Mediating effect of mutuality on caregiver burden in Parkinson's disease partners.

Objectives: Parkinson's disease (PD) is a complex neurodegenerative disorder with a broad list of motor and non-motor symptoms (NMS) that has been shown to affect the relationship quality (mutuality) and caregiver burden. However, little is known if the effect of motor and NMS on caregiver burden is mediated by mutuality. Therefore, the aim of this study was to explore if perceived mutuality by patients and partners mediates the effect of motor and NMS on caregiver burden.Methods: Data were collected from 51 dyads with one PD patient, including measures of motor signs, NMS, impaired cognition, patients' and partners' perceived mutuality, caregiver burden and dependency in activities in daily life (ADL). Structural equation model with manifest variables were applied to explore if patients' and partners' mutuality score mediated the effect of motor signs, NMS, ADL or impaired cognition on caregiver burden.Result: Our results suggest that having a partner with PD who is dependent in ADL or has impaired cognition decreases partners' mutuality which leads to elevated burden. Motor symptoms or other NMS were not associated with partners' mutuality or caregiver burden. Instead, increasing severity of motor symptoms decrease patients' mutuality in turn leading to lower level of partners' mutuality.Conclusion: Our findings enhance the understanding of the complexity of living with PD for the partner and suggest that clinical assessment should include evaluation of how PD symptoms influence the quality of the relationship between partners and patients.

The older patient's experience of the healthcare chain and information when undergoing colorectal cancer surgery according to the enhanced recovery after surgery concept.

AIMS AND OBJECTIVES: To describe how older patients experience the healthcare chain and information given before, during and after colorectal cancer surgery. BACKGROUND: Most persons with colorectal cancer are older than 70 years and undergo surgery with subsequent enhanced recovery programmes aiming to quickly restore preoperative function. However, adaptation of such programmes to suit the older patient has not been made. DESIGN: Qualitative descriptive study. METHOD: Semi-structured interviews were conducted on 16 patients undergoing colorectal cancer surgery at a Swedish University Hospital. The inductive content analysis was employed. RESULTS: During the period of primary investigation and diagnosis, a paucity of information regarding the disease and management, and lack of help in coping with the diagnosis of cancer and its impact on future life, leads to a feeling of vulnerability. During their stay in hospital, the patient's negative perception of the hospital environment, their need for support, and uncertainty and anxiety about the future are evident. After discharge, rehabilitation is perceived as lacking in structure and individual adaptation, leading to disappointment. Persistent difficulty with nutrition delays recovery, and confusion regarding division of responsibility between primary and specialist care leads to increased anxiety and feelings of vulnerability. Information on self-care is perceived as inadequate. Furthermore, provided information is not always understood and therefore not useful. CONCLUSION: Information before and after surgery must be tailored to meet the needs of older persons, considering the patient's knowledge and ability to understand. Furthermore, individual nutritional requirements and preoperative physical activity and status must be taken into account when planning rehabilitation. RELEVANCE TO CLINICAL PRACTICE: Patient information must be personalised and made understandable. This can improve self-preparation and participation in the own recovery. Special needs must be addressed early and followed up.

Increased 1-year survival and discharge to independent living in overweight hip fracture patients: A prospective study of 843 patients.

BACKGROUND AND PURPOSE: Hip fracture patients usually have low body mass index (BMI), and suffer further postoperative catabolism. How BMI relates to outcome in relatively healthy hip fracture patients is not well investigated. We investigated the association between BMI, survival, and independent living 1 year postoperatively. PATIENTS AND METHODS: This prospective multicenter study involved 843 patients with a hip fracture (mean age 82 (SD 7) years, 73% women), without severe cognitive impairment and living independently before admission. We investigated the relationship between BMI and both 1-year mortality and ability to return to independent living. RESULTS: Patients with BMI > 26 had a lower mortality rate than those with BMI < 22 and those with BMI 22-26 (6%, 16%, and 18% respectively; p = 0.006). The odds ratio (OR) for 1-year survival in the group with BMI > 26 was 2.6 (95% CI: 1.2-5.5) after adjustment for age, sex, and physical status. Patients with BMI > 26 were also more likely to return to independent living after the hip fracture (OR = 2.6, 95% CI: 1.4-5.0). Patients with BMI < 22 had similar mortality and a similar likelihood of independent living to those with BMI 22-26. INTERPRETATION: In this selected group of patients with hip fracture, the overweight and obese patients (BMI > 26) had a higher survival rate at 1 year, and returned to independent living to a higher degree than those of normal (healthy) weight. The obesity paradox and the recommendations for optimal BMI need further consideration in patients with hip fracture.

Mini Nutritional Assessment (MNA) is Rather a Reliable and Valid Instrument to Assess Nutritional Status in Iranian Healthy Adults and Elderly with a Chronic Disease.

This study aimed to evaluate the usefulness of the Mini Nutritional Assessment (MNA) to assess nutritional status of Iranian population and to compare its psychometric properties between patients suffering from a chronic disease, healthy elderly and younger adults. As a group of elderly with a chronic disease, 143 Parkinson's disease (PD) patients and as the control group, 467 healthy persons were enrolled. The Persian-translated version of MNA was filled-up through interviews together with anthropometric measurements. Cronbach's α coefficient of entire MNA was 0.66 and 0.70 in healthy individuals and PD patients, respectively. The total MNA score could significantly discriminate the ones with BMI ≥ 24kg/m(2) in both groups. In general, MNA was a valid and reliable tool for nutritional assessment. We acknowledge study limitations including lack of serum measurements and a selection bias towards mild-to-moderate PD. MNA is a more reliable tool in older healthy individuals and rather younger elderly with PD.

A novel 6-item screening questionnaire for Parkinsonism: validation and comparison between different instruments.

BACKGROUND: Several instruments have been developed to screen Parkinson's disease (PD); yet, there is no consensus on the items, number of questions, and diagnostic accuracy. We aimed to develop a new questionnaire combining the best items with highest validity to screen parkinsonism and to compare its diagnostic value with that of the previous instruments using the same database. METHODS: 157 patients with parkinsonism and 110 healthy controls completed a comprehensive screening questionnaire consisting of 25 items on different PD symptoms used in previous studies. To select the optimal items, clinical utility index (CUI) was calculated and those who met at least good negative utility (CUI ≥0.64) were selected. Receiver operating characteristics (ROC) curves analysis was used to compare the area under the curve (AUC) of different screening instruments. RESULTS: Six items on 'stiffness & rigidity', 'tremor & shaking', 'troublesome buttoning', 'troublesome arm swing', 'feet stuck to floor' and 'slower daily activity' demonstrated good CUI. The new screening instrument had the largest AUC (0.977) compared to other instruments. CONCLUSIONS: We selected a new set of six items to screen parkinsonism, which showed higher diagnostic values compared to the previously developed questionnaires. This screening instrument could be used in population-based PD surveys in poor-resource settings.

Psychometric study of the Persian short-form eight-item Parkinson's disease questionnaire (PDQ-8) to evaluate health related quality of life (HRQoL).

BACKGROUND: To assess validation and reliability of the Persian version of the short-form 8-item Parkinson's disease questionnaire (PDQ-8) and to compare its psychometric properties with that of the long-form questionnaire (PDQ-39) in order to evaluate the health-related quality of life (HRQoL) in patients with Parkinson's disease (PD). METHODS: This cross-sectional study was conducted on 114 non-demented idiopathic PD (IPD) patients consecutively recruited from an outpatient referral movement disorder clinic. Patients were interviewed to fill in the Persian version of PDQ-39 and PDQ-8 questionnaires and clinical examination was performed to measure disease severity indices. RESULTS: The Cronbach's alpha coefficient of the entire PDQ-8 was 0.740 (95% CI: 0.661-0.806). Replacement of PDQ-8 items with other questions with the highest internal consistency within each dimension of the original PDQ-39 did not improve Cronbach's alpha coefficient [0.723 (95% CI: 0.639-0.794)]. The scores from both PDQ-8 and PDQ-39 had significant correlation with the Hoehn & Yahr (rPDQ-8 = 0.376, rPDQ-39 = 0.442), and Schwab & England (rPDQ-8 = -0.503, rPDQ-39 = -0.598) disease severity scales and disease duration (rPDQ-8 = 0.342, rPDQ-39 = 0.396). CONCLUSIONS: Persian version of the short-form PDQ (PDQ-8) was shown to be a valid and reliable instrument to assess disease-specific HRQoL in a PD population when used independently. Although the PDQ-8 items were not necessarily those with the highest internal consistency in the components of PDQ-39, they entirely showed proper psychometric properties especially in mental and behavioral aspects. PDQ-8 is a practical and informative instrument in daily clinical practice where clinicians are in shortage of time and when a validated self-reported brief questionnaire is of value.

Seizures and epilepsy in elderly patients of an urban area of Iran: clinical manifestation, differential diagnosis, etiology, and epilepsy subtypes.

The incidences of seizures and epilepsy in the population show a peak after 60 years of age. Due to the lack of reported clinical aspects of seizure and epilepsy in the older patients in our region in Iran, this study was conducted to describe the clinical manifestation, etiology, differential diagnosis, and epilepsy subtypes of epilepsy and seizure. A cross-sectional retrospective study was performed on all consecutively elderly seizure and epilepsy patients, referred to the Epilepsy Association in the city of Qom, Iran over a 10-year period. A total of 466 patients aged >60 years were admitted. 31 % of the patients had epilepsy or seizure and 69 % of them had non-epileptic events. The most prevalent differential diagnoses in the beginning were syncope and cardiovascular disorders. The most frequent clinical symptom of epilepsy was generalized tonic-clonic seizures (75 %). The most common cause of seizure was systemic metabolic disorder (27 %). In epileptic elderly patients, no cause was ascertained for 38 % and the most frequently observed pathological factors were cerebrovascular diseases, which accounted for 24 %. The most common type of epileptic seizure was generalized epileptic seizures (75 %). 10 % of elderly epileptic patients suffered from status epilepticus, which was primarily caused by anoxia. Despite the rising rate and potentially profound physical and psychosocial effects of seizures and epilepsy, these disorders have received surprisingly little research focus and attention in Iran. Referring older patients to a specialist or a specialist epilepsy center allows speedy assessment, appropriate investigation and treatment, and less likely to miss the diagnosis.

Short- and long-term effects of tactile massage on salivary cortisol concentrations in Parkinson's disease: a randomised controlled pilot study.

BACKGROUND: Parkinson's disease (PD) is a chronic neurodegenerative disorder with limited knowledge about the normal function and effects of non-pharmacological therapies on the hypothalamic-pituitary-adrenal (HPA) axis. The aim of the study was to analyse the basal diurnal and total secretion of salivary cortisol in short- and long-term aspects of tactile massage (TM). DESIGN: Prospective, Controlled and Randomised Multicentre Trial. SETTING AND INTERVENTIONS: Forty-five women and men, aged 50-79 years, were recruited. Twenty-nine of them were blindly randomised to tactile massage (TM) and 16 of them to the control group, rest to music (RTM). Ten interventions were given during 8 weeks followed by a 26 weeks of follow up. Salivary cortisol was collected at 8 am, 1 pm, 8 pm, and 8 am the next day, on five occasions. With the first and eighth interventions, it was collected immediately before and after intervention. MAIN OUTCOME MEASURES: The primary aim was to assess and compare cortisol concentrations before and immediately after intervention and also during the follow-up period. The secondary aim was to assess the impact of age, gender, body mass index (BMI), duration and severity of PD, effects of interventional time-point of the day, and levodopa doses on cortisol concentration. RESULTS: The median cortisol concentrations for all participants were 16.0, 5.8, 2.8, and 14.0 nmol/L at baseline, later reproduced four times without significant differences. Cortisol concentrations decreased significantly after TM intervention but no change in diurnal salivary cortisol pattern was found. The findings of reduced salivary cortisol concentrations immediately after the interventions are in agreement with previous studies. However, there was no significant difference between the TM and control groups. There were no significant correlations between cortisol concentrations and age, gender, BMI, time-point for intervention, time interval between anti-parkinson pharmacy intake and sampling, levodopa doses, duration, or severity of PD. CONCLUSIONS: Diurnal salivary cortisol rhythm was normal. Salivary cortisol concentrations were significantly reduced after the TM intervention and after RTM, but there were no significant differences between the groups and no sustained long-term effect. No associations were seen between salivary cortisol concentration and clinical and/or pharmacological characteristics. TRIAL REGISTRATION: ClinicalTrial.gov, NCT01734876 and FoU Sweden 108881.

Challenges of Teleneurology in the Care of Complex Neurodegenerative Disorders: The Case of Parkinson's Disease with Possible Solutions.

Teleneurology is a specialist field within the realm of telemedicine, which is dedicated to delivering neurological care and consultations through virtual encounters. Teleneurology has been successfully used in acute care (e.g., stroke) and outpatient evaluation for chronic neurological conditions such as epilepsy and headaches. However, for some neurologic entities like Parkinson's disease, in which an in-depth physical examination by palpating muscles and performing neurologic maneuvers is the mainstay of monitoring the effects of medication, the yield and feasibility of a virtual encounter are low. Therefore, in this prospective review, we discuss two promising teleneurology approaches and propose adjustments to enhance the value of virtual encounters by improving the validity of neurological examination: 'hybrid teleneurology', which involves revising the workflow of virtual encounters; and 'artificial intelligence (AI)-assisted teleneurology', namely the use of biosensors and wearables and data processing using AI.

Clinical aspects of palliative care in advanced Parkinson's disease.

Parkinson's disease (PD) is one of the most common neurodegenerative disorders of the elderly population. Few therapeutic options are available for patients with PD requiring palliative care. Treatment of the early stages of PD is entirely different from later stages. During the later stages, the palliative care model is introduced to provide the patient with comfort and support. Early palliative care in PD requires minimization of dyskinesias and decreasing occurrence of motor and non-motor off times in an effort to maximize independent motor function. In the later stages, the focus of treatment shifts to treating the predominant non-motor symptoms and having a more supportive and palliative nature. The purpose of this review is to provide a summary of the palliative care management issues and palliative care management options of end-stage PD patients.

Gender differences in diagnostic tools, medication, time to medication, and nonmotor symptoms in Parkinsonian patients.

BACKGROUND: Swedish National Quality Registers (NQRs) play an important role in collecting large amounts of diagnosis-specific data, symptoms, and treatments. The subset of data, Parkinson's Registry, has been in use for more than 20 years and represents all counties and hospitals in Sweden where neurological care is provided. OBJECTIVE: To study the differences between genders regarding diagnostic tools, pharmacological interventions, and self-reported symptoms in patients with symptoms originating from basal ganglia disease, either idiopathic or secondary Parkinsonism (PD). METHODS: PD-diagnosed patients from a mix of urban and rural locations were chosen from the NQR and sorted by gender. Self-reported, first-experienced PD-related symptoms defined the debut point of PD. RESULTS: In all, data from 1,217 patients were analyzed: 502 (41%) females/715 (59%) males. A total of 493 imaging investigations were performed, where of 239 (48% females/52% males) had a CT scan performed, 120 (24% females/29% males) had a dopamine transporter scans, and 134 (23% females/26% males) had a magnetic resonance imaging performed (Fisher's exact test, P = 0.19). The average time in years from symptom onset to start of first treatment, and from first to second added treatment was 2;7/2;9 (females) and 5;1/5;2 (males). Nonmotor symptoms were more prominent among males, especially in memory and gastrointestinal domains, including drooling and obstipation. Significantly more sexual problems were reported from males; 26% versus 7% (Fisher's exact test, P < 0.0001). CONCLUSIONS: Differences between genders were identified in this study. Sexual problems and cognitive decline were more frequent among males. More advanced diagnostic imaging techniques were performed among males. The time point for a second added medication was earlier for males than females.

Effect of methylphenidate and/or levodopa combined with physiotherapy on mood and cognition after stroke: a randomized, double-blind, placebo-controlled trial.

BACKGROUND/AIM: Stimulant medications can enhance mood and cognition in stroke rehabilitation, but human clinical trial results are inconclusive. We sought to prospectively study the effects of levodopa (LD) and/or methylphenidate (MPH) in combination with physiotherapy on mood and cognition following stroke in human subjects. METHODS: Ischemic stroke patients were enrolled in our study 15 to 180 days after stroke onset. The patients were randomized into four medication groups (MPH, LD, MPH + LD, or placebo) and received a 15-day course of medication therapy (1 dose daily) and 45-min standard physiotherapy treatment daily. Mood and cognitive function were assessed at the study onset and 15, 90 and 180 days after study enrollment. RESULTS: The strongest improvement of mood and cognition was found between baseline and the first follow-up immediately after the intervention. A significant improvement in mood was also found in the combined treatment group (MPH + LD) at 90 and 180 days, compared to the placebo group. CONCLUSIONS: A 15-day course of daily MPH + LD combined with physiotherapy over a 3-week period was safe and significantly improved mood status in ischemic stroke patients. Future studies are needed which determine the optimal therapeutic window for and dosage of psychostimulants as well as identify those stroke patients who might benefit the most from treatment.

A stroke study of an urban area of Iran: risk factors, length of stay, case fatality, and discharge destination.

BACKGROUND: The Iranian population is aging rapidly, which causes huge medical concern for health care of this population. This trend will lead to an increase in stroke incidence in the future. The aim of this study was to investigate the epidemiologic patterns, risk factors, length of hospitalization, hospital discharge destination, and case fatality of patients with ischemic stroke from a city of Iran as well as analyses of interaction of these factors. METHODS: A cross-sectional, multihospital-based study was performed on all consecutively discharged and diagnosed patients with ischemic stroke in the city of Qom, Iran, between March 2006 and September 2008. RESULTS: A total of 953 patients, 48.9% men and 51.1% women, were included. The mean age was 68+/-13.82 years. Hypertension was found in 64% of patients, followed by diabetes mellitus (36%), heart disease (34%), hypercholesterolemia (32%), and smoking (20%). The average length of stay (LOS) was 7.7 days (95% confidence interval 7.2-8.2). Women had a significantly longer LOS compared with men (8.4 v 7 days, P = .0075) and patients with heart disease had a significantly longer LOS (9 days, 95% confidence interval 7.8-10, P = .004). Overall 1-month fatality rate was 15.3%. CONCLUSION: Hypertension and diabetes mellitus are more frequent here than average global findings. One-month case fatality was higher than in European countries but less than in developing countries. The most interesting difference comparing developed countries is the destination, which should be addressed. We strongly recommend establishing a stroke registry, establishing primary prevention, and promoting rehabilitation facilities in Iran.

A prospective study on the development of Alzheimer's disease with regard to thyroid-stimulating hormone and homocysteine.

BACKGROUND/AIM: The combination of elevated total homocysteine (tHcy) levels and low levels of thyroid-stimulating hormone (TSH) are linked to Alzheimer's disease (AD) in some studies, although the evidence is mixed. Our objective was to prospectively investigate the association between tHcy and TSH and the subsequent development of AD. METHODS: A subsample of 200 nondemented subjects was taken from the Kungsholmen Project, a population-based study among people > or =75 years. Information about tHcy and TSH levels were taken from the baseline investigation of the Kungsholmen Project study. RESULTS: Increased tHcy levels were related to an elevated risk of AD (n = 61) after a mean follow-up time of 6.7 years. People with high tHcy (the 3rd tertile) had more than twice as high a risk of developing AD than those with low tHcy, even after adjusting for age, sex, education, ApoE status, MMSE score and laboratory parameters. tHcy was negatively correlated with TSH (p = 0.02). There was neither an influence of TSH nor an interaction between tHcy and TSH in the development of AD. CONCLUSIONS: These results suggest that homocysteine, but not TSH, is involved in the development of AD. The connection between elevated tHcy and low TSH levels needs to be studied further.

Neuropathic Pain Prevalence of Older Adults in an Urban Area of Iran: A Population-Based Study.

BACKGROUND: Pain prevalence would increase as the population grows older, but the exact prevalence rate is not apparent in Iran. OBJECTIVES: This study, therefore, set out to reveal the prevalence of pain, especially neuropathic type and explore its associated comorbidities among Iranian older adults in a large urban population-based survey. METHODS: 5326 older people, aged ≥ 60 years, were randomly chosen by a multistage, cluster sampling method. The selected people then were interviewed by using the following instruments: a standard questionnaire about pain, questions of interview part of Douleur Neuropathique 4 Questions (DN4) and its comorbidities, GHQ-28, and a sociodemographic checklist. Descriptive statistics and multiple regression analysis were conducted to analyze the gathered data. RESULTS: The average of the participants' age was 68.92 ± 7.02 years. Of 5326 participants, 2529 (47.5%) of participants were male. About one-third of this population had chronic pain. Chronic neuropathic pain prevalence was 13.7% and nociceptive in 30%. Knee pain (20.6%) and feet dysesthesia (7.8%) were the most common sites of nociceptive and neuropathic pain, respectively. Results of multiple regression analysis revealed that the major comorbidities of chronic pain were osteoporosis, disability, diabetes mellitus, and stroke. Neuropathic pain experiences were significantly associated with GHQ-28 scores (t=-11.42, P<0.001). CONCLUSIONS: In addition to neuropathic pain, other subtypes of pain prevalence and the comorbidities are determined in the community-dwelling elder adults. This study highlights the importance of neuropathic pain and its adverse consequences and can be used to manage this populations' needs in Iran effectively.

Preoperative geriatric assessment and follow-up of patients older than 75 years undergoing elective surgery for suspected colorectal cancer.

OBJECTIVES: We investigated the predictive value of specific tools used in a Comprehensive Geriatric Assessment (CGA) with regard to postoperative outcome in patients 75 years and older undergoing elective colorectal cancer (CRC) surgery. Furthermore, recovery was followed over the first postoperative year using the same assessment tools. MATERIAL AND METHODS: Baseline clinical and CGA variables including functional and nutritional status, pressure sore risk, fall risk, cognition, depression, polypharmacy, comorbidity, and health-related quality-of-life (HRQoL) were prospectively recorded. Outcome variables were postoperative complications and length of stay (LOS). Patients were likewise followed up at one, three and twelve months postoperatively. RESULTS: Forty-nine patients underwent surgery (median age 81 years). Forty-three per cent had ASA (American Society of Anesthesiologists) class 2 47% had ASA class 3. Postoperative complications occurred in 32.7%. Median LOS was eight days. In univariate analyses, none of the parameters tested predicted postoperative complication or LOS. During follow-up, all patients recovered to baseline values apart from HRQoL which was still reduced at three and twelve months (p = .017). Nutritional status had improved twelve months after surgery (p = .011). CONCLUSIONS: No association could be found in this study between the results of a comprehensive geriatric assessment and prolonged length of stay or postoperative complication rate after elective surgery for colorectal cancer. Patients recovered well during the first year after surgery. Quality of life, however, was still lower than prior to surgery.