Undetected ophthalmological disorders in Parkinson's disease.

BACKGROUND: Ophthalmological disorders are common and frequently disabling for people with Parkinson's disease (PD). However, details on the prevalence, severity and impact of ophthalmological disorders thus far lacking. We aimed to identify PD patients with undetected ophthalmological disorders in a large cross-sectional, observational study. METHODS: We previously delivered a screening questionnaire to detect ophthalmological symptoms (Visual impairment in PD questionnaire; VIPD-Q) to 848 patients. Here, we report on a subgroup of 102 patients who received complete ophthalmological assessment aimed at identifying clinically relevant ophthalmological diseases, which were classified as either vison-threatening or not. Impact on daily life functioning was measured using the visual functioning-25 questionnaire (VFQ-25) and fall frequency. RESULTS: Almost all patients (92%) had one or more clinically relevant ophthalmological disorders. Of those, 77% had a potentially vision-threatening disease, while 34% had a potentially treatable ophthalmological disease which impacted on quality of life. The most prevalent ophthalmological disorders were dry eyes (86%), ocular misalignment (50%) and convergence insufficiency (41%). We found a weak but significant association between clinically relevant ophthalmological diseases and both fall frequency (R2 = 0.15, p = 0.037) and VFQ-25 score (R2 = 0.15, p = 0.02). The VIPD-Q could not correctly identify patients with relevant ophthalmological disorders. CONCLUSIONS: Surprisingly, in our study sample, many participants manifested previously undetected ophthalmological diseases, most of which threatened vision, impacted on daily life functioning and were amenable to treatment. Screening for these ophthalmological disorders using a questionnaire asking about symptoms seems insufficient. Instead, episodic ophthalmological assessments should be considered for PD patients, aiming to identify vision-threatening yet treatable diseases. TRIAL REGISTRATION: Dutch Trial Registration, NL7421.

Seeing ophthalmologic problems in Parkinson disease: Results of a visual impairment questionnaire.

OBJECTIVE: To determine the prevalence and clinical effect of ophthalmologic symptoms in patients with Parkinson disease (PD), compared with controls, using a standardized questionnaire. METHODS: In this observational, cross-sectional, multicenter study, 848 patients with PD and 250 healthy controls completed the Visual Impairment in Parkinson's Disease Questionnaire (VIPD-Q). The VIPD-Q addressed 4 domains according to structures: (1) ocular surface; (2) intraocular; (3) oculomotor; and (4) optic nerve. The questionnaire also assessed the effect of ophthalmologic symptoms on daily activities. RESULTS: One or more ophthalmologic symptoms were reported by 82% (95% confidence interval [CI], 80-85) of patients, compared with 48% (95% CI, 42-54) of controls (p < 0.001). Patients with PD experienced more ophthalmologic symptoms across all domains than controls (p < 0.001), as reflected by a higher VIPD-Q total score among patients (median 10 [interquartile range (IQR) 13]) than controls (median 2 [IQR 5]; p < 0.001). Ophthalmologic symptoms interfered with daily activities in 68% (95% CI, 65-71) of patients, compared with 35% (95% CI, 29-41) of controls (p < 0.001). CONCLUSION: Patients with PD have a higher prevalence of ophthalmologic symptoms than controls. Moreover, these frequently interfere with daily activities. A screening questionnaire such as the VIPD-Q may help with identifying ophthalmologic symptoms in PD, thereby enabling more timely treatment.

Towards seeing the visual impairments in Parkinson's disease: protocol for a multicentre observational, cross-sectional study.

BACKGROUND: Visual disorders are common in Parkinson's disease (PD) but their exact frequency and severity are unknown. Good visual functioning is crucial for patients with PD, because of their need to compensate for loss of automated motor control and their postural instability, forcing patients to guide their movements visually. Here, we describe the study design of a cross-sectional, multi-centre study aiming to: (1) validate the Visual Impairment screening questionnaire (VIPD-Q, which aims to identify PD patients who should be referred to an ophthalmologist for further assessment); (2) study the prevalence of visual disorders in PD; (3) study the severity and clinical impact of different types of visual disorders in PD; and (4) explore treatment options for ophthalmologic disorders in PD, as a basis for future guideline development. METHODS: This study consists of two phases. In phase one, 750 PD patients and 250 healthy controls will be recruited to complete the VIPD-Q. In phase two, a subgroup of responders (n = 100) (with the highest and lowest scores on the VIPD-Q) will be invited for an extensive neurological and ophthalmological assessment. The in-depth ophthalmologic examination will serve as the "gold standard" for validating the VIPD-Q. Moreover, these assessments will be used to study associations between visual disorders and clinical presentation, in order to gain more insight in their clinical impact. DISCUSSION: Our study will heighten the awareness of visual problems in PD and offers a robust starting point to systematically approach this subject. In current daily practice, the association between visual problems and PD is far from obvious to both patients and clinicians. Consequently, patients may not adequately report visual problems themselves, while clinicians miss potentially treatable visual disorders. Routinely asking patients to complete a simple screening questionnaire could be an easy solution leading to timely identification of visual problems, tailored treatment, restored mobility, greater independence and improved quality of life. TRIAL REGISTRATION: Dutch Trial Registration, NL7421 , Registered on 4 December 2018 - Retrospectively registered.

Diplopia in Parkinson's disease: visual illusion or oculomotor impairment?

INTRODUCTION: Approximately 20% of patients with Parkinson's disease (PD) experience diplopia; however, the cause of the diplopia is unclear. We aimed to explore the association of diplopia, and its subtypes, with oculomotor abnormalities, impaired vision, and visual hallucinations, in patients with PD. METHODS: This exploratory study included 41 PD patients, recruited from two general hospitals, of whom 25 had diplopia and 16 did not have diplopia, as well as 23 healthy controls (HCs). We defined subtypes of diplopia as selective diplopia, i.e., diplopia of single objects, and complete diplopia, i.e., diplopia of the entire visual field. All participants underwent a full orthoptic and ophthalmologic examination. RESULTS: PD patients with diplopia had a high prevalence of oculomotor abnormalities (84%), impaired vision (44%), and visual hallucinations (44%), compared to PD patients without diplopia (33%, 6%, and none, respectively, p < 0.01), and compared to HCs (23%, 9%, and none, respectively, p < 0.01). Oculomotor abnormalities were equally prevalent in both subtypes of diplopia (selective and complete), whereas impaired vision was predominantly found in patients with selective diplopia. Moreover, only patients with selective diplopia had visual hallucinations. CONCLUSIONS: In PD patients, diplopia may be indicative of oculomotor or visual impairments. Hence, it is worthwhile to refer PD patients with diplopia to an orthoptist and an ophthalmologist for evaluation and, possibly, treatment of diplopia. Furthermore, in the case of selective diplopia, the neurologist should consider the presence of visual hallucinations, which may require the adjustment of the patient's medication.

In vivo exploration of retinal nerve fiber layer morphology in Parkinson's disease patients.

Thinning of the retinal nerve fiber layer (RNFL) is a recently discovered feature of Parkinson's disease (PD). Its exact pathological mechanism is yet unknown. We aimed to determine whether morphological changes of the RNFL are limited to RNFL thinning or also comprise an altered internal structure of this layer. Therefore, we investigated RNFL thickness and applied the RNFL attenuation coefficient (RNFL-AC), a novel method derived from optical coherence tomography, in PD patients and healthy controls (HCs). In this pilot study, we included 20 PD patients and 20 HCs matched for age, sex, and ethnicity. An ophthalmologist investigated all participants thoroughly, and we acquired retinal images from both eyes of each participant with a Spectralis optical coherence tomography system. We obtained both the RNFL-AC and RNFL thickness from peripapillary RNFL scans for the entire RNFL, as well as for each quadrant separately. We found no significant differences in the average RNFL-AC or the RNFL-AC of the separate retinal quadrants between PD patients and the HC group. However, compared to the HC group, PD patients had a significantly thinner RNFL in the temporal retinal quadrant. RNFL thinning was found in the temporal quadrant in PD patients without a corresponding change in the RNFL-AC. These findings suggest a reduction in the number of RNFL axons (atrophy) without other major changes in the structural integrity of the remaining RNFL.

Baseline predictors of maintenance of intervention-induced changes in physical activity and sitting time among diabetic and pre-diabetic patients: a descriptive case series.

BACKGROUND: The aim of this study was to explore the predictive value of baseline characteristics in relation to changes in physical activity (PA) and sedentary behaviour among diabetic and pre-diabetic patients participating in a primary care based exercise intervention. We used a descriptive case series among diabetic and pre-diabetic patients (n = 119, 50.8% male, mean age 65.5 (SD = 7.8)). Measurements took place with questionnaires at baseline and two years after the start of the intervention. Predictor variables included demographic factors, Body Mass Index, baseline PA and sitting time, and baseline socio-cognitive profile. RESULTS: At follow-up, respondents spent more time being physically active than at baseline. For the total group, the average sitting time remained almost unchanged between the two measurements. Further exploration showed that respondents who had relatively high levels of PA at the start of the intervention, increased their total sitting time, while respondents with relatively low levels of PA at the start decreased their sitting time. The socio-cognitive profile did not predict behaviour change. The intervention appeared to be suitable for people with a low-education level, but the results should be interpreted in view of the limitations of the study such as the non-controlled design, self-reported outcomes and selective drop-out of participants. CONCLUSIONS: Interventions for this specific target group may need to put more emphasis on the prevention of increased sitting time. The finding that the socio-cognitive profile did not predict behaviour change may underline the proposition that decisions to initiate and maintain PA behaviour change are to a large extend non-linear events. Acknowledging the possible non-linearity of the relationship between socio-cognitive determinants and behaviour change will help our understanding of this complex and dynamic process.

Isolated headache in general practice: determinants for delay in referral in patients with subarachnoid haemorrhage.

BACKGROUND: A delay in diagnosing aneurismal subarachnoid haemorrhage (SAH) occurs in a substantial proportion of patients who present with headache as the only symptom. OBJECTIVE: To identify determinants for a delay in referral in patients with SAH, who present with isolated headache to the general practitioner (GP). METHODS: For all 112 patients with SAH admitted to the hospital between October 2008 and June 2009, we sent a questionnaire to the GPs asking for details presented during the initial GP visit. In this retrospective study, we included 31 patients with SAH who initially presented with isolated headache. We assessed acuteness of headache onset, history of headaches and a patient delay as determinants for delayed referral (> 2 h after a visit to the GP), by calculating risk ratios (RRs) with corresponding 95% confidence intervals (CIs). RESULTS: Referral was delayed in 18 of these 31 patients. The delay occurred in all 10 patients in whom the GP was unaware of the acute onset of headache and in 8 of 21 patients in whom the GP was aware of this symptom (RR: 2.6; 95% CI: 1.5-4.5). A history of headaches (RR: 1.8; 95% CI: 1.1-3.0) and a patient delay (RR: 2.1; 95% CI: 1.0-4.5) also increased the probability of delayed referral. CONCLUSION: In patients with SAH who presented with isolated headache to the GP, GP's unawareness of the acute onset of the headache, a history of headaches and late presentation by the patient increased the probability of delayed referral.

Factors determining the motivation of primary health care professionals to implement and continue the 'Beweegkuur' lifestyle intervention programme.

AIM: To examine factors explaining motivation among health care professionals to implement and continue a multidisciplinary primary care-based lifestyle intervention, called BeweegKuur, to support prevention and treatment of type 2 diabetes mellitus. METHODS: Questionnaire research with two measurements among Dutch general practitioners, practice nurses and physiotherapists participating in a pilot study. At baseline, professionals were generally preparing to start the implementation. At second measurement, all practices were implementing BeweegKuur. RESULTS: The results reveal a positive motivation among professionals to implement and continue the intervention. The motivation of practice nurses to continue implementation was lower compared with other professionals. Social support by colleagues, compatibility and perceived relative advantage of the intervention for the professionals were associates of the baseline motivation to implement it. High-baseline self-efficacy and profession (i.e. not being practice nurse) positively predicted the motivation to continue the intervention at second measurement. CONCLUSIONS: Professionals in our study can be characterized as innovators or early adopters, and inclusion of BeweegKuur in the basic health insurance package may persuade other adoption categories to implement the intervention. An intensified focus on skills building (e.g. motivational interviewing skills, general lifestyle counselling skills) is expected to contribute to sustained high-quality implementation of the intervention.

Sitting time and Body Mass Index in diabetics and pre-diabetics willing to participate in a lifestyle intervention.

This cross-sectional study examined the relationship between Body Mass Index (BMI), total sitting time and total physical activity time in a generally overweight or obese population of type 2 diabetics or pre-diabetics willing to participate in a lifestyle intervention [n = 221, 55.1% male, mean age (SD) 62.0 (9.9), mean BMI (SD) 31.4 (5.0)]. In addition, we aimed to identify demographic and psychosocial associates of the motivation to become more physically active. The measurement instrument was a self-report questionnaire. Results showed that total sitting time was more closely related to BMI than total physical activity time. Subjects with a higher weight status were more sedentary, but they were also more motivated to be physically active. On the other hand, their self-efficacy to be physically active was lower than subjects with a lower weight status. Lifestyle interventions to decrease the risk of obesity and type 2 diabetes should aim not only at increasing total physical activity time, but also at reducing the total sitting time. Despite generally high levels of motivation among these obese participants, intervention designers and intermediaries should be aware of their low level of self-efficacy towards being physically active.

Development and implementation of a lifestyle intervention to promote physical activity and healthy diet in the Dutch general practice setting: the BeweegKuur programme.

BACKGROUND: The number of patients with diabetes is increasing. BeweegKuur (Dutch for 'Exercise Therapy') is a Dutch lifestyle intervention which aims to effectively and feasibly promote physical activity and better dietary behaviour in primary health care to prevent diabetes. METHODS: The goal of this paper is to present the development process and the contents of the intervention, using a model of systematic health promotion planning. The intervention consists of a 1-year programme for diabetic and prediabetic patients. Patients are referred by their general practitioner (GP) to a lifestyle advisor (LSA), usually the practice nurse or a physiotherapist. Based on specific inclusion criteria and in close collaboration with the patient, an individual exercise programme is designed and supervised by the LSA. This programme can be attended at existing local exercise facilities or (temporarily) under the supervision of a specialized exercise coach or physiotherapist. All participants are also referred to a dietician and receive diet-related group education. In the first pilot year (2008), the BeweegKuur programme was implemented in 7 regions in the Netherlands (19 GP practices and health centres), while 14 regions (41 GP practices and health centres) participated during the second year. The aim is to implement BeweegKuur in all regions of the Netherlands by 2012. DISCUSSION: The BeweegKuur programme was systematically developed in an evidence- and practice-based process. Formative monitoring studies and (controlled) effectiveness studies are needed to examine the diffusion process and the effectiveness and cost-effectiveness of the intervention.

Longitudinal changes in GPs' task perceptions, self-efficacy, barriers and practices of nutrition education and treatment of overweight.

BACKGROUND: GPs play a role in prevention by giving nutrition education and advice on overweight. Over the years, GP's tasks and working environment changed. OBJECTIVE: To know how task perceptions, perceptions of own ability and perceived barriers regarding nutrition education and treatment of overweight of Dutch GPs have developed from 1992 to 2007. METHODS: In all, 488 GPs, first included in study in 1992, were asked in 2007 to return the Wageningen PCPs Nutritional Practices Questionnaire. Crohnbach's alphas and sum scores were calculated and differences between 1992 and 2007 were investigated using a paired t-test. RESULTS: In all, 247 GPs responded (51%). 'Noticing patients overweight and guidance of treatment' did not change in GPs from 1992 to 2007. The task perception about health education and prevention did not change and the perception of daily activities shifted from the curative to the preventive side. Interest in the influence of nutrition on health increased in 2007. GPs less often managed to counsel on nutrition in daily practice. Their perceived capacity to counsel and their self-efficacy regarding overweight management declined over the years. In 2007, more GPs perceived the barriers 'lack of time' to treat overweight and to give nutrition education. The most important barrier in 2007 was lack of patient motivation. CONCLUSIONS: The GPs perceived overweight and nutrition education as important and were still favourable towards prevention. However, their potential to give nutrition education or guide in treatment of overweight was not fully utilized because of decreased self-efficacy factors and perceived barriers.