[Clinical experience in the treatment of motor fluctuations in Parkinson's disease. Delphi consensus of a group of experts in movement disorders]. / Experiencia clínica en el tratamiento de las fluctuaciones motoras en la enfermedad de Parkinson. Consenso Delphi de un grupo de expertos en trastornos del movimiento.

INTRODUCTION: Motor fluctuations are one of the most common complications of Parkinson's disease and their treatment is still a complex matter. Therefore, from the Neurology Movement Disorders Group we present our clinical experience in the treatment of these complications, with the intention of it being useful in decision-making in daily clinical practice. DEVELOPMENT: Nineteen questions were developed based on a literature review and an open survey answered by members of this group. These issues were discussed in two phases, using the Delphi methodology. Considering the results of the survey, levodopa dose adjustment and dopamine agonists are the option with the best efficacy/tolerability ratio in the treatment of motor fluctuations. Rotigotine is useful in the motor fluctuations associated with gastroparesis, and intermittent subcutaneous apomorphine has positive effects in patients with unpredictable off periods. The most relevant adverse effect associated with dopamine agonists is impulse control disorder. Catechol-O-methyltransferase inhibitors are useful in the initial stages of motor fluctuations, especially in wearing off. Monoamine oxidase inhibitors are generally drugs that are well-tolerated and useful in motor fluctuations. If these measures are not effective, second-line treatments should be indicated on a case-by-case basis. CONCLUSION: The clinical profile of patients with Parkinson's disease is paramount in deciding the most appropriate therapy for the treatment of motor fluctuations.

TITLE: Experiencia clínica en el tratamiento de las fluctuaciones motoras en la enfermedad de Parkinson. Consenso Delphi de un grupo de expertos en trastornos del movimiento.Introducción. Las fluctuaciones motoras son una de las complicaciones más frecuentes en la enfermedad de Parkinson y su tratamiento sigue siendo complejo. Por ello, desde el Grupo de Trastornos del Movimiento de la Asociación Madrileña de Neurología presentamos nuestra experiencia clínica en el tratamiento de estas complicaciones, con la intención de que sea de utilidad en la toma de decisiones en la práctica clínica diaria. Desarrollo. Se elaboraron 19 preguntas a partir de una revisión bibliográfica y una encuesta abierta respondida por los miembros de dicho grupo. Dichas cuestiones se debatieron en dos fases, utilizando la metodología Delphi. Considerando los resultados de la encuesta, el ajuste de la dosis de levodopa y los agonistas dopaminérgicos son la opción con mejor relación eficacia/tolerabilidad en el tratamiento de las fluctuaciones motoras. La rotigotina es útil en las fluctuaciones motoras asociadas a gastroparesia, y la apomorfina subcutánea intermitente, en pacientes con off impredecible. El efecto adverso más relevante asociado a los agonistas dopaminérgicos es el trastorno del control de impulsos. Los inhibidores de la catecol-O-metiltransferasa son útiles en las fluctuaciones motoras de inicio, especialmente en el wearing off. Los inhibidores de la monoaminooxidasa son fármacos, en general, bien tolerados y útiles en las fluctuaciones motoras. En caso de que estas medidas no resulten eficaces, se deben indicar terapias de segunda línea de manera individualizada. Conclusión. El perfil clínico del paciente con enfermedad de Parkinson es primordial para decidir la terapia más adecuada en el tratamiento de las fluctuaciones motoras.

[Relationship between essential tremor, Parkinson's disease and dementia with Lewy bodies]. / Relación entre temblor esencial, enfermedad de Parkinson y demencia con cuerpos de Lewy.

INTRODUCTION: Although essential tremor (ET), Parkinson's disease (PD) and dementia with Lewy bodies (DLB) are considered to be distinct illnesses, there is a certain overlap between some of their clinical, pathological and genetic features. AIM: To conduct a critical examination of the evidence for and against the association between these three pathological conditions. DEVELOPMENT: The body of evidence supporting the notion of a relation between ET and PD is growing all the time; the same can be said of the fact that a postural tremor may appear years before the onset of other extrapyramidal symptoms, the involvement of common genes in the development of both conditions or the presence of common pathological findings. In addition, it has also been suggested that there are several aspects linking PD and DLB, and it has even been claimed that that they might be part of the clinical spectrum of the same disease. The concept of ET as a benign single-symptom disease has changed in recent years and, since it has been related to cognitive disorders and Lewy bodies in the central nervous system, it is now considered to be a neurodegenerative pathology. CONCLUSIONS. ET, PD and DLB could represent different points on the same clinical spectrum.

Antidepressants in Parkinson's disease. Recommendations by the movement disorder study group of the Neurological Association of Madrid. / Antidepresivos en la enfermedad de Parkinson. Recomendaciones del grupo de trastornos del movimiento de la Asociación Madrileña de Neurología.

INTRODUCTION: Although antidepressants are widely used in Parkinson's disease (PD), few well-designed studies to support their efficacy have been conducted. DEVELOPMENT: These clinical guidelines are based on a review of the literature and the results of an AMN movement disorder study group survey. CONCLUSIONS: Evidence suggests that nortriptyline, venlafaxine, paroxetine, and citalopram may be useful in treating depression in PD, although studies on paroxetine and citalopram yield conflicting results. In clinical practice, however, selective serotonin reuptake inhibitors are usually considered the treatment of choice. Duloxetine may be an alternative to venlafaxine, although the evidence for this is less, and venlafaxine plus mirtazapine may be useful in drug-resistant cases. Furthermore, citalopram may be indicated for the treatment of anxiety, atomoxetine for hypersomnia, trazodone and mirtazapine for insomnia and psychosis, and bupropion for apathy. In general, antidepressants are well tolerated in PD. However, clinicians should consider the anticholinergic effect of tricyclic antidepressants, the impact of serotonin-norepinephrine reuptake inhibitors on blood pressure, the extrapyramidal effects of antidepressants, and any potential interactions between monoamine oxidase B inhibitors and other antidepressants.

The high prevalence of impulse control behaviors in patients with early-onset Parkinson's disease: A cross-sectional multicenter study.

INTRODUCTION: In Parkinson's disease patients, impulse control disorders (ICDs) have been associated with younger age and early disease onset, yet the prevalence of ICDs in early-onset Parkinson's disease (EOPD) patients has yet to be studied. Thus, we set out to compare the prevalence of impulse control behaviors (ICBs) in a cohort of EOPD patients with that in age and gender matched healthy controls (HCs), as well as to analyze the association of these symptoms with the use of dopaminergic drugs and other clinical or demographic factors. METHODS: A cross-sectional, multicenter study was carried out on patients recruited from outpatient Movement Disorder Clinics, assessing ICBs using the short form of the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP). In addition, depression and quality of life (QoL) were measured, along with other demographic and clinical variables. RESULTS: Of the 87 EOPD patients, 49 (58.3%) displayed an ICB, as did 28 of the 87 HCs (32.9%; p=0.001). Most of the EOPD patients that displayed an ICB (91.8%) were medicated with a dopamine agonist (DA) and accordingly, DA treatment was associated with a 7-fold increased risk of developing an ICB. Patients with ICBs had a higher depression score and a worse QoL. CONCLUSIONS: ICBs are much more prevalent in EOPD patients than in HCs and they are associated with DA intake, depression and a worse QoL.

[Rotigotine in the treatment of Parkinson's disease. A study on a sample of 150 patients]. / Rotigotina en el tratamiento de la enfermedad de Parkinson. Experiencia sobre una muestra de 150 pacientes.

INTRODUCTION: Rotigotine is a non-ergot dopamine agonist that has become the first treatment for Parkinson's disease formulated as a transdermal release system. Its side effects are very similar to those of other dopamine agonists, as well as those deriving from the site of application, while its advantages include a once-daily administration, the absence of interactions with foods and steady levels in plasma. AIM: To determine the frequency of and reasons for withdrawing rotigotine in 150 consecutive patients diagnosed with Parkinson's disease. PATIENTS AND METHODS: A retrospective analysis was carried out using the database at our Movement Disorders Unit in order to identify the first 150 patients who were treated with rotigotine. Only patients with Parkinson's disease who were free of intracranial lesions, psychiatric pathologies or dementia were eligible for inclusion in the sample. Patients were evaluated before and at two, four and six months after beginning treatment with rotigotine. RESULTS: In all, 85 males and 65 females were identified. A total of 110 of them had previously been treated with dopamine agonists. Although 12% of the patients dropped out, 88% of them continued the treatment. The reasons for withdrawing were worsening of the clinical condition (12 patients), lack of effectiveness (three patients), drowsiness (two patients) and dyskinesias (one patient). CONCLUSIONS: Rotigotine is safe and effective as medication in the treatment of Parkinson's disease. The fact that most of the drop-outs were due to a worsening of the clinical signs and symptoms after changing from another dopamine agonist suggests the need for an equivalence between other agonists and rotigotine.

[Zonisamide in refractory essential tremor]. / Zonisamida en el temblor esencial refractario.

INTRODUCTION: Essential tremor is one of the most frequent movement disorders. It is characterized by postural and action tremor that may affect different regions of the body. Among current treatments propranolol and primidone are included. However, these two drugs have demonstrated a limited efficacy and several adverse events. Additionally, they are contraindicated in patients with cardiac insufficiency and several respiratory diseases. New antiepileptic drugs are revealing as a possibility in the treatment of this disease. AIM. To evaluate efficacy and tolerability of zonisamide in the treatment of essential tremor. PATIENTS AND METHODS: We perform a retrospective study about 13 patients with essential tremor refractory to an average of 2.8 drugs. Age, sex, zonisamide dosage, adverse events, duration and response to the treatment before and after the treatment were collected and analysed. Average zonisamide dosage was 215 mg/day and average duration of the treatment was 121 days. RESULTS: Nine of 13 patients included in our study experienced a good response. A positive response was understood as a decrease on the limitation of daily activities and an improvement on neurological examination. Zonisamide was well tolerated and no patient abandoned the study for this reason. CONCLUSIONS: Our data suggest that zonisamide is effective and well tolerated in the treatment of essential tremor. Placebo-controlled and bigger studies are warranted to confirm these results.

[Botulinum toxin type A in the treatment of neuropathic pain in a case of postherpetic neuralgia]. / Toxina botulínica tipo A en el tratamiento del dolor neuropático en un caso de neuralgia postherpética.

INTRODUCTION: Botulinum toxin type A has been used in a wide range of neurological diseases such as migraine, cervical dystonia, spasticity or tics. However, the use of this drug in the treatment of neuropathic pain is still uncommon despite the fact that more and more cases supporting its role as an alternative treatment are emerging in the literature. CASE REPORT: Herein, we report a case of an 83 year old woman who suffered from severe pain with neuropathic characteristics due to postherpetic neuralgia which was refractory to different conventional therapies. The neuropathic pain was dramatically improved by multiple botulinum toxin type A injections and the analgesia lasted 2 months. Treatment was well tolerated and there were no side effects. CONCLUSIONS: Using botulinum toxin has been effective and well tolerated in the treatment of postherpetic neuralgia in our patient. Despite the fact that its action mechanisms is still unknown, we consider that botulinum neurotoxin may be an alternative treatment in relieving refractory neuropathic pain and that controlled studies are needed to study this possibility.

[Korsakoff's syndrome secondary to left thalamic bleeding]. / Síndrome de Korsakoff secundario a hemorragia talámica izquierda.

Korsakoff's syndrome is characterised by an important impairment in memory in comparison to other cognitive functions. Presence of confabulations is frequent but they are not characteristic of this syndrome. Alcohol abuse is the main cause of this syndrome but it also has been associated to other causes, like malnutrition or structural lesions. Although the role of thalamus in memory processing is well established, the development of confabulations in the setting of a thalamic lesion is poorly described in the literature. We present a 61 year-old hypertensive man, with an important impairment in anterograde memory, confabulations and acalculia after a left thalamic haemorrhage. Other cognitive functions were intact except a partial temporal disorientation. Thalamic dementia is generally caused by bilateral thalamic damage. Usually, all cognitive functions are impaired. As thalamus takes part in Papez's circuit, either thalamic nuclei or their connections lesions may originate memory impairment. However, although a relation between the presence of confabulations and connections from thalamus to frontal lobe lesions has been described, there is almost no evidence in the literature.