The modern pre-levodopa era of Parkinson's disease: insights into motor complications from sub-Saharan Africa.

During the past decade, a number of large drug trials suggested that the initiation of levodopa therapy should be delayed to reduce the risk of motor complications in patients with Parkinson's disease. However, the relative contribution of the cumulative exposure to levodopa and of disease progression to the pathophysiology of motor fluctuations and dyskinesias is still poorly understood. In this 4-year multicentre study, we investigated a large cohort of patients with Parkinson's disease in a sub-Saharan African country (Ghana), where access to medication is limited and the initiation of levodopa therapy often occurs many years after onset. The primary objective was to investigate whether the occurrence of motor complications is primarily related to the duration of levodopa therapy or to disease-related factors. Study design included a cross-sectional case-control analysis of data collected between December 2008 and November 2012, and a prospective study of patients followed-up for at least 6 months after the initiation of levodopa therapy. Ninety-one patients fulfilled criteria for clinical diagnosis of idiopathic Parkinson's disease (58 males, mean age at onset 60.6 ± 11.3 years). Demographic data were compared to those of 2282 consecutive Italian patients recruited during the same period, whereas nested matched subgroups were used to compare clinical variables. Demographic features, frequency and severity of motor and non-motor symptoms were comparable between the two populations, with the only exception of more frequent tremor-dominant presentation in Ghana. At baseline, the proportion of Ghanaian patients with motor fluctuations and dyskinesias was 56% and 14%, respectively. Although levodopa therapy was introduced later in Ghana (mean disease duration 4.2 ± 2.8 versus 2.4 ± 2.1 years, P < 0.001), disease duration at the occurrence of motor fluctuations and dyskinesias was similar in the two populations. In multivariate analysis, disease duration and levodopa daily dose (mg/kg of body weight) were associated with motor complications, while the disease duration at the initiation of levodopa was not. Prospective follow-up for a mean of 2.6 ± 1.3 years of a subgroup of 21 patients who were drug-naïve at baseline [median disease duration 4.5 (interquartile range, 2.3-5) years] revealed that the median time to development of motor fluctuations and dyskinesias after initiation of levodopa therapy was 6 months. We conclude that motor fluctuations and dyskinesias are not associated with the duration of levodopa therapy, but rather with longer disease duration and higher levodopa daily dose. Hence, the practice to withhold levodopa therapy with the objective of delaying the occurrence of motor complications is not justified.

Nutritional status and dietary habits in Parkinson's disease patients in Ghana.

OBJECTIVE: Dietary treatment is important for the management of Parkinson's disease (PD). Our objective was to describe the dietary habits and assess the nutritional status of Ghanaian patients with PD. This study is part of a larger project, for which Ghana has been selected as a pilot country. METHODS: Fifty-five Ghanaian patients with PD and 12 healthy Ghanaian controls were recruited. We assessed nutritional status, investigated dietary habits, and assessed the prevalence of the nutritional complications of PD (e.g., constipation and dysphagia). RESULTS: The mean daily caloric intake was about 1200 kcal/d in patients with PD and in controls. The typical diet was based on semisolid foods, usually vegetable soups accompanied by cereal flour or root starch or sometimes chicken or fish. The intake of milk and its derivatives was low. The prevalences of constipation and dysphagia in patients with PD were 49% and 21%, respectively. CONCLUSION: This study has yielded information that could be useful for the study of the management of PD and for the assessment of response to therapy.