Ahmad Delbari

Management of depression in elderly stroke patients

Poststroke depression (PSD) in elderly patients has been considered the most common neuropsychiatric consequence of stroke up to 6–24 months after stroke onset. When depression appears within days after stroke onset, it is likely to remit, whereas depression at 3 months is likely to be sustained for 1 year. One of the major problems posed by elderly stroke patients is how to identify and optimally manage PSD. This review provides insight to identification and management of depression in elderly stroke patients. Depression following stroke is less likely to include dysphoria and more likely characterized by vegetative signs and symptoms compared with other forms of late-life depression, and clinicians should rely more on nonsomatic symptoms rather than somatic symptoms. Evaluation and diagnosis of depression among elderly stroke patients are more complex due to vague symptoms of depression, overlapping signs and symptoms of stroke and depression, lack of properly trained health care personnel, and insufficient assessment tools for proper diagnosis. Major goals of treatment are to reduce depressive symptoms, improve mood and quality of life, and reduce the risk of medical complications including relapse. Antidepressants (ADs) are generally not indicated in mild forms because the balance of benefit and risk is not satisfactory in elderly stroke patients. Selective serotonin reuptake inhibitors are the first choice of PSD treatment in elderly patients due to their lower potential for drug interaction and side effects, which are more common with tricyclic ADs. Recently, stimulant medications have emerged as promising new therapeutic interventions for PSD and are now the subject of rigorous clinical trials. Cognitive behavioral therapy can also be useful, and electroconvulsive therapy is available for patients with severe refractory PSD.

Motor, Psychiatric and Fatigue Features Associated with Nutritional Status and Its Effects on Quality of Life in Parkinson’s Disease Patients

Objectives Parkinson’s disease (PD) patients are more likely to develop impaired nutritional status because of the symptoms, medications and complications of the disease. However, little is known about the determinants and consequences of malnutrition in PD. This study aimed to investigate the association of motor, psychiatric and fatigue features with nutritional status as well as the effects of malnutrition on different aspects of quality of life (QoL) in PD patients. Methods One hundred and fifty patients with idiopathic PD (IPD) were recruited in this study. A demographic checklist, the Unified Parkinson’s Disease Rating Scale (UPDRS), the Hospital Anxiety and Depression Scale (HADS) and the Fatigue Severity Scale (FSS) were completed through face-to-face interviews and clinical examinations. The health-related QoL (HRQoL) was also evaluated by means of the Parkinson’s Disease Questionnaire (PDQ-39). For evaluation of nutritional status, the Mini Nutritional Assessment (MNA) questionnaire was applied together with anthropometric measurements. Results Thirty seven (25.3%) patients were at risk of malnutrition and another 3 (2.1%) were malnourished. The total score of the UPDRS scale (r = −0.613, P<0.001) and PD duration (r = −0.284, P = 0.002) had a significant inverse correlation with the total MNA score. The median score of the Hoehn and Yahr stage was significantly higher in PD patients with abnormal nutritional status [2.5 vs. 2.0; P<0.001]. More severe anxiety [8.8 vs. 5.9; P = 0.002], depression [9.0 vs. 3.6; P<0.001] and fatigue [5.4 vs. 4.2; P<0.001] were observed in PD patients with abnormal nutritional status. Except for stigma, all other domains of the PDQ-39 were significantly correlated with the total score of the MNA. Conclusion Our study demonstrates that disease duration, severity of motor and psychiatric symptoms (depression, anxiety) and fatigue are associated with nutritional status in PD. Different aspects of the HRQoL were affected by patients’ nutritional status especially the emotional well-being and mobility domains.

Effect of methylphenidate and/or levodopa coupled with physiotherapy on functional and motor recovery after stroke--a randomized, double-blind, placebo-controlled trial.

Lokk J, Salman Roghani R, Delbari A. Effect of methylphenidate and/or levodopa coupled with physiotherapy on functional and motor recovery after stroke – a randomized, double‐blind, placebo‐controlled trial. 
Acta Neurol Scand: 2011: 123: 266–273.
© 2010 John Wiley & Sons A/S.

Restless legs syndrome in patients with Parkinson's disease: a comparative study on prevalence, clinical characteristics, quality of life and nutritional status.

Restless legs syndrome (RLS) is a common neurological disorder that can coexist with Parkinsons disease (PD). However, the association between these two movement disorders is quite poorly explored and previous findings are controversial in different aspects.

A Stroke Study of an Urban Area of Iran: Risk Factors, Length of Stay, Case Fatality, and Discharge Destination

BACKGROUND The Iranian population is aging rapidly, which causes huge medical concern for health care of this population. This trend will lead to an increase in stroke incidence in the future. The aim of this study was to investigate the epidemiologic patterns, risk factors, length of hospitalization, hospital discharge destination, and case fatality of patients with ischemic stroke from a city of Iran as well as analyses of interaction of these factors. METHODS A cross-sectional, multihospital-based study was performed on all consecutively discharged and diagnosed patients with ischemic stroke in the city of Qom, Iran, between March 2006 and September 2008. RESULTS A total of 953 patients, 48.9% men and 51.1% women, were included. The mean age was 68+/-13.82 years. Hypertension was found in 64% of patients, followed by diabetes mellitus (36%), heart disease (34%), hypercholesterolemia (32%), and smoking (20%). The average length of stay (LOS) was 7.7 days (95% confidence interval 7.2-8.2). Women had a significantly longer LOS compared with men (8.4 v 7 days, P = .0075) and patients with heart disease had a significantly longer LOS (9 days, 95% confidence interval 7.8-10, P = .004). Overall 1-month fatality rate was 15.3%. CONCLUSION Hypertension and diabetes mellitus are more frequent here than average global findings. One-month case fatality was higher than in European countries but less than in developing countries. The most interesting difference comparing developed countries is the destination, which should be addressed. We strongly recommend establishing a stroke registry, establishing primary prevention, and promoting rehabilitation facilities in Iran.

Stroke epidemiology and one-month fatality among an urban population in Iran

Objective Stroke is one of the most common causes of death and disability in Iran. This study evaluated stroke patient profiles with respect to rate, risk factors, and one-month fatality. Material and method A cross-sectional, hospital-based study on all stroke patients older than 45 years admitted to hospitals in the city of Qom throughout 2001. Results Four hundred and sixty patients older than 45 years were admitted as stroke. The annual stroke rate was estimated to 338/100 000 (95% confidence interval, 300–360) inhabitants older than 45 years. The annual rate of stroke was 384/100 000 (95% confidence interval, 381–386) when adjusted to the European population. Stroke subtypes were; ischaemic infarction 75%, intracranial haemorrhage 20·7%, subarachnoid haemorrhage 3%, and undetermined 1·3%. Main risk factors were hypertension in 74·6% and diabetes in 55·7%. Mortality rate was 24·6% within the first month. Conclusion Stroke incidence was higher than in Western countries. Hypertension and diabetes mellitus were considerably more frequent in our studied stroke patients than in other developing countries. Our findings need to be addressed in future health education programmes in Iran identifying patients at risk and focusing on more aggressive prevention programmes to lower stroke incidence.

Heterogeneous Determinants of Quality of Life in Different Phenotypes of Parkinson's Disease.

Objectives Health-related quality of life (HRQoL) is considered a very important outcome indicator in patients with Parkinson’s disease (PD). A broad list of motor and non-motor features have been shown to affect HRQoL in PD, however, there is a dearth of information about the complexity of interrelationships between determinants of HRQoL in different PD phenotypes. We aimed to find independent determinates and the best structural model for HRQoL, also to investigate the heterogeneity in HRQoL between PD patients with different phenotypes regarding onset-age, progression rate and dominant symptom. Methods A broad spectrum of demographic, motor and non-motor characteristics were collected in 157 idiopathic PD patients, namely comorbidity profile, nutritional status, UPDRS (total items), psychiatric symptoms (depression, anxiety), fatigue and psychosocial functioning through physical examination, validated questionnaires and scales. Structural equation model (SEM) and multivariate regressions were applied to find determinants of Parkinson’s disease summary index (PDSI) and different domains of HRQoL (PDQ-39). Results Female sex, anxiety, depression and UPDRS-part II scores were the significant independent determinants of PDSI. A structural model consisting of global motor, global non-motor and co-morbidity indicator as three main components was able to predict 89% of the variance in HRQoL. In older-onset and slow-progression phenotypes, the motor domain showed smaller contribution on HRQoL and the majority of its effects were mediated through non-motor features. Comorbidity component was a significant determinant of HRQoL only among older-onset and non-tremor-dominant PD patients. Fatigue was not a significant indicator of non-motor component to affect HRQoL in rapid-progression PD. Conclusions Our findings showed outstanding heterogeneities in the pattern and determinants of HRQoL among PD phenotypes. These factors should be considered during the assessments and developing personalized interventions to improve HRQOL in PD patients with different phenotypes or prominent feature.

Reliability and Validity of the Persian Version of the Fatigue Severity Scale in Idiopathic Parkinson’s Disease Patients

As one of the most frequent symptoms, measurement of fatigue is an issue of interest in Parkinsons disease (PD). The fatigue severity scale (FSS) is one of the recommended questionnaires for this purpose. The aim of our study was to evaluate psychometric properties of the Persian version of the FSS (FSS-Per) to assess fatigue in PD patients. Ninety nondemented idiopathic Parkinsons disease (IPD) patients were consecutively recruited from an outpatient referral movement disorder clinic. In addition to the disease severity scales, the FSS-Per was used for fatigue measurement. The internal consistency coefficient was larger than 0.8 for all of the items with a total Cronbachs alpha of 0.96 (95% CI: 0.95–0.97). The FSS-Per score correlated with the UPDRS score (r = 0.55, P < 0.001) and the “Hoehn and Yahr” (HY) stage (r = 0.48, P < 0.001). The total score of the FSS-Per significantly discriminated IPD patients with more severe disability (HY stage > 2) versus those with less severe disease (HY stage ≤2) (AUC = 0.81 (95% CI: 0.72–0.90)). The FSS-Per fulfilled a high internal consistency and construct validity to measure the severity of fatigue in Iranian IPD patients. These acceptable psychometric properties were reproducible in subgroups of IPD patients regarding different levels of education, disease severity, sex and age groups.

Prevalence of Malnutrition in Patients with Parkinson's Disease: A Comparative Study with Healthy Controls using Mini Nutritional Assessment (MNA) Questionnaire

BACKGROUND The magnitude of malnutrition in the Parkinsons disease (PD) population has yet to be accurately quantified. OBJECTIVE We aimed to estimate and compare the prevalence of malnourished and those at risk of malnutrition in Iranian PD patients with a matched control group using the mini nutritional assessment (MNA) and anthropometric measurements. METHODS Nutritional status was evaluated in 143 Iranian PD patients (case group) and 145 age- and sex-matched healthy controls (control group) using the validated Persian version of the MNA. Individuals suffering from chronic comorbidities influencing nutritional state (hypertension and diabetes), following special diets and those with cognitive impairment were excluded. Using the MNA, a total score of <17 indicated malnutrition and scores of 17-23.5 signified cases at risk for malnutrition. RESULTS The mean of total MNA score was not significantly different between two study groups [24.4 (SD = 3.8) in controls vs. 25.1 (SD = 3.4) in PD patients; P = 0.094]. Three (2.1%) PD patients were suffering from malnutrition and another 37 (25.9%) were at risk of malnutrition; while in control group similar feature was observed (2.0% malnourished and 35.2% at risk of malnutrition; P = 0.228). The mean of calf circumference (CC) was significantly lower in PD patients [34.9 (SD = 3.8) cm vs. 36.0 (SD = 5.1) cm; P = 0.046]. CONCLUSIONS Our findings indicate the same nutritional status among mild to moderate PD patients compared with healthy controls. However, more than a quarter of the PD population was found to be at risk of malnutrition necessitating more attention towards nutritional assessment in PD.

Clinical aspects of palliative care in advanced Parkinson’s disease

Parkinsons disease (PD) is one of the most common neurodegenerative disorders of the elderly population. Few therapeutic options are available for patients with PD requiring palliative care. Treatment of the early stages of PD is entirely different from later stages. During the later stages, the palliative care model is introduced to provide the patient with comfort and support. Early palliative care in PD requires minimization of dyskinesias and decreasing occurrence of motor and non-motor off times in an effort to maximize independent motor function. In the later stages, the focus of treatment shifts to treating the predominant non-motor symptoms and having a more supportive and palliative nature. The purpose of this review is to provide a summary of the palliative care management issues and palliative care management options of end-stage PD patients.