G. Deuschl

Frequency of dementia, depression, and other neuropsychiatric symptoms in 1,449 outpatients with Parkinson’s disease

Neuropsychiatric symptoms (NPS) of Parkinson’s disease (PD) are of growing diagnostic and therapeutic importance. Data on their prevalence and characteristics have been primarily derived from highly selective clinical populations. We have conducted a national study in the outpatient care sector to provide a fuller characterization of the frequency of dementia, depression, and other NPS in PD outpatients. We also examined associations with biosocial and neurological variables. A nationwide representative sample of 1,449 PD outpatients was examined with a standardized clinical interview. PD severity was rated with the Hoehn and Yahr (HY) scale and the Unified Parkinson’s Disease Rating Scale. Depression was measured with the Montgomery-Asberg Depression Rating Scale. Cognitive impairment and dementia were assessed with the Mini-Mental State Exam and according to diagnostic criteria. Logistic regression analyses were used to investigate associations. At least one NPS occurred in 71% of all patients with PD. The estimated prevalences (ranges) by age group and HY-stage were: depression, 25% (13.2–47.9%), dementia, 29% (12.2–59.4%), and psychotic syndromes, 12.7% (3.1–40.9%). Other frequent complications were sleep disturbances (49%) and anxiety (20%). Depression was associated with gender but not with age. Dementia was associated with age. The rates and comorbidity of depression and dementia were driven by PD severity. NPS were highly prevalent in our comprehensive patient sample, largely representative of management problems occurring in an outpatient setting. PD outpatients are at an increased risk for all neuropsychiatric conditions, increasing with PD severity but not with age or age of onset (except dementia), revealing challenging symptom patterns.

Autonomic dysfunction in 3414 Parkinson's disease patients enrolled in the German Network on Parkinson's disease (KNP e.V.): the effect of ageing

We analysed non‐motor symptoms (NMS) related to autonomic dysfunction in 3414 patients with Parkinsons disease (PD) enrolled in the multicentre registry of the German Competence Network on PD. Orthostatic hypotension (>20 mmHg systolic or >10 mmHg diastolic) was reported for 10% of women and 11% of men, urinary incontinence for 22% of women and 21% of men, sexual dysfunction for 8% of women and 30% of men (50% of whom reported erectile dysfunction) and sleep disturbances for 43% of women and 35% of men. Autonomic symptoms occurred in a frequency similar to severe disabling dyskinesia which was reported for 16% of women and 11% of men. A logistic regression analyses with age, sex and disease duration as covariates revealed a significant correlation of orthostatic hypotension and urinary incontinence with age and disease duration whilst sexual dysfunction was related to age only. These observations suggests that the effects of the PD process and ageing contribute to non‐levodopa responsive NMS. Sleep disturbances were more common in women and a correlation was found with disease duration only supporting the notion that sleep is specifically affected in PD.

Depression and care-dependency in Parkinson’s disease: Results from a nationwide study of 1449 outpatients

Parkinsons disease (PD) is frequently compounded by neuropsychiatric complications, increasing disability. The combined effect of motor and mental status on care-dependency in PD outpatients is not well characterized. We conducted a cross-sectional study of 1449 PD outpatients. The assessment comprised the Montgomery-Asberg Depression Rating Scale (MADRS) and the diagnostic criteria for dementia. PD severity and treatment complications were rated using Hoehn and Yahr staging and the Unified Parkinsons Disease Rating Scale (UPDRS) IV. The acknowledged level of care-dependency was documented. Care-dependency was present in 18.3% of all patients. A total of 13.9% had dementia, 18.8% had depression, and 14.3% had both. Regression analyses revealed increasing effects of age, PD duration, and PD severity on care-dependency in all three mental-disorder subgroups with the strongest effects in patients with depression only. Depressed patients with antidepressive treatment still had significantly higher PD severity, higher MADRS and UPDRS-IV scores but were not more likely to be care-dependent than non-depressed patients. Older age, longer duration and increased severity of PD contribute to care-dependency in patients with untreated depression. Treatment of depression is associated with lower rates of care-dependency.

[Dementia and depression determine care dependency in Parkinson's disease: analysis of 1,449 outpatients receiving nursing care in Germany]

BACKGROUND Parkinsons disease (PD) is frequently accompanied by dementia or depression which can aggravate the clinical picture of the disease and increase the risk of care dependency (CD). Little is known about the associations between PD, these neuropsychiatric comorbidities and CD in outpatients. PATIENTS AND METHODS A nationwide sample of outpatients (n=1,449) was examined by office-based neurologists (n=315) comprising the documentation of the general, neurological status and the degree of CD. The dementia status was clinically rated according to the established DSM-IV criteria. Depression was screened with the Montgomery-Asberg Depression Rating Scale (MADRS). RESULTS Overall, 18.3% of all patients were care dependent. Even after adjustment for PD severity, patients with depression (OR=2.8; 95% CI 1.8-4.3), dementia (OR=2.7; 95% CI 1.8-4.1) or both (OR=3.9; 95% CI 2.5-60,0) were at higher risk for CD than patients without dementia or depression. Patients aged ≥76 years were fourfold more likely to be care dependent than patients aged ≤65 years (OR=3.5; 95% CI 2.3-5.5). Across all age groups, patients with depression featured the highest increments (from 11.9 to 42.0%). CONCLUSION The risk for CD is substantially elevated in outpatients with PD when further neuropsychiatric symptoms are present. The data suggest that depression contributes equally to disability as does dementia.

Tiefe Hirnstimulation bei Morbus Parkinson: wann und für wen?

Deep brain stimulation (DBS) is an effective and evidence-based treatment option for Parkinsons disease. Studies have shown that DBS has good and long-term effects on motor function and quality of life for patients in an advanced stage of the disease and that it is more effective than medical therapy alone. Moreover, a favorable effect of DBS could also be detected at an earlier stage of the disease. On the other hand, possible risks and side effects of the procedure need to be taken into consideration. These can manifest as procedure-related complications, such as bleeding and infections in addition to stimulation-associated phenomena, such as neuropsychiatric disorders and motor side effects. Despite the good effects of DBS important issues still need to be addressed which will be discussed in this article considering the results of several new randomized and controlled clinical studies. For patients with Parkinsons disease with early fluctuations and dyskinesia, DBS has been found to be superior to the best pharmaceutical treatment; therefore, DBS can be considered as a treatment option in the earlier course of the disease. The diagnostic evaluation and the exclusion of contraindications are crucial for patient selection. The choice of the target should be based on the individual symptoms in patients although the subthalamic nucleus (STN) can be considered the standard target. In every case an individual assessment of chances and risks must be conducted and realistic goals and reasonable expectations must be defined.ZusammenfassungDie tiefe Hirnstimulation (THS) stellt eine effektive und evidenzbasierte Therapieoption in der Behandlung der Parkinson-Erkrankung dar. Studien haben belegt, dass die THS gute und langanhaltende Effekte auf die Motorik und die Lebensqualität der Patienten in einem fortgeschrittenen Krankheitsstadium hat und einer rein medikamentösen Therapie überlegen ist. Erst kürzlich konnte nun auch eine positive Wirkung der THS in einem früheren Stadium der Erkrankung nachgewiesen werden. Dem stehen die Risiken und Nebenwirkungen des Verfahrens gegenüber, die sich als prozedural-assoziierte Komplikationen, wie Blutungen und Infektionen, aber auch als therapieassoziierte Phänomene, wie etwa neuropsychiatrische Störungen und motorische Nebenwirkungen, manifestieren können. Trotz der guten Wirksamkeit der THS bleiben weiterhin wichtige klinische Fragen offen, denen sich diese Übersichtsarbeit unter Berücksichtigung neuer randomisierter, kontrollierter Studien widmet.Nach diesen Studien ist die THS der besten medikamentösen Behandlung schon früher im Krankheitsverlauf, nämlich beim ersten Auftreten von Wirkfluktuationen oder Dyskinesien, überlegen und kann somit schon zu diesem Zeitpunkt als Therapieoption in Erwägung gezogen werden. Die strenge Indikationsstellung ist ebenso wie der Ausschluss von Kontraindikationen für den Erfolg der Intervention entscheidend. Die Wahl des Zielpunktes sollte sich an der individuellen Symptomausprägung des Patienten ausrichten, wobei sich der Nucleus subthalamicus (STN) als Standardziel etabliert hat. In jedem Fall müssen eine individuelle Abwägung von Chancen und Risiken erfolgen und mit dem Patienten eine realistische Zielsetzung sowie angemessene Erwartungen formuliert werden.SummaryDeep brain stimulation (DBS) is an effective and evidence-based treatment option for Parkinson’s disease. Studies have shown that DBS has good and long-term effects on motor function and quality of life for patients in an advanced stage of the disease and that it is more effective than medical therapy alone. Moreover, a favorable effect of DBS could also be detected at an earlier stage of the disease. On the other hand, possible risks and side effects of the procedure need to be taken into consideration. These can manifest as procedure-related complications, such as bleeding and infections in addition to stimulation-associated phenomena, such as neuropsychiatric disorders and motor side effects. Despite the good effects of DBS important issues still need to be addressed which will be discussed in this article considering the results of several new randomized and controlled clinical studies.For patients with Parkinson’s disease with early fluctuations and dyskinesia, DBS has been found to be superior to the best pharmaceutical treatment; therefore, DBS can be considered as a treatment option in the earlier course of the disease. The diagnostic evaluation and the exclusion of contraindications are crucial for patient selection. The choice of the target should be based on the individual symptoms in patients although the subthalamic nucleus (STN) can be considered the standard target. In every case an individual assessment of chances and risks must be conducted and realistic goals and reasonable expectations must be defined.

Die neue Tremorklassifikation der International Parkinson and Movement Disorder Society

Tremor is one of the most frequent movement disorders. The recently published new classification of the Movement Disorder Society separates the clinical description of tremor syndromes as so-called axis 1 symptom constellations from the etiologies of tremor (axis 2). The same tremor syndromes can therefore be combined with different causes and vice versa. The terminology used in this classification is precisely defined and thereby also the necessary language for medical communication. Frequent tremor syndromes, such as enhanced physiologic tremor, dystonic and parkinsonian tremor as well as focal tremors and task and position-specific tremors are discussed with respect to the phenomenology, and current therapy.

[Deep brain stimulation for Parkinson's disease: timing and patient selection].

Deep brain stimulation (DBS) is an effective and evidence-based treatment option for Parkinsons disease. Studies have shown that DBS has good and long-term effects on motor function and quality of life for patients in an advanced stage of the disease and that it is more effective than medical therapy alone. Moreover, a favorable effect of DBS could also be detected at an earlier stage of the disease. On the other hand, possible risks and side effects of the procedure need to be taken into consideration. These can manifest as procedure-related complications, such as bleeding and infections in addition to stimulation-associated phenomena, such as neuropsychiatric disorders and motor side effects. Despite the good effects of DBS important issues still need to be addressed which will be discussed in this article considering the results of several new randomized and controlled clinical studies. For patients with Parkinsons disease with early fluctuations and dyskinesia, DBS has been found to be superior to the best pharmaceutical treatment; therefore, DBS can be considered as a treatment option in the earlier course of the disease. The diagnostic evaluation and the exclusion of contraindications are crucial for patient selection. The choice of the target should be based on the individual symptoms in patients although the subthalamic nucleus (STN) can be considered the standard target. In every case an individual assessment of chances and risks must be conducted and realistic goals and reasonable expectations must be defined.ZusammenfassungDie tiefe Hirnstimulation (THS) stellt eine effektive und evidenzbasierte Therapieoption in der Behandlung der Parkinson-Erkrankung dar. Studien haben belegt, dass die THS gute und langanhaltende Effekte auf die Motorik und die Lebensqualität der Patienten in einem fortgeschrittenen Krankheitsstadium hat und einer rein medikamentösen Therapie überlegen ist. Erst kürzlich konnte nun auch eine positive Wirkung der THS in einem früheren Stadium der Erkrankung nachgewiesen werden. Dem stehen die Risiken und Nebenwirkungen des Verfahrens gegenüber, die sich als prozedural-assoziierte Komplikationen, wie Blutungen und Infektionen, aber auch als therapieassoziierte Phänomene, wie etwa neuropsychiatrische Störungen und motorische Nebenwirkungen, manifestieren können. Trotz der guten Wirksamkeit der THS bleiben weiterhin wichtige klinische Fragen offen, denen sich diese Übersichtsarbeit unter Berücksichtigung neuer randomisierter, kontrollierter Studien widmet.Nach diesen Studien ist die THS der besten medikamentösen Behandlung schon früher im Krankheitsverlauf, nämlich beim ersten Auftreten von Wirkfluktuationen oder Dyskinesien, überlegen und kann somit schon zu diesem Zeitpunkt als Therapieoption in Erwägung gezogen werden. Die strenge Indikationsstellung ist ebenso wie der Ausschluss von Kontraindikationen für den Erfolg der Intervention entscheidend. Die Wahl des Zielpunktes sollte sich an der individuellen Symptomausprägung des Patienten ausrichten, wobei sich der Nucleus subthalamicus (STN) als Standardziel etabliert hat. In jedem Fall müssen eine individuelle Abwägung von Chancen und Risiken erfolgen und mit dem Patienten eine realistische Zielsetzung sowie angemessene Erwartungen formuliert werden.SummaryDeep brain stimulation (DBS) is an effective and evidence-based treatment option for Parkinson’s disease. Studies have shown that DBS has good and long-term effects on motor function and quality of life for patients in an advanced stage of the disease and that it is more effective than medical therapy alone. Moreover, a favorable effect of DBS could also be detected at an earlier stage of the disease. On the other hand, possible risks and side effects of the procedure need to be taken into consideration. These can manifest as procedure-related complications, such as bleeding and infections in addition to stimulation-associated phenomena, such as neuropsychiatric disorders and motor side effects. Despite the good effects of DBS important issues still need to be addressed which will be discussed in this article considering the results of several new randomized and controlled clinical studies.For patients with Parkinson’s disease with early fluctuations and dyskinesia, DBS has been found to be superior to the best pharmaceutical treatment; therefore, DBS can be considered as a treatment option in the earlier course of the disease. The diagnostic evaluation and the exclusion of contraindications are crucial for patient selection. The choice of the target should be based on the individual symptoms in patients although the subthalamic nucleus (STN) can be considered the standard target. In every case an individual assessment of chances and risks must be conducted and realistic goals and reasonable expectations must be defined.

Tiefe Hirnstimulation bei Morbus Parkinson: wann und für wen?@@@Deep brain stimulation for Parkinson’s disease: timing and patient selection

Deep brain stimulation (DBS) is an effective and evidence-based treatment option for Parkinsons disease. Studies have shown that DBS has good and long-term effects on motor function and quality of life for patients in an advanced stage of the disease and that it is more effective than medical therapy alone. Moreover, a favorable effect of DBS could also be detected at an earlier stage of the disease. On the other hand, possible risks and side effects of the procedure need to be taken into consideration. These can manifest as procedure-related complications, such as bleeding and infections in addition to stimulation-associated phenomena, such as neuropsychiatric disorders and motor side effects. Despite the good effects of DBS important issues still need to be addressed which will be discussed in this article considering the results of several new randomized and controlled clinical studies. For patients with Parkinsons disease with early fluctuations and dyskinesia, DBS has been found to be superior to the best pharmaceutical treatment; therefore, DBS can be considered as a treatment option in the earlier course of the disease. The diagnostic evaluation and the exclusion of contraindications are crucial for patient selection. The choice of the target should be based on the individual symptoms in patients although the subthalamic nucleus (STN) can be considered the standard target. In every case an individual assessment of chances and risks must be conducted and realistic goals and reasonable expectations must be defined.ZusammenfassungDie tiefe Hirnstimulation (THS) stellt eine effektive und evidenzbasierte Therapieoption in der Behandlung der Parkinson-Erkrankung dar. Studien haben belegt, dass die THS gute und langanhaltende Effekte auf die Motorik und die Lebensqualität der Patienten in einem fortgeschrittenen Krankheitsstadium hat und einer rein medikamentösen Therapie überlegen ist. Erst kürzlich konnte nun auch eine positive Wirkung der THS in einem früheren Stadium der Erkrankung nachgewiesen werden. Dem stehen die Risiken und Nebenwirkungen des Verfahrens gegenüber, die sich als prozedural-assoziierte Komplikationen, wie Blutungen und Infektionen, aber auch als therapieassoziierte Phänomene, wie etwa neuropsychiatrische Störungen und motorische Nebenwirkungen, manifestieren können. Trotz der guten Wirksamkeit der THS bleiben weiterhin wichtige klinische Fragen offen, denen sich diese Übersichtsarbeit unter Berücksichtigung neuer randomisierter, kontrollierter Studien widmet.Nach diesen Studien ist die THS der besten medikamentösen Behandlung schon früher im Krankheitsverlauf, nämlich beim ersten Auftreten von Wirkfluktuationen oder Dyskinesien, überlegen und kann somit schon zu diesem Zeitpunkt als Therapieoption in Erwägung gezogen werden. Die strenge Indikationsstellung ist ebenso wie der Ausschluss von Kontraindikationen für den Erfolg der Intervention entscheidend. Die Wahl des Zielpunktes sollte sich an der individuellen Symptomausprägung des Patienten ausrichten, wobei sich der Nucleus subthalamicus (STN) als Standardziel etabliert hat. In jedem Fall müssen eine individuelle Abwägung von Chancen und Risiken erfolgen und mit dem Patienten eine realistische Zielsetzung sowie angemessene Erwartungen formuliert werden.SummaryDeep brain stimulation (DBS) is an effective and evidence-based treatment option for Parkinson’s disease. Studies have shown that DBS has good and long-term effects on motor function and quality of life for patients in an advanced stage of the disease and that it is more effective than medical therapy alone. Moreover, a favorable effect of DBS could also be detected at an earlier stage of the disease. On the other hand, possible risks and side effects of the procedure need to be taken into consideration. These can manifest as procedure-related complications, such as bleeding and infections in addition to stimulation-associated phenomena, such as neuropsychiatric disorders and motor side effects. Despite the good effects of DBS important issues still need to be addressed which will be discussed in this article considering the results of several new randomized and controlled clinical studies.For patients with Parkinson’s disease with early fluctuations and dyskinesia, DBS has been found to be superior to the best pharmaceutical treatment; therefore, DBS can be considered as a treatment option in the earlier course of the disease. The diagnostic evaluation and the exclusion of contraindications are crucial for patient selection. The choice of the target should be based on the individual symptoms in patients although the subthalamic nucleus (STN) can be considered the standard target. In every case an individual assessment of chances and risks must be conducted and realistic goals and reasonable expectations must be defined.

Demenz und Depression determinieren Pflegebedürftigkeit bei M. ParkinsonDementia and depression determine care dependency in Parkinson’s disease

BACKGROUND Parkinsons disease (PD) is frequently accompanied by dementia or depression which can aggravate the clinical picture of the disease and increase the risk of care dependency (CD). Little is known about the associations between PD, these neuropsychiatric comorbidities and CD in outpatients. PATIENTS AND METHODS A nationwide sample of outpatients (n=1,449) was examined by office-based neurologists (n=315) comprising the documentation of the general, neurological status and the degree of CD. The dementia status was clinically rated according to the established DSM-IV criteria. Depression was screened with the Montgomery-Asberg Depression Rating Scale (MADRS). RESULTS Overall, 18.3% of all patients were care dependent. Even after adjustment for PD severity, patients with depression (OR=2.8; 95% CI 1.8-4.3), dementia (OR=2.7; 95% CI 1.8-4.1) or both (OR=3.9; 95% CI 2.5-60,0) were at higher risk for CD than patients without dementia or depression. Patients aged ≥76 years were fourfold more likely to be care dependent than patients aged ≤65 years (OR=3.5; 95% CI 2.3-5.5). Across all age groups, patients with depression featured the highest increments (from 11.9 to 42.0%). CONCLUSION The risk for CD is substantially elevated in outpatients with PD when further neuropsychiatric symptoms are present. The data suggest that depression contributes equally to disability as does dementia.