Optimizing Treatment in Undertreated Late-Stage Parkinsonism: A Pragmatic Randomized Trial.

BACKGROUND: Treatment of patients with late-stage parkinsonism is often sub-optimal. OBJECTIVE: To test the effectiveness of recommendations by a movement disorder specialist with expertise in late-stage parkinsonism. METHODS: Ninety-one patients with late-stage parkinsonism considered undertreated were included in apragmatic a pragmatic multi-center randomized-controlled trial with six-month follow-up. The intervention group received a letter with treatment recommendations to their primary clinician based on an extensive clinical assessment. Controls received care as usual. The primary outcome was the Unified Parkinson Disease Rating Scale (UPDRS)part-II (Activities of Daily Living). Other outcomes included quality-of-life (PDQ-8), mental health (UPDRS-I), motor function (UPDRS-III), treatment complications (UPDRS-IV), cognition (Mini-mental-state-examination), non-motor symptoms (Non-Motor-Symptoms-scale), health status (EQ-5D-5L) and levodopa-equivalent-daily-dose (LEDD). We also assessed adherence to recommendations. In addition to intention-to-treat analyses, a per-protocol analysis was conducted. RESULTS: Sample size calculation required 288 patients, but only 91 patients could be included. Treating physicians followed recommendations fully in 16 (28%) and partially in 21 (36%) patients. The intention-to-treat analysis showed no difference in primary outcome (between-group difference = -1.2, p = 0.45), but there was greater improvement for PDQ-8 in the intervention group (between-group difference = -3.7, p = 0.02). The per-protocol analysis confirmed these findings, and showed less deterioration in UPDRS-part I, greater improvement on UPDRS-total score and greater increase in LEDD in the intervention group. CONCLUSIONS: The findings suggest that therapeutic gains may be reached even in this vulnerable group of patients with late-stage parkinsonism, but also emphasize that specialist recommendations need to be accompanied by better strategies to implement these to further improve outcomes.

Parkinson disease in long term care facilities: a review of the literature.

Parkinson disease (PD) is common in long term care (LTC) facilities. The number of institutionalized patients with PD will rise sharply in the coming decades because of 2 concurrent phenomena: aging of the population leads to an increased PD prevalence and improved quality of care has led to a prolonged survival in advanced disease stages. Only a few studies have investigated the prevalence and clinical characteristics of patients with PD in LTC facilities. Even fewer studies have addressed the treatment strategies used to support these institutionalized patients, who are mostly in advanced stages of the disease. The available evidence suggests that current management of patients with PD in LTC facilities is less than optimal. In the Netherlands, and we suspect in many other countries, there are no formal guidelines for treating patients with PD who have been admitted to a LTC facility. In this review, we describe the epidemiology, clinical characteristics, and clinical management of patients with PD in LTC settings. We also address potentially modifiable elements of care and provide several recommendations to improve the management of PD in these facilities. We conclude by suggesting a possible guide for future research in this area.

Nonmotor symptoms in nursing home residents with Parkinson's disease: prevalence and effect on quality of life.

OBJECTIVES: To determine the prevalence of nonmotor symptoms (NMS) in nursing home (NH) residents with Parkinson's disease (PD) and to establish the association with quality of life. DESIGN: Cross-sectional. SETTING: Nursing homes in the southeast of the Netherlands. PARTICIPANTS: Nursing home residents with PD and a Mini-Mental State Examination score of 18 or greater (N = 73; mean age 78.7, disease duration 10 years, mainly Hoehn and Yahr Stages 4 (38%) and 5 (49%)) underwent detailed examination to determine the prevalence of NMS. MEASUREMENTS: Validated instruments for PD-related NMS were used to examine the NH residents with PD. The overall burden of NMS, and autonomic problems in particular, were measured using the Non-Motor Symptoms Scale (NMSS). Depression, neuropsychiatric symptoms, sleep problems, cognitive dysfunction, and motor impairments were focused on in further detail using established clinimetric tests. Linear regression analysis was used to examine the relationship between these symptoms and quality of life, which was measured using the Parkinson's Disease Questionnaire (PDQ-8). RESULTS: The NMSS revealed a mean of nearly 13 different NMS per resident. Autonomic problems (constipation, urinary urgency) were particularly prevalent (48-75% of residents). Depressive symptoms were present in 45%. The most prevalent neuropsychiatric symptoms other than depression were irritability and apathy. The most common sleep problems were overall poor nighttime sleep quality, daytime sleepiness, and nocturia. Cognitive problems were highly prevalent, and 77% of the residents met the criteria for PD-related dementia. High scores were also obtained for motor impairments. Mean PDQ-8 score was high, indicating poor quality of life. Poor quality of life was most strongly associated with the prevalence and severity of overall NMS burden (coefficient of determination = 0.45). CONCLUSION: Nonmotor symptoms were highly prevalent in NH residents with PD. Quality of life was poor, largely because of NMS. Because many NMS are potentially treatable, diagnosis and treatment of these severely affected individuals deserve more attention.

Motor profile and drug treatment of nursing home residents with Parkinson's disease.

OBJECTIVES: To examine the clinical characteristics, motor impairments, and drug treatments of nursing home residents with Parkinson's disease (PD). DESIGN: Cross-sectional study. SETTING: Nursing homes in the southeast of the Netherlands. PARTICIPANTS: Nursing home residents with PD and a Mini-Mental State Examination score of 18 or greater seen by a physician with experience in movement disorders. MEASUREMENTS: Participant characteristics, motor function, and dopaminergic medications were assessed. The Short Parkinson's Evaluation Scale/SCales for Outcomes in Parkinson's disease (SPES-SCOPA) was used to assess motor impairments and disabilities. RESULTS: Seventy-three nursing home residents with PD (mean age 78.7; 45% male; mean disease duration 10.1 years; Hoehn and Yahr 4 (38%) and 5 (49%)) were included. Most residents were severely disabled, 49% being wheelchair bound. According to the SPES-SCOPA, 44% of residents were "off" (in a motor state in which they are slow and stiff) most of the time. Dyskinesias were encountered infrequently. Most residents were mainly treated with levodopa monotherapy, and daily doses varied widely (20-1,600 mg, mean 673 mg); 25% of residents were treated with less than 400 mg levodopa daily, and 8% received no levodopa at all. The movement disorders specialist considered 32 residents to be possibly undertreated. CONCLUSION: These findings show that PD in nursing home residents is characterized by severe motor impairment and a high proportion of daily "off" time, which underscores the need for better management of PD in nursing homes, for example within specialized institutions or with periodic consultations by a movement disorders expert.

[Non-motor symptoms of Parkinson's disease]. / Niet-motorische symptomen van de ziekte van Parkinson.

Parkinson's disease has traditionally been viewed as a disease with only motor features. Nowadays, a wide variety of non-motor symptoms and signs are also recognised as being characteristic of the disease. Non-motor symptoms, most importantly autonomic dysfunction, neuropsychiatric symptoms and sleep problems, are prevalent in virtually all Parkinson's disease patients and influence the quality of life more than the motor symptoms. Patients may visit a variety of health care professionals, but non-motor symptoms are often missed, because physicians do not explicitly ask patients about them or do not recognise them as being part of the disease. Knowledge of non-motor symptoms is important to avoid unnecessary additional testing. Specific treatment options are available, as described in the Dutch multidisciplinary guidelines on Parkinson's disease.

[Meningoencephalitis caused by varicella zoster virus]. / Meningo-encefalitis door varicella-zostervirus.

Varicella zoster virus (VZV) belongs to the group of herpes viruses. It can cause a number of nervous system infections. We present 2 of 4 patients seen recently suffering from acute meningoencephalitis, in which VZV proved to be the infectious agent. The first patient was a 57-year-old woman with headache, vomiting, and sudden aggressiveness. The second patient was a 60-year-old man with headache, nausea, and vomiting. Neither patient had skin eruptions usually associated with VZV reactivation, nor had either recently suffered from herpes zoster. Both patients had in their cerebrospinal fluid a lymphocytic pleocytosis, a decreased glucose concentration and and an elevated protein concentration. The patients recovered within a few days of starting intravenous treatment with aciclovir 10 mg/kg 3 times daily for one week. Recent literature shows that VZV is a common pathogen in meningoencephalitis and is probably underestimated as a putative cause of this condition. VZV meningoencephalitis usually has a mild course, but serious complications have been reported. Patients present with headache and usually fever. Nuchal rigidity and meningeal irritation are not always present. Since the advent of the PCR technique, VZV has been readily demonstrable. Anti-viral treatment is advised despite the lack of placebo-controlled studies, and may be combined with prednisone.