Clinical utility of a personalized and long-term monitoring device for Parkinson's disease in a real clinical practice setting: An expert opinion survey on STAT-ON™.

BACKGROUND: STAT-ON™ is an objective tool that registers ON-OFF fluctuations making possible to know the state of the patient at every moment of the day in normal life. Our aim was to analyze the opinion of different Parkinson's disease experts about the STAT-ON™ tool after using the device in a real clinical practice setting (RCPS). METHODS: STAT-ON™ was provided by the Company Sense4Care to Spanish neurologists for using it in a RCPS. Each neurologist had the device for at least three months and could use it in PD patients at his/her own discretion. In February 2020, a survey with 30 questions was sent to all participants. RESULTS: Two thirds of neurologists (53.8% females; mean age 44.9±9 years old) worked in a Movement Disorders Unit, the average experience in PD was 16±6.9 years, and 40.7% of them had previously used other devices. A total of 119 evaluations were performed in 114 patients (range 2-9 by neurologist; mean 4.5±2.3). STAT-ON™ was considered "quite" to "very useful" by 74% of the neurologists with an overall opinion of 6.9±1.7 (0, worst; 10, best). STAT-ON™ was considered better than diaries by 70.3% of neurologists and a useful tool for the identification of patients with advanced PD by 81.5%. Proper identification of freezing of gait episodes and falls were frequent limitations reported. CONCLUSION: STAT-ON™ could be a useful device for using in PD patients in clinical practice.

Palliative care management in patients with Parkinson's disease and other movement disorders in Spain. National survey of neurologists.

INTRODUCTION: Palliative care in neurodegenerative diseases is useful but underused. The objective of this study is to know how palliative care (PC) is applied in Spain in order to identify limitations and unmet needs. MATERIALS AND METHODS: It is a descriptive, observational, cross-sectional study, anonymous survey type of 20 questions, directed and answered by neurologists dedicated to movement disorders (MD) in Spain. RESULTS: 58 responses were obtained from neurologists from 15 autonomous communities. 69% answered that they did not have a specialised MD nursing facility but did have a PC team in their centre (81%). No specific protocol for PC in MD was identified. All except one neurologist stated that they lacked sufficient training in PC, the main training need being the "advance directives explanation". Only 1 in 4 neurologists answered routinely explaining advance healthcare planning to their patients, recognising up to 84.5% of neurologists not knowing how to assess the patient's competence. 60.3% of those surveyed answered that between 10% and 30% of their patients would be candidates for PC, although 1 in 3 said they were not clear when to refer the patient to PC. 100% of neurologists affirmed the priority need to implement PC protocols in MD. CONCLUSIONS: Our study shows a formative deficit in PC in this area and in the care of the patient with movement disorders and their environment, and should serve as a starting point to develop consensual care protocols.

Staging Parkinson's Disease Combining Motor and Nonmotor Symptoms Correlates with Disability and Quality of Life.

INTRODUCTION: In a degenerative disorder such as Parkinson's disease (PD), it is important to establish clinical stages that allow to know the course of the disease. Our aim was to analyze whether a scale combining Hoehn and Yahr's motor stage (H&Y) and the nonmotor symptoms burden (NMSB) (assessed by the nonmotor symptoms scale (NMSS)) provides information about the disability and the patient's quality of life (QoL) with regard to a defined clinical stage. MATERIALS AND METHODS: Cross-sectional study in which 603 PD patients from the COPPADIS cohort were classified according to H&Y (1, stage I; 2, stage II; 3, stage III; 4, stage IV/V) and NMSB (A: NMSS = 0-20; B: NMSS = 21-40; C: NMSS = 41-70; D: NMSS ≥ 71) in 16 stages (HY.NMSB, from 1A to 4D). QoL was assessed with the PDQ-39SI, PQ-10, and EUROHIS-QOL8 and disability with the Schwab&England ADL (Activities of Daily Living) scale. RESULTS: A worse QoL and greater disability were observed at a higher stage of H&Y and NMSB (p < 0.0001). Combining both (HY.NMSB), patients in stages 1C and 1D and 2C and 2D had significantly worse QoL and/or less autonomy for ADL than those in stages 2A and 2B and 3A and 3B, respectively (p < 0.005; e.g., PDQ-39SI in 1D [n = 15] vs 2A [n = 101]: 28.6 ± 17.1 vs 7.9 ± 5.8; p < 0.0001). CONCLUSION: The HY.NMSB scale is simple and reflects the degree of patient involvement more accurately than the H&Y. Patients with a lower H&Y stage may be more affected if they have a greater NMS burden.

Manejo de la enfermedad de Parkinson y otros trastornos del movimiento en mujeres en edad fértil: Parte 1 / Management of Parkinson's disease and other movement disorders in woman of childbearing age: Part 1

INTRODUCCIÓN: El manejo de la enfermedad de Parkinson en la mujer en edad fértil nos plantea como principal reto el manejo de la enfermedad y los fármacos durante el embarazo y lactancia. El aumento de la edad gestacional de la mujer hace más probable que la incidencia de embarazos pueda incrementarse. OBJETIVO: Definir las características clínicas y los factores que condicionan la vida de la mujer en edad fértil con enfermedad de Parkinson y definir una guía de actuación y manejo del embarazo en estas pacientes. RESULTADOS: Este documento de consenso se ha realizado mediante una búsqueda bibliográfica exhaustiva y discusión de los contenidos realizados por un grupo de expertos en trastornos del movimiento de la Sociedad Española de Neurología. CONCLUSIONES: La enfermedad de Parkinson afecta a todos los aspectos relacionados con la salud sexual y reproductiva de la mujer en edad fértil. Se debe planificar el embarazo en las mujeres con enfermedad de Parkinson para minimizar los riesgos teratogénicos sobre el feto. Se recomienda un abordaje multidisciplinar de estas pacientes para tener en cuenta todos los aspectos implicados

INTRODUCTION: The main challenge of Parkinson's disease in women of childbearing age is managing symptoms and drugs during pregnancy and breastfeeding. The increase in the age at which women are having children makes it likely that these pregnancies will become more common in future. OBJECTIVES: This study aims to define the clinical characteristics of women of childbearing age with Parkinson's disease and the factors affecting their lives, and to establish a series of guidelines for managing pregnancy in these patients. RESULTS: This consensus document was developed through an exhaustive literature search and a discussion of the available evidence by a group of movement disorder experts from the Spanish Society of Neurology. CONCLUSIONS: Parkinson's disease affects all aspects of sexual and reproductive health in women of childbearing age. Pregnancy should be well planned to minimise teratogenic risk. A multidisciplinary approach should be adopted in the management of these patients in order to take all relevant considerations into account

Manejo de la enfermedad de Parkinson y otros trastornos del movimiento en mujeres en edad fértil: parte 2 / Management of Parkinson's disease and other movement disorders in women of childbearing age: Part 2

INTRODUCCIÓN: Muchas enfermedades que cursan con trastornos del movimiento hipercinético comienzan o afectan a mujeres en edad fértil. Es importante conocer los riesgos que tienen las mujeres con estas enfermedades durante el embarazo, así como los posibles efectos de los tratamientos sobre el feto. OBJETIVOS: Definir las características clínicas y los factores que condicionan la vida de la mujer en edad fértil con distonía, corea, síndrome de Tourette, temblor y síndrome de piernas inquietas. Definir una guía de actuación y manejo del embarazo y lactancia en las pacientes con esta enfermedad. DESARROLLO: Este documento de consenso se ha realizado mediante una búsqueda bibliográfica exhaustiva y discusión de los contenidos llevadas a cabo por un Grupo de Expertos en Trastornos del Movimiento de la Sociedad Española de Neurología (SEN). CONCLUSIONES: En todas las mujeres que padecen o comienzan con trastornos del movimiento hipercinéticos se debe valorar el riesgo-beneficio de los tratamientos, reducir al máximo la dosis eficaz o administrarlo de forma puntual en los casos en que sea posible. En aquellas enfermedades de causa hereditaria es importante un consejo genético para las familias. Es importante reconocer los trastornos del movimiento desencadenados durante el embarazo como determinadas coreas y síndrome de piernas inquietas

INTRODUCTION: Many diseases associated with hyperkinetic movement disorders manifest in women of childbearing age. It is important to understand the risks of these diseases during pregnancy, and the potential risks of treatment for the fetus. OBJECTIVES: This study aims to define the clinical characteristics and the factors affecting the lives of women of childbearing age with dystonia, chorea, Tourette syndrome, tremor, and restless legs syndrome, and to establish guidelines for management of pregnancy and breastfeeding in these patients. RESULTS: This consensus document was developed through an exhaustive literature search and a discussion of the content by a group of movement disorder experts from the Spanish Society of Neurology. CONCLUSIONS: We must evaluate the risks and benefits of treatment in all women with hyperkinetic movement disorders, whether pre-existing or with onset during pregnancy, and aim to reduce effective doses as much as possible or to administer drugs only when necessary. In hereditary diseases, families should be offered genetic counselling. It is important to recognise movement disorders triggered during pregnancy, such as certain types of chorea and restless legs syndrome

Management of Parkinson's disease and other movement disorders in woman of childbearing age: Part 1. / Manejo de la enfermedad de Parkinson y otros trastornos del movimiento en mujeres en edad fértil: Parte 1.

INTRODUCTION: The main challenge of Parkinson's disease in women of childbearing age is managing symptoms and drugs during pregnancy and breastfeeding. The increase in the age at which women are having children makes it likely that these pregnancies will become more common in future. OBJECTIVES: This study aims to define the clinical characteristics of women of childbearing age with Parkinson's disease and the factors affecting their lives, and to establish a series of guidelines for managing pregnancy in these patients. RESULTS: This consensus document was developed through an exhaustive literature search and a discussion of the available evidence by a group of movement disorder experts from the Spanish Society of Neurology. CONCLUSIONS: Parkinson's disease affects all aspects of sexual and reproductive health in women of childbearing age. Pregnancy should be well planned to minimise teratogenic risk. A multidisciplinary approach should be adopted in the management of these patients in order to take all relevant considerations into account.

Management of Parkinson's disease and other movement disorders in women of childbearing age: Part 2. / Manejo de la enfermedad de Parkinson y otros trastornos del movimiento en mujeres en edad fértil: parte 2.

INTRODUCTION: Many diseases associated with hyperkinetic movement disorders manifest in women of childbearing age. It is important to understand the risks of these diseases during pregnancy, and the potential risks of treatment for the fetus. OBJECTIVES: This study aims to define the clinical characteristics and the factors affecting the lives of women of childbearing age with dystonia, chorea, Tourette syndrome, tremor, and restless legs syndrome, and to establish guidelines for management of pregnancy and breastfeeding in these patients. RESULTS: This consensus document was developed through an exhaustive literature search and a discussion of the content by a group of movement disorder experts from the Spanish Society of Neurology. CONCLUSIONS: We must evaluate the risks and benefits of treatment in all women with hyperkinetic movement disorders, whether pre-existing or with onset during pregnancy, and aim to reduce effective doses as much as possible or to administer drugs only when necessary. In hereditary diseases, families should be offered genetic counselling. It is important to recognise movement disorders triggered during pregnancy, such as certain types of chorea and restless legs syndrome.

Mood in Parkinson's disease: From early- to late-stage disease.

BACKGROUND: Although depression is known to be frequent in Parkinson's disease (PD), it is unclear how mood can change and/or impact on patient's quality of life (QoL) over time. Our aim was to analyze the frequency of depression, mood related factors and the contribution of mood to a patient's QoL perception in regard to disease duration. METHODS: PD patients recruited from the COPPADIS cohort from January 2016 to November 2017 were included in this cross-sectional study. Three groups were defined: <5 years (Group A); from 5 to <10 years (Group B); ≥10 years (Group C). Analysis with well-planned linear regression models was conducted to determine how different factors contribute to mood (Beck Depression Inventory-II [BDI-II] as dependent variable), to health-related QoL (39-item Parkinson's Disease Questionnaire [PDQ-39SI] as dependent variable) and to global QoL (European Health Interview Survey - Quality of Life Eight-Item Index [EUROHIS-QOL8] as dependent variable). RESULTS: Six hundred and sixty-three PD patients (62.6 ± 8.9 years old, 59.6% males) were included: Group A, 50.1% (n = 332); Group B, 33.3% (n = 221) and Group C, 16.6% (n = 110). There were no differences between the three groups in terms of the frequency of depressive symptoms nor the frequency of depression type (major vs. minor vs. subthreshold) (p = 0.729). However, the unique percent variance of PDQ-39SI and EUROHIS-QOL8 explained by BDI-II total score was 2 (23.7%) and threefold (26.9%), respectively, in Group C compared to the other two groups. EUROHIS-QOL8 total score provided the highest unique contribution to mood (16.8%). CONCLUSIONS: Although depression-type frequency does not appear to change over time in PD; the contribution of mood on QoL perception is greater in patients with longer disease duration.

Clinical utility of a personalized and long-term monitoring device for Parkinson's disease in a real clinical practice setting: An expert opinion survey on STAT-ON™.

BACKGROUND: STAT-ON™ is an objective tool that registers ON-OFF fluctuations making possible to know the state of the patient at every moment of the day in normal life. Our aim was to analyze the opinion of different Parkinson's disease experts about the STAT-ON™ tool after using the device in a real clinical practice setting (RCPS). METHODS: STAT-ON™ was provided by the Company Sense4Care to Spanish neurologists for using it in a RCPS. Each neurologist had the device for at least three months and could use it in PD patients at his/her own discretion. In February 2020, a survey with 30 questions was sent to all participants. RESULTS: Two thirds of neurologists (53.8% females; mean age 44.9±9 years old) worked in a Movement Disorders Unit, the average experience in PD was 16±6.9 years, and 40.7% of them had previously used other devices. A total of 119 evaluations were performed in 114 patients (range 2-9 by neurologist; mean 4.5±2.3). STAT-ON™ was considered "quite" to "very useful" by 74% of the neurologists with an overall opinion of 6.9±1.7 (0, worst; 10, best). STAT-ON™ was considered better than diaries by 70.3% of neurologists and a useful tool for the identification of patients with advanced PD by 81.5%. Proper identification of freezing of gait episodes and falls were frequent limitations reported. CONCLUSION: STAT-ON™ could be a useful device for using in PD patients in clinical practice.

Quality of life and non-motor symptoms in Parkinson's disease patients with subthreshold depression.

BACKGROUND: The role of subthreshold depression (subD) in Parkinson's Disease (PD) is not clear. The present study aimed to compare the quality of life (QoL) in PD patients with subD vs patients with no depressive disorder (nonD). Factors related to subD were identified. MATERIAL AND METHODS: PD patients and controls recruited from the COPPADIS cohort were included. SubD was defined as Judd criteria. The 39-item Parkinson's disease Questionnaire (PDQ-39) and the EUROHIS-QOL 8-item index (EUROHIS-QOL8) were used to assess QoL. RESULTS: The frequency of depressive symptoms was higher in PD patients (n = 694) than in controls (n = 207) (p < 0.0001): major depression, 16.1% vs 7.8%; minor depression, 16.7% vs 7.3%; subD, 17.4% vs 5.8%. Both health-related QoL (PDQ-39; 18.1 ±â€¯12.8 vs 11.6 ±â€¯10; p < 0.0001) and global QoL (EUROHIS-QOL8; 3.7 ±â€¯0.5 vs 4 ±â€¯0.5; p < 0.0001) were significantly worse in subD (n = 120) than nonD (n = 348) PD patients. Non-motor Symptoms Scale (NMSS) total score was higher in subD patients (45.9 ±â€¯32 vs 29.1 ±â€¯25.8;p < 0.0001). Non-motor symptoms burden (NMSS;OR = 1.019;95%CI 1.011-1.028; p < 0.0001), neuropsychiatric symptoms (NPI; OR = 1.091; 95%CI 1.045-1.139; p < 0.0001), impulse control behaviors (QUIP-RS; OR = 1.035; 95%CI 1.007-1063; p = 0.013), quality of sleep (PDSS; OR = 0.991; 95%CI 0.983-0.999; p = 0.042), and fatigue (VAFS-physical; OR = 1.185; 95%CI 1.086-1.293; p < 0.0001; VAFS-mental; OR = 1.164; 95%CI 1.058-1.280; p = 0.0001) were related to subD after adjustment to age, disease duration, daily equivalent levodopa dose, motor status (UPDRS-III), and living alone. CONCLUSIONS: SubD is a frequent problem in patients with PD and is more prevalent in these patients than in controls. QoL is worse and non-motor symptoms burden is greater in subD PD patients.

Non-motor symptoms burden, mood, and gait problems are the most significant factors contributing to a poor quality of life in non-demented Parkinson's disease patients: Results from the COPPADIS Study Cohort.

OBJECTIVE: To identify factors related to a poor health-related and global quality of life (QoL) in a cohort of non-demented Parkinson's disease (PD) patients and compare to a control group. METHODS: The data correspond to the baseline evaluation of the COPPADIS-2015 Study, an observational, 5-year follow-up, multicenter, evaluation study. Three instruments were used to assess QoL: (1) the 39-item Parkinson's disease Questionnaire (PDQ-39), (2) a subjective rating of global QoL (PQ-10), and (3) the EUROHIS-QOL 8-item index (EUROHIS-QOL8). Multiple linear regression methods were used to evaluate the direct impact of different variables on these QoL measures. RESULTS: QoL was worse in PD patients (n = 692; 62.6 ±â€¯8.9 years old, 60.3% males) than controls (n = 206; 61 ±â€¯8.3 years old, 49.5% males): PDQ-39, 17.1 ±â€¯13.5 vs 4.4 ±â€¯6.3 (p < 0.0001); PQ-10, 7.3 ±â€¯1.6 vs 8.1 ±â€¯1.2 (p < 0.0001); EUROHIS-QOL8, 3.8 ±â€¯0.6 vs 4.2 ±â€¯0.5 (p < 0.0001). A high correlation was observed between PDQ-39 and Non-Motor Symptoms Scale (NMSS) (r = 0.72; p < 0.0001), and PDQ-39 and Beck Depression Inventory-II (BDI-II) (r = 0.65; p < 0.0001). For health-related QoL (PDQ-39), non-motor symptoms burden (NMSS), mood (BDI-II), and gait problems (Freezing Of Gait Questionnaire [FOGQ]) provided the highest contribution to the model (ß = 0.32, 0.28, and 0.27, respectively; p < 0.0001); whereas mood and gait problems contributed the most to global QoL (PQ-10, ß = -0.46 and -0.21, respectively; EUROHIS-QOL8, ß = -0.44 and -0.23, respectively). CONCLUSIONS: QoL is worse in PD patients than in controls. Mood, non-motor symptoms burden, and gait problems seem to be the most relevant factors affecting health-related and global perceived QoL in non-demented PD patients.

COPPADIS-2015 (COhort of Patients with PArkinson's DIsease in Spain, 2015): an ongoing global Parkinson's disease project about disease progression with more than 1000 subjects included. Results from the baseline evaluation.

BACKGROUND AND PURPOSE: In Parkinson's disease (PD), the course of the disorder is highly variable between patients. Well-designed, prospective studies for identifying PD progression biomarkers are necessary. Our aim was to show the results of baseline evaluations of an ongoing global PD project, COPPADIS-2015 (Cohort of Patients with PArkinson's DIsease in Spain, 2015). METHODS: This was an observational, descriptive, nationwide study (Spain). The recruitment period ended in October 2017. Baseline evaluation included more than 15 validated scales and complementary studies in a subgroup of participants. RESULTS: In total, 1174 subjects from 35 centres were considered valid for baseline analysis: 694 patients (62.6 ± 8.9 years old, 60.3% males), 273 caregivers (58.5 ± 11.9 years old, 31.8% males) and 207 controls (61 ± 8.3 years old, 49.5% males). The mean disease duration was 5.5 ± 4.4 years. Hoehn and Yahr stage was 1 or 2 in 90.7% of the patients whilst 33.9% and 18.1% of them presented motor fluctuations and dyskinesias, respectively. The mean Non-Motor Symptoms Scale total score was 45.4 ± 38.1, and 30.4% of the patients presented cognitive impairment, 16.1% major depression, 12.7% impulse control disorder, 7.2% compulsive behaviour, 57.2% pain and 13.2% falls. Compared to the control group, PD patients presented a significantly higher burden of non-motor symptoms and a worse quality of life. More than 300 subjects conducted complementary studies (serum biomarkers, genetic and neuroimaging). CONCLUSIONS: Parkinson's disease is a complex disorder and different non-motor symptoms are frequently present and are more prevalent than in controls. In real clinical practice it is important to ask for them.

Angeítis aislada del sistema nervioso central / Isolated cerebral angiitis

Introducción. La angeítis granulomatosa aislada del sistema nervioso central se define histológicamente por la presencia de una inflamación granulomatosa que se distribuye desde los vasos meníngeos y se extiende hacia el parénquima a lo largo de venas y de arterias de calibre variable. Las alteraciones clínicas más frecuentes en estos pacientes son la cefalea y cuadros de encefalopatía. Caso clínico. Presentamos el caso clínico de una paciente que inicia crisis convulsivas de inicio parcial con generalización secundaria, diagnosticado mediante biopsia cerebral, con buena respuesta clínica al tratamiento inmunosupresor (corticoides y ciclofosfamida). Realizamos una actualización bibliográfica sobre esta patología. Conclusiones. La sintomatología tan heterogénea que presentan los pacientes con esta patología provoca en numerosas ocasiones confusión y retraso en el diagnóstico. La confirmación histológica mediante la realización de una biopsia cerebral y meníngea es el parámetro determinante para el diagnóstico de la angeítis granulomatosa del sistema nervioso central (AU)

Introduction: Isolated cerebral angiitis of the central nervous system is defined histologically by presence of granulomatous inflammation in the meningeal vessels, and parenchyma throughout veins and arteries of variable size. The most common clinical manifestations are headache and encephalopathy. Case Report: We present the clinical case of a patient with epileptic seizures of focal onset, secondary generalized, diagnosed by cerebral biopsy. Clinical response to immunosuppressive treatment (corticosteroid and cyclophosphamyde) was excellent. We make a bibliographic review and update. Conclusion: The heterogeneous clinical symptomatology of this disease leads to confusion and delay in diagnosis. Histological confirmation by cerebral and meningeal biopsy is the best parameter for diagnosis of isolated cerebral angiitis of the central nervous system (AU)

[Isolated cerebral angiitis]. / Angeítis aislada del sistema nervioso central.

INTRODUCTION: Isolated cerebral angiitis of the central nervous system is defined histologically by presence of granulomatous inflammation in the meningeal vessels, and parenchyma throughout veins and arteries of variable size. The most common clinical manifestations are headache and encephalopathy. CASE REPORT: We present the clinical case of a patient with epileptic seizures of focal onset, secondary generalized, diagnosed by cerebral biopsy. Clinical response to immunosuppressive treatment (corticosteroid and cyclophosphamyde) was excellent. We make a bibliographic review and update. CONCLUSION: The heterogeneous clinical symptomatology of this disease leads to confusion and delay in diagnosis. Histological confirmation by cerebral and meningeal biopsy is the best parameter for diagnosis of isolated cerebral angiitis of the central nervous system.

[Levodopa and cognitive disorders in Parkinson's disease]. / Levodopa y alteraciones cognitivas en la enfermedad de Parkinson.

AIMS: Most of the patients with Parkinson's disease evaluated in formal neuropsychological studies are found to have cognitive disorders similar to those of patients with lesions in the prefrontal cortex. A large number of anatomical, physiological, pharmacological and clinical data indicate that dopamine transmission plays an important role in frontal cortical functions. We review the main types of cognitive impairment in Parkinson's disease and their response to treatment with levodopa. DEVELOPMENT: In studies involving the acute administration of levodopa, the results obtained with regard to the cognitive functions have been heterogeneous, since improvements, exacerbations and the absence of any changes have all been observed. This heterogeneity is affected by methodological problems deriving from the disease itself, the treatment administered and the way evaluation is carried out. Longitudinal studies show a pattern of initial improvement, followed by stability, or maintenance, over a period of 2 or 3 years and then renewed exacerbation with no response to levodopa. On occasions, patients may only respond after a certain period of continued treatment. Generally speaking, the more severe the cognitive impairment is, the poorer the response to levodopa will be. CONCLUSIONS: Therapy with levodopa modifies, in one sense or another, the cognitive disorders in Parkinson's disease, which indicates that the dopaminergic deficit unquestionably plays a role in these disorders. The absence of response in some patients or in some cognitive functions or the fact that it 'wears off' in most patients suggests that the dopaminergic deficit is only one of the factors in the aetiopathogenesis of the cognitive dysfunction found in Parkinson's disease.

Levodopa y alteraciones cognitivas en la enfermedad de Parkinson / Levodopa and cognitive disorders in parkinson’s disease

Objetivo. La mayoría de los pacientes con enfermedadde Parkinson valorados con estudios neuropsicológicos formalespresentan alteraciones cognitivas semejantes a las de los pacientescon lesiones de la corteza prefrontal. Múltiples datos anatómicos,fisiológicos, farmacológicos y clínicos indican que la transmisióndopaminérgica desempeña un papel importante en las funcionescorticales de tipo frontal. Revisamos los principales déficit cognitivosen la enfermedad de Parkinson y su respuesta al tratamientocon levodopa. Desarrollo. En estudios de administración aguda delevodopa, los resultados sobre las funciones cognitivas han sidoheterogéneos, ya que se han descrito mejorías, empeoramientos oausencia de cambios. En esta heterogeneidad influyen problemasmetodológicos derivados de la propia enfermedad, del tratamientoadministrado y de la forma de evaluación. En estudios longitudinalesse aprecia un patrón de mejoría inicial, mantenimiento duranteun período de 2 o 3 años y nuevo empeoramiento sin respuesta a lalevodopa. Ocasionalmente, los pacientes pueden responder sólotras un cierto tiempo de tratamiento continuado. En general, a mayorgravedad del déficit cognitivo, menor respuesta a la levodopa.Conclusiones. El tratamiento con levodopa modifica, en uno u otrosentido, las alteraciones cognitivas en la enfermedad de Parkinson,lo que indica que el déficit dopaminérgico cumple un papel indudableen esas alteraciones. La ausencia de respuesta en algunos pacienteso en algunas funciones cognitivas o su esfumación en lamayoría, sugiere que el déficit dopaminérgico es sólo uno de losfactores en la etiopatogenia de la disfunción cognitiva encontradaen la enfermedad de Parkinson

Aims. Most of the patients with Parkinson’s disease evaluated in formal neuropsychological studies are found tohave cognitive disorders similar to those of patients with lesions in the prefrontal cortex. A large number of anatomical,physiological, pharmacological and clinical data indicate that dopamine transmission plays an important role in frontalcortical functions. We review the main types of cognitive impairment in Parkinson’s disease and their response to treatmentwith levodopa. Development. In studies involving the acute administration of levodopa, the results obtained with regard to thecognitive functions have been heterogeneous, since improvements, exacerbations and the absence of any changes have allbeen observed. This heterogeneity is affected by methodological problems deriving from the disease itself, the treatmentadministered and the way evaluation is carried out. Longitudinal studies show a pattern of initial improvement, followed bystability, or maintenance, over a period of 2 or 3 years and then renewed exacerbation with no response to levodopa. Onoccasions, patients may only respond after a certain period of continued treatment. Generally speaking, the more severe thecognitive impairment is, the poorer the response to levodopa will be. Conclusions. Therapy with levodopa modifies, in onesense or another, the cognitive disorders in Parkinson’s disease, which indicates that the dopaminergic deficit unquestionablyplays a role in these disorders. The absence of response in some patients or in some cognitive functions or the fact that it‘wears off’ in most patients suggests that the dopaminergic deficit is only one of the factors in the aetiopathogenesis of thecognitive dysfunction found in Parkinson’s disease

[An update on the diagnosis of vascular dementia]. / Actualización en el diagnóstico de la demencia vascular.

INTRODUCTION: Vascular dementia (VD) is the second most frequent cause of dementia after Alzheimer's disease in western societies. It includes a heterogeneous group of disorders in which vascular factors are believed to play a vital role in the development of cognitive impairment. Aims and development. Our aim was to determine what instruments can be used to diagnose VD and to what extent such a diagnosis is reliable. To this end, we review the diagnostic criteria that have been used up to now, the role played by neuropsychology, the value of neurosonology studies, and the growing development of neuroimaging techniques, especially magnetic resonance. CONCLUSIONS: Current diagnostic criteria for VD select a group that is clinically and aetiologically very heterogeneous. Such criteria need shifting towards new evidence-based criteria derived from analyses of population studies that focus on the early stages of the disease and that make a proper distinction between patients with mixed dementia. The subcortical subtype of vascular cognitive impairment (SVCI) is a form of vascular impairment that is more homogeneous and which selects more representative patients with a more predictable clinical pattern, natural history, response to treatment and prognosis. These characteristics make SVCI cases an ideal group for comparisons between clinical trials and studies.

Actualización en el diagnóstico de la demencia vascular / An update on the diagnosis of vascular dementia

Introduction. Vascular dementia (VD) is the second most frequent cause of dementia after Alzheimer’s disease in western societies. It includes a heterogeneous group of disorders in which vascular factors are believed to play a vital role in the development of cognitive impairment. Aims and development. Our aim was to determine what instruments can be used to diagnose VD and to what extent such a diagnosis is reliable. To this end, we review the diagnostic criteria that have been used up to now, the role played by neuropsychology, the value of neurosonology studies, and the growing development of neuroimaging techniques, especially magnetic resonance. Conclusions. Current diagnostic criteria for VD select a group that is clinically and aetiologically very heterogeneous. Such criteria need shifting towards new evidence-based criteria derived from analyses of population studies that focus on the early stages of the disease and that make a proper distinction between patients with mixed dementia. The subcortical subtype of vascular cognitive impairment (SVCI) is a form of vascular impairment that is more homogeneous and which selects more representative patients with a more predictable clinical pattern, natural history, response to treatment and prognosis. These characteristics make SVCI cases an ideal group for comparisons between clinical trials and studies (AU)

Introducción. La demencia vascular (DV) es la segunda causa de demencia tras la enfermedad de Alzheimer en la sociedad occidental. Incluye un grupo heterogéneo de trastornos en los que se piensa que los factores vasculares desempeñan un papel esencial en el desarrollo del deterioro cognitivo. Objetivo y desarrollo. Nuestro objetivo es analizar con qué instrumentos y con qué fiabilidad somos capaces de diagnosticar la DV. Para ello, revisamos los criterios diagnósticos existentes hasta la actualidad, el papel de la neuropsicología, del estudio neuroecográfico y el creciente desarrollo de las técnicas de neuroimagen, en especial la resonancia magnética. Conclusión. Los criterios diagnósticos actuales para la DV seleccionan a un grupo clínica y etiológicamente muy heterogéneo, y es necesario modificarlos hacia unos nuevos criterios basados en evidencias, derivados del análisis de estudios poblacionales que se centren en la enfermedad en sus estadios iniciales, y que diferencien adecuadamente a los pacientes con demencia mixta. El subtipo de deterioro cognitivo vascular subcortical (DCVS) representa una forma de deterioro vascular más homogéneo y que selecciona a pacientes más representativos, con un cuadro clínico, evolución, respuesta al tratamiento y pronóstico más predecibles. Estas características hacen del DCVS un grupo ideal para la comparabilidad de estudios y ensayos clínicos (AU)

[Delays before and after arrival at the hospital in the treatment of strokes]. / Retraso extrahospitalario e intrahospitalario en el tratamiento del ictus.

INTRODUCTION: Only a minority of patients with acute stroke are eligible for fibrinolysis, and the main reason for this is that time runs out and goes beyond the therapeutic window. The chief delay occurs prior to arrival at the hospital, but there is also a nosocomial delay, which has received far less attention. AIMS: The purpose of our study was to describe the data on delays occurring before and after arrival at the hospital in a sample of patients with acute stroke, and to analyse possible associated factors, including the overload on health care services in the Emergency department, an aspect that has not previously been evaluated. PATIENTS AND METHODS: Epidemiological data, times of delays before and after entering the hospital, means of transport used and the health care workload in the Emergency department of the day of admission were collected for all the stroke patients admitted to the Stroke Unit of the Hospital General Universitario de Alicante throughout the period under study. RESULTS: From an initial sample of 460 patients, 423 were finally included in the study, with a mean delay before and after admission to hospital of 3.99 and 2.36 hours, respectively. Use of an ambulance and the haemorrhagic and transient ischemic attack subtypes were linked to a shorter delay before reaching the hospital, and arrival during the night shift was the only factor associated to a longer delay once inside the hospital. CONCLUSIONS: In our environment, there is a need to establish strategies aimed at shortening the times stroke patients take to reach the hospital and the time that elapses before they are attended.

Retraso extrahospitalario e intrahospitalario en el tratamiento del ictus / Delays before and after arrival at the hospital in the treatment of strokes

Introducción. Sólo una minoría de pacientes con ictus agudo es candidata a fibrinólisis, y el principal motivo es sobrepasar temporalmente la ventana terapéutica. El principal retraso se produce hasta la llegada al hospital, pero también existe, y ha sido menos estudiado, un retraso intrahospitalario. Objetivo. Describir los datos de retraso extrahospitalario e intrahospitalario en una muestra de pacientes con ictus agudo y analizar los posibles factores asociados, entre ellos la sobrecarga asistencial en el área de Urgencias, aspecto previamente no evaluado. Pacientes y métodos. Se recogieron de forma sistemática los datos epidemiológicos, los tiempos de retraso extrahospitalario e intrahospitalario, el medio de trasporte empleado y la carga asistencial en Urgencias en el día del ingreso de todos los pacientes con ictus que ingresaron en la Unidad de Ictus del Hospital General Universitario de Alicante durante el período de estudio. Resultados. De una muestra inicial de 460 pacientes, se incluyeron en el estudio 423, con una mediana de retraso extrahospitalario e intrahospitalario de 3,99 y 2,36 horas, respectivamente. El uso de ambulancia y los subtipos hemorrágico y accidente isquémico transitorio se asociaron a un menor retraso extrahospitalario, mientras que la llegada durante el turno de noche fue el único factor asociado a un mayor retraso intrahospitalario. Conclusiones. Se evidencia la necesidad en nuestro medio de iniciar estrategias encaminadas a mejorar las latencias con la que los pacientes con enfermedad cerebrovascular acuden y se atienden en el ámbito hospitalario

Introduction. Only a minority of patients with acute stroke are eligible for fibrinolysis, and the main reason for this is that time runs out and goes beyond the therapeutic window. The chief delay occurs prior to arrival at the hospital, but there is also a nosocomial delay, which has received far less attention. Aims. The purpose of our study was to describe the data on delays occurring before and after arrival at the hospital in a sample of patients with acute stroke, and to analyse possible associated factors, including the overload on health care services in the Emergency department, an aspect that has not previously been evaluated. Patients and methods. Epidemiological data, times of delays before and after entering the hospital, means of transport used and the health care workload in the Emergency department of the day of admission were collected for all the stroke patients admitted to the Stroke Unit of the Hospital General Universitario de Alicante throughout the period under study. Results. From an initial sample of 460 patients, 423 were finally included in the study, with a mean delay before and after admission to hospital of 3.99 and 2.36 hours, respectively. Use of an ambulance and the haemorrhagic and transient ischemic attack subtypes were linked to a shorter delay before reaching the hospital, and arrival during the night shift was the only factor associated to a longer delay once inside the hospital. Conclusions. In our environment, there is a need to establish strategies aimed at shortening the times stroke patients take to reach the hospital and the time that elapses before they are attended