Non-Motor Symptoms Assessed by Non-Motor Symptoms Questionnaire and Non-Motor Symptoms Scale in Parkinson's Disease in Selected Asian Populations.

BACKGROUND: Ethnic variations have been described in medical conditions, such as hypertension, diabetes, and multiple sclerosis. Whether ethnicity plays a role in Parkinson's disease (PD), particularly with regard to non-motor symptoms (NMS), remains unclear. Existing literature is diverse, controversial, and inadequately documented. This review aims to analyse and report the currently available literature on NMS, specifically in Asian PD patients. SUMMARY: We conducted a literature review using PubMed, searching for articles and currently available publications that reference and assess NMS in PD patients living in Asia using the validated NMS Questionnaire (NMS Quest) and NMS Scale (NMSS). In total, 24 articles were included: 12 using the NMS Quest and 12 using the NMSS. Symptoms of constipation, memory impairment, and nocturia were the most frequently self-reported symptoms (NMS Quest) in selected Asian populations, while symptoms within the domains sleep/fatigue, attention/memory, and mood/apathy were most prevalent when applying the health-professional completed NMSS. Key Messages: NMS are generally prevalent and highly burdensome within selected Asian PD populations living in countries included in this review. Our review suggests that NMS-driven phenotypic heterogeneity is present in Asian patients, and compared to Western PD populations there might be variations in assessed NMS.

Analysis of SCA8, SCA10, SCA12, SCA17 and SCA19 in patients with unknown spinocerebellar ataxia: a Thai multicentre study.

BACKGROUND: About 50 % of Thai patients with adult-onset spinocerebellar ataxia (SCA) was Machado-Joseph disease (MJD), SCA1, SCA2 and SCA6. The author investigated further on less common SCAs in the patients without any known mutations. METHODS: DNA samples of 82 index patients who were genetically excluded MJD, SCA1, SCA2, SCA6, SCA7 and dentatorubro-pallidoluysian atrophy (DRPLA) were examined. Analysis of SCA8, SCA10, SCA12, SCA17 and SCA19 genes were comprehensively performed. Normal range of trinucleotide repeat expansion sizes of TATA-box-binding protein gene (TBP) were also determined in 374 control subjects. RESULTS: Eight patients carried ≥42 CAG/CAA repeat allele in the TBP consistent with SCA17. The pathological repeat alleles ranged from 42 to 57 repeats. All patients had significant degree of cognitive dysfunction. Other non-ataxic phenotypes comprised of parkinsonism, chorea, dystonia and myoclonus. A sporadic patient carried a heterozygous 41-repeat allele developed chronic progressive cerebellar degeneration commenced at the age of 28 years. Whilst, 2 % of the control subjects (8/374) carried the 41-repeat allele. Five of the carriers were re-examined, and revealed that four of them had parkinsonism and/or cognitive impairment without cerebellar signs. Analysis of other types of SCAs was all negative. CONCLUSIONS: This is the first study of SCA8, SCA10, SCA12, SCA17 and SCA19 in Thais. SCA17 appears to be an important cause of ataxia in Thailand. Although, the pathological cut-off point of the TBP repeat allele remains unclear, the finding suggests that the 41-repeat may be a pathological allele resulting late-onset or mild phenotype. Apart from ataxia, cognitive impairment and parkinsonism may be clinical presentations in these carriers.

The impact of the nocturnal disabilities of Parkinson's disease on caregivers' burden: implications for interventions.

Parkinson's disease (PD) imposes a burden on those who care for the person afflicted. The objective of this study was to assess and analyze the main determinants of caregivers' burden, especially the nocturnal manifestations of PD. This multi-center, national, cross-sectional study included 89 patient-caregiver pairs. Caregiver self-assessments were performed with Hospital Anxiety and Depression Scale (HADS) and Zarit Caregiver Burden Interview (ZCBI). Patient self-assessments were performed with Modified Parkinson's Disease Sleep Scale (MPDSS), Nocturnal Akinesia Dystonia and Cramp Score (NADCS), HADS and Parkinson's Disease Quality of Life Questionnaire (PDQ-8). Most of the caregivers were employed women, and the majority had been permanently taking care of the patient for 6.8 ± 5.4 years. The study found that the ZCBI mean score of the caregivers significantly worsened as patients became more dependent (HY: 4-5, p = 0.036), and the mean ZCBI score of spousal caregivers (19.4; SD 15.5) was significantly higher than that of the offspring group (11.7; SD 7.9) (p = 0.008). Disease duration (r = 0.22), NADCS (r = 0.38), MPDSS (r = -0.36), PDQ-8 SI (r = 0.39) and HADS (total, anxiety and depression) scores (r = 0.46-0.49), and HADS (total, anxiety and depression scores (r = 0.37-0.52), had significant negative effect on caregivers' burden. Moderate association was found on MPDSS item 14 (r = 0.38) and NADCS akinesia score (r = 0.37). Patients' anxiety, nocturnal akinesia and the feeling of tiredness and sleepiness upon awakening in the morning were independent predictors of caregivers' burden (adjusted R2 = 0.46). Based on these findings, treatment of early mood symptoms of the patients and caregivers at risk may be helpful for the effective management of PD and it is also important to have well-designed psycho-educational and multicomponent interventions in the community for caregivers of persons with PD.

Nocturnal manifestations of atypical and vascular parkinsonism: how do they differ from Parkinson's disease?

While nocturnal disturbances of Parkinson's disease (PD) are increasingly recognized as being part of a continuum that includes daytime manifestations, there is still little analysis in the medical literature that assesses these complex phenomena in patients with atypical (AP) and vascular parkinsonisms (VP). The objective of our study was to determine the prevalence of these disturbances in patients with AP and VP and to determine the range of nighttime symptoms that occur compared with those in patients with PD. This comparison was done using a semi-structured interview and self-rated questionnaires in 63 AP and VP patients (PSP 24, MSA 24, CBD 5, and VP 10), and 208 PD patients. 61 AP and VP patients (96.8%) and 201 PD patients (96.6%) reported at least one nocturnal symptom with a score of less than 6 on the Modified Parkinson's Disease Sleep Scale (MPDSS). Nocturnal akinesia, as measured on the Nocturnal Akinesia, Dystonia, and Cramp Score, was found to be significantly greater in patients with PSP (p = 0.006), MSA (p = 0.002), and CBD (p = 0.012) than PD patients, but not VP patients (p = 0.428). Like those with PD, patients with AP and VP identified the problem of getting up at night to urinate (MPDSS item 8) as being the most frequent and troublesome nocturnal symptom. MSA and PSP patients reported more frequent (p = 0.001) and troublesome (p < 0.001) urinary incontinence (MPDSS item 9) than PD patients and MSA patients had more severe problems with unexpectedly falling asleep during the day (MPDSS item 15) than PD patients (p = 0.003). In summary, our study determined that nocturnal manifestations are commonly experienced by patients with AP and VP and highlighted specific nocturnal symptoms, which are more prevalent and troublesome in certain AP syndromes. The concept of 24-h control of symptoms should not be limited to only PD and we recommend that all who are involved in the care of AP and VP patients should realize that many nocturnal symptoms are experienced by these patients and a multidisciplinary approach should be utilized to address these problems.

Nocturnal journey of body and mind in Parkinson's disease: the manifestations, risk factors and their relationship to daytime symptoms. Evidence from the NIGHT-PD study.

Nocturnal manifestations of Parkinson's disease (PD) are myriad, have diverse etiologies and include motor, sleep, urinary, and neuropsychiatric symptoms which are often associated with daytime somnolence. While most patients perceive these symptoms as troublesome, the recognition of nocturnal problems related to PD is still low in clinical practice. We conducted a survey using semi-structured interviews and self-rated questionnaires of 215 consecutive patients with PD enrolled in three centers in Thailand to determine the prevalence and risk factors of nocturnal disabilities and their relationship to daytime symptoms. We found that 96.6% of patients reported the presence of nocturnal symptoms as determined by the modified version of Parkinson's Disease Sleep Scale (MPDSS). Our survey indicated that the most frequent and distressing symptom was the interruption of sleep to pass urine (56.7%, 4.4 ± 3.9). The severity of symptoms revealed in the MPDSS increased along with the disease duration (p < 0.05) and Hoehn and Yahr stages (p = 0.01). There were similar to findings of the Nocturnal Akinesia Dystonia and Cramp Score (NADCS) where patients with advanced disease had significantly higher NADCS scores than early/moderate disease (p < 0.001). There was a significant correlation of total MPDSS scores with the total scores of the 9-item Wearing-Off Questionnaire (WOQ-9); (r = -0.43, p < 0.05) [motor (r = -0.35, p < 0.05) and nonmotor subscores (r = -0.43, p < 0.05)]; total nonmotor symptoms (NMS) scores (r = -0.55, p < 0.05); Parkinson's Disease Questionnaire-8 Summary Index (PDQ-8 SI) (r = -0.52, p < 0.05); and the total NADCS (r = -0.35, p < 0.05). Multiple regression analysis identified PDQ-8 SI (ß = -0.27, p = 0.005) as the most significant predictor of nocturnal manifestations of PD, followed by the nonmotor subscore of WOQ (ß = -0.24, p = 0.006), and the NMS item 20 (feeling light-headed, dizzy, or weak when standing from sitting or lying) (ß = -0.22, p = 0.003). Our study found that nocturnal symptoms of PD are very common and we suggest that good clinical practice should include a comprehensive review of nighttime manifestations, particularly for those patients who already experience "wearing-off" symptoms.

Updating the recommendations for treatment of tardive syndromes: A systematic review of new evidence and practical treatment algorithm.

BACKGROUND: Management of tardive syndromes (TS) is challenging, with only a few evidence-based therapeutic algorithms reported in the American Academy of Neurology (AAN) guideline in 2013. OBJECTIVE: To update the evidence-based recommendations and provide a practical treatment algorithm for management of TS by addressing 5 questions: 1) Is withdrawal of dopamine receptor blocking agents (DRBAs) an effective TS treatment? 2) Does switching from typical to atypical DRBAs reduce TS symptoms? 3) What is the efficacy of pharmacologic agents in treating TS? 4) Do patients with TS benefit from chemodenervation with botulinum toxin? 5) Do patients with TS benefit from surgical therapy? METHODS: Systematic reviews were conducted by searching PsycINFO, Ovid MEDLINE, PubMed, EMBASE, Web of Science and Cochrane for articles published between 2012 and 2017 to identify new evidence published after the 2013 AAN guidelines. Articles were classified according to an AAN 4-tiered evidence-rating scheme. To the extent possible, for each study we attempted to categorize results based on the description of the population enrolled (tardive dyskinesia [TD], tardive dystonia, tardive tremor, etc.). Recommendations were based on the evidence. RESULTS AND RECOMMENDATIONS: New evidence was combined with the existing guideline evidence to inform our recommendations. Deutetrabenazine and valbenazine are established as effective treatments of TD (Level A) and must be recommended as treatment. Clonazepam and Ginkgo biloba probably improve TD (Level B) and should be considered as treatment. Amantadine and tetrabenazine might be considered as TD treatment (Level C). Pallidal deep brain stimulation possibly improves TD and might be considered as a treatment for intractable TD (Level C). There is insufficient evidence to support or refute TS treatment by withdrawing causative agents or switching from typical to atypical DRBA (Level U).

Can therapeutic Thai massage improve upper limb muscle strength in Parkinson's disease? An objective randomized-controlled trial.

Muscle weakness is a frequent complaint amongst Parkinson's disease (PD) patients. However, evidence-based therapeutic options for this symptom are limited. We objectively measure the efficacy of therapeutic Thai massage (TTM) on upper limb muscle strength, using an isokinetic dynamometer. A total of 60 PD patients with muscle weakness that is not related to their 'off' periods or other neurological causes were equally randomized to TTM intervention (n = 30), consisting of six TTM sessions over a 3-week period, or standard medical care (no intervention, n = 30). Primary outcomes included peak extension and flexion torques. Scale-based outcomes, including Unified Parkinson's Disease Rating Scale (UPDRS) and visual analogue scale for pain (VAS) were also performed. From baseline to end of treatment, patients in the intervention group showed significant improvement on primary objective outcomes, including peak flexion torque (F = 30.613, p < .001) and peak extension torque (F = 35.569, p < .001) and time to maximal flexion speed (F = 14.216, p = .001). Scale-based assessments mirrored improvements in the objective outcomes with a significant improvement from baseline to end of treatment of the UPDRS-bradykinesia of a more affected upper limb (F = 9.239, p = .005), and VAS (F = 69.864, p < .001) following the TTM intervention, compared to the control group. No patients reported adverse events in association with TTM. Our findings provide objective evidence that TTM used in combination with standard medical therapies is effective in improving upper limb muscle strength in patients with PD. Further studies are needed to determine the efficacy of TTM on other motor and non-motor symptoms in PD.

Exploring Bedroom Usability and Accessibility in Parkinson's Disease (PD): The Utility of a PD Home Safety Questionnaire and Implications for Adaptations.

BACKGROUND: Although bedrooms are identified as a major location for accidents among Parkinson's disease (PD) patients, there are no studies that specifically evaluate the bedroom environments of PD patients. OBJECTIVE: To examine the physical bedroom environment of patients with PD by generating a home safety questionnaire to rate bedroom accessibility and usability specifically for PD patients, and piloting it in a small set of PD patients, to identify environmental barriers and recommend adaptations to reduce accident risks. METHODS: Questionnaire development was based on the concept of Personal (P)-Environmental (E) fit. The P component covers five clinical domains that contribute to a patients' current state of health, including PD-related motor symptoms, PD-related non-motor symptoms, gait and balance impairments, comorbidities, and limitations on specific activities. The E component focuses on both indoor (bedroom, bathroom, living room, stairs, and kitchen), and outdoor (outdoor area and entrance) areas within a home where PD patients commonly get injured. Total score for the whole questionnaire is 171. A higher score indicates more P-E problems. RESULTS: Comprehension of questions was tested for content validity with an item-objective congruence index of above 0.6 for all items. High internal consistency (reliability) was confirmed by Cronbach's alpha coefficient of 0.828 (r). The pilot in five PD patients gave a mean total score of 48.2 ± 7.29 with a mean score on personal and environmental components of 16.8 ± 5.12 and 31.4 ± 4.51, respectively. CONCLUSION: This PD home safety questionnaire is a valid and reliable instrument for examining P-E problems by a multidisciplinary team during their home visits. More studies, involving a large number of PD patients, are needed to establish its utility as a screening instrument in PD patients to assess for home adaptations.

Objective Measurement and Monitoring of Nonmotor Symptoms in Parkinson's Disease.

The comprehensive evaluation of nonmotor symptoms (NMS) in Parkinson's disease (PD) starts with the awareness of physicians, patients, and caregivers on their nature, clinical presentation, and effect on patient's daily activities and quality of life. This awareness can be better achieved if the symptoms can be visualized, measured, and monitored. As NMS are largely subjective in nature, a majority of them cannot be visualized (unlike tremor, which is easily seen), making their identification and quantification difficult. While symptoms are nonmotor, it does not mean that they are not measurable, as many NMS are integral to motor symptoms of Parkinson's, yet often neglected. In this review, we attempt to provide the most up-to-date and comprehensive literature review on the objective measurement and monitoring of NMS in PD. The aim is to make it clinically relevant by approaching NMS by domains as identified in the NMS Questionnaire. A section on the assessment of nonmotor fluctuations is also included, providing prospects for future objective monitoring. With the advances of technology, it is likely that many NMS will have objective outcomes, thus making these symptoms easily measurable and hopefully lead to future clinical trials that incorporate nonmotor outcomes. Nevertheless, it still requires a physician's judgment to determine which method, scales, objective measures, or monitoring devices or a combination of these is most appropriate to the individual patient in order to answer a particular clinical question.

Knowledge, attitudes and perceptions of Parkinson's disease: A cross-sectional survey of Asian patients.

BACKGROUND: A knowledge gap about Parkinson's disease (PD) often exists amongst PD patients, the level and accuracy of which can influence their attitude and perceptions about the disease. Increased awareness of this information deficit can help physicians identify interventions that will improve patient's knowledge and perceptions about PD. OBJECTIVES: To evaluate general understanding of PD and identify knowledge gaps amongst PD patients using a validated PD knowledge questionnaire. METHODS: A cross-sectional, questionnaire-based study was conducted in 108 PD patients (34 working; 74 retired). The questionnaire covers three domains of PD, including diagnosis, therapeutic options, and disease course with a total knowledge score ranging from 0 to 26. Subjects with dementia were excluded. RESULTS: Patient misconceptions were reflected in the mean (SD) total, diagnosis, therapeutic options, and disease course scores: 14.64 (3.32), 7.76 (1.93), 3.85 (1.28), and 3.03 (1.41) respectively. The working age subgroup had significantly higher knowledge scores than the retired age group for the whole questionnaire (p=0.004), as well as the diagnosis (p=0.001) and therapeutic sections (p=0.023). Three dependent variables, including younger age at recruitment (<60years old), female gender, and higher disease duration (≥4years), were identified as predictors of a higher level of PD knowledge amongst PD patients. CONCLUSION: Significant knowledge gaps were identified amongst PD patients in all three aspects of the questionnaire. Timely identification of patients with inaccurate or insufficient disease-related knowledge could help healthcare professionals choose more suitable multimodal educational interventions.

Axial Sensory Tricks in Chorea-Acanthocytosis: Insights into Phenomenology.

BACKGROUND: Trunk flexion and axial extension are characteristic symptoms of chorea-acanthocytosis (ChAc). PHENOMENOLOGY SHOWN: A 41-year-old male with ChAc (confirmed by VPS13A mutations) reported that his involuntary axial movements were significantly ameliorated by either folding his arms over his chest or putting his hands behind his head. EDUCATIONAL VALUE: These apparent "sensory tricks" suggest a dystonic pathophysiology, and also merit further study to analyze their potential for symptom control in ChAc.

Tremor's glove-an innovative electrical muscle stimulation therapy for intractable tremor in Parkinson's disease: A randomized sham-controlled trial.

BACKGROUND: Medically refractory resting tremor is a debilitating symptom of Parkinson's disease (PD) patients. In our pilot study, modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) temporarily suppressed tremor. OBJECTIVES: To investigate the efficacy of EMS, delivered using Tremor's glove, as a treatment of resting hand tremor. PATIENTS AND METHODS: Thirty PD patients with medically refractory resting tremor were randomly allocated to a Tremor's glove group (n=15) or a sham glove group (n=15). Gloves were placed on the most tremulous hand for 30min per testing session. Demographics, clinical rating scales, and tremor parameters (RMS of angular velocity and angular displacement, peak magnitude, and frequency) were assessed before and during stimulation. Correlations with validated clinical rating scales were performed. RESULTS: There were no statistically significant differences between groups in demographics, rating scales, or tremor parameters. During stimulation, significant reduction in RMS angular velocity (as percentage) in every axis and peak magnitude in axis (x-, y-) and UPDRS tremor score, were found with Tremor's glove compared to the sham groups (p<0.05, each). Significant moderate correlations were observed between a percentage reduction of RMS angular velocity in every axis and UPDRS tremor scores. Mean duration of tremor reduction after stimulation was 107.78±104.15s. No serious adverse events were observed. CONCLUSION: In this study, EMS-based Tremor's glove was effective in suppressing resting hand tremor in PD patients. Tremor's glove is light-weight with a good safety profile, making it a future potential therapeutic option for PD patients with medically refractory tremor.

Systematic review of hardware-related complications of Deep Brain Stimulation: Do new indications pose an increased risk?

INTRODUCTION: Deep Brain Stimulation (DBS) is an effective treatment extended broadly to many neurological and psychiatric disorders. Nevertheless, complications may arise during DBS procedures or following implantation due to implanted hardware. This may result in both minor and major adverse events that may necessitate hardware removal and/or compromise maximal therapeutic benefit for the patient. OBJECTIVES AND METHODS: To identify relevant literature on hardware-related complications from DBS procedures by performing a systematic review, and propose how to identify at-risk group and possible preventive approaches. RESULTS: Of 4592 abstract screened, 96 articles fulfilled the selection criteria and were reviewed. Overall, the most common hardware-related complications were infections (5.12% of patients), followed by lead migration (1.60%), fracture or failure of the lead or other parts of the implant (1.46% and 0.73%, respectively), IPG malfunctions (1.06% of patients), and skin erosions without infections (0.48% of patients). New indications for DBS, including Tourette's syndrome, cluster headache, and refractory partial epilepsy, were found to bear a higher incidence of hardware-related infections than established indications such as Parkinson's disease. The highest rate of lead fracture or failure was found in dystonia patients (4.22%). Ultimately, the highest rate of pain at the implantation sites was found in refractory partial epilepsy patients (16.55%). CONCLUSION: Our analysis identified a variety of potential hardware-related complications among patients who underwent DBS procedures. Patients who were at risk of complications, such as patients with dystonia and off-label indications (e.g. Tourette's syndrome) should be informed prior to surgery and closely followed thereafter.

Physicians' role in the determination of fitness to drive in patients with Parkinson's disease: systematic review of the assessment tools and a call for national guidelines.

BACKGROUND: Physicians are usually at the forefront when the issue of driving ability is raised by Parkinson's disease (PD) patients or their family members, even though few have been formally trained in this area. OBJECTIVES AND METHODS: To identify relevant literature on driving assessment tools in patients with PD by performing a systematic review on this subject in order to provide background information for physicians on what types of driving assessment are available, and to delineate the role of physicians in providing fitness to drive recommendations. RESULTS: Of 1,490 abstracts screened, 55 articles fulfilled the selection criteria that investigated assessment of driving ability in PD patients with questionnaires, off-road testing battery, driving simulators, and driving skill tests (on-road tests and naturalistic driving test). Despite different methodology across studies, PD patients were observed to commit more driving errors than controls. Poor driving performance correlated with motor, visual, and cognitive severity. Excessive daytime somnolence was common in PD drivers and the presence of falling asleep while driving was identified to be a significant predictor of car accidents. CONCLUSION: Although the evidence indicated more driving errors among PD drivers as identified by various assessment tools, the extent on how physicians should be involved in the evaluation process and make related recommendations remain unclear. Driving safety is an important public health issue in PD that needs better-defined specific legal and medical guidelines. National guidelines that establish risk assessment protocols involving multidisciplinary assessments are needed to assist physicians in making appropriate referrals for additional evaluations and recommendations when patients are deemed to be unsafe drivers.

What daily activities increase the risk of falling in Parkinson patients? An analysis of the utility of the ABC-16 scale.

BACKGROUND: Although the strongest predictor of falling in Parkinson's disease is the number of falls in the preceding year, little information is available on what types of daily activities (ADLs) that are associated with a significant fall risk in this population. OBJECTIVES: To determine balance confidence (FOF) in PD patients by utilizing the 16-item Activities-Specific Balance Confidence Scale (ABC-16), and identifying specific activities from this scale that are predictors of future falls. METHODS: 160 patients with PD, and 52 age-matched healthy controls completed the Thai-validated version of the ABC-16. The number of falls during the past month was obtained from both groups. RESULTS: PD patients reported lower confidence in their ability to maintain balance during ADLs compared to controls (p<0.001) with the lowest confidence score being item 16 (walking on slippery sidewalks). A significant negative correlation was observed between the number of falls in the previous month, and a mean ABC-16 score (r=-0.387, p<0.001). Logistic regression analysis identified the strongest predictor of fall in PD patients was item 9 (getting in/out of car; OR=4.8), followed by item 6 (standing on chair to reach; OR=3.4), and item 3 (picking up slippers from floor; OR=2.6). All of these high-risk activities involve movement in the vertical orientation. CONCLUSION: FOF was more common in PD patients than controls. In patients with postural instability and visual impairment, high-risk activities should be minimized, avoided, or performed only under supervision. It is recommended that fall prevention strategies include physical therapy interventions that are targeted at these activities.

Impact of Neu-botulinumtoxinA on the Severity and Quality of Life of Cervical Dystonia Patients.

BACKGROUND: Cervical dystonia (CD) is a debilitating neurological disorder that may gravely affect a patient's quality of life (QoL). Botulinum toxin treatment has been approved as a first-line treatment for this condition. This study aims to look at the efficacy and impact on the QoL of neu-botulinumtoxinA, a newer and cheaper botulinum toxin type A, in patients with CD. METHODS: This is a prospective, open-label, single-arm study. CD patients were recruited and evaluated for severity of CD using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), and for QoL using the Craniocervical Dystonia Questionnaire (CDQ-24), and the 36-item Short Form Health Survey questionnaire (SF-36) at baseline and 6 weeks after injection. RESULTS: Twenty patients were recruited. Significant improvement was shown in part 1 and total TWSTRS score and total CDQ-24 scores. Analysis of individual items of the TWSTRS scale showed significant improvement in rotation, duration of CD, and work ability. Significant improvements in the QoL were also seen in some items of the stigma, emotional wellbeing, and energy/fatigue domains of the CDQ-24 and SF-36 questionnaires. DISCUSSION: Neu-botulinumtoxinA is efficacious in treating CD symptoms and improving QoL of patients with CD. A larger, double-blinded study is needed to study the extent of improvements.

Understanding the role of the Parkinson's disease nurse specialist in the delivery of apomorphine therpy.

Optimal care of Parkinson's disease (PD) patients should involve a multidisciplinary team (MDT) of which a PD nurse specialist (PDNS) is a key member. The role of a PDNS is particularly prominent in the care of advanced PD patients suitable for apomorphine because, in addition to nursing skills, apomorphine treatment requires liaison, training, interaction and coordination with patients, caregivers and other members of the MDT as well as the interface with primary care physicians. The therapeutic success of apomorphine therapy depends not only upon the pharmacologic drug response, but also on how well the patient understands his/her disease and how to handle the therapy. In this respect, a PDNS is a vital member of the MDT who provides education and training, support, and is available for consultation when problems arise. In this article, we review the literature on the contribution of PDNSs in both continuous subcutaneous apomorphine infusion and intermittent subcutaneous apomorphine injection and highlight the various beneficial aspects of PDNS care, supported by scientific evidence when available. Despite a low level of published evidence, there is strong clinical evidence that the impact of PDNSs on the management of apomorphine therapy is vital and indispensable for the success of this treatment.

Postural instability, the absence of sexual intercourse in the past month, and loss of libido are predictors of sexual dysfunction in Parkinson's disease.

OBJECTIVE: To determine the prevalence and predictors of sexual dysfunction (SD) in Parkinson's disease (PD) patients. BACKGROUND: Assessments of SD in the professional literature is limited. Understanding the predictors of SD can help physicians focus on this problem in vulnerable patients. METHOD: A total of 60 PD patients and 60 controls answered the Arizona Sexual Experiences Scale-Thai Version (ASEX-Thai) and the Hamilton Depression Rating Scale (HAMD) questionnaires, and were asked on 3 additional sets of questions about premature ejaculation (PE), dyspareunia, and hypersexual disorders. RESULT: The prevalence of SD in PD patients and controls was 81.6% and 48.3% respectively (p < 0.05). PD patients had lower BMI, lower uric acid level, higher HAMD score and had sexual intercourse (SI) less frequently. SD correlated with greater disease severity and depression. The most distressing problem in male patients was PE (51.4%) and orgasmic dissatisfaction (76%) for female patients. Logistic regression analysis found 3 factors were related to SD: no SI in the past month (p < 0.001), postural instability (PI) (p = 0.028), and HAMD item 14 (p = 0.021), predicting SD with the OR of 12.2, 5.5, and 5.0 respectively. CONCLUSIONS: SD in PD is common and usually occurs with depression. Absence of SI in the past month, PI, and loss of libido are predictors of SD in PD. A simple and quick screening of SD can be routinely performed by inquiring patients about the frequency of SI and the examination of the pull test. Detailed assessment of sexual functioning and depression may guide physicians in proper management.