Robert Caslake

Age-, gender-, and socioeconomic status-specific incidence of Parkinson's disease and parkinsonism in North East Scotland: The PINE study

There have been few high quality incidence studies of Parkinsons disease (PD). We measured age-, gender- and socioeconomic-specific incidence rates for parkinsonism and PD in north-east Scotland, and compared our results with those of previous high quality studies. Incident patients were identified prospectively over three years by several overlapping methods from primary care practices (total population 311,357). Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Drug-induced parkinsonism was excluded. Patients had yearly follow-up to improve diagnostic accuracy. Incidence rates using clinical diagnosis at latest follow-up were calculated for all parkinsonism and for PD by age, gender and socioeconomic status. Meta-analysis with similar studies was performed. Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD 9.8; 61% men). The crude annual incidence of parkinsonism was 28.7 per 100,000 (95% confidence interval (CI) 25.7-31.8) and PD 17.9 per 100,000 (95% CI 15.5-20.4). PD was more common in men (age-adjusted male to female ratio 1.87:1, 95% CI 1.55-2.23) but there was no difference by socioeconomic status. Meta-analysis of 12 studies showed an incidence of PD (adjusted to the 1990 Scottish population) of 14.6 per 100,000 (95% CI 12.2-17.3) with considerable heterogeneity (I(2) 95%), partially explained by population size and recruitment duration. The incidence of PD was similar to other high quality studies. The incidence of PD was not affected by socioeconomic status.

Shape analysis of 123I-N-ω-fluoropropyl-2-β-carbomethoxy-3β-(4-iodophenyl) nortropane single-photon emission computed tomography images in the assessment of patients with parkinsonian syndromes

PurposeThe purpose of this study was to show the viability and performance of a shape-based pattern recognition technique applied to 123I-N-ω-fluoropropyl-2-&bgr;-carbomethoxy-3&bgr;-(4-iodophenyl) nortropane single-photon emission computed tomography (FP-CIT SPECT) in patients with parkinsonism. MethodsA fully automated pattern recognition tool, based on the shape of FP-CIT SPECT images, was written using Java. Its performance was evaluated and compared with QuantiSPECT, a region-of-interest-based quantitation tool, and observer performance using receiver operating characteristic analysis and κ statistics. The techniques were compared using a sample of patients and controls recruited from a prospective community-based study of first presentation of parkinsonian symptoms with longitudinal follow up (median 3 years). ResultsThe shape-based technique as well as the conventional semiquantitative approach was performed by experienced observers. The technique had a high level of automation, thereby avoiding observer/operator variability. ConclusionA pattern recognition approach is a viable alternative to traditional methods of analysis in FP-CIT SPECT and has additional advantages.

Age-, and gender-specific incidence of vascular parkinsonism, progressive supranuclear palsy, and parkinsonian-type multiple system atrophy in North East Scotland: the PINE study.

INTRODUCTION There have been few incidence studies of vascular parkinsonism (VP), progressive supranuclear palsy (PSP), and parkinsonian-type multiple system atrophy (MSA-P). We measured the age-, gender- and socioeconomic-specific incidence rates for these conditions in north-east Scotland. METHODS Incident non drug-induced parkinsonian patients were identified prospectively over three years by several overlapping methods from a baseline primary care population of 311,357. Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Patients had yearly follow-up to improve diagnostic accuracy. Incidence rates using the diagnosis by established research criteria at latest follow-up were calculated for each condition by age, gender, and socioeconomic status. RESULTS Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD 9.8; 61% men). The crude annual incidence was 3.2 per 100,000 (95% confidence interval (CI) 2.2-4.3) for VP, 1.7 per 100,000 (95% CI 1.0-2.4) for PSP, and 1.4 per 100,000 (95% CI 0.8-2.1) for MSA-P. VP and MSA-P were more common in men (age-adjusted male to female ratios 2.58 (95% CI 1.65-3.83) and 8.65 (95% CI 4.73-14.5) respectively). Incidence did not vary with socioeconomic status. DISCUSSION This is the first community-based, prospective study to report the incidence of vascular parkinsonism and the third to report the incidence of PSP and MSA-P. Further follow-up and comparison with similar studies in different populations will yield valuable prognostic and aetiological information on these conditions.

The Mini-Mental Parkinson’s (MMP) as a Cognitive Screening Tool in People with Parkinson’s Disease

BACKGROUND Cognitive decline is common in Parkinsons disease (PD) but may not be adequately identified by the mini-mental state examination (MMSE), which is better suited to Alzheimers disease. The mini-mental Parkinson (MMP) examination is a cognitive screening tool designed in French specifically for PD. We aimed to establish the validity and reliability of the English language version of the MMP compared with the MMSE. METHODS People with various stages of PD underwent testing with the MMP and MMSE, which was then compared with a reference standard battery of neuropsychological tests to identify those with significant cognitive impairment. RESULTS Forty-nine patients were recruited. Both the MMP and MMSE were significantly correlated with scores on all the neuropsychological tests in the validation battery. The median MMP score was proportionally lower (80% of maximum) than the MMSE (90% of maximum) in PD patients with cognitive impairment and those with prior neuropsychiatric complications but there was no difference between the MMP and MMSE in areas under the curves (0.84) for detecting cognitive impairment. Test-retest reliability of the MMP was good (intra-class correlation coefficient 0.793). An MMP of 28 or lower out of 32 detected cognitive impairment with 87% sensitivity and 76% specificity. DISCUSSION The English language version of the MMP has now been validated. It detects more cognitive deficits in PD patients than the MMSE and identifies significant cognitive impairment in those with PD at least as well as the MMSE.

Parkinson's disease misdiagnosed as stroke.

Parkinson’s disease (PD) is a neurodegenerative disease, the clinical features of which are usually asymmetrical at presentation. This can lead to difficulty in differentiating it from other asymmetric neurological disorders. We present two cases where idiopathic PD was initially misdiagnosed as stroke, leading to a delay in appropriate symptomatic therapy. Physicians involved in diagnosis and treatment of people with strokes should consider PD when formulating their differential diagnosis.

Medicine in older adultsPractical advice for prescribing in old age

Optimizing drug therapy is an essential part of caring for an older person. Prescribing in this group has unique challenges because of the high interindividual variability in pharmacological response and the fact that frailty, rather than age, predicts physiological responses to external stimuli. The effects of drugs and how they are handled by the body change in a number of ways with increasing age. With decreasing life expectancy, drugs used for secondary prevention might not be appropriate, particularly where their adverse effects lead to a reduction in short-term quality of life. The issue of polypharmacy is of particular concern in older people who, compared with younger individuals, tend to have more disease conditions for which therapies are prescribed. A number of drugs and combinations of drugs are particularly likely to cause harm to the older person with frailty, and these should be prescribed only where there is clear benefit. Unfortunately, the process of weighing the benefits and risks of drugs in this group is made more difficult by a paucity of directly relevant evidence. Formal criteria to identify potentially inappropriate medications have been developed, but can be cumbersome to apply and suffer from a lack of flexibility. Regular medication review is an important part of management of this patient group. Suggested strategies for this are discussed.

The incidence and long-term prognosis of parkinsonian disorders in North East Scotland (the PINE Study): methods and initial recruitment

Twelfth International Congress of Parkinsons disease and Movement Disorders, Chicago, USA, 22-26 June 2008

Difficulties with control arms in repetitive magnetic stimulation studies

In their paper Arri and colleagues1 describe a small, randomised, crossover study that appears to demonstrate dramatic, if temporary, improvement in camptocormia in people with Parkinsons disease (PD) as a result of repetitive trans-spinal magnetic stimulation (rTSMS). While it is hard to argue that this treatment does not bear further investigation, it is not the effect of the treatment, but the lack of effect of the sham intervention that bears further discussion. One of the factors that has made trials in repetitive magnetic stimulation, usually applied transcranially (rTMS), difficult …

Changes in diagnosis with follow-up in an incident cohort of patients with parkinsonism

Twelfth International Congress of Parkinsons disease and Movement Disorders, Chicago, USA, 22-26 June 2008