Expert Consensus on the Use of On-Demand Treatments for OFF Episodes in Parkinson's Disease: A Modified Delphi Panel.

Background: On-demand treatments can treat OFF episodes in Parkinson's disease, however, there is limited information regarding when to prescribe them. Objective: Develop expert consensus to determine appropriate clinical factors for considering on-demand treatments. Methods: Using a RAND/UCLA modified Delphi panel method, a panel developed consensus on the use of on-demand treatments for OFF episodes. Results: The panel agreed on-demand treatments were appropriate when OFF episodes were associated with greater functional impact and interfered with basic daily activities. The panel also agreed on-demand treatment may be appropriate for patients with morning akinesia and/or delayed ON of first levodopa dose and >1 type of OFF episode (eg, early morning OFF or wearing OFF regardless of frequency). Conclusions: Experts agreed on-demand treatment is appropriate for many patients with OFF episodes. The greater the functional impact of OFF episodes, the more likely experts agreed that on-demand treatment is appropriate to prescribe.

Using Telemedicine to Assess and Manage Psychosis in Neurodegenerative Diseases in Long-Term Care.

The coronavirus disease 2019 (COVID-19) epidemic has forced a sudden global implementation of telemedicine strategies, including in long-term care (LTC) facilities where many people with dementia and Parkinson disease (PD) reside. Telemedicine offers a unique set of advantages for residents in LTC facilities if effectively supported and implemented, including expanded access to specialists in rural or underserved areas or for people with dementia who cannot travel for off-site visits. Many medical and psychiatric organizations have recently issued new or updated guidelines on the use of telemedicine. On October 22, 2020, a multidisciplinary consensus panel was convened to collate a list of best practices for LTC facilities and specialists when conducting telemedicine with residents with dementia-related psychosis or PD-related psychosis (PDP). A collaborative effort between specialists, facility administrators, and facility staff is essential for the success of telemedicine in the LTC setting. Telemedicine in LTC facilities comes with increased administrative and technical challenges that fall heavily on the shoulders of the LTC facility administrators and staff. Specialists can ease this burden by maintaining flexibility and ensuring expression of empathy and thanks to the staff who are facilitating the visits. LTC staff can provide specialists with valuable information about their patients to aid in evaluation and diagnosis. Specialists can facilitate this exchange of information by speaking to staff who work closely with the resident about any signs of hallucinations or delusions they may have observed. Educational efforts can increase staff understanding of dementia and PDP and empower them to engage with, and facilitate the resident's treatment plan. Using these strategies to take advantage of the benefits of telemedicine, specialists and LTC staff can together expand and improve care for LTC facility residents with dementia-related psychosis or PDP.

Using Telemedicine to Assess and Manage Psychosis Among Outpatients with Neurodegenerative Disease.

The presence of hallucinations and delusions in patients with neurodegenerative disease correlates negatively with function, cognition, quality of life, and survival. When these patients still have insight, the treatment of mild hallucinations may reduce the risk of progression to more severe symptoms, specifically hallucinations without insight or delusions. On October 22, 2020, a multidisciplinary consensus panel comprising United States-based experts in geriatric psychiatry, geriatric medicine, family medicine, movement disorders, and neuropsychology was convened remotely to discuss best practices for using telemedicine to evaluate, diagnose, and treat psychosis in patients with neurodegenerative diseases. This review reflects the opinions and recommendations discussed at this meeting. Despite drawbacks, telemedicine can offer several advantages over in-person care, particularly for older adults, and may be a unique opportunity for care of patients with neuropsychiatric symptoms. While telemedicine may not be suitable for all patients, it allows the involvement of specialists from multiple geographic locations and the extension of care to homebound individuals. Patients with neurodegenerative diseases who are likely to become homebound as the disease advances may benefit greatly from telemedicine as a standard of care. Healthcare provided via telemedicine should be nothing less than what would be offered to the patient in person. Telemedicine may present some difficulties, including technological issues and inherent constraints of remote care, but with proper planning many problems could be diminished. Technical issues associated with telemedicine are inevitable but may be partially offset by providing clear directions ahead of any tele-visit to ensure connectivity and access to the videoconferencing platform. Alternative procedures to communicate should be established in the eventuality of technological issues. Using these strategies, telemedicine can serve as a valuable complement to traditional in-person practices for the diagnosis and management of hallucinations and delusions associated with Parkinson's disease psychosis or dementia-related psychosis.

Initial experiences of US neurologists in practice during the COVID-19 pandemic via survey.

OBJECTIVE: To test the hypothesis that US neurologists were experiencing significant challenges with lack of personal protective equipment (PPE), rapid changes in practice, and varying institutional protocols, we conducted this survey study. The current coronavirus disease of 2019 (COVID-19) pandemic has caused widespread disease and death. Rapid increases in patient volumes have exposed weaknesses in health care systems and challenged our ability to provide optimal patient care and adequate safety measures to health care workers (HCWs). METHODS: A 36-item survey was distributed to neurologists around the United States through various media platforms. RESULTS: Over a 1-week period, 567 responses were received. Of these, 56% practiced in academia. A total of 87% had access to PPE, with 45% being asked to reuse PPE due to shortages. The pandemic caused rapid changes in practice, most notably a shift toward providing care by teleneurology, although a third experienced challenges in transitioning to this model. Wide variations were noted both in testing and in the guidance provided for the exposed, sick, or vulnerable HCWs. Notably, 59% of respondents felt that their practices were doing what they could, although 56% did not feel safe taking care of patients. CONCLUSIONS: Results from our survey demonstrate significant variability in preparedness and responsiveness to the COVID-19 pandemic in neurology, affected by region, health care setting, and practice model. Practice guidelines from professional societies and other national entities are needed to improve protection for physicians and their patients, promote recommended practice changes during a pandemic, and optimize future preparedness for public health emergencies.

Treating refractory depression in Parkinson's disease: a meta-analysis of transcranial magnetic stimulation.

BACKGROUND: Parkinson's disease (PD) is often accompanied by clinically identified depression. Providing effective pharmacotherapies that concomitantly treat both motor and psychological symptoms can pose a challenge to physicians. For this reason, alternatives to standard anti-depressant treatments, such as repetitive transcranial magnetic stimulation (rTMS), have been evaluated within the Parkinson's population. METHODS: A literature search was conducted on the PubMed database for all studies that evaluated rTMS as a treatment in patients with both depression and PD. A meta-analysis was performed on all studies that reported mean pre- and post-rTMS depression inventory scores. Widely used depression inventories included both self-report and clinician-administered measures. Effect size for individual study groups and across all studies was calculated. RESULTS: Six of 7 studies meeting inclusion criteria reported significantly improved depression scores, large effect sizes, and significant p-values. Total weighted average effect size was calculated at 1.32 across all study groups that applied rTMS. CONCLUSIONS: Across all but one study, rTMS appears to effectively reduce depression scores among self-reported and clinician administered inventories. The total weight average effect size showed that, when considering study sample sizes and degree of findings, this form of neurostimulation can relieve PD patients of their depressive symptoms. Further, rTMS is a promising alternative to traditional anti-depressant therapies when treating refractory depression in patients with PD.

Coexisting adult polyglucosan body disease with frontotemporal lobar degeneration with transactivation response DNA-binding protein-43 (TDP-43)-positive neuronal inclusions.

Frontotemporal lobar degeneration with ubiquitin-positive inclusions (FTLD-U) is one of the most common pathological findings associated with the clinical FTLD syndromes. However, molecular characterization with genetic sequencing and protein expression techniques are recognizing many new subtypes for FTLDs. FTLDs are diverse and new nomenclature schemes have been proposed based on the molecular defects that are being discovered ( Mackenzie et al., 2010 , Acta Neuropathologica, 119, 1). Adult polyglucosan body disease (APBD) is a very rare disorder associated with systemic neurological signs and symptoms including progressive dementia with executive dysfunction and motor neuron disease. We report the clinical course of an individual with a clinical FTLD and the as yet unreported findings of coexistent APBD with FTLD-U and transactivation response DNA-binding protein-43 (TDP-43)-positive inclusions at autopsy (or more accurately, FTLD-TDP). It is unclear if these distinct findings are coincidental in this individual, or if pathogenic pathways may intersect to promote these coexisting pathologies.