Onanong Jitkritsadakul

Updating the recommendations for treatment of tardive syndromes: A systematic review of new evidence and practical treatment algorithm

BACKGROUND Management of tardive syndromes (TS) is challenging, with only a few evidence-based therapeutic algorithms reported in the American Academy of Neurology (AAN) guideline in 2013. OBJECTIVE To update the evidence-based recommendations and provide a practical treatment algorithm for management of TS by addressing 5 questions: 1) Is withdrawal of dopamine receptor blocking agents (DRBAs) an effective TS treatment? 2) Does switching from typical to atypical DRBAs reduce TS symptoms? 3) What is the efficacy of pharmacologic agents in treating TS? 4) Do patients with TS benefit from chemodenervation with botulinum toxin? 5) Do patients with TS benefit from surgical therapy? METHODS Systematic reviews were conducted by searching PsycINFO, Ovid MEDLINE, PubMed, EMBASE, Web of Science and Cochrane for articles published between 2012 and 2017 to identify new evidence published after the 2013 AAN guidelines. Articles were classified according to an AAN 4-tiered evidence-rating scheme. To the extent possible, for each study we attempted to categorize results based on the description of the population enrolled (tardive dyskinesia [TD], tardive dystonia, tardive tremor, etc.). Recommendations were based on the evidence. RESULTS AND RECOMMENDATIONS New evidence was combined with the existing guideline evidence to inform our recommendations. Deutetrabenazine and valbenazine are established as effective treatments of TD (Level A) and must be recommended as treatment. Clonazepam and Ginkgo biloba probably improve TD (Level B) and should be considered as treatment. Amantadine and tetrabenazine might be considered as TD treatment (Level C). Pallidal deep brain stimulation possibly improves TD and might be considered as a treatment for intractable TD (Level C). There is insufficient evidence to support or refute TS treatment by withdrawing causative agents or switching from typical to atypical DRBA (Level U).

Systematic review of hardware-related complications of Deep Brain Stimulation: Do new indications pose an increased risk?

INTRODUCTION Deep Brain Stimulation (DBS) is an effective treatment extended broadly to many neurological and psychiatric disorders. Nevertheless, complications may arise during DBS procedures or following implantation due to implanted hardware. This may result in both minor and major adverse events that may necessitate hardware removal and/or compromise maximal therapeutic benefit for the patient. OBJECTIVES AND METHODS To identify relevant literature on hardware-related complications from DBS procedures by performing a systematic review, and propose how to identify at-risk group and possible preventive approaches. RESULTS Of 4592 abstract screened, 96 articles fulfilled the selection criteria and were reviewed. Overall, the most common hardware-related complications were infections (5.12% of patients), followed by lead migration (1.60%), fracture or failure of the lead or other parts of the implant (1.46% and 0.73%, respectively), IPG malfunctions (1.06% of patients), and skin erosions without infections (0.48% of patients). New indications for DBS, including Tourettes syndrome, cluster headache, and refractory partial epilepsy, were found to bear a higher incidence of hardware-related infections than established indications such as Parkinsons disease. The highest rate of lead fracture or failure was found in dystonia patients (4.22%). Ultimately, the highest rate of pain at the implantation sites was found in refractory partial epilepsy patients (16.55%). CONCLUSION Our analysis identified a variety of potential hardware-related complications among patients who underwent DBS procedures. Patients who were at risk of complications, such as patients with dystonia and off-label indications (e.g. Tourettes syndrome) should be informed prior to surgery and closely followed thereafter.

Identifying gaps in knowledge about Parkinson disease among medical professionals in Thailand

Although Dr. James Parkinson wrote his classic essay “The Shaking Palsy” almost 200 years ago to inform the scientific and medical communities about the disease that now bears his name, the fundamental dynamics of Parkinson disease (PD) are still not fully understood.1 Perhaps because the criteria for diagnosing PD all relate to movements, many people, including physicians, have the misconception that PD primarily is a movement disorder when, in fact, it has a great impact on many other physical and psychological functions as well. In light of the absence of a definitive understanding of the basic etiology of PD and the comprehensive scope of its impact, the medical responses to this neurodegenerative disease often are influenced by misconceptions based on myths and false assumptions.

What daily activities increase the risk of falling in Parkinson patients? An analysis of the utility of the ABC-16 scale

BACKGROUND Although the strongest predictor of falling in Parkinsons disease is the number of falls in the preceding year, little information is available on what types of daily activities (ADLs) that are associated with a significant fall risk in this population. OBJECTIVES To determine balance confidence (FOF) in PD patients by utilizing the 16-item Activities-Specific Balance Confidence Scale (ABC-16), and identifying specific activities from this scale that are predictors of future falls. METHODS 160 patients with PD, and 52 age-matched healthy controls completed the Thai-validated version of the ABC-16. The number of falls during the past month was obtained from both groups. RESULTS PD patients reported lower confidence in their ability to maintain balance during ADLs compared to controls (p<0.001) with the lowest confidence score being item 16 (walking on slippery sidewalks). A significant negative correlation was observed between the number of falls in the previous month, and a mean ABC-16 score (r=-0.387, p<0.001). Logistic regression analysis identified the strongest predictor of fall in PD patients was item 9 (getting in/out of car; OR=4.8), followed by item 6 (standing on chair to reach; OR=3.4), and item 3 (picking up slippers from floor; OR=2.6). All of these high-risk activities involve movement in the vertical orientation. CONCLUSION FOF was more common in PD patients than controls. In patients with postural instability and visual impairment, high-risk activities should be minimized, avoided, or performed only under supervision. It is recommended that fall prevention strategies include physical therapy interventions that are targeted at these activities.

Understanding the role of the Parkinson's disease nurse specialist in the delivery of apomorphine therapy

Optimal care of Parkinsons disease (PD) patients should involve a multidisciplinary team (MDT) of which a PD nurse specialist (PDNS) is a key member. The role of a PDNS is particularly prominent in the care of advanced PD patients suitable for apomorphine because, in addition to nursing skills, apomorphine treatment requires liaison, training, interaction and coordination with patients, caregivers and other members of the MDT as well as the interface with primary care physicians. The therapeutic success of apomorphine therapy depends not only upon the pharmacologic drug response, but also on how well the patient understands his/her disease and how to handle the therapy. In this respect, a PDNS is a vital member of the MDT who provides education and training, support, and is available for consultation when problems arise. In this article, we review the literature on the contribution of PDNSs in both continuous subcutaneous apomorphine infusion and intermittent subcutaneous apomorphine injection and highlight the various beneficial aspects of PDNS care, supported by scientific evidence when available. Despite a low level of published evidence, there is strong clinical evidence that the impact of PDNSs on the management of apomorphine therapy is vital and indispensable for the success of this treatment.

Exploring the effect of electrical muscle stimulation as a novel treatment of intractable tremor in Parkinson's disease

BACKGROUND As the pathophysiology of tremor in Parkinson disease (PD) involves a complex interaction between central and peripheral mechanisms, we propose that modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) may improve tremor temporarily. OBJECTIVES To determine the efficacy of EMS as a treatment for drug resistant tremor in PD patients. METHODS This study was a single-blinded, quasi-experimental study involving 34 PD patients with classic resting tremor as confirmed by tremor analysis. The EMS was given at 50Hz over the abductor pollicis brevis and interrosseus muscles for 10s with identified tremor parameters before and during stimulation as primary outcomes. RESULTS Compared to before stimulation, we observed a significant reduction in the root mean square (RMS) of the angular velocity (p<0.001) and peak magnitude (p<0.001) of resting tremor while tremor frequency (p=0.126) and dispersion (p=0.284) remained unchanged during stimulation. The UPDRS tremor score decreased from 10.59 (SD=1.74) before stimulation to 8.85 (SD=2.19) during stimulation (p<0.001). The average percentage of improvement of the peak magnitude and RMS angular velocity was 49.57% (SD=38.89) and 43.81% (SD=33.15) respectively. 70.6% and 61.8% of patients experienced at least 30% tremor attenuation as calculated from the peak magnitude and RMS angular velocity respectively. CONCLUSIONS Our study demonstrated the efficacy of EMS in temporarily improving resting tremor in medically intractable PD patients. Although tremor severity decreased, they were not completely eliminated and continued with a similar frequency, thus demonstrating the role of peripheral reflex mechanism in the modulation of tremor, but not as a generator. EMS should be further explored as a possible therapeutic intervention for tremor in PD.

Nocturnal Manifestations of Atypical Parkinsonian Disorders

Although nocturnal disturbances are increasingly recognized as an integral part of the continuum of daytime manifestations of Parkinsons disease (PD), there is still little evidence in the medical literature to support the occurrence of these complex phenomena in patients with atypical parkinsonian disorders (APDs). Based on the anatomical substrates in APDs, which are considered to be more extensive outside the basal ganglia than in PD, we might expect that patients with APDs encounter the whole range of nocturnal disturbances, including motor, sleep disorders, autonomic dysfunctions, and neuropsychiatric manifestations at a similar, or even greater, frequency than in PD. This article is a review of the current literature on the problems at nighttime of patients with progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration, and dementia with Lewy bodies. MEDLINE, life science journals and online books were searched by querying appropriate key words. Reports were included if the studies were related to nocturnal manifestations in APDs. Forty articles fulfilled the selection criteria. Differences between these symptoms in APDs and PD are highlighted, given the evidence available about each manifestation. This analysis of nocturnal manifestations of APDs suggests the need for future studies to address these issues to improve the quality of life not only of patients with APDs but the caregivers who encounter the challenges of supporting these patients on a daily basis.

Knowledge, attitudes and perceptions of Parkinson's disease: A cross-sectional survey of Asian patients

BACKGROUND A knowledge gap about Parkinsons disease (PD) often exists amongst PD patients, the level and accuracy of which can influence their attitude and perceptions about the disease. Increased awareness of this information deficit can help physicians identify interventions that will improve patients knowledge and perceptions about PD. OBJECTIVES To evaluate general understanding of PD and identify knowledge gaps amongst PD patients using a validated PD knowledge questionnaire. METHODS A cross-sectional, questionnaire-based study was conducted in 108 PD patients (34 working; 74 retired). The questionnaire covers three domains of PD, including diagnosis, therapeutic options, and disease course with a total knowledge score ranging from 0 to 26. Subjects with dementia were excluded. RESULTS Patient misconceptions were reflected in the mean (SD) total, diagnosis, therapeutic options, and disease course scores: 14.64 (3.32), 7.76 (1.93), 3.85 (1.28), and 3.03 (1.41) respectively. The working age subgroup had significantly higher knowledge scores than the retired age group for the whole questionnaire (p=0.004), as well as the diagnosis (p=0.001) and therapeutic sections (p=0.023). Three dependent variables, including younger age at recruitment (<60years old), female gender, and higher disease duration (≥4years), were identified as predictors of a higher level of PD knowledge amongst PD patients. CONCLUSION Significant knowledge gaps were identified amongst PD patients in all three aspects of the questionnaire. Timely identification of patients with inaccurate or insufficient disease-related knowledge could help healthcare professionals choose more suitable multimodal educational interventions.

Physicians’ role in the determination of fitness to drive in patients with Parkinson’s disease: systematic review of the assessment tools and a call for national guidelines

BackgroundPhysicians are usually at the forefront when the issue of driving ability is raised by Parkinson’s disease (PD) patients or their family members, even though few have been formally trained in this area.Objectives and methodsTo identify relevant literature on driving assessment tools in patients with PD by performing a systematic review on this subject in order to provide background information for physicians on what types of driving assessment are available, and to delineate the role of physicians in providing fitness to drive recommendations.ResultsOf 1,490 abstracts screened, 55 articles fulfilled the selection criteria that investigated assessment of driving ability in PD patients with questionnaires, off-road testing battery, driving simulators, and driving skill tests (on-road tests and naturalistic driving test). Despite different methodology across studies, PD patients were observed to commit more driving errors than controls. Poor driving performance correlated with motor, visual, and cognitive severity. Excessive daytime somnolence was common in PD drivers and the presence of falling asleep while driving was identified to be a significant predictor of car accidents.ConclusionAlthough the evidence indicated more driving errors among PD drivers as identified by various assessment tools, the extent on how physicians should be involved in the evaluation process and make related recommendations remain unclear. Driving safety is an important public health issue in PD that needs better-defined specific legal and medical guidelines. National guidelines that establish risk assessment protocols involving multidisciplinary assessments are needed to assist physicians in making appropriate referrals for additional evaluations and recommendations when patients are deemed to be unsafe drivers.

Non-Motor Symptoms Assessed by Non-Motor Symptoms Questionnaire and Non-Motor Symptoms Scale in Parkinson's Disease in Selected Asian Populations

Background: Ethnic variations have been described in medical conditions, such as hypertension, diabetes, and multiple sclerosis. Whether ethnicity plays a role in Parkinsons disease (PD), particularly with regard to non-motor symptoms (NMS), remains unclear. Existing literature is diverse, controversial, and inadequately documented. This review aims to analyse and report the currently available literature on NMS, specifically in Asian PD patients. Summary: We conducted a literature review using PubMed, searching for articles and currently available publications that reference and assess NMS in PD patients living in Asia using the validated NMS Questionnaire (NMS Quest) and NMS Scale (NMSS). In total, 24 articles were included: 12 using the NMS Quest and 12 using the NMSS. Symptoms of constipation, memory impairment, and nocturia were the most frequently self-reported symptoms (NMS Quest) in selected Asian populations, while symptoms within the domains sleep/fatigue, attention/memory, and mood/apathy were most prevalent when applying the health-professional completed NMSS. Key Messages: NMS are generally prevalent and highly burdensome within selected Asian PD populations living in countries included in this review. Our review suggests that NMS-driven phenotypic heterogeneity is present in Asian patients, and compared to Western PD populations there might be variations in assessed NMS.