Assessment of the Relationship between Non-motor features and Severity of Parkinson's Disease Patients in Bangladesh.

Parkinson's disease (PD) is second most common neurodegenerative disorder after Alzheimer's disease that may present with both motor and non-motor symptoms (NMSs). Many of the ignored NMSs may potentiate further deterioration of the patient's quality of life (QoL). But there is scarcity of data regarding NMSs of PD patients and their relationship with the disease severity in Bangladesh. This study was aimed to investigate the frequency of NMSs and assess their debatable impact on the severity of PD patients in Bangladesh. This cross-sectional type of observational study was conducted in neurology department of Dhaka Medical College Hospital, Bangladesh from January 2012 to June 2013 which recruited 60 eligible PD patients. The PD patients and disease severity was demonstrated by UK Parkinson's Disease Society Brain Bank criteria for idiopathic PD and the Hoehn and Yahr scale respectively. Whereas, NMSs were demonstrated by the self-structured questionnaire which had encountered 30 common symptoms of PD. The mean age of our study cohort was found 57.88±10.56 years with male female ration 2:1. According to the Hoehn and Yahr (H & Y) severity scale 38.3%, 38.3%, 20.1% and 3.3% patients had been suffering from stage ?, stage II, stage III and stage ?V Parkinson's disease respectively. Irrespective of the severity of the PD the frequency of NMSs was nocturia (66.7%), sadness or blues (65.0%), memory disturbance (61.7%), anxiety (58.3%), insomnia (56.7%), orthostatic hypotension (55.0%), erectile dysfunction (50.0%), urinary urgency (46.7%), anhedonia (45.0%), olfactory disturbance (38.3%), constipation (38.3%), hyper or hypo sexuality (31.7%) and restless leg syndrome (31.7%). However, after head-to-head NMSs analysis, daytime dribbling of saliva (p=0.024), urinary urgency (p=0.036), nocturia (p=0.001), weight loss (p=0.001), anhedonia (p=0.027), excessive daytime sleepiness (p=0.024), insomnia (p=0.007), vivid dream (p=0.024), REM behavior disorder (p=0.010), restless leg syndrome/ periodic leg movements (p=0.043) had significantly been reported higher among the stage II PD patients than that of stage I patients. Whereas fall (p=0.001), dysphagia or choking (p=0.002), constipation (p=0.003), fecal incontinence (p=0.033), excessive daytime sleepiness (p=0.033), anxiety (p=0.036) and anhedonia (p=0.044) were significantly more prevalent among the advanced stage (III) than stage (II) PD patients. Mean total NMS increased significantly with PD severity based on H and Y staging with a mean NMSQ-T (Non-Motor Symptoms Questionnaire Test) of 5.43 in stage 1, 9.22 in stage 2, 13.75 in stage 3 and 17.0 in stage 4 (p=0.0001). This study revealed that there was high frequency of NMSs among the PD patients and most common symptoms were nocturia, sadness, memory impairment, anxiety, insomnia, orthostatic hypotension, erectile dysfunction, anhedonia, urinary urgency and constipation. Finally, the more advanced disease as indicated by a higher H&Y stage was associated with significantly higher number of reported NMSs.

Association of History of Dizziness and Long-term Adverse Outcomes With Early vs Later Orthostatic Hypotension Assessment Times in Middle-aged Adults.

Importance: Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. It is not known whether measurements performed immediately after standing predict adverse events as strongly as measurements performed closer to 3 minutes. Objective: To compare early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes. Design, Setting, and Participants: This was a prospective cohort study of middle-aged (range, 44-66 years) participants in the Atherosclerosis Risk in Communities Study (1987-1989). Exposures: Orthostatic hypotension, defined as a drop in blood pressure (BP) (systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg) from the supine to standing position, was measured up to 5 times at 25-second intervals. Main Outcomes and Measures: We determined the association of each of the 5 OH measurements with history of dizziness on standing (logistic regression) and risk of fall, fracture, syncope, motor vehicle crashes, and all-cause mortality (Cox regression) over a median of 23 years of follow-up (through December 31, 2013). Results: In 11 429 participants (mean age, 54 years; 6220 [54%] were women; 2934 [26%] were black) with at least 4 OH measurements after standing, after adjustment OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds; range, 21-62 seconds) was the only measurement associated with higher odds of dizziness (odds ratio [OR], 1.49; 95% CI, 1.18-1.89). Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1000 person-years. Measurement 2 was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1000 person-years. Furthermore, after adjustment measurement 1 was significantly associated with risk of fall (hazard ratio [HR], 1.22; 95% CI, 1.03-1.44), fracture (HR, 1.16; 95% CI, 1.01-1.34), syncope (HR, 1.40; 95% CI, 1.20-1.63), and mortality (HR, 1.36; 95% CI, 1.23-1.51). Measurement 2 (mean [SD], 53 [7.5] seconds; range, 43-83 seconds) was associated with all long-term outcomes, including motor vehicle crashes (HR, 1.43; 95% CI, 1.04-1.96). Measurements obtained after 1 minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes. Conclusions and Relevance: In contrast with prevailing recommendations, OH measurements performed within 1 minute of standing were the most strongly related to dizziness and individual adverse outcomes, suggesting that OH be assessed within 1 minute of standing.

Evaluation of Two New Indices of Blood Pressure Variability Using Postural Change in Older Fallers.

To evaluate the utility of blood pressure variability (BPV) calculated using previously published and newly introduced indices using the variables falls and age as comparators.While postural hypotension has long been considered a risk factor for falls, there is currently no documented evidence on the relationship between BPV and falls.A case-controlled study involving 25 fallers and 25 nonfallers was conducted. Systolic (SBPV) and diastolic blood pressure variability (DBPV) were assessed using 5 indices: standard deviation (SD), standard deviation of most stable continuous 120 beats (staSD), average real variability (ARV), root mean square of real variability (RMSRV), and standard deviation of real variability (SDRV). Continuous beat-to-beat blood pressure was recorded during 10 minutes' supine rest and 3 minutes' standing.Standing SBPV was significantly higher than supine SBPV using 4 indices in both groups. The standing-to-supine-BPV ratio (SSR) was then computed for each subject (staSD, ARV, RMSRV, and SDRV). Standing-to-supine ratio for SBPV was significantly higher among fallers compared to nonfallers using RMSRV and SDRV (P = 0.034 and P = 0.025). Using linear discriminant analysis (LDA), 3 indices (ARV, RMSRV, and SDRV) of SSR SBPV provided accuracies of 61.6%, 61.2%, and 60.0% for the prediction of falls which is comparable with timed-up and go (TUG), 64.4%.This study suggests that SSR SBPV using RMSRV and SDRV is a potential predictor for falls among older patients, and deserves further evaluation in larger prospective studies.

Diagnosing orthostatic hypotension: a narrative review of the evidence.

BACKGROUND: Orthostatic hypotension (OH) is very common, particularly in older populations. Diagnostic criteria exist but appear to be arbitrary rather than evidence based. This review will visit the evidence for diagnostic strategies for OH. DATA SOURCES: Medline (OvidSP), EMBASE (OvidSP), ISI Web of Science, the Health Technology Assessments Database and the Cochrane Library. AREAS OF AGREEMENT: A 5-min rest is required before measuring baseline. An active stand with continuous blood pressure (BP) monitoring is preferable to a tilt test to identify initial OH in particular. At least 2 min in the upright position is required. A systolic drop of 20 or a diastolic drop of 10 is supported by the evidence. Reproducibility when testing for OH is poor. AREAS OF CONTROVERSY: Is the active stand preferable to the tilt test to diagnose classical OH? Although continuous BP monitoring increases diagnostic rates, does it improve clinical outcomes? Should symptoms be used to inform diagnosis? AREAS TIMELY FOR RESEARCH: Establishing the long-term clinical outcomes for transient drops in BP detected on continuous, non-invasive monitoring. Evaluating the different patterns of BP drop to aid diagnosis and direct treatment.

The changing face of orthostatic and neurocardiogenic syncope with age.

AIM: Reports of the outcomes of syncope assessment across a broad spectrum of ages in a single population are scarce. It is our objective to chart the varying prevalence of orthostatic and neurocardiogenic syncope (NCS) as a patient ages. METHODS: This was a retrospective study. All consecutive patients referred to a tertiary referral syncope unit over a decade were included. Patients were referred with recurrent falls or orthostatic intolerance. Tilt tests and carotid sinus massage (CSM) were performed in accordance with best practice guidelines. RESULTS: A total of 3002 patients were included (1451 short tilt, 127 active stand, 1042 CSM and 382 prolonged tilt). Ages ranged from 11 to 91 years with a median (IQR) of 75 (62-81) years. There were 1914 females; 1088 males. Orthostatic hypotension (OH) was the most commonly observed abnormality (test positivity of 60.3%). Those with OH had a median (IQR) age of 78 (71-83) years. Symptomatic patients were significantly younger than asymptomatic (P = 0.03). NCS demonstrated a bimodal age distribution. Of 194 patients with carotid sinus hypersensitivity, the median age (IQR) was 77 (68-82) years. Those with vasovagal syncope (n = 80) had a median (IQR) age of 30 (19-44) years. There were 57 patients with isolated postural orthostatic tachycardia syndrome. Of the total patients, 75% were female. They had a median (IQR) age of 23 (17-29) years. CONCLUSION: We have confirmed, in a single population, a changing pattern in the aetiology of syncope as a person ages. The burden of disease is greatest in the elderly.

Falls risk factors: assessment and management to prevent falls and fractures.

Falls and fragility fractures are common, dangerous, and important public health challenges. They are best understood as geriatric syndromes with close relation to frailty and other aging-related health problems. They are associated with many risk factors, in all health domains - physical, psychological, social, and environmental. At a population level, the challenge is to improve the health and well-being of all older people to reduce the incidence of falls. At a clinical level, the challenge is to assess the individual risk factors and apply evidence-based individually tailored, multifactorial interventions. The most powerful component is strength-and-balance exercise training.

Manual assessment of the initial fall in blood pressure after orthostatic challenge at high altitude.

OBJECTIVE: Dizziness is a symptom of acute mountain sickness (AMS). This study tested whether immediate fall in systolic blood pressure (BP) on standing was more severe at altitude and whether this was associated with symptoms of dizziness. METHODS: Eighty-five lowlanders flew into La Paz, Bolivia (3650 m), and after 4 to 5 days of acclimatization ascended in 90 minutes to the Chacaltaya Laboratory (5200 m) by road. Blood pressure was measured on 5 occasions, 3 times at 5200 m and twice at sea level, before and after the expedition using a mercury sphygmomanometer. Both a supine and an erect (within 15 seconds of standing) BP measurement were recorded. Participants recorded whether they felt dizzy on standing. A mixed-effect model was used to test for a difference in the change in BP for time and altitude. RESULTS: The immediate fall in systolic BP observed on standing was significantly greater (P < .001) on all 3 altitude study days (18.2, 23.4, and 20.7 mm Hg) than at sea level (12.2 and 12.4 mm Hg). There was no significant difference in the change in diastolic BP or change in mean arterial BP between sea level and altitude. CONCLUSIONS: The immediate drop in systolic BP observed on standing was greater at altitude. However, mean arterial pressure was maintained, and we found no association between the degree of immediate fall in BP and dizziness or AMS.

Assessment of autonomic symptoms in diabetics: the Swedish version of the Autonomic Symptom Profile.

OBJECTIVES: Autonomic dysfunction (AD) is a complication of diabetes and may be associated with troubling symptoms and increased mortality. Commonly, AD is detected by objective physiological tests and only recently, a validated self-completed English questionnaire assessing AD symptoms, the Autonomic Symptom Profile (ASP), was developed. The aims of this study were to translate the ASP into Swedish and evaluate its reliability and validity. METHODS: Forward and back translations were performed. Thirty-one patients with type I diabetes, 200 population-based controls and two AD experts participated in the study. Test-retest reliability was evaluated by letting 25 patients to fill in the ASP twice. Content validity was evaluated by two Swedish AD experts and construct validity was evaluated by studying associations between the ASP total score and five objective autonomic nervous function test variables. Finally, discriminant validity was evaluated by studying differences in the ASP total and domain scores between patients and controls. RESULTS: The translation was accepted without changes. Test-retest reliability and content validity of the Swedish ASP were considered good. The construct validity was considered acceptable with two significant associations between the ASP total score and the autonomic nervous function test variables. In addition, discriminant validity was considered acceptable with regard to the ASP total score as well as the sexual dysfunction, sleep disorder and vasomotor dysfunction domain scores significantly differing between patients and controls. CONCLUSION: The Swedish version of the ASP was considered a reliable and valid instrument for the study of AD symptoms in patients with type I diabetes.

Fall-risk assessment and management in clinical practice: views from healthcare providers.

OBJECTIVES: To determine the extent to which healthcare providers reportedly address evidence-based fall risk factors in older patients after exposure to an educational intervention and to determine barriers reportedly encountered when these healthcare providers intervene with or refer older patients with identified fall-risk factors. DESIGN: Cross-sectional study using a structured interview. SETTING: Geographic area of Connecticut where the Connecticut Collaboration for Fall Prevention (CCFP) has been implemented. PARTICIPANTS: Emergency department (ED) physicians, hospital-based discharge planners or care coordinators (nurses or social workers), home health agency nurses, and office-based primary care physicians (total n=33) after exposure to the CCFP implementation team. MEASUREMENTS: Self-reported practices (direct intervention or referral) and barriers when addressing seven evidence-based risk factors for falls: gait and transfer impairments, balance disturbances, multiple medications, postural hypotension, sensory and perceptive deficits, foot and footwear problems, and environmental hazards. RESULTS: Respondents were most likely to report directly intervening with or referring older patients for gait and transfer impairments (85%) and balance disturbances (82%) and least likely to do so when encountering foot or footwear problems (58%) and sensory or perceptive deficits (61%). ED physicians reported lowest rates of direct intervention or referral for foot or footwear problems (20%), home health agency nurses for sensory or perceptive deficits (50%), and office-based primary care physicians for foot or footwear problems (50%). Patient compliance was the most commonly reported barrier to successful direct intervention across several risk factors, whereas inadequate availability of other healthcare providers and lack of Medicare reimbursement were the most commonly reported barriers to successful patient referrals. CONCLUSION: After exposure to the CCFP implementation team, the majority of healthcare providers reported directly intervening or referring patients when addressing all risk factors, but results pinpointed specific healthcare provider groups with room for improvement in assessment and management of specific risk factors. Patient education appears to be a necessary adjunct to healthcare provider training, because patient compliance was a reported barrier to optimal intervention by healthcare providers.

Assessment of autonomic function in untreated adult coeliac disease.

AIM: Some recent studies showed that alteration of upper-gut motility in coeliac disease may be related to dysfunction of autonomic nervous system. The aim of our study was to investigate whether autonomic nervous system was altered in untreated and unselected coeliac disease patients. METHODS: We studied 8 untreated and consecutive coeliac disease patients (2 males and 6 females, age range 37+/-14.5 years). Histological evaluation of duodenal mucosa, anti-gliadin antibodies (AGA), antiendomysial antibodies (EMA) and anti-tTG antibodies and sorbitol H2 breath test were performed in all patients. Extrinsic autonomic neuropathy was assessed by the standardized measurement of cardiovascular reflexes (lying-to-standing, Valsalva manoeuvre, deep breathing, sustained handgrip). The results obtained were compared with a healthy, asymptomatic control group (6 males and 7 females, age range 42.3+/-13.5 years). RESULTS: Coeliac patients exhibited a lower increase of PAS as a response to isometric effort, a reduction of spectral power LF as a response to clinostatic position, but without statistical significance. Also they showed a lower tolerance to orthostatic position, associated with a latent disequilibrium of sympathetic-vagal balance, a relative prevalence of parasympathetic component of the autonomic function. However, these results were not statistically significant when compared with control group (P = n.s.). And they were unchanged after 6 and 12 mo of gluten-free diet. CONCLUSION: This study failed to confirm a significant correlation between autonomic dysfunction and coeliac disease, yet we could not exclude a role of autonomic dysfunction in the genesis of systemic symptoms in some coeliacs.

[Clinical assessment of phlebopathy severity by specification of leg heaviness symptom]. / Klinicheskaia otsenka tiazhesti flebopatii na osnove detalizatsii simptoma tiazhelykh nog.

The paper presents the first attempt to differentiate phlebopathy severity on the basis of subjective information, which serves a key parameter of decompensation assessment reflecting individual range of daily living activity and functional load. Phlebopathy is defined as structural and functional insufficiency of venous wall, decreased ability to maintain stable volume both of particular veins and leg venous system as a whole during prolonged orthostasis. From 1995 to 2001 different forms of leg varices were diagnosed and treated in 583 patients. The most common complaint expressed by 567 patients (97.0%) was the heaviness and bursting pain in legs caused by daily orthostasis. Four clinical groups were clearly defined: 0 grade - no heaviness in legs; 1 grade - episodes of heaviness after excess daily load; 2 grade - regular heaviness in legs not demanding obligate evening rest with updrawn legs; 3 grade - permanent heaviness in legs demanding rest with legs updrawn. Permanent symptom (the last 2 groups) can be subdivided according to timing of symptom onset: a) in the afternoon, b) in the forenoon. The data analysis demonstrated that the symptom of leg heaviness during orthostasis caused by increased creep of venous walls was be a subjective equivalent to phlebopathy severity. The time of symptom onset and degree of manifestation correlated with the severity of venous wall incompetence. This method can be used to evaluate functional status of leg venous circulation both during initial assessment and for treatment or rehabilitation monitoring.

Assessment of autonomic function in patients with a Parkinsonian syndrome.

The integrity of the autonomic nervous system was assessed in 11 Parkinsonian patients with symptoms suggestive of autonomic dysfunction. Three had the additional clinical features of the Shy-Drager variant of idiopathic orthostatic hypotension and were found to have a gross disturbance of vasomotor, sudomotor, pilomotor, and bladder function; assessment indicated that a lesion was present at sympathetic ganglionic level or beyond in two cases, though a more centrally placed lesion may well have been present also, as in the third case. In the remaining eight patients with paralysis agitans no unequivocal functional disturbance was found except in the bladder; nevertheless, the low resting blood pressure and the supersensitivity to intravenously infused L-noradrenaline in the three patients in whom it was tested is taken to imply defective regulation from higher centres, with a consequent reduction in impulse traffic at sympathetic nerve terminals. Such a concept is supported by experimental studies in animals and would account for the low renin and aldosterone secretion rates and reduced noradrenaline formation reported by others in patients with paralysis agitans.