Psychometric properties of the mutuality scale in Swedish dyads with Parkinson's disease.

OBJECTIVES: The 15-item mutuality scale (MS) has been used in several neurological conditions assessing the quality of relationship associations with negative effects of the caregiving situation. The aim of this study was to translate the original MS into Swedish and assess its psychometric properties in Parkinson's disease (PD). MATERIALS AND METHODS: Following the forward-backward translation method, the scale was evaluated regarding linguistic correctness at a conceptual level and user-friendliness. The scale was filled out by a sample of 50 care dyads where one was having PD. Scale assumptions and scale structure were evaluated using floor/ceiling effect and principal component analyses (PCA) with promax rotation. Internal consistency was evaluated using Cronbach's alpha and mean inter-item correlation coefficients. RESULTS: The Swedish MS was evaluated as user-friendly and relevant by the participants. The scale demonstrated no floor/ceiling effect and showed high internal consistency (α≥0.93) with a mean inter-item correlation coefficient of ≥0.5. Through the PCA, a two factor solution emerged, which accounted for 67% and 64% of the variance of the MS score by PD-partners and PD-patients, respectively. However, some variables were complex and discarded in the final solution. CONCLUSION: Our findings provide initial support of the Swedish MS as a user-friendly and useful instrument with acceptable psychometric properties even though more research is needed to evaluate the existence of subscales.

Inappropriate drug use in elderly patients is associated with prolonged hospital stay and increased postoperative mortality after colorectal cancer surgery: a population-based study.

AIM: The study aimed to investigate whether continuing potentially inappropriate medication (PIM) is associated with length of hospital stay (LOS) and postoperative mortality in elderly people undergoing colorectal cancer surgery. METHOD: The Swedish National Colorectal Cancer Register and the Swedish Prescribed Drug Register provided matched data on 7279 patients aged 75 years or more who had undergone bowel resection for colorectal cancer between 2007 and 2010. Patients were divided into two groups depending on whether or not they were taking PIM at the time of surgery. The primary efficacy variables were the LOS and 30-day postoperative mortality. RESULTS: Of the 7279 patients, 22.5% (1641) of the patients were exposed to at least one PIM and the total number of drugs taken in this group was six, compared with three in the non-PIM group (P < 0.001). Postoperative mortality was higher in the PIM group (7.1% vs 4.5%, P < 0.001), and LOS was longer (10 days vs 9, P = 0.001). When adjusted for independent predictors, the differences in LOS (odds ratio 1.14; 95% confidence interval 1.00-1.29, P = 0.046) and postoperative mortality (odds ratio 1.43; 95% confidence interval 1.11-1.85, P = 0.006) remained significant. CONCLUSION: The use of PIM prior to surgery is associated with increased postoperative mortality and prolonged hospital stay. Although no causal relationship is proved, the results add a further aspect to preoperative optimization of elderly patients about to have major colorectal surgery.

Restless legs syndrome in patients with Parkinson's disease: a comparative study on prevalence, clinical characteristics, quality of life and nutritional status.

BACKGROUND: Restless legs syndrome (RLS) is a common neurological disorder that can coexist with Parkinson's disease (PD). However, the association between these two movement disorders is quite poorly explored and previous findings are controversial in different aspects. OBJECTIVE: To compare prevalence of RLS in Iranian PD population with a matched control group and to investigate the impact of comorbid RLS on quality of life (QoL), nutritional status, and clinical characteristics in PD population. METHODS: This study was conducted on 108 individuals with idiopathic PD (IPD) and 424 matched controls. RLS was diagnosed using the International Restless Legs Syndrome Study Group (IRLSSG) criteria. Further assessments were performed on clinical characteristics, PD severity scales, psychiatric features, nutritional status, fatigue, and QoL in PD patients with and without RLS. RESULTS: Restless legs syndrome was significantly more common among the patients with IPD (14.8%) compared to the controls (7.5%) [OR = 2.1 (95% CI: 1.1-4.0)]. IPD subjects with RLS had significantly higher anxiety score [10.1 (SD = 5.1) vs 5.9 (SD = 5.0); P = 0.003], worse nutritional status [23.7 (SD = 2.7) vs 25.4 (SD = 3.7); P = 0.008], and poorer QoL [26.9 (SD = 13.1) vs 17.0 (SD = 13.2); P = 0.006]. The number of positive answers to the IRLSSG diagnostic criteria had significant direct correlation with unpredictability of the off periods and the presence of symptomatic orthostasis. CONCLUSIONS: Our study demonstrated a higher prevalence of RLS in patients with PD compared to general population. PD patients with RLS suffer from more anxiety, worse nutritional status, and worse QoL. RLS negatively accompanies with psychiatric problems, emotional behaviors, stigma, and cognitive impairment.

Management of colon cancer in the elderly: a population-based study.

AIM: Although the median age of patients diagnosed with colon cancer is over 70 years, little is known about specific characteristics and management in the elderly. The aim of this study was to define the characteristics of colon cancer in elderly patients and compare the quality of preoperative assessment and surgery with that of younger patients undergoing surgery for colon cancer. METHOD: Data on 15,255 patients diagnosed with colon cancer between 2007 and 2010 were retrieved from the Swedish National Colon Cancer Register. Of these, 12,959 underwent surgical resection: 6141 were 75 years or older while 6818 were younger. The χ(2) test, Mann-Whitney U-test and univariable and multivariable logistic regression analyses were used for between-group comparison. RESULTS: Older patients were more likely to be female (54% older/48% younger) and have right-sided cancer (60% older/49% younger). Among patients who underwent resection, the elderly were less often evaluated regarding tumour stage prior to surgery (59% older/65% younger) and they were less often evaluated at a multidisciplinary team conference (26% older/34% younger). Elderly patients more frequently underwent emergency surgery (22% older/19% younger) despite having an earlier cancer stage. When adjusted for stage, fewer elderly patients underwent a radical curative procedure (OR for noncurative resection 1.19; 95% CI 1.06-1.33). CONCLUSION: Routine management of patients with colon cancer is age-dependent. Patients aged 75 years and older are less often completely staged and less often evaluated at a multidisciplinary team conference prior to surgery. Adjusted for stage, fewer elderly patients undergo curative resection.

Drug and treatment costs in Parkinson's disease patients in Sweden.

BACKGROUND: Parkinson's disease (PD) is a chronic neurodegenerative disease expected to cause great costs. The aim of this study was to calculate drug and treatment costs in patients with PD in Sweden. METHOD: All healthcare contacts of patients with PD in Stockholm County, Sweden, were extracted from registers together with information on reimbursements from the authorities to the caregivers. PD-related costs were calculated together with non-PD-related costs. Cost per patient was calculated and extrapolated to the whole Swedish population, taking population demographics into consideration. In addition, nationwide PD drug sales statistics were included. RESULTS: The PD prevalence of Stockholm County was estimated to 196 per 100,000 inhabitants, resulting in an estimated total of about 22,000 patients with PD in Sweden. The cost per patient was estimated to SEK 76,000 of which drug costs accounted for SEK 15,880. The annual direct costs in patients with PD in Sweden were SEK 1.7 billion in 2009. CONCLUSION: Our study estimates high direct costs in patients with PD in Sweden, SEK 1.7 billion, 52% for inpatient care, 27% for outpatient care and 21% for drugs. With an ageing population and the medical progress, the financial burden on society will most probably increase in the future. This study might initiate and provide information for discussions about future cost allocations and healthcare priorities.

Effect of methylphenidate and/or levodopa coupled with physiotherapy on functional and motor recovery after stroke--a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Amphetamine-like drugs are reported to enhance motor recovery and activities of daily living (ADL) in stroke rehabilitation, but results from trials with humans are inconclusive. This study is aimed at investigating whether levodopa (LD) and/or methylphenidate (MPH) in combination with physiotherapy could improve functional motor recovery and ADL in patients with stroke. MATERIAL AND METHODS: A randomized, double-blind, placebo-controlled trial with ischemic stroke patients randomly allocated to one of four treatment groups of either MPH, LD or MPH+LD or placebo combined with physiotherapy was performed. Motor function, ADL, and stroke severity were assessed by Fugl-Meyer (FM), Barthel index (BI), and National Institute of Health Stroke Scale (NIHSS) at baseline, 15, 90, and 180 days respectively. RESULTS: All participants showed recovery of motor function and ADL during treatment and at 6-month follow-up. There were slightly but significant differences in BI and NIHSS compared to placebo at the 6-month follow-up. CONCLUSION: Ischemic chronic stroke patients having MPH and/or LD in combination with physiotherapy showed a slight ADL and stroke severity improvement over time. Future studies should address the issue of the optimal therapeutic window and dosage of medications to identify those patients who would benefit most.

Homocysteine and holo-transcobalamin and the risk of dementia and Alzheimers disease: a prospective study.

BACKGROUND: Elevated total homocysteine (tHcy) levels may be caused by vitamin B12 deficiency and are linked to Alzheimers disease (AD) in some studies, although the evidence is mixed. Another marker of vitamin B12 deficiency, holo-transcobalamin (holo-TC), has not been studied in a prospective setting. OBJECTIVE: To investigate the association between tHcy and holo-TC and the subsequent development of dementia and AD in a prospective study. METHODS: A sub-sample of 228 non-demented subjects was taken from the Kungsholmen Project, a population-based longitudinal study amongst persons 75+ years. tHcy and holo-TC were analysed at baseline. RESULTS: Increasing tHcy levels were related to an increased risk of dementia (n = 83) and AD (n = 61) after a mean follow-up time of 6.7 years. Persons with high tHcy (the fourth quartile) had more than twice as high a risk of developing AD than persons with low tHcy, even after adjusting for confounding or mediating factors. The third quartile of holo-TC was associated with a reduced risk of AD, after adjusting for Hcy and other confounders. CONCLUSIONS: These results suggest that Hcy is involved in the development of dementia and AD. The role of holo-TC was less clear and this marker needs to be studied further.

Dipyridamole-associated headache in stroke patients--interindividual differences?

BACKGROUND: Secondary pharmacological prevention of ischemic stroke or transient ischemic attack (TIA) is often provided with acetylsalicylic acid (ASA), dipyridamole (DP) or a combination of the two. A problem with DP is the occurrence of headache, sometimes leading to medication cessation. By using a titration regime of DP the incidence of headache gets lower. However, there are no studies on interindividual differences in the incidence of headache with regard to age, gender, localization of stroke and the number of days since stroke onset. METHOD: 20 stroke units in Sweden recruited newly diagnosed stroke and TIA patients in need for thrombocyte antiaggregating therapy. They were offered a titration regime of the combination ASA 25 mg + DP 200 mg once daily for 5 days followed by twice daily. Baseline characteristics of the patients were recorded and headache symptoms were filled in by each patient in a diary for 10 consecutive days. Rescue medication with paracetamol was optional. RESULTS: 174 ischemic stroke patients with a mean age of 70.3 years, 63% men and 37% women, were recruited. Headache of any kind was reported in 70 patients (40.2%) and 37 (21.3%) assessed the headache as moderate/severe. Six patients stopped medication due to headache. A subsiding character of the headache was found with a mean of 3.1 days. Patients with TIA had a significantly higher risk of getting headache compared to manifest stroke, regardless of localization. There was a trend towards higher risk in younger age groups and females. No effect was seen on the number of days since stroke onset. CONCLUSION: DP is often associated with subsiding headache, however, with only few patients stopping medication due to headache. Being a younger female with a TIA seems to increase the risk of getting headache when having DP medication. Careful and adequate information about the possibly occurring headache should be given to patients prescribed a DP medication in order to increase compliance and optimize the pharmacological secondary stroke prevention.

Hyperhomocysteinemia and methylenetetrahydrofolate reductase polymorphism in patients with Parkinson's disease.

Elevated levels of homocysteine have been observed in Parkinson's disease (PD) patients treated with levodopa. However, it is not studied if duration of PD or PD per se is associated with hyperhomocysteinemia. In the present study, the levels of homocysteine in 99 levodopa-treated PD patients, 15 untreated PD patients and 100 controls were examined. We focused on the influence of levodopa dose, duration of therapy and disease as well as genetic (C677T methylenetetrahydrofolate reductase (MTHFR) polymorphism) and environmental factors. We found that levodopa-treated PD patients had elevated homocysteine plasma levels as compared to controls (p < 0.05), but the levels did not depend on levodopa doses. Another factor influencing homocysteine level was the duration of PD (p < 0.001). The frequency of allele C677T of MTHFR gene did not differ between PD and controls. In conclusion, hyperhomocysteinemia is associated with the duration of PD and levodopa treatment and possibly also with PD per se.

Medical intelligence in Sweden. Vitamin B12: oral compared with parenteral?

BACKGROUND: Sweden is the only country in which oral high dose vitamin B12 has gained widespread use in the treatment of deficiency states. OBJECTIVE: The aim of the study was to describe prescribing patterns and sales statistics of vitamin B12 tablets and injections in Sweden 1990-2000.Design, setting, and sources: Official statistics of cobalamin prescriptions and sales were used. RESULTS: The use of vitamin B12 increased in Sweden 1990-2000, mainly because of an increase in the use of oral high dose vitamin B12 therapy. The experience, in statistical terms a "total investigation", comprised 1,000,000 patient years for tablets and 750,000 patient years for injections. During 2000, 13% of residents aged 70 and over were treated with vitamin B12, two of three with the tablet preparation. Most patients in Sweden requiring vitamin B12 therapy have transferred from parenteral to oral high dose vitamin B12 since 1964, when the oral preparation was introduced. CONCLUSION: The findings suggest that many patients in other post-industrial societies may also be suitable for oral vitamin B12 treatment.

Changes in motor performance in persons with Parkinson's disease after exercise in a mountain area.

For one week in autumn, over a period of three consecutive years, a total of 12 persons with Parkinson's disease (PD) participated in daily walks of about 4 kilometers in a mountain area in Sweden in order to train rhythm, balance and coordination on the soft heaths. These persons were 60-78 years of age and had been found to be between stage 1 and stage 3 on the Hoehn and Yahr Staging Scale. The aim of the study was to find out whether a week of daily walks in the Swedish mountains would affect the motor performance of persons with PD, objectively and quantitatively assessed by a computer-assisted, opto-electronic movement analysis program, the Posturo-Locomotor-Manual (PLM) test. As compared with those before the journey, the results showed improved motor performance both immediately after the walking week and also at 3 but not 6 months later. The first year of participation showed the most pronounced improvements. The results demonstrate a long-lasting improvement in decreased movement time, indicating enhanced general motor performance and also an improved simultaneous index (SI), indicating a possible effect on the central nervous system. These findings, along with participants' narratives about what they did after returning home, may be indicative of strengthened self-confidence.

[Folate/cobalamin in the elderly--deficiency symptoms are common and difficult to catch]. / Folat/kobalamin hos äldre--bristtillstånd vanliga och svårfångade.

Elderly persons are especially exposed to folate deficiency, whereas normal/subnormal folate levels do not exclude tissue deficiency. Accompanying diseases, medication, and life style factors may contribute to/cause deficiency. Among available determinants of folate/cobalamin state homocysteine is a swift and sensitive marker. Symptoms of deficiency can be haematological, neurological or neuropsychiatric but there are probably also cardio-vascular manifestations. The association is generally stronger between homocysteine levels and symptoms than between vitamin-related levels and symptoms. The duration and the severity of symptoms are of importance for the improvement of neurological and neuropsychiatric symptoms when substitution is performed. The physician should make an individualized investigation to establish the probable cause, where nutritional factors and atrophic gastritis are most prominent. Folate enriched food as well as multivitamin supplementation are reported to be safe and beneficial for blood folate and homocysteine normalisation.

Cerebrovascular diseases and depression: epidemiology, mechanisms and treatment.

Both cerebrovascular disease (CVD) and depression are common conditions in the elderly, and there is emerging evidence of a bi-directional relationship: 1) depression can cause CVD and stroke, transient ischemic attack; and 2) subcortical CVD are associated with increased risk for depression. The frequency of poststroke depression is highest during the first month after the stroke, but remains high even after several years. Depression is associated with poorer functional prognosis and higher mortality after stroke. There is good evidence that severity of functional impairment, high neuroticism, low social support as well as genetic factors are associated with an increased risk for post-stroke depression. Deep white matter lesions are the most consistent imaging correlate of depression. Potential mechanisms mediating the association between depression and CVD are neuroinflammation and HPA-axis activation, fronto-subcortical circuit lesions, and serotonergic dysfunction. Antidepressants have demonstrated effect on poststroke depression in meta-analyses, and such drugs as well as vitamin B can reduce the incidence of depression in stroke survivors. In addition, serotonergic drugs may strengthen poststroke motor and cognitive recovery, potentially through restorative mechanisms. Psychotherapeutic strategies such as problem-solving therapy seem to be effective. There is emerging evidence that treatment of cardiovascular disease and risk-factors can reduce the risk for late-life depression, but more studies are needed to test this hypothesis.

Lack of information and access to advanced treatment for Parkinson's disease patients.

BACKGROUND: Parkinson's disease (PD) patients' own knowledge and experience and access to information, in relation to advanced treatment methods, are very limited. The aim of this study was to map out PD patients' perception about various advanced treatment methods, their availability and regional differences in medical care, and to investigate patients' experience of their medication and quality of life. METHODS: A survey was sent to 4886 PD patients of the Swedish Parkinson's Disease Association covering demography, the patient's illness, current treatment, received information about advanced treatment alternatives, and health status. Advanced PD was considered as patients diagnosed >5 years ago, using PD medication >5 times/day, and experiencing motor complications >2 hours/day. RESULTS: In total, 3327/4886 persons (68%) responded (57% men) of which 1300 (39%) were classified as having advanced PD. Mean age was 71 years with a median disease duration of 8 years. The treating physician was a neurologist (86%) but varied between counties (96% to 52%) and was most frequent in urban areas. Doctor appointments were 1.7 times/year with regional variation (2.1 to 1.1). Three out of four patients had heard of advanced treatment options and were interested, but were denied treatment. Only a small proportion of patients were informed of these by their physician. Nine percent were satisfied with their medication (including 4% of advanced patients). One third of patients experienced their general health as poor or very poor. CONCLUSION: The majority of Swedish PD patients are treated by neurologists. Annual numbers of doctors' appointments were low in an international context and can partly be explained by the shortage of neurologists and other trained specialists. Doctors only provided a small proportion of patients with advanced therapy information, despite patients' interest. Hence, improvement is warranted regarding doctor appointments, information about various advanced treatment options, and their availability.

Diurnal salivary cortisol concentrations in Parkinson's disease: increased total secretion and morning cortisol concentrations.

BACKGROUND: Parkinson's disease (PD) is a chronic neurodegenerative disorder. There is limited knowledge about the function of the hypothalamic-pituitary-adrenal axis in PD. The primary aim of this prospective study was to analyze diurnal salivary cortisol concentrations in patients with PD and correlate these with age, gender, body mass index (BMI), duration of PD, and pain. The secondary aim was to compare the results with a healthy reference group. METHODS: Fifty-nine PD patients, 35 women and 24 men, aged 50-79 years, were recruited. The reference group comprised healthy individuals matched for age, gender, BMI, and time point for sampling. Salivary cortisol was collected at 8 am, 1 pm, and 8 pm, and 8 am the next day using cotton-based Salivette(®) tubes and analyzed using Spectria(®) Cortisol I(125). A visual analog scale was used for estimation of pain. RESULTS: The median cortisol concentration was 16.0 (5.8-30.2) nmol/L at 8 am, 5.8 (3.0-16.4) at 1 pm, 2.8 (1.6-8.0) at 8 pm, and 14.0 (7.5-28.7) at 8 am the next day. Total secretion and rate of cortisol secretion during the day (8 am-8 pm) and the concentration of cortisol on the next morning were lower (12.5 nmol/L) in the reference group. No significant correlations with age, gender, BMI, duration of PD, Hoehn and Yahr score, Unified Parkinson's Disease Rating Scale III score, gait, pain, or cortisol concentrations were found. CONCLUSION: The neurodegenerative changes in PD does not seem to interfere with the hypothalamic-pituitary-adrenal axis. Salivary cortisol concentrations in PD patients were increased in the morning compared with the reference group, and were not influenced by motor dysfunction, duration of disease, or coexistence of chronic or acute pain.

Caregiver strain in Parkinson's disease and the impact of disease duration.

AIM: The task of managing care for patients with Parkinson's disease (PD) often falls upon a family member taking on the role as a caregiver (CG) implying a burden on these CGs. The aim of this study was to evaluate CG strain of PD patients with regarding different psychosocial domains and the influence of PD/CG duration of PD. METHODS: A cross-sectional telephone interview survey of 451 CGs randomly selected from the registry of the Swedish Parkinson's Disease Association. A structured questionnaire covering sociodemographic, psychosocial, and general CG factors, sleep and depression of the CG as well as issues of the patient's disease was used by 4 independent interviewers blinded to the study objective. RESULTS: Four hundred and four of 451 (90%) CGs responded with a mean age of 68.5 years with 62% females. The results were stratified in 3 groups with regard to disease duration of the PD patient, 0-4, 5-10, and >11 years, respectively. General health condition of the CGs was regarded satisfactory independent of disease duration. Insufficient sleep and disease related stress were considered to be prominent in 36% and 61%, respectively, being significantly more prominent in the group with the longest disease duration. Decreased mood was reported in 31% with no difference between groups. More than 30% of CGs also experienced daily problems with tiredness and sleep disturbance; 27% hypertension; 17% muscle strain, headache and fatigue; and 14% gastro-intestinal problems most items regardless of disease duration. The most troublesome symptoms of the patients to the CGs were reported to be the motor dysfunction (58%). More than half experienced little or no understanding of their situation. CONCLUSION: CGs are afflicted with strain and burden in many psychosocial and somatic domains despite satisfactory general wellbeing independent of disease duration. The longer disease duration, and, accordingly CG duration, the more impact on certain domains of CG burden, however, with little understanding of their situation. These findings should be given greater consideration when organizing and planning for PD care in the health care system and the community.

Effects of amphetamine and/or L-dopa and physiotherapy after stroke - a blinded randomized study.

OBJECTIVES: Major therapeutic advances in the rehabilitation of subacute stroke are lacking. A promising approach is treatment with facilitating drugs like amphetamine or levodopa in combination with physiotherapy. METHODS: In a randomized, double-blind, placebo-controlled clinical trail, the effect of 10 sessions with either 20 mg of D-amphetamine, 100 mg of L-dopa or 10 mg of D-amphetamine + 50 mg of L-dopa combined with physiotherapy during a 2-week period was investigated in 25 patients admitted to a stroke rehabilitation unit. Motor function (Fugl-Meyer score) and activities of daily living (Barthel's index) were assessed. RESULTS: All patients improved significantly over the intervention period. Drug-treated patients did not show any additional increase in motor function or ADL. CONCLUSION: It is feasible and safe to perform larger clinical trials with this type of four-arm design. However, the lack of significant effects could be because of type, dosage, and time of drugs as well as the physical intervention strategy.

Psychoendocrine concomitants in patients following a new design of a geriatric day-care unit.

BACKGROUND: Seventeen nondemented geriatric day-care attendees were subjected to a reorganized rehabilitation programme. It is suggested that increased control of and participation in the rehabilitation process might decrease psychoendocrine stress from uncertainty and passivity. METHOD: The new programme was a change from a traditional one-shift day-care into a two-shift design with two different patient sets a day. The programme was more individualized and time-efficient with written short- and long-term goals. Regular multidisciplinary case conferences were held with the patients to follow and feedback the progress of each individual patient. The patients were prospectively followed with stress markers such as prolactin, cortisol, dehydroepiandrosterone (DHA - a testosterone metabolite), estradiol, serum lipids and serum glucose. RESULTS: There was significant increase in anabolic hormones (DHA, estradiol), which contrasted with a significant decrease in catabolic hormones (prolactin, cortisol) during the actual day-care period. This pattern was restored at the 24-week follow-up for estradiol and prolactin, but with a continuous increase for DHA. Serum lipids and glucose were unaffected. CONCLUSIONS: This study found psychoendocrine changes that might have been elicited by a reorganization of the delivery of health care in elderly and handicapped patients. Further research is needed in order to understand these changes as well as the ideal structure and content of geriatric day-care programmes from a psychophysiological point of view.