On the use of low-cost computer peripherals for the assessment of motor dysfunction in Parkinson's disease--quantification of bradykinesia using target tracking tasks.

The potential of computer games peripherals to measure the motor dysfunction in Parkinson's diseases is assessed. Of particular interest is the quantification of bradykinesia. Previous studies used modified or custom haptic interfaces, here an unmodified force feedback joystick and steering wheel are used with a laptop. During testing an on screen cursor moves in response to movements of the peripheral, the user has to track a continuously moving target (pursuit tracking), or move to a predetermined target (step tracking). All tasks use movement in the horizontal axis, allowing use of joystick or steering wheel. Two pursuit tracking tasks are evaluated, pseudo random movement, and a swept frequency task. Two step tracking tasks are evaluated, movement between two or between two of five fixed targets. Thirteen patients and five controls took part on a weekly basis. Patients were assessed for bradykinesia at each session using standard clinical measures. A range of quantitative measures was developed to allow comparison between and within patients and controls using analysis of variance (ANOVA). Both peripherals are capable of discriminating between controls and patients, and between patients with different levels of bradykinesia. Recommendations for test procedures and peripherals are given.

A novel computer-based technique for the assessment of tremor in Parkinson's disease.

Parkinson's disease (PD) is a common neurodegenerative disease and the diagnosis of its idiopathic form remains challenging. The diagnosis of idiopathic form is based on clinical features which can have poor sensitivity with about 25% of patients diagnosed as having the disease actually having other conditions. In this study we assess the suitability and clinical value of a low cost computer-based system as an aid to diagnosis of PD, in particular the presence of tremor. All participants (12 patients and 10 controls) performed a shape-tracing task using a graphic tablet attached to a laptop. To assess the presence of tremors in the collected data, a statistical spectral analysis of the moment-to-moment fluctuations in the position signal of the output from the digitising tablet was performed. This allowed the comparison of power spectrums obtained from the control and patient responses respectively. A peak in log power between the 5 Hz & 6 Hz can clearly be identified in the patient's spectrum and is indicative of Parkinson's related tremor and no similar peak could be seen in the control's spectrum, suggesting this type of sequential task and automated data analysis may be useful in the diagnosis of tremor.

The therapeutic challenges in the older Parkinson's disease patient.

The information explosion in Parkinson's disease challenges the individual clinician to apply available knowledge to the management of individual patients. The application of current algorithms and guidelines is not straightforward in the older patient. Decision analysis reveals that clinical decisions may be simple, complex or chaotic. The more factors that have to be taken into account in making a decision, the more that decision moves from being evidence-based to intuitive. Decisions are made within conceptual frameworks. The dominant models in Parkinson's disease are biomedical or rehabilitation-based. Although the rehabilitation model lacks a sound evidence base, it is the principles of rehabilitation that dominate the management of the older patient. Analysis of the decisions made in a Parkinson's disease clinic demonstrates that the doctor's role is complex and many decisions taken are not evidence-based. Parkinson's disease is not a simple movement disorder but a neuro-psychiatric complex. The incurable nature and chronicity of the disease dictate the need for multidisciplinary working. Quality of life studies reveal wide variations in the expectations and needs of patients. Studies of the impact and costs of the disease put the cost of drugs into perspective. Studies in Parkinson's disease can involve very different populations. A cohort of elderly patients shows significant differences from the populations who are selected to participate in multi-centre trials. There is an increasing challenge for geriatricians to ensure that pragmatic trials are undertaken. Psychiatric problems - dementia, depression, and hallucinations - are common in the elderly and best management of these problems is unclear. Choices in drug regimes need to take into account the complex interactions between ageing, comorbility and Parkinson's disease.

Updated guidelines for the management of Parkinson's disease.

New data on diagnosis, drug therapy, surgery and psychosocial concerns have emerged since the publication of the 1998 Guidelines for the Management of Parkinson's Disease. This article reviews new data and addresses issues left unanswered in the previous guidelines.

The contribution of apraxic speech to working memory deficits in Parkinson's disease.

This article links two formerly separate areas of research associated with Parkinson's disease (PD): speech and memory. It is proposed that speech deficits occur in PD not merely at the level of muscular control, as is commonly termed dysarthria, but also at the level of speech planning and programming, more aptly described as a form of apraxia. It is further argued that PD patient groups exhibit small deficits in verbal span, and the link between apraxic speech and verbal span is elucidated via Baddeley's (1986) model of working memory. An experiment is described in which aspects of speech of 36 PD and 43 healthy control subjects were rated and classified, and measures of span and articulation rate for words of different syllable lengths were taken. Twenty-three PD subjects had dysarthric speech, while 14 of them had apraxic speech, which was associated with lower memory span scores for longer words. It is concluded that apraxic speech can be a source of reduced memory span in PD. In addition to implications for rehabilitation and therapeutic work with PD sufferers, these findings advance our theoretical understanding of the Parkinsonian syndrome.

The role of entacapone in the management of Parkinson's disease.

Catechol-O-methyltransferase (COMT) inhibition is an important advance in the treatment of Parkinson's disease. This consensus statement provides guidelines for the optimal use of the only currently available COMT inhibitor, entacapone (Comtess, Orion Pharma (UK) Ltd, Newbury, Berkshire).

Understanding memory for faces in Parkinson's disease: the role of configural processing.

It has previously been reported that unfamiliar face recognition memory is impaired in Parkinson's disease (PD) [(Dewick, H. C., Hanley, J. R., Davies, A. D. M., Playfer, J. R. & Turnbull, C. J., Perception and memory for faces in Parkinson's disease. Neuropsychologia, 1991, 29, 785-802), (Haeske-Dewick, H. C., Are perception and memory for faces influenced by a specific age at onset factor in Parkinson's disease? Neuropsychologia, 1996, 34, 315-320), (Levin, B. E., Llabre, M. M. & Weiner, W. J., Cognitive impairments associated with early Parkinson's disease. Neurology, 1989, 39, 557-561)]. In the work reported here, we consider the possible mechanisms that might underlie this impairment. 28 PD patients and 28 controls were given a two-part test of recognition memory for words and faces, and two perceptual tests to measure their configural and componential processing ability. We found that PD patients were significantly worse than controls on the recognition memory test for faces, but not when the stimuli were words. In addition, PD patients were significantly impaired relative to controls on the closure test (FCT) used to measure configural processing, but there was no difference between the two groups on a test of componential processing ability. Multiple regression analyses revealed that even after accounting for the influence of age, intelligence and level of depression, configural processing ability was the important predictor of unfamiliar face recognition memory in Parkinson's disease. There was no effect of Parkinson's disease specific variables on either face recognition or FCT performance. In addition, some recently diagnosed patients were poor at face recognition. It is suggested that face configuration skills may be affected very early in the course of Parkinson's disease, and that this may be connected to the fact that considerable nigrostriatal degeneration and alteration in brain neurotransmitter levels occur before the clinical symptoms of PD appear.

Targeting Parkinson's disease--the case for early referral.

Parkinson's disease (PD) is a chronic and disabling condition, for which guidelines for best practice have recently been implemented in the U.K. One of the key issues discussed is the provision of a continuum of care by a multidisciplinary team, which must comprise professionals with specialist expertise, including a PD specialist nurse and patient carer(s). Emphasis is placed on the importance of referral of de novo patients to specialist centres for confirmation of diagnosis and management. A synopsis of the classes of drugs available, differential diagnosis and the role of drug treatment in PD are also presented. The guidelines highlight that revision of national guidelines to form local protocols and working practices will improve and integrate care for PD patients. The significance of teamwork and good communication between primary care specialists in the management of PD is emphasised throughout.

A case of coprophagia presenting with sialadenitis.

PRESENTATION: a 94-year-old woman with dementia was admitted to an acute geriatric ward with increasing confusion and falls. On two occasions she developed submandibular masses. Faeces were aspirated from her mouth and a diagnosis made of recurrent submandibular sialadenitis secondary to coprophagia. OUTCOME: the submandibular mass settled with antibiotics and oral care. Coprophagia was not observed on the ward, but faecal smearing was noted. With regular toileting, this behaviour ceased and sialadenitis did not recur.

Guidelines for the management of Parkinson's disease. The Parkinson's Disease Consensus Working Group.

Parkinson's disease is a chronic and disabling illness and there is currently wide variation in its management. This article presents the first UK-specific guidelines for the management of Parkinson's disease and it contains a treatment decision free to aid the physician in deciding when and how to treat patients. We hope this document will prove useful to all those involved in the planning and delivery of care to patients with Parkinson's disease.

Gastroesophageal reflux in patients fed by percutaneous endoscopic gastrostomy (PEG): detection by a simple scintigraphic method.

OBJECTIVES: Gastroesophageal scintigraphy has been described as a sensitive and accurate way to detect and quantitate gastroesophageal reflux (GER). Our objectives here were to evaluate the usefulness of a modified scintigraphic technique in the detection of GER and lung aspiration in patients fed by percutaneous endoscopic gastrostomy (PEG), and to assess the incidence of GER after insertion of PEG. Further, we sought to examine whether or not the underlying cause of dysphagia plays any significant part in the causation of GER. METHODS: Twenty-two patients, 13 with neurological dysphagia and nine with mechanical dysphagia, were studied. Each patient received 25 MBq of Tc-99m-tin colloid in orange juice followed by 300 ml of normal saline through the PEG tube. Dynamic and static images were taken immediately and at 4 h over esophagus, stomach, and lungs. RESULTS: Twelve patients (10 with neurological dysphagia) had GER and one had aspiration into the lungs. In all but one patient GER occurred in the immediate postprandial period. CONCLUSIONS: Scintigraphy is useful in assessing GER in PEG-fed patients. We also note that GER is a major problem in patients with PEG, especially in those with neurological dysphagia.

A case of intrahepatic cholestasis due to amyloidosis.

Amyloidosis commonly involves the liver but clinical features of liver disease are rare. We report a case of cholestasis and hepatic failure in an 85-year-old man due to primary amyloidosis. This has not been reported previously in anyone of this advanced age. We discuss the clinical features of hepatic amyloidosis and the importance of making a diagnosis.

Parkinson's disease.

Parkinson's disease is a common disabling disease of old age. The diagnosis of idiopathic Parkinson's disease is based on clinical signs and has poor sensitivity, with about 25% of patients confidently diagnosed as having the disease actually having other conditions such as multi-system atrophy and other parkinsonism-plus syndromes. Benign essential tremor and arteriosclerotic pseudo-parkinsonism can easily be confused with Parkinson's disease. The cause of Parkinson's disease remains unknown. Speculative research highlights the role of oxidative stress and free radical mediated damage to dopaminergic cells. Parkinson's disease is the one neurodegenerative disorder in which drugs have been demonstrated to be of value. There is now a wide variety of drugs and formulations available, including anticholinergics, amantidine, L-dopa, dopamine agonists including apomorphine, selegiline and soon to be available catechol-O-methyltransferase inhibitors. Disabling side-effects of treatment, fluctuations, dyskinesias and psychiatric problems require strategic use of the drugs available. There is an increasing potential for neurosurgical intervention.

Gait disturbance in Alzheimer's disease: a clinical study.

Gait disturbance is common in patients with Alzheimer's disease (AD). The aim of this study was to analyse the clinical gait syndromes of patients with AD using Nutt's classification. Fifty-five patients who satisfied the NINCDS-ADRDA criteria for probable AD and 55 controls were recruited from a geriatric and a psychogeriatric unit. Patients with classical musculoskeletal or neurological syndromes causing gait disturbance were excluded. A standardized neurological examination was carried out in all subjects. Twenty-two (40%) patients and ten (18%) controls had a higher level gait disorder (p < 0.01). The pattern of gait disturbance in AD patients varied according to the stage of the disease. Cautious gait was the commonest gait disorder in AD patients with mild dementia, while frontal gait disorder was the commonest disturbance in patients with severe dementia. The prevalence of frontal release signs (gegenhalten or any primitive reflex) was highest among patients with frontal gait disorder.

What factors influence patient preferences regarding cardiopulmonary resuscitation?

The aims of this study were to investigate the impact of medical and non-medical factors on the cardiopulmonary resuscitation (CPR) preferences of patients, to determine which of them are the most important to patients when considering CPR, and to compare the views of older (> or = 70 years) and younger (< 70 years) patients. We interviewed 180 patients, 86 of whom were aged 70 years or older. 'I do not want to be a burden on my family' was the most important factor for older patients, and they were more ready to leave the decision to the doctor than were the younger patients. 'I want to retain my capacity to think clearly' was most important to younger patients. In general, younger patients gave higher ratings in favour of CPR than older patients. Increased age, drug abuse, dementia, pain, poor functional status and a low likelihood of success were associated with a lower preference rating for CPR in both age groups.