Thursday, 28 June 2012

Addenbrooke's Cognitive Examination-Revised for mild cognitive impairment in Parkinson's disease

Mov Disord. 2012 Jun 25. doi: 10.1002/mds.25084. [Epub ahead of print]

McColgan P, Evans JR, Breen DP, Mason SL, Barker RA, Williams-Gray CH.

Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom. 


Cognitive impairment is common in Parkinson's disease (PD), even in the early stages, and appropriate screening tools are needed.

We investigated the utility of the Addenbrooke's Cognitive Examination-Revised for detecting mild cognitive impairment (MCI) in PD in an incident population-representative cohort (n = 132) and investigated the relationship between performance on this instrument and behavior and quality of life (n = 219).

Twenty-two percent met criteria for MCI. Receiver operating curve analysis revealed an area under the curve of 0.81. A cutoff <89 gave a sensitivity of 69% and specificity of 84%. Scores on this instrument were highly correlated with the Parkinson's Disease Cognitive Rating Scale, and there were significant correlations with the Cambridge Behavioral Inventory-Revised and Parkinson's Disease Questionnaire 39.

This instrument is a useful screening tool for PD-MCI, and poor performance is significantly related to impaired behavior and quality of life.

Rapid eye movement sleep behavior disorder and subtypes of Parkinson's disease

Mov Disord. 2012 Jun 25. doi: 10.1002/mds.25086. [Epub ahead of print]
Romenets SR, Gagnon JF, Latreille V, Panniset M, Chouinard S, Montplaisir J, Postuma RB.

Department of Neurology, McGill University, Montreal General Hospital, Montreal, Quebec, Canada.

Numerous studies have explored the potential relationship between rapid eye movement sleep behavior disorder (RBD) and manifestations of PD. Our aim was to perform an expanded extensive assessment of motor and nonmotor manifestations in PD to identify whether RBD was associated with differences in the nature and severity of these manifestations. PD patients underwent polysomnography (PSG) to diagnose the presence of RBD. Participants then underwent an extensive evaluation by a movement disorders specialist blinded to PSG results. Measures of disease severity, quantitative motor indices, motor subtypes, therapy complications, and autonomic, psychiatric, visual, and olfactory dysfunction were assessed and compared using regression analysis, adjusting for disease duration, age, and sex. Of 98 included patients, 54 had RBD and 44 did not. PD patients with RBD were older (P = 0.034) and were more likely to be male (P < 0.001). On regression analysis, the most consistent links between RBD and PD were a higher systolic blood pressure (BP) change while standing (-23.9 ± 13.9 versus -3.5 ± 10.9; P < 0.001), a higher orthostatic symptom score (0.89 ± 0.82 versus 0.44 ± 0.66; P = 0.003), and a higher frequency of freezing (43% versus14%; P = 0.011). A systolic BP drop >10 could identify PD patients with RBD with 81% sensitivity and 86% specificity. In addition, there was a probable relationship between RBD and nontremor predominant subtype of PD (P = 0.04), increased frequency of falls (P = 0.009), and depression (P = 0.009). Our results support previous findings that RBD is a multifaceted phenomenon in PD. Patients with PD who have RBD tend to have specific motor and nonmotor manifestations, especially orthostatic hypotension.

Wednesday, 27 June 2012

A single-question screen for rapid eye movement sleep behavior disorder: A multicenter validation study

Mov Disord. 2012 Jun;27(7):913-6. doi: 10.1002/mds.25037. Epub 2012 May 30.

Postuma RB, Arnulf I, Hogl B, Iranzo A, Miyamoto T, Dauvilliers Y, Oertel W, Ju YE, Puligheddu M, Jennum P, Pelletier A, Wolfson C, Leu-Semenescu S, Frauscher B, Miyamoto M, Cochen De Cock V, Unger MM, Stiasny-Kolster K, Livia Fantini M, Montplaisir JY.

Department of Neurology, McGill University, Montreal General Hospital, Montreal, Québec, Canada; Centre d'Études Avancées en Médecine du Sommeil, Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada.


Idiopathic rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia that is an important risk factor for Parkinson's disease (PD) and Lewy body dementia. Its prevalence is unknown. One barrier to determining prevalence is that current screening tools are too long for large-scale epidemiologic surveys. Therefore, we designed the REM Sleep Behavior Disorder Single-Question Screen (RBD1Q), a screening question for dream enactment with a simple yes/no response.

Four hundred and eighty-four sleep-clinic-based participants (242 idiopathic RBD patients and 242 controls) completed the screen during a multicenter case-control study. All participants underwent a polysomnogram to define gold-standard diagnosis according to standard criteria.

We found a sensitivity of 93.8% and a specificity of 87.2%. Sensitivity and specificity were similar in healthy volunteers, compared to controls or patients with other sleep diagnoses.

A single-question screen for RBD may reliably detect disease, with psychometric properties favorably comparable to those reported for longer questionnaires. © 2012 Movement Disorder Society.

Voice algorithms spot Parkinson's disease

Check out this BBC news report on voice recognition technology for the diagnosis of Parkinson's

Sunday, 24 June 2012

A cohort study on diet and the risk of Parkinson's disease: the role of food groups and diet quality.

Br J Nutr. 2012 Apr 13:1-9. [Epub ahead of print]

Sääksjärvi K, Knekt P, Lundqvist A, Männistö S, Heliövaara M, Rissanen H, Järvinen R.

National Institute for Health and Welfare, PO Box 30, 00271 Helsinki, Finland.

Previous studies on individual foods and nutrients and Parkinson's disease (PD) risk have been inconsistent. Furthermore, only one study has examined the association between the quality of diet and PD. We investigated the prediction of food groups and diet quality on PD in the Finnish Mobile Clinic Survey (1966-72). The population comprised 4524 individuals, aged 40-79 years and free from PD at baseline. Data collection included health examinations, a questionnaire and a 1-year dietary history interview. A modified Alternate Healthy Eating Index was formed to assess diet quality. Statistical analyses were based on Cox's model. During a 41-year follow-up, eighty-five incident cases of PD occurred. No statistically significant associations were found between PD incidence and most of the food groups examined. A few exceptions were fruits and berries in men and milk in women, which showed positive associations. An inverse association between the intake of meat products and PD was found in women. The diet quality index did not predict PD, the adjusted relative risk between the highest and lowest quartiles being 1·83 (95 % CI 0·65, 5·18) in men and 0·97 (95 % CI 0·38, 2·48) in women. The present study suggests that since most of the single food groups or the quality of diet did not predict PD occurrence, the role of diet is apparently rather modest.

Alcohol and risk of Parkinson's disease in a large, prospective cohort of men and women

Mov Disord. 2012 Jun 19. doi: 10.1002/mds.25050. [Epub ahead of print]

Palacios N, Gao X, O'Reilly E, Schwarzschild M, McCullough ML, Mayo T, Gapstur SM, Ascherio AA.

Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA. 

Addictive behaviors, such as cigarette smoking and coffee drinking, have been associated with a reduced risk of Parkinson's disease (PD). Whether alcohol consumption is also associated with PD risk is less certain. We prospectively followed 132,403 participants in the Cancer Prevention Study II Nutrition Cohort from 1992 to 2005. Alcohol intake was assessed at baseline. Incident cases of PD (n = 605; 389 male and 216 female) were confirmed by treating physicians and medical record review. Relative risks (RRs) were estimated using proportional hazards models, adjusting for age, smoking, and other risk factors. Alcohol consumption was not significantly associated with PD risk. After adjustment for age, smoking, and other risk factors, the RR comparing men consuming 30 or more grams of alcohol per day (highest category) to nondrinker men was 1.29 (95% confidence interval [CI]: 0.90, 1.86; P trend: 0.40), and the RR comparing women consuming 15 or more grams of alcohol (highest category) per day to nondrinker women was 0.77 (95% CI: 0.41, 1.45; P trend: 0.87). Consumption of beer, wine, or liquor was also not associated with PD risk. The results of this large, prospective study do not support an association between alcohol intake and risk of PD.

Image from

The progression of non-motor symptoms in Parkinson's disease and their contribution to motor disability and quality of life.

J Neurol. 2012 Jun 19. [Epub ahead of print]

Antonini A, Barone P, Marconi R, Morgante L, Zappulla S, Pontieri FE, Ramat S, Ceravolo MG, Meco G, Cicarelli G, Pederzoli M, Manfredi M, Ceravolo R, Mucchiut M, Volpe G, Abbruzzese G, Bottacchi E, Bartolomei L, Ciacci G, Cannas A, Randisi MG, Petrone A, Baratti M, Toni V, Cossu G, Del Dotto P, Bentivoglio AR, Abrignani M, Scala R, Pennisi F, Quatrale R, Gaglio RM, Nicoletti A, Perini M, Avarello T, Pisani A, Scaglioni A, Martinelli PE, Iemolo F, Ferigo L, Simone P, Soliveri P, Troianiello B, Consoli D, Mauro A, Lopiano L, Nastasi G, Colosimo C.

Department for Parkinson's Disease, IRCCS San Camillo, Via Alberoni 70, Venice, Italy,

Non-motor symptoms are gaining relevance in Parkinson's disease (PD) management but little is known about their progression and contribution to deterioration of quality of life. We followed prospectively 707 PD patients (62 % males) for 2 years. We assessed non-motor symptoms referred to 12 different domains, each including 1-10 specific symptoms, as well as motor state (UPDRS), general cognition, and life quality. Hoehn & Yahr (H&Y) stage was used to categorize patient status (I-II mild; III moderate; IV-V severe). We found that individual non-motor symptoms had variable evolution over the 2-year follow-up with sleep, gastrointestinal, attention/memory and skin disturbances (hyperhidrosis and seborrhea) becoming more prevalent and psychiatric, cardiovascular, and respiratory disorders becoming less prevalent. Development of symptoms in the cardiovascular, apathy, urinary, psychiatric, and fatigue domains was associated with significant life-quality worsening (p < 0.0045, alpha with Bonferroni correction). During the observation period, 123 patients (17 %) worsened clinically while 584 were rated as stable. There was a fivefold greater increase in UPDRS motor score in worse compared with stable patients over 24 months (p < 0.0001 vs. baseline both in stable and worse group). The total number of reported non-motor symptoms increased over 24 months in patients with motor worsening compared to stable ones (p < 0.001). Thirty-nine patients died (3.4 % of patients evaluable at baseline) with mean age at death of 74 years. Deceased patients were older, had significantly higher H&Y stage and motor score, and reported a greater number of non-motor symptoms at baseline. In conclusion, overall non-motor symptom progression does not follow motor deterioration, is symptom-specific, and only development of specific domains negatively impacts quality of life. These results have consequences for drug studies targeting non-motor features.

Saturday, 16 June 2012

Risk factors for Parkinson's disease may differ in men and women: An exploratory study.

Horm Behav. 2012 Jun 8. [Epub ahead of print]
Savica R, Grossardt BR, Bower JH, Ahlskog JE, Rocca WA.


Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN, USA; Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, USA.


Although several environmental and genetic risk or protective factors have been associated with Parkinson's disease (PD), their interactions overall and in men and women separately remain unknown. We used the medical records-linkage system of the Rochester Epidemiology Project to identify 196 subjects who developed PD in Olmsted County, MN, from 1976 through 1995. Each incident case was matched by age (±1year) and sex to a general population control. We considered the following 12 risk or protective factors: personal history of head trauma, pesticide use, immunologic diseases, anemia, hysterectomy (in women only), cigarette smoking, coffee consumption, and education; and family history of parkinsonism, essential tremor, dementia, or psychiatric disorders. We used recursive partitioning analyses to explore interactions overall and in men and women separately and used logistic regression analyses to test for interactions. In the overall group, we observed the independent effects of anemia, lack of coffee consumption (never vs. ever), and head trauma; however, the findings were different in men and women. In men, we observed the independent effects of lack of coffee consumption (never vs. ever), head trauma, and pesticide use, and a suggestive synergistic interaction between immunologic diseases and family history of dementia. By contrast, in women, anemia was the most important factor and we observed a suggestive synergistic interaction between anemia and higher education. Risk factors for PD and their interactions may differ in men and women.

Changes on brief cognitive instruments over time in Parkinson's disease.

Mov Disord. 2012 Jun 12. doi: 10.1002/mds.25070. [Epub ahead of print]
Lessig S, Nie D, Xu R, Corey-Bloom J.


Department of Neurosciences, University of California San Diego, San Diego, California, USA; VA Medical Center San Diego, San Diego, California, USA.


Two hundred and twenty-one subjects with Parkinson's disease (PD) were examined using the Mini-Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA), with a subset of these (n = 98) examined on repeat testing up to 3 years. The MoCA was more sensitive in identifying cognitive deficit, specifically in the domains of visuospatial abilities, language, and memory. In longitudinal study, the MMSE changed significantly over time, particularly in patients with disease duration of >10 years. The MoCA, however, did not change significantly, even when subjects were stratified by age, MMSE score, and disease duration. This suggests that the MoCA may be more sensitive for detecting early cognitive change in PD, but that the MMSE, and not the MoCA, may be better for tracking cognitive decline.

Nicotine as a potential neuroprotective agent for Parkinson's disease.

Mov Disord. 2012 Jun 12. doi: 10.1002/mds.25028. [Epub ahead of print]
Quik M, Perez XA, Bordia T.


Center for Health Sciences, SRI International, Menlo Park, California, USA.


Converging research efforts suggest that nicotine and other drugs that act at nicotinic acetylcholine receptors (nAChRs) may be beneficial in the management of Parkinson's disease. This idea initially stemmed from the results of epidemiological studies that demonstrated that smoking is associated with a decreased incidence of Parkinson's disease. The subsequent finding that nicotine administration protected against nigrostriatal damage in parkinsonian animal models led to the idea that nicotine in tobacco products may contribute to this apparent protective action. Nicotine most likely exerts its effects by interacting at nAChRs. Accumulating research indicates that multiple subtypes containing nAChRs, including α4β2, α6β2, and/or α7, may be involved. Stimulation of nAChRs initially activates various intracellular transduction pathways primarily via alterations in calcium signaling. Consequent adaptations in immune responsiveness and trophic factors may ultimately mediate nicotine's ability to reduce/halt the neuronal damage that arises in Parkinson's disease. In addition to a potential neuroprotective action, nicotine also has antidepressant properties and improves attention/cognition. Altogether, these findings suggest that nicotine and nAChR drugs represent promising therapeutic agents for the management of Parkinson's disease.

Image from My Planet Guides

Cardiovascular physiology in premotor Parkinson's disease: A neuroepidemiologic study.

Mov Disord. 2012 Jun 14. doi: 10.1002/mds.24979. [Epub ahead of print]
Jain S, Ton TG, Perera S, Zheng Y, Stein PK, Thacker E, Strotmeyer ES, Newman AB, Longstreth WT Jr.


University of Pittsburgh School of Medicine, Department of Neurology, Pittsburgh, Pennsylvania, USA.


Changes in cardiovascular physiology in Parkinson's disease (PD) are common and may occur prior to diagnostic parkinsonian motor signs. We investigated associations of electrocardiographic (ECG) abnormalities, orthostasis, heart rate variability, and carotid stenosis with the risk of PD diagnosis in the Cardiovascular Health Study, a community-based cohort of older adults. ECG abnormality, orthostasis (symptomatic or asymptomatic), heart rate variability (24-hour Holter monitoring), and any carotid stenosis (≥1%) by ultrasound were modeled as primary predictors of incident PD diagnosis using multivariable logistic regression. Incident PD cases were identified by at least 1 of the following: self-report, antiparkinsonian medication use, and ICD-9. If unadjusted models were significant, they were adjusted or stratified by age, sex, and smoking status, and those in which predictors were still significant (P ≤ .05) were also adjusted for race, diabetes, total cholesterol, low-density lipoprotein, blood pressure, body mass index, physical activity, education level, stroke, and C-reactive protein. Of 5888 participants, 154 incident PD cases were identified over 14 years of follow-up. After adjusting models with all covariates, those with any ECG abnormality (odds ratio [OR], 1.45; 95% CI, 1.02-2.07; P = .04) or any carotid stenosis (OR, 2.40; 95% CI, 1.40-4.09; P = .001) at baseline had a higher risk of incident PD diagnosis. Orthostasis and heart rate variability were not significant predictors. This exploratory study suggests that carotid stenosis and ECG abnormalities occur prior to motor signs in PD, thus serving as potential premotor features or risk factors for PD diagnosis. Replication is needed in a population with more thorough ascertainment of PD onset.

Occupational exposure to pesticides and Parkinson's disease: A systematic review and meta-analysis of cohort studies.

Environ Int. 2012 Jun 12;46C:30-43. [Epub ahead of print]
Van Maele-Fabry G, Hoet P, Vilain F, Lison D.



To systematically review available cohort studies and estimate quantitatively the association between occupational exposure to pesticides and Parkinson's disease (PD).


Studies were identified from a MEDLINE search through 30 November 2011 and from the reference lists of identified publications. Relative risk (RR) estimates were extracted from 12 studies published between 1985 and 2011. Meta-rate ratio estimates (mRR) were calculated according to fixed and random-effect meta-analysis models. Meta-analyses were performed on the whole set of data and separate analyses were conducted after stratification for gender, exposure characterisation, PD cases identification, geographic location, reported risk estimator and cohort study design.


A statistically significant increased risk of PD was observed when all studies were combined (mRR=1.28; 95% confidence interval [CI]: 1.03-1.59) but there was a high heterogeneity and inconsistency among studies. The highest increased risks were observed for studies with the best design, i.e. reporting PD diagnosis confirmed by a neurologist (mRR=2.56; CI: 1.46-4.48; n=4), for cohort studies reporting incidence of PD (mRR=1.95; CI: 1.29-2.97; n=3) as well as for prospective cohorts (mRR=1.39; CI: 1.09-1.78; n=6). A significant increased risk was also seen for banana, sugarcane and pineapple plantation workers (mRR=2.05; CI: 1.23-3.42; n=2).


The present study provides some support for the hypothesis that occupational exposure to pesticides increases the risk of PD.

Image from

Tuesday, 12 June 2012

Check out the Parkinson's Movement Website!

PARKINSON’S MOVEMENT is a novel concept designed to engage people
with Parkinson’s in their own futures, by raising expectations, knowledge and
opinion, with the ultimate emphasis on a cure.

PARKINSON’S MOVEMENT is a research-focussed,  patient-driven platform for information and canvassing within the Parkinson’s community. Informed bloggers, webinars, polls, debates and so much more create a patient-focussed hub.

Understanding and prevention of "therapy-" induced dyskinesias.

Parkinsons Dis. 2012;2012:640815. Epub 2012 May 23.

Aviles-Olmos I, Kefalopoulou Z, Foltynie T.

Unit of Functional Neurosurgery Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London WC1N3BG, UK.

L-dopa is the most effective, currently available treatment for Parkinson's disease (PD), but it leads to the development of involuntary movements known as L-dopa-induced dyskinesia (LID) in the majority of patients after long-term use. Both gene and cell therapy approaches are the subject of multiple ongoing studies as potential ways of relieving symptoms of PD without the complication of dyskinesia. However, the spectre of dyskinesia in the absence of L-dopa, the so-called "off-phase" or graft-induced dyskinesia (GID), remains a major obstacle particularly in the further development of cell therapy in PD, but it is also a concern for proponents of gene therapy approaches. LID results from nonphysiological dopamine release, supersensitivity of dopamine receptors, and consequent abnormal signalling through mechanisms of synaptic plasticity. Restoration of physiological circuitry within the basal ganglia loops is ultimately the aim of all cell and gene therapy approaches but each using distinctive strategies and accompanied by risks of exacerbation of LID or development of "off-phase"/GID. In this paper we discuss the details of what is understood regarding the development of dyskinesias with relevance to cell and gene therapy and potential strategies to minimize their occurrence.

Friday, 8 June 2012

Olfactory dysfunctions in neurodegenerative disorders.

J Neurosci Res. 2012 Jun 5. doi: 10.1002/jnr.23054. [Epub ahead of print]
Ruan Y, Zheng XY, Zhang HL, Zhu W, Zhu J.

Department of Otorhinolaryngology, Head and Neck surgery, First Hospital of Jilin University, Changchun, China; Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.

Olfactory dysfunction is a common symptom in the patients with neurodegenerative disorders, particularly in Parkinson's disease (PD) and Alzheimer's disease (AD). Recently, studies of olfactory dysfunction have focused on its potential as a medication-independent biomarker for disease progression and as an early indicator for the diagnosis of neurodegenerative disorders. In the past decades, great achievements have been obtained in elucidating the neuroanatomy and the function of olfactory system, yet the pathogenesis of olfactory dysfunction in neurodegenerative disorders remains elusive. The neuropathologic changes of olfactory dysfunction in neurodegenerative diseases may involve the olfactory epithelium, olfactory bulb, primary olfactory cortices, and their secondary targets changes. This article summarizes the up-to-date knowledge on pathophysiological changes of the olfactory system in neurodegenerative disorders and attempts to find the association between olfactory dysfunction and neurodegenerative disorders.

This picture was taken from

Metabolic markers or conditions preceding Parkinson's disease: A case-control study.

Mov Disord. 2012 Jun 1. doi: 10.1002/mds.25016. [Epub ahead of print]
Savica R, Grossardt BR, Ahlskog JE, Rocca WA.

Department of Neurology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Several metabolic markers or conditions have been explored as possible risk or protective factors for Parkinson's disease (PD); however, results remain conflicting. We further investigated these associations using a case-control study design. We used the medical records-linkage system of the Rochester Epidemiology Project to identify 196 subjects who developed PD in Olmsted County, Minnesota, from 1976 through 1995. Each incident case was matched by age (±1 year) and sex to a general population control. We reviewed the complete medical records of cases and controls in the medical records-linkage system to abstract information about body mass index (BMI), cholesterol level, hypertension, and diabetes mellitus preceding the onset of PD (or the index year). There were no significant differences between cases and controls for the metabolic markers or conditions investigated. No significant associations were found using 2 cutoffs for BMI level (BMI ≥ 25 or BMI ≥ 30 kg/m(2) ) and 3 cutoffs for cholesterol levels (>200, >250, or >300 mg/dL). Neither a diagnosis of hypertension or the documented use of antihypertensive medications was significantly associated with the subsequent risk of PD (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.65-1.54; P = .99) nor was a diagnosis of diabetes mellitus or the use of glucose-lowering medications (OR, 0.77; 95% CI, 0.37-1.57; P = .47). Our study, based on historical information from a records-linkage system, does not support an association between BMI, cholesterol level, hypertension, or diabetes mellitus with later development of PD.

Thursday, 7 June 2012

Impulsive and compulsive behaviors during dopamine replacement treatment in Parkinson's disease and other disorders.

Curr Drug Saf. 2012 Feb 1;7(1):63-75.
Raja M, Rita Bentivoglio A.


Prisciano 26, 00136 - Rome, Italy.


Impulsive and compulsive behaviors, including pathologic gambling, hypersexuality, compulsive shopping, compulsive eating, excessive engagement in hobbies, punding, and Dopamine Dysregulation Syndrome (DDS), are increasingly reported serious side-effects of dopaminergic medication, used in the treatment of Parkinson's Disease (PD) and other disorders. Dopamine Agonists (DA) are strongly related with Impulse Control Disorders (ICDs), while L-dopa is associated with DDS. The present paper focuses on ICDs. The estimated prevalence of ICDs in PD patients treated with DA is as high as 14%. ICDs pathophysiology is complex, due to multiple contributing factors. Dopamine neurotransmission along the meso-cortico-limbic pathway is a modulator of risk behavior and can be altered in PD and in the course of dopaminergic treatment. Psychiatric complications, associated with treatment of PD are still underdiagnosed, although their consequences can be serious, even catastrophic. Physicians treating PD with DA should warn the patients and their relatives of the risk of inducing ICDs. Psychiatrists should be trained to recognize these side effects, that can mimic primary psychiatric conditions. The management of ICDs includes discontinuation of DA or switching from DA to other drugs for the treatment of PD. Cognitive behavior therapy, serotonin selective reuptake inhibitors, nalmefene, zonisamide, low dose of anti-dopaminergic drugs, as quetiapine or clozapine, can be effective. Psychological, spiritual, and ethical support (familial or individual) can help.

This picture comes from an American website run by the National Parkinson Foundation. The link to their website is

BBC Health Page on Movement Disorders

This link leads to a BBC webpage that defines terms such as dyskinesia, dystonia, ataxia and tremor.

Treatment patterns and associated costs with Parkinson's disease levodopa induced dyskinesia.

J Neurol Sci. 2012 Jun 2. [Epub ahead of print]
Suh DC, Pahwa R, Mallya U.


College of Pharmacy, Chung-Ang University, Seoul, South Korea.



This study examined the treatment patterns, direct healthcare costs and predictors of treatment costs associated with levodopa-induced dyskinesia (LID) in Parkinson's disease (PD).


This retrospective cohort study followed PD patients for 1-year pre- and post-onset of LID, using a large US health insurance claims database from January 1, 2004 to December 31, 2008. Patients with LID were matched to patients without LID based on propensity scores to control for potential selection bias. Descriptive statistics and bootstrap techniques were employed to assess patient demographic and clinical characteristics and costs incurred. Factors influencing treatment costs were analyzed using a generalized linear model with log-link function and gamma distribution. Costs were adjusted to 2009 prices.


After patients developed LID, their total treatment costs were increased from $18,645 during the 12months preceding LID onset to $26,439 for the 12-month period subsequent to LID onset (incremental costs of $7795: P<0.001). PD-related costs increased from $3917 to $8110 (incremental costs of $4194: p<0.001) LID events, medical resource utilization, higher levodopa dosage, and use of alternative PD medications were associated with increases in total treatment costs. Few changes in medication treatment patterns were noted following the initial LID, with only slight increases in levodopa dosage and few additions of alternative agents.


In the United States, PD patients with LID impose a significant economic burden when compared to patients without LID. Currently available, treatment strategies for dyskinesia should be used more frequently in PD management, and new treatment strategies should be considered as they may lower healthcare costs.

Wednesday, 6 June 2012

Alzheimer plaques in 3D

Alzheimer plaques in 3D

Nonmotor symptoms as presenting complaints in Parkinson's disease: a clinicopathological study

Mov Disord. 2008 Jan;23(1):101-6.
O'Sullivan SS, Williams DR, Gallagher DA, Massey LA, Silveira-Moriyama L, Lees AJ.

Reta Lila Weston Institute of Neurological Studies, Institute of Neurology, University College London, London, United Kingdom.

Nonmotor symptoms (NMS) are increasingly recognized as a significant cause of morbidity in later stages of Parkinson's disease (PD). Prodromal NMS are also a well recognized component of the clinical picture in some patients but the prevalence of NMS as presenting complaints, and their impact on clinical management, in pathologically-proven cases of PD is unknown. The presenting complaints of 433 cases of pathologically-proven PD archived at the Queen Square Brain Bank for Neurological Diseases were identified from the clinical case notes. 91/433 (21%) of patients with PD presented with NMS of which the most frequent were pain (15%), urinary dysfunction (3.9%), anxiety, or depression (2.5%). Presenting with NMS is associated with a delayed diagnosis of PD (Mann-Whitney U, P = 0.001). These patients were more likely to be misdiagnosed initially and were more likely to have been referred to orthopedic surgeons or rheumatologists than neurologists (nonmotor group 5.5% vs. motor group 44.2%, chi(2) P < 0.0001). NMS are commonly seen as presenting complaints in pathologically confirmed PD, and initial misdiagnosis may be associated with potentially inappropriate medical interventions. Presenting with NMS does not affect the motor response to medication, but is associated with shorter disease duration (chi(2) P = 0.016).

Musculoskeletal problems as an initial manifestation of Parkinson's disease: A retrospective study

J Neurol Sci. 2012 May 30. [Epub ahead of print]
Farnikova K, Krobot A, Kanovsky P.

Department of Neurology, Palacky University Medical School, University Hospital, Olomouc, Czech Republic.


The purpose of this study was to review the prevalence of musculoskeletal pain in the prodromal phase of PD, before the PD diagnosis is made.

A retrospective review of 82 PD patients was performed. Hospital inpatient notes and outpatient clinic admission notes were reviewed. The initial complaints prompting patients to seek medical attention were noted, as were the initial diagnoses. The symptoms were considered retrospectively to be associated with PD.

Musculoskeletal pain was present as a prodromal PD symptom in 27 (33%) cases initially diagnosed with osteoarthritis, degenerative spinal disease, and frozen shoulder. The mean time from the initial symptom appearance to dopaminergic treatment was 6.6years in the musculoskeletal pain group and 2.3years in the group with typical PD signs. Significant improvement of musculoskeletal pain after the initiation of dopaminergic treatment was present in 23 (85%) cases.

Of the PD patients who went on to develop motor features of PD, one third manifested musculoskeletal pain as the initial symptom. A good response to L-DOPA therapy was seen in 85% of cases presenting with musculoskeletal pain. Our findings suggest that musculoskeletal pain may be a significant feature in earlier PD stages.

The image above was taken from

Dopamine Induced Neurodegeneration in a PINK1 Model of Parkinson's Disease.

PLoS One. 2012;7(5):e37564. Epub 2012 May 25.
Gandhi S, Vaarmann A, Yao Z, Duchen MR, Wood NW, Abramov AY.

Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom.


Parkinson's disease is a common neurodegenerative disease characterised by progressive loss of dopaminergic neurons, leading to dopamine depletion in the striatum. Mutations in the PINK1 gene cause an autosomal recessive form of Parkinson's disease. Loss of PINK1 function causes mitochondrial dysfunction, increased reactive oxygen species production and calcium dysregulation, which increases susceptibility to neuronal death in Parkinson's disease. The basis of neuronal vulnerability to dopamine in Parkinson's disease is not well understood.

We investigated the mechanism of dopamine induced cell death in transgenic PINK1 knockout mouse neurons. We show that dopamine results in mitochondrial depolarisation caused by mitochondrial permeability transition pore (mPTP) opening. Dopamine-induced mPTP opening is dependent on a complex of reactive oxygen species production and calcium signalling. Dopamine-induced mPTP opening, and dopamine-induced cell death, could be prevented by inhibition of reactive oxygen species production, by provision of respiratory chain substrates, and by alteration in calcium signalling.

These data demonstrate the mechanism of dopamine toxicity in PINK1 deficient neurons, and suggest potential therapeutic strategies for neuroprotection in Parkinson's disease.

The full-text of this paper is available at the link below

Tuesday, 5 June 2012

Interventions to evaluate fitness to drive among people with chronic conditions: Systematic review of literature.

Accid Anal Prev. 2012 May 31. [Epub ahead of print]
Marino M, de Belvis A, Basso D, Avolio M, Pelone F, Tanzariello M, Ricciardi W.


Institute of Hygiene and Preventive Medicine, Catholic University of Sacred Heart, Rome, Italy.


When an health condition has been identified, the question of whether to continue driving depends not on a medical diagnosis, but on the functional consequences of the illness. The complex nature of physical and mental impairments and their relationship with safe driving make the availability of evidence based tools necessary for health professionals. The review aims at identifying and summarizing scientific findings concerning the relationship between neuropsychological and clinical screening tests and fitness to drive among people with chronic conditions. Studies were searched for driving ability evaluation by road test or simulator, clinical/neuropsychological examinations of participants with chronic diseases or permanent disablement impairing driving performance, primary outcomes as fatal/non-fatal traffic injuries and secondary outcomes as fitness to drive assessment. Twenty-seven studies fulfilled the inclusion criteria. Some studies included more than one clinical condition. The illness investigated were Alzheimer Disease (n=6), Parkinson Disease (n=8), Cardiovascular Accident (n=4), Traumatic Brain Injuries (n=3), Sleep Apnea Syndrome (n=2), Narcolepsy (n=1), Multiple Sclerosis (n=1) and Hepatic Encephalopathy (n=1), comorbidities (n=3). No studies match inclusion criteria about Myasthenia Gravis, Diabetes Mellitus, Renal Diseases, Hearing Disorders and Sight Diseases. No studies referred to primary outcomes. The selected studies provided opposite evidences. It would be reasonable to argue that some clinical and neuropsychological tests are effective in predicting fitness to drive even if contrasting results support that driving performance decreases as a function of clinical and neuropsychological decline in some chronic diseases. Nevertheless we found no evidence that clinical and neuropsychological screening tests would lead to a reduction in motor vehicle crashes involving chronic disabled drivers. It seems necessary to develop tests with proven validity for identifying high-risk drivers so that physicians can provide guidance to their patients in chronic conditions, and also to medical advisory boards working with licensing offices.

This link will take you to the current 'At a Glance' medical standards of fitness to drive. Information about Parkinson's disease is given on page 9.

Above picture from Devon County Council website

Magnetic resonance imaging of the substantia nigra in Parkinson's disease.

Mov Disord. 2012 May 30. doi: 10.1002/mds.25015. [Epub ahead of print]
Lehéricy S, Sharman MA, Santos CL, Paquin R, Gallea C.


Centre de NeuroImagerie de Recherche-CENIR (, Groupe Hospitalier Pitie-Salpetriere, Paris, France; Universite Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle epiniere, UMR-S975, Paris, France; Inserm, U975, Paris, France; CNRS, UMR 7225, Paris, France; ICM-Institut du Cerveau et de la Moelle epiniere, Paris, France.


Until recently, conventional magnetic resonance imaging (MRI) was most often negative in Parkinson's disease or showed nonspecific findings. Recent developments in structural MRI, including relaxometry, magnetization transfer, and neuromelanin imaging, have demonstrated improved contrast and enabled more accurate visualization of deep brain nuclei, in particular, the substantia nigra. Meanwhile, diffusion imaging has provided useful biomarkers of substantia nigra degeneration, showing reduced anisotropy and anatomical connectivity with the striatum and thalamus. These advances in structural imaging are complemented by findings of magnetic resonance spectroscopy on brain metabolism and resting-state functional MRI on functional connectivity. This article presents an overview of these new structural, metabolic, and resting-state functional MRI techniques and their implications for Parkinson's disease. The techniques are reviewed in the context of their potential for better understanding the disease in terms of diagnosis and pathophysiology and as biomarkers of its progression.

The above image is from the HowStuffWorks website (click link below)

For more information about MRI scans click the link to the NHS website below

Essential Tremor

This is a nice report from American TV channel WYOW News 19's Medical Monday report.

Distinguishing essential tremor from Parkinson's disease: bedside tests and laboratory evaluations.

Expert Rev Neurother. 2012 Jun;12(6):687-96.
Thenganatt MA, Louis ED.


Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.


Distinguishing essential tremor from Parkinson's disease can be challenging, both in the early stages of these diseases and as these diseases progress. Various tremor types (rest, postural, kinetic and intention) may be seen in both essential tremor and Parkinson's disease. Furthermore, with time, the two diseases may coexist within a single patient. Detailed clinical examination with attention to specific features of tremor (frequency, amplitude, pattern and distribution) and associated neurological findings may help distinguish patients with the two diseases. Laboratory testing may provide information that further aids in differentiating the two diseases. These tests include accelerometry and surface electromyography, spiral analysis, dopamine transporter imaging, olfactory testing and, eventually, postmortem histopathology. These tests have limitations and their diagnostic utility requires additional study.

Sunday, 3 June 2012

The management of Parkinson's disease in sub-Saharan Africa.

Expert Rev Neurother. 2012 Jun;12(6):661-6.
Dotchin C, Walker R.


Northumbria Healthcare NHS Foundation Trust, Department of Elderly Medicine, North Tyneside General Hospital, Rake Lane, North Shields, NE29 8NH, UK.


The vast majority of patients with Parkinson's disease (PD) in sub-Saharan Africa are undiagnosed and untreated with impaired quality of life and markedly increased mortality rates. PD is a progressive neurodegenerative disorder that becomes increasingly common as people age. Diagnosis remains predominantly clinical based on motor symptoms: tremor, rigidity, bradykinesia and postural instability. In developed countries, it is well recognized and very few patients will not be diagnosed and treated. However, in developing countries, such as those in sub-Saharan Africa, evidence suggests that most patients are undiagnosed, and even if they are diagnosed, they do not have access to sustainable, affordable, drug treatment and medical supervision. There is a lack of awareness, both within the general population and also among healthcare professionals, and many patients seek help from traditional healers. Even if they are diagnosed, treatment is often too expensive, and supplies are sporadic. There is a great need to increase awareness of PD within the general population and the fact that the symptoms are treatable. Education of healthcare workers about PD is also important, but a major challenge is there are few doctors and even fewer neurologists. Awareness raising and training will be to no avail, unless the problem of an affordable, reliable supply of drug treatment can be tackled.

Livedo reticularis associated with rasagiline (Azilect).

J Drugs Dermatol. 2012 Jun 1;11(6):764-5.
Strowd LC, Lee AD, Yosipovitch G.


This is a case report of a 69-year-old female with Parkinson's disease who developed an asymptomatic eruption on her legs bilaterally. Clinical and histologic examination was consistent with livedo reticularis, which was temporally associated with initiation of rasagiline. The pathogenesis of livedo reticularis is discussed along with the possible mechanisms for both rasagiline and amantidine causing drug-induced livedo reticularis in patients.

Plain English - LRRK2 G2019S Parkinson's disease with more benign phenotype than idiopathic

This research study compared patients with Parkinson's who carry the commonest gene mutation associated with the disease (called LRRK2),...