Malco Rossi

Decision-making in Parkinson’s disease patients with and without pathological gambling

Background and purpose:  Pathological gambling (PG) in Parkinson’s disease (PD) is a frequent impulse control disorder associated mainly with dopamine replacement therapy. As impairments in decision‐making were described independently in PG and PD, the objective of this study was to assess decision‐making processes in PD patients with and without PG.

Autosomal dominant cerebellar ataxias: a systematic review of clinical features.

To assess, through systematic review, distinctive or common clinical signs of autosomal dominant cerebellar ataxias (ADCAs), also referred to as spinocerebellar ataxias (SCAs) in genetic nomenclature.

Validation of a new scale for the evaluation of sialorrhea in patients with Parkinson's disease

Sialorrhea is common in Parkinson disease (PD), affecting approximately 70% to 75% of patients. Several tools for measuring saliva volume or production exist, but none are designed specifically for assessing sialorrhea‐related discomfort. The objective of this study was to develop and validate a clinical scale for subjective evaluation of sialorrhea in PD. In Phase I, internal consistency of the Sialorrhea Clinical Scale for PD (SCS‐PD) was established in 39 PD patients. In Phase II, scale validity was proven through saliva volume measurements obtained in 49 PD patients and 27 healthy volunteers. Internal consistency estimated using Cronbachs alpha was 0.78, indicating none of the original seven items tested needed to be removed. Twenty‐one patients complaining of sialorrhea (63%) studied during Phase II, showed higher SCS‐PD scores but no differences in saliva volume. SCS‐PD scores showed significant correlation with saliva volume (r = 0.41; P = 0.004) and with total Unified Parkinsons Disease Rating Scale Part III (UPDRS III) scores (r = 0.70). Furthermore, saliva volume showed inverse relation to age in PD patients as well as in controls (r = −0.3 and r = −0.4; P < 0.05), but SCS‐PD scores did not. The SCS‐PD scale showed good internal consistency and validity, providing support for its use in routine clinical sialorrhea‐related discomfort evaluation.

Parkinson's disease sleep scale, sleep logs, and actigraphy in the evaluation of sleep in parkinsonian patients.

The aim of this study was to compare the results of the day-to-day self-evaluation of sleep quality by sleep logs with Parkinson’s disease sleep scale (PDSS) in Parkinson’s disease (PD) patients. Actigraphy was used as an independent analysis of nighttime activity interfering with sleep. A total of 71 idiopathic PD patients and 21 age- and sex-matched normal individuals lacking any type of sleep disturbance were recruited. Sleep was evaluated by PDSS, 7-d sleep log and actigraphy. Sleep logs and PDSS showed reduced sleep quality and daytime somnolence scores in moderate/severe PD patients as compared to healthy controls. Significant correlations were found between sleep quality in sleep logs and all domains of PDSS sleep quality, except for the presence of nocturia, which correlated with nocturnal activity. PD severity and depression were the only predictors of reduced sleep quality. The retrospective and day-to-day sleep self-evaluations were coincident. Reduced sleep quality was related to increased PD severity and depression scores.

Management of constipation in Parkinson’s disease

Introduction: Constipation is a frequent non-motor feature of Parkinson’s disease (PD). It is the most common gastrointestinal symptom of the disease and it can precede motor symptoms by as much as 20 years. Constipation can produce discomfort and affect activities of daily living, productivity and quality of life, thus warranting early diagnosis and treatment. Areas covered: In this review, the safety and efficacy of traditional and novel strategies for constipation management will be discussed. A treatment algorithm for constipation in PD will be presented. Expert opinion: Polyethylene glycol and lubiprostone are first-line compounds recommended by evidence-based medicine guidelines for the treatment of constipation due to slow colonic transit in PD. Management of constipation secondary to defecatory dysfunction due to pelvic floor dyssynergia can be done by levodopa or apomorphine injections, botulinum toxin type A injection into the puborectalis muscle, and nonpharmacological interventions, like biofeedback therapy or functional magnetic stimulation, which showed some benefit in PD patients with constipation, but in general more extensive studies are warranted.

Validation of the sleep related items of the Non-motor Symptoms Questionnaire for Parkinson's disease (NMSQuest)

BACKGROUND The Non-motor Symptoms Questionnaire (NMSQuest) is a recently developed questionnaire for the evaluation of non-motor symptoms in Parkinsons disease (PD) patients, which includes sleep disorders evaluation. The clinical validity of the questionnaire has not been explored. OBJECTIVE To assess the performance of the sleep/fatigue domain of the NMSQuest against other sleep measures. METHODS Seventy PD patients were instructed to wear an actigraph and to fill in a sleep log over seven consecutive days in addition to the Parkinsons Disease Sleep Scale (PDSS) and the NMSQuest. RESULTS PD patients who reported daytime sleepiness on NMSQuest obtained a significantly worse score on the PDSS sleepiness domain than PD patients who did not (12.0+/-4.7 vs. 14.7+/-3.4, p<0.009). Patients reporting difficulty getting to sleep or staying asleep at night, showed lower scores on PDSS sleep quality domain than those without difficulties (15.8+/-5.4 vs. 22.3+/-4.6, p<0.001). The presence of vivid dreams, acting out dreams and restlessness on NMSQuest correlated with PDSS and sleep log scores. Increased nocturnal activity was noted in subjects reporting acting out dreams. Furthermore, the number of positive answers to the sleep-fatigue questions of the NMSQuest correlated significantly with PDSS total score, sleep log total score and nocturnal activity measured by actigraphy. CONCLUSION NMSQuest sleep-fatigue domain identified appropriately sleep disturbances indicating its usefulness as a screening tool for sleep disorders in PD patients.

Movement Disorders in Autosomal Dominant Cerebellar Ataxias: A Systematic Review

Autosomal dominant cerebellar ataxias (ADCAs) are clinically heterogeneous disorders classified according to genetic subtype and collectively known as SCAs. In a few SCAs, movement disorders can be the most frequent extracerebellar sign. The aim of this article is to perform a systematic review of movement disorders frequency and characteristics in ADCAs. This work consisted of a structured search of electronic databases up to January 2013. Publications containing descriptions of ADCA clinical features written in several languages were selected initially based on title and abstract screening, followed by full‐text reading of potentially relevant publications. Clinical findings and demographic data on genetically confirmed patients were extracted. Analysis of individual patient data from subjects with movement disorders was performed using the chi‐square test and logistic regression. One thousand and sixty‐six publications reviewing 12,151 patients from 30 different SCAs were analyzed. Individual data were available from 755 patients with at least one type of movement disorder during overall disease course. Of 422 patients in whom onset symptom data were available, one third referred a movement disorder as the initial symptom. During overall disease course, parkinsonism was common in many SCA subtypes, frequently described in the absence of ataxia and characterized as responding to dopaminergic medications. Motor complications developed occasionally in some patients as did nigrostriatal imaging alterations. Other frequent features were dystonia, chorea, and myoclonus. Rare conditions, such as akathisia, paroxysmal nonkinesigenic dyskinesia, or stiff person‐like syndrome, were also reported. ADCA descriptions included a full range of movement disorders. Aside from postural or intention tremor, dopamine‐responsive parkinsonism and dystonia were the most common.

Activity—Rest Rhythm Abnormalities in Parkinson's Disease Patients are Related to Dopaminergic Therapy

ABSTRACT Objectives: To compare going to bed, waking-up, and immobility onset and offset times in Parkinsons disease (PD) patients receiving levodopa and/or dopamine agonists (i.e., dopaminergic therapy or DT) with “de novo” patients and healthy controls and to correlate these parameters with self-reported sleep disturbances. Methods: Fifteen “de novo” and 60 PD patients on DT were included in the study. Twenty-three subjects without history of sleep complaints and similar age and sex distributions as the PD patients served as controls. Going to bed and waking-up times were registered in 7-day sleep logs. Nocturnal immobility onset and offset times were measured using actigraphy. Sleep disorders were assessed applying the PD sleep scale (PDSS). Results: Patients on DT showed earlier waking-up and immobility offset times (40 min) compared with controls and “de novo” patients. Multivariable regression analysis showed that DT but not Hoehn & Yahr score was a significant and independent predictor of early awakening time (OR == 4.0, 95%% CI == 1.15–14.13). Patients manifesting more frequent nighttime psychotic symptoms and more frequent daytime somnolence showed earlier going to bed and waking-up times. Conclusions: Results suggest that activity–rest rhythm alteration in PD may be a consequence of DT but not of disease stage. Altered sleep cycles correlated with diurnal somnolence and nocturnal psychosis.

Nonmotor Symptoms Groups in Parkinson's Disease Patients: Results of a Pilot, Exploratory Study

Nonmotor symptoms (NMS) like neuropsychiatric symptoms, sleep disturbances or autonomic symptoms are a common feature of Parkinsons disease (PD). To explore the existence of groups of NMS and to relate them to PD characteristics, 71 idiopathic non-demented PD out-patients were recruited. Sleep was evaluated by the PD Sleep Scale (PDSS). Several neuropsychiatric, gastrointestinal and urogenital symptoms were obtained from the NMSQuest. Sialorrhea or dysphagia severity was obtained from the Unified PD Rating Scale activities of daily living section. MADRS depression scale was also administered. Exploratory factor analysis revealed the presence of 5 factors, explaining 70% of variance. The first factor included PDSS measurement of sleep quality, nocturnal restlessness, off-related problems and daytime somnolence; the second factor included nocturia (PDSS) and nocturnal activity; the third one included gastrointestinal and genitourinary symptoms; the forth one included nocturnal psychosis (PDSS), sialorrhea and dysphagia (UPDRS); and the last one included the MADRS score as well as neuropsychiatric symptoms. Sleep disorders correlated with presence of wearing-off, nocturia with age >69 years, and nocturnal psychosis with levodopa equivalent dose or UPDRS II score. Neuropsychiatric symptoms correlated with UPDRS II+III score and non-tricyclic antidepressants. These results support the occurrence of significant NMS grouping in PD patients.

Actigraphic evaluation of motor fluctuations in patients with Parkinson's disease.

ABSTRACT Background: There is growing interest in developing inexpensive and objective motor fluctuation evaluation methods for Parkinsons disease (PD). Objectives: We aim to compare activity level in the off state, on state, and dyskinetic periods as evaluated either by a physician during a levodopa challenge or by a 72-hr on–off diary self-evaluation in the ambulatory setting. Finally, the effect of daily activities on motor activity in PD and healthy controls was further explored. Methods: The study was conducted in three consecutive phases. For phase I, in which the on state, off state, and dyskinesia were evaluated using actigraphy, recordings were made during standard acute levodopa challenge in nine dyskinetic PD patients. For phase II, a different set of 16 dyskinetic PD patients was monitored in the ambulatory setting for 72 consecutive hours by actigraphy and a standardized on–off diary. For phase III, 62 PD patients and 14 age- and sex-matched healthy controls wore an actigraph and completed a daily activities diary for 7 days. Results: No differences in activity level between on state and off state during the acute levodopa challenge (phase I) or the 72-hr ambulatory period (phase II) were found. Activity during dyskinesia periods was significantly higher than during on state periods without dyskinesia (p < .01). During the third phase, dyskinetic PD patients and healthy controls showed higher actigraphy-measured activity as compared to de novo, stable, or fluctuating PD (p < .0001), which remained unaltered by daily activities performed during the study period. Tremor UPDRS scores did not correlate with activity level. Conclusions: These results confirm the lack of specificity of simple wrist-worn actigraphy and further suggest it may be suitable for dyskinesia assessment but not for on state and off state evaluation.