Katherine Grosset

Problematic gambling on dopamine agonists: Not such a rarity.

Excessive gambling is recognized with dopamine agonist therapy, but the prevalence is unknown. We assessed the prevalence of excess gambling by specific prospective enquiry in Parkinsons disease patients attending six West Scotland movement disorder clinics. Of 388 patients taking anti‐Parkinson medication, 17 (4.4%) developed pathological gambling, all of whom were prescribed dopamine agonists. Thus, 8% of patients taking dopamine agonists had pathological gambling. Pathological gambling is not uncommon, and patients should be made aware of this potential adverse effect.

Suboptimal medication adherence in Parkinson's disease.

Patients take less medication than prescribed in many disease areas but evidence for suboptimal therapy adherence in Parkinsons disease (PD) is limited. A single‐center observational study of antiparkinsonian medication was undertaken using electronic monitoring (MEMS; Aardex, Zug, Switzerland) over 3 months. Of 68 patients approached, 6 declined and 8 dropped out, leaving 54 patients (taking 117 preparations) with available data. Poorer compliance was associated significantly with younger age, with taking more antiparkinsonian tablets per day, with higher depression scores, and with poorer quality of life. Of the 54 evaluable patients, 11 (20%) had average total compliance of under 80% (underusers) and 43 (80%) had average total compliance of over 80% (satisfactory adherence). Underusers had median total compliance of 65% (interquartile range, 37–74) versus 98% (interquartile range, 93–102) in the satisfactory adherence group. Timing compliance (number of doses taken in the correct time interval) was poor in both underusers (median, 11%; interquartile range, 2–20) and those with satisfactory adherence (median, 25%; interquartile range, 11–73). In conclusion, poorer compliance is associated with younger age, depression, and more tablets per day, and one‐fifth of PD patients underuse medication. Consideration of drug therapy adherence has implications in the management of PD.

Adherence to Antiparkinson medication in a Multicenter European study

Two small studies reported suboptimal therapy adherence in Parkinsons disease. We conducted a larger multicenter European study to assess medicine‐taking behavior. Parkinsons disease patients taking dopaminergic therapy were enrolled in 8 centers in 5 countries, and disease severity and demographics recorded. Antiparkinson drug adherence was measured for 4 weeks using electronic monitoring bottles which record the date and time of cap opening (Aardex®, Switzerland). One hundred twelve patients, mean age 65 years (standard deviation (SD) 10), with Parkinsons disease for 7.7 (SD 8.2) years completed the study. Total median adherence (doses taken/doses prescribed) was 97.7% (interquartile range [IQ] 90.6–100), days adherence (correct dose days) was 86.2% (IQ 61.1–96.2) and timing adherence (doses taken at correct time intervals) was 24.4% (IQ 5.3–56.5). Fourteen patients (12.5%) took less than 80% of prescribed doses, which was defined as suboptimal adherence. Patients with satisfactory adherence took a median of 8 mg/day (IQ 0–33) less than their prescribed dose of levodopa (P = NS), while suboptimal adherence patients took a median of 481 mg/day (IQ 205–670) less than their prescribed dose (P = 0.0006). The Parkinson motor score was significantly higher in patients with suboptimal adherence at 29 (IQ 20–40), versus those with satisfactory adherence at 19 (IQ 13–26), P = 0.005. Once daily drugs had significantly better adherence when compared with drugs prescribed more frequently (P < 0.0001). Suboptimal therapy adherence is associated with significant deviation from prescribed levodopa doses, despite greater Parkinsons motor severity. Optimizing oral medication intake has a potential role in maximizing the therapy response in Parkinsons disease.

Switching from ergot to nonergot dopamine agonists in Parkinson's disease: A clinical series and five‐drug dose conversion table

Of 99 patients on ergot‐derived dopamine agonists informed about possible long‐term side effects, switching to a nonergot was undertaken in 88 (89%). There were adverse events in 26%. After 11 months, 82% were on their switch agonist and 93% were on any agonist. Switching dopamine agonists is feasible in this population.

Two-year follow-up in 150 consecutive cases with normal dopamine transporter imaging.

Background and aims Functional pre-synaptic dopamine brain imaging is generally abnormal when parkinsonism is degenerative (such as in idiopathic Parkinsons disease) and normal in patients with non-degenerative movement disorder (such as essential tremor). However, some patients diagnosed as early Parkinsons disease have normal presynaptic dopamine imaging. Follow-up of patients with normal imaging should help determine whether such patients truly have degenerative parkinsonism (and therefore represent false negative imaging results), or emerge as cases of non-degenerative parkinsonism (and therefore represent initial clinical over-diagnosis of Parkinsons disease). Methods and results One hundred and fifty cases with normal 123I-FP-CIT SPECT undertaken during routine care over a 3-year period were reviewed 2.4 years (interquartile range, 2.2–3.1 years) after SPECT. Diagnosis after follow-up was non-degenerative parkinsonism or tremor in 146 (97%), who did not progress clinically, and degenerative parkinsonism in four (3%), in whom clinicial progression was noted. Anti-Parkinson therapy was used in 36, and withdrawn in 27 with no deterioration in 25. Patients strictly fulfilling Brain Bank criteria (part 1) were more likely to undergo a trial of anti-Parkinson therapy (P<0.05) but were no more likely to maintain or respond to anti-Parkinson therapy than those not fulfilling criteria. Conclusion The clinical profile and therapy response during follow-up of patients with normal presynaptic dopamine imaging supports the diagnosis of a non-degenerative movement disorder in nearly all cases.

Patient-perceived involvement and satisfaction in Parkinson's disease: Effect on therapy decisions and quality of life

Patient‐centered consultation styles are associated with higher patient satisfaction and improved health outcomes in diabetes and hypertension. In outpatient neurology, dissatisfaction with communication relates significantly to noncompliance. We undertook a single‐center study in Parkinsons disease (PD) using standardized questionnaires to score patient‐perceived involvement in therapy decisions (score 4 = low to 25 = high) and satisfaction with the consultation (score 1 = low to 7 = high). Correlation was tested against health outcomes of Unified Parkinsons Disease Rating Scale (UPDRS) Motor score, activities of daily living (UPDRS 2 and Schwab and England), Parkinsons disease quality of life (PDQ‐39), Mini‐Mental State Examination (MMSE), and Geriatric Depression Scale (GDS). Of 117 patients enrolled, 107 (91%) fully completed the questionnaires. Mean patient‐perceived involvement scored 14.4 (SD, 2.8). Mean satisfaction scored 5.3 (SD 0.7). Higher involvement was associated with increased satisfaction (r = 0.28; P = 0.003), particularly distress relief (r = 0.38; P < 0.0001). Communication scores correlated significantly with compliance intent (r = 0.6; P < 0.0001). There was no correlation between either involvement or satisfaction and UPDRS, Schwab and England, MMSE, or GDS. Quality of life was significantly associated with depression, UPDRS, duration of PD, compliance intent, and satisfaction. The significant positive association between compliance intent and quality of life in the more satisfied patient replicates findings in other disease areas. Due attention to these aspects in delivering care to the PD patient is appropriate.

Medicine‐taking behavior: Implications of suboptimal compliance in Parkinson's disease

Management of Parkinsons disease (PD) depends primarily on oral medication. There are several drug classes and multiple doses and formulations, which make optimizing therapy complex. Variable drug absorption and the short half‐life of most antiparkinson treatments, especially levodopa, are a main focus in understanding complications and have encouraged alternative delivery systems to limit fluctuation and dyskinesia at later stages. Comparatively little attention is paid to the way patients take their oral medication. Variable medicine‐taking behavior can affect the clinicians understanding of the diagnosis and rate of progression, and further prescription of PD medication. Medicine overuse in later stage PD is well documented and causes psychiatric disturbance and increases motor complications, but evidence of undertreatment and erratic intake is emerging, which is likely to affect motor control and quality of life adversely. Methods of quantifying compliance are compared for accuracy and limitations. Understanding medicine‐taking behavior is a first step in optimizing therapy and requires consideration of a patients personal beliefs about their medicines. Although the benefits of regularizing oral medicine‐taking in a practical, achievable way in PD remain untested, such an approach might prolong and smooth the benefits of oral medication and is worthy of further research.

Alpha-synuclein in peripheral tissues and body fluids as a biomarker for Parkinson's disease – a systematic review

Parkinsons disease (PD) is neuropathologically characterized as an alpha‐synucleinopathy. Alpha‐synuclein‐containing inclusions are stained as Lewy bodies and Lewy neurites in the brain, which are the pathological hallmark of PD. However, alpha‐synuclein‐containing inclusions in PD are not restricted to the central nervous system, but are also found in peripheral tissues. Alpha‐synuclein levels can also be measured in body fluids. The aim of this study was to conduct a systematic review of available evidence to determine the utility of alpha‐synuclein as a peripheral biomarker of PD. We searched PubMed (1948 to 26 May 2013), Embase (1974 to 26 May 2013), the Cochrane Library (up to 26 May 2013), LILACS (up to 26 May 2013) and CINAHL (up to 26 May 2013) for the studies of alpha‐synuclein in peripheral tissues or body fluids in PD. A total of 49 studies fulfilled the search criteria. Peripheral tissues such as colonic mucosa showed a sensitivity of 42–90% and a specificity of 100%; submandibular salivary glands showed sensitivity and specificity of 100%; skin biopsy showed 19% sensitivity and 80% specificity in detecting alpha‐synuclein pathology. CSF alpha‐synuclein had 71–94% sensitivity and 25–53% specificity for distinguishing PD from controls. Plasma alpha‐synuclein had 48–53% sensitivity and 69–85% specificity. Neither plasma nor CSF alpha‐synuclein is presently a reliable marker of PD. This differs from alpha‐synuclein in solid tissue samples of the enteric and autonomic nervous system, which offer some potential as a surrogate marker of brain synucleinopathy.

Accuracy of Parkinson's Disease Diagnosis in 610 General Practice Patients in the West of Scotland

UK‐based community studies have found high rates of misdiagnosis in Parkinsons disease (PD). Searches of prescription databases and case records identified 610 patients taking antiparkinson therapy for a PD diagnosis in 92 West of Scotland General Practices. Patients with no documented progression of parkinsonism and/or no increase in antiparkinson medication for 3 years were assessed by two movement disorder specialists. FP‐CIT SPECT scanning was performed in clinically uncertain cases. Those considered unlikely to have PD had antiparkinson drugs tapered then stopped, with a minimum of 6 months follow‐up. Age, sex and disease duration matched controls were also assessed. 64 of 89 (71.9%) patients meeting selection criteria were assessed, of whom 36 (56.3%) were appropriate for therapy withdrawal. Thirty three of those 36 patients (91.7%) and 3 of 64 (4.7%) controls stopped antiparkinson therapy without deterioration giving an overall total of 36 of 610 (5.9%). The revised diagnoses in this group were mainly essential tremor (ET) (n = 14) and vascular parkinsonism (VP) (n = 10). Patients managed in Primary Care were significantly more likely to complete therapy withdrawal than those attending a specialist clinic (15.3% vs. 2.6%, P < 0.0001). The total annual cost of antiparkinson medication for these 36 patients was £13,400; the mean duration of diagnosis was 6.8 years (SD 5.6). At least 1 in every 20 patients taking medication for PD is misdiagnosed. Nearly all of these patients can be identified by simple screening of prescription databases and case records in Primary Care, followed by clinical review, which allows withdrawal of unnecessary medication.

Effect of educational intervention on medication timing in Parkinson's disease: a randomized controlled trial

BackgroundMedicine usage in Parkinsons disease patients is often imperfect, in particular irregular timing of medication. The effect of informing Parkinsons disease patients about the continuous dopaminergic hypothesis (to encourage regular medicine intake) on medication adherence and motor control was tested.MethodsPatients were randomised either to the active group (receiving the intervention) or control group (no extra information). Antiparkinson medicine usage was monitored for 3 months before and after the intervention using electronic pill bottles which record the date and time of opening (MEMS®, Aardex, Switzerland) and data used to calculate the percentage of doses taken at correct time intervals.Results43 patients (52%) were randomised to active counselling, and 40 (48%) were controls (standard management). The intervention effect (difference in timing adherence pre- to post-intervention between the 2 groups) was 13.4% (CI 5.1 to 21.7), p = 0.002. Parkinson motor scores did not change significantly (active group 0.1, CI -3.4 to 3.7) versus controls (4.5, CI 1.6 to 7.1), p = 0.06.ConclusionTiming adherence, but not motor scores, improves by providing patients with extra information. Therapy timing is of potential importance in Parkinsons disease management.Trial registration numberNCT00361205