTIVE: Nonmotor symptoms are common in Parkinson's disease (PD). Health-related quality of life (HRQoL) is negatively affected by different factors, of which pain and sleep disturbances are important contributors. This study was performed to evaluate and describe subjective experiences of pain, sleeping patterns, and HRQoL in a cohort of PD patients with chronic pain. METHODS: A total of 45 participants with established PD for more than 2 years, and PD-related pain for the preceding three months, were recruited from three sites in Sweden. Data regarding time point for onset, duration and degree of pain parameters, body localization of pain, external influences, and treatments were obtained. HRQoL was evaluated with the Short Form-36(®) Health Survey, and sleeping patterns were registered with the Parkinson's disease Sleep Scale, both completed along with a questionnaire. RESULTS: In one-third of participants, pain preceded the PD diagnosis. Median pain score measured with a visual analog scale was 6.6 and 5.9 (for females and males, respectively) the week before the study. In almost half of the participants, pain was present during all their waking hours. Significantly more females described their pain as troublesome, while more males described their pain as irritating. Feelings of numbness and creeping sensations at night were strongly associated with the maximal visual analog scale scores. Polypharmacy was common; 89% used medication for anxiety/insomnia, and 18% used antidepressants. Only one-third of patients who reported pain relief with analgesics had these prescribed on their drug lists. Sleep was characterized by frequent awakenings. Urinary urgency and restless legs were frequently reported as troublesome. Patients rated HRQoL as significantly worse in all items compared with a healthy reference population matched for age and sex. CONCLUSIONS: Experiences of chronic PD-related pain are complex; there is substantial sleep fragmentation and negative impact on HRQoL.

Direct switch from levodopa/benserazide or levodopa/carbidopa to levodopa/carbidopa/entacapone in Parkinson's disease patients with wearing-off: efficacy, safety and feasibility--an open-label, 6-week study.

The study objective was to assess the efficacy, safety and feasibility of switching from levodopa/benserazide (LB) or levodopa/carbidopa (LC) to levodopa/carbidopa/entacapone (LCE) in Parkinson's disease (PD) patients with wearing-off. This was a multicenter, open-label, 6-week study; the primary outcome was success rate based on the patient-assessed Clinical Global Impression of Change (P-CGI-C). Secondary outcomes included investigator-assessed CGI-C (I-CGI-C), change from baseline in Unified Parkinson's Disease Rating Scale (UPDRS), motor/non-motor wearing-off symptoms and quality of life-visual analog scale (QoL-VAS). After switching to LCE, 77% of patients reported an 'improvement' (p < 0.0001 vs. patients reporting 'no change or worsening'). Significant improvements were seen in I-CGI-C, UPDRS and QoL-VAS, regardless of prior therapy. Oral levodopa dosing was increased in 28% of patients; the primary outcome remained significant when these patients were excluded. The data suggest that switching from LB/LC to LCE provided a significant benefit in PD patients with wearing-off.