Minjik Kim

Nonmotor Symptoms and Cognitive Decline in de novo Parkinson's Disease.

BACKGROUND Cognitive impairments are common in Parkinsons disease (PD). Despite its clinical importance, the development of dementia is still difficult to predict. In this study, we investigated the possible associations between non-motor symptoms and the risk of developing dementia within a 2-year observation period in PD. METHODS A total of 80 patients with PD participated in this study. Nonmotor symptoms (the Nonmotor Symptoms Questionnaire), PD status (Unified Parkinsons Disease Rating Scale), depression (Geriatric d Depression Scale or Montgomery-Asberg Depression Scale), stereopsis and severity of nonmotor symptoms (Non-motor symptoms scale) were assessed. Global cognitive function (Mini-Mental State Examination) were evaluated at baseline and 2 years later. RESULTS Presence of depression, vivid dreaming, REM sleep behavior disorders, hyposmia, abnormal stereopsis, non-smoking and postural instability/ gait disturbance phenotype were associated with a significantly more rapid decline of Mini-Mental State Examination. Logistic regression analyses demonstrated that depression (odds ratio=13.895), abnormal stereopsis (odds ratio=10.729), vivid dreaming (odds ratio=4.16), REM sleep behavior disorders (odds ratio=5.353) and hyposmia (odds ratio=4.911) were significant independent predictors of dementia risk within 2 years. Postural instability/ gait disturbance phenotype and age >62 years were also independent predictors of dementia risk (odd ratio=38.333, odds ratio=10.625). CONCLUSIONS We suggest that depression, vivid dreaming, REM sleep behavior disorders, hyposmia and abnormal stereopsis are closely associated with cognitive decline, and that presence of these nonmotor symptoms predict the subsequent development of Parkinsons disease dementia.

Nonmotor symptoms in essential tremor: Comparison with Parkinson's disease and normal control.

BACKGROUND Recently, the definition of essential tremor (ET) has evolved to have two different meanings. One refers to classic ET, a benign mono-symptomatic disorder, and the other refers to a heterogeneous neurodegenerative disorder. The aim of this study was to categorize nonmotor symptoms according to ET phenotype, and compare them, along with autonomic function, in people with Parkinsons disease (PD) and normal controls. METHODS We divided patients with ET into 3 subtypes according to their motor features: 23 Pure-ET, 25 Cerebellar-ET, and 12 Parkinsonism-ET. Comparisons were made between 30 PD subjects and 22 normal controls, and 60 subjects with ET. The following assessments were conducted: the Nonmotor Symptoms Scale, the Mini-Mental State Exam, Montreal Cognitive Assessment, the Montgomery-Asberg Depression Rating Scale, Neuropsychiatric Inventory Questionnaire, Beck Anxiety Inventory, the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and the Scales for Outcomes in Parkinsons Disease-Autonomic. RESULTS There were significant differences in the Nonmotor Symptoms Scale total scores of the ET, PD, and control groups (ET: 25.500 ± 2.346; PD: 27.960 ± 3.267; CONTROL 3.328 ± 3.796.). There were no significant differences in terms of each ET phenotype. ET patients had significant cognitive dysfunction, neuropsychiatric problems including depression and have complained about significant autonomic dysfunction and excessive daytime somnolence compared to normal controls. CONCLUSIONS Patients with ET have several nonmotor symptoms similar to those of patients with PD, which have a similar impact on their quality of life. Therefore, nonmotor symptoms should be considered in the clinical evaluation and management of ET.

The interrelationship between non-motor symptoms in Atypical Parkinsonism

BACKGROUND Atypical Parkinsonism is less common and has more severe symptoms than Parkinsons disease (PD). Little is known about the non-motor symptom (NMS) characteristics of multiple systemic atrophy (MSA) or progressive supranuclear palsy (PSP). We report the interrelationship of NMS in MSA, PSP, and PD. METHODS We studied 117 cases of PD and 57 of Atypical Parkinsonism. Out of the 57 patients, 31 had multiple systemic atrophy parkinsonian subtype (MSA-P), 14 had multiple systemic atrophy cerebellar dysfunction subtype (MSA-C), and 12 had PSP. We assessed the condition of the patients using the United Parkinsons Disease Rating Scale part III (UPDRS-III), the modified Hoehn & Yahr scale (H&Y), the non-motor symptom scale (NMSS), and the Parkinsons Disease Questionnaire (PDQ-39). RESULTS In Atypical Parkinsonism, the NMSS scores significantly correlated with PDQ-39 scores, but not with UPDRS-III. In the MSA-P group, the mood/cognitive domain significantly correlated with both the urinary and sleep/fatigue domains. In the MSA-C group, the sleep/fatigue domain correlated with the mood/cognition and cardiovascular domains. Finally, in the PSP and PD groups, the attention/memory domain significantly correlated with the sleep/fatigue and mood/cognition domains. DISCUSSION These results suggest that, with respect to cognitive function, dysautonomia and sleep/fatigue are detrimental factors in MSA and PSP, respectively.

Is reduced arm and leg swing in Parkinson's disease associated with rigidity or bradykinesia?

BACKGROUND AND PURPOSE Arm and leg swings during gait are reduced and asymmetric in Parkinsons disease (PD). Although rigidity and bradykinesia are interconnected with each other, and related with gait hypokinesia including arm and leg swing alteration, it remains uncertain which factor is more responsible for the decrease of arm and leg swings. The study aimed to uncover which factor between rigidity and bradykinesia is more associated with the reduction of arm and leg swings during gait. METHODS Patients with PD were selected and divided into a concordance group (21 patients) representing a match of both symptoms and a discordance group (nineteen patients) exhibiting a mismatch of pronounced rigidity and bradykinesia. Visual inspections of video clips for asymmetric features of gait and posture including arm swing, leg swing, shoulder position, external foot rotation were analyzed and accessed by two independent neurologists blindly. RESULTS The side of more pronounced rigidity was significantly and moderately related with the side of more decreased arm and leg swings (p<0.001, κ=0.592 in arm swing; p=0.011, κ=0.432 in leg swing, respectively), but the side of more dominant bradykinesia was associated with neither arm nor leg swing asymmetry (p=1, κ=0.014 in arm swing; p=1, κ=-0.036 in leg swing). In addition, asymmetric posturing including shoulder position and a laterally rotated foot showed no relationship with rigidity or bradykinesia. CONCLUSION The reduction of arm and leg swings during gait in PD was associated with rigidity, but not with bradykinesia.

Clinical phenotype of drug-naïve Parkinson's disease based on nonmotor symptoms.

BACKGROUND Nonmotor symptoms in Parkinsons disease (PD) are heterogeneous and can result in a variety of symptoms at various disease stages. The objective of the present study was to identify clinically meaningful nonmotor symptoms and to assess the relationship between changes in nonmotor symptoms and cognition and motor symptoms. METHODS A total of 159 patients who had drug-naïve PD participated in this study. Nonmotor symptoms (Nonmotor Symptoms Scale), PD status (Unified Parkinsons Disease Rating Scale), depression (Geriatric Depression Scale or Montgomery-Asberg Depression Scale) and health-related quality of life (39-item Parkinsons Disease Questionnaire) were assessed. An exploratory factor analysis was performed to establish a nonmotor symptom factor, which was analyzed to evaluate whether the results were associated with the clinical severity measures. RESULTS Exploratory factor analysis revealed one factor comprised of sleep/fatigue, attention/memory and mood/cognition. The modified Hoehn and Yahr Stage, Unified Parkinsons Disease Rating Scale Part III, Montgomery-Asberg Depression Scale and the 39-item Parkinsons Disease Questionnaire Summary Index were independently associated with the sleep/fatigue, attention/memory and mood/cognition domains. The presence of these domains was associated with advanced Parkinsons disease or depressed mood. CONCLUSIONS This study shows that motor impairment and depressed mood in PD are related to sleep/fatigue, attention/memory and mood/cognition. Sleep/fatigue, attention/memory and mood/cognition also had a major impact on health-related quality of life. It is appropriate to identify patients with severe motor symptoms and depressed mood in order to signify the need to consider more detailed care and further assessment.

Lesions on DWI and the outcome in hyperacute posterior circulation stroke

BACKGROUND few studies have addressed the association between the characteristics of ischemic lesions detected by diffusion-weighted imaging (dWi) and the clinical outcome in patients with hyperacute posterior circulation ischemic stroke. this study demonstrates a relationship between the findings assessed by dWi and the outcome in patients with hyperacute posterior circulation ischemic stroke. METHODS We reviewed data from 118 patients who had posterior circulation ischemic stroke within six hours from the onset of their symptoms. the clinical outcome included early neurological deterioration (end) and a favorable outcome at three months after the onset of symptoms. using dWi, the lesion volume and the number and location of injured anatomical regions were analyzed to evaluate whether the results correlated with the clinical outcome measures. RESULTS the number of injured anatomical regions assessed by dWi was associated with the initial and delayed neurological status. Both the total volume and the number of injured anatomical regions associated with end and a favorable outcome. analysis of the location of the injured regions determined that only a pontine lesion independently associated with end. interestingly, four out of five patients who underwent decompressive craniectomy exhibited a large infarction volume but minor symptoms. CONCLUSIONS in patients with hyperacute posterior circulation ischemic strokes, the lesions assessed by dWi were associated with the clinical outcome, regardless of the initial neurological status. dWi is an effective initial imaging tool for assessing the extent of lesions and clinical outcomes in patients with hyperacute posterior circulation ischemic stroke.

Differential diagnosis of parkinsonism with visual inspection of posture and gait in the early stage

BACKGROUND Parkinsons disease (PD) differs from atypical parkinsonism in many clinical aspects. Principally, posture and gait are distinct features in the early stages of the disease; thus, these differences can be helpful in differential diagnosis. METHODS We analyzed videos of patients with PD or atypical parkinsonism. A total of 76 patients with early PD (n=56) or atypical parkinsonism (n=20) were included. Items related to posture and gait were classified into three categories (standing, gait and associated symptoms) and each sub-item was analyzed. RESULTS Asymmetric arm-swing (p=0.004) and accompanying tremor (p=0.016) were significant indicators of early-stage PD. Staggering gait (p=0.007) and en-bloc turning (p=0.026) were more common in atypical parkinsonism. Characteristics with a high odds-ratio for atypical parkinsonism were en-bloc turning (β=8.475, p=0.032) and normal arm-swing (β=14.6084, p=0.036). CONCLUSIONS Visual inspection of gait and posture provides reliable clues in the differential diagnosis of parkinsonism.

Quantification of the Effect of Medication and Deep Brain Stimulation on Parkinsonian Rigidity

This study aims to quantify the effects of medication (Med) and deep brain stimulation (DBS) on resting rigidity in patients with Parkinson`s disease. We tested 10 limbs of five patients under each of four treatment conditions: 1) baseline, 2) DBS, 3) Med, 4) DBS + Med. Rigidity at the wrist joint was assessed using the Unified Parkinson`s Disease Rating Scale (UPDRS). The examiner randomly imposed flexion and extension movement on patient`s wrist joint. Resistance to passive movement was quantified by viscoelastic properties. Not only rigidity score but also damping constant showed improvements in rigidity by DBS and Med treatments (p