Occupational pesticide exposure and screening tests for neurodegenerative disease among an elderly population in Costa Rica.

BACKGROUND: Pesticides have been associated with Parkinson's disease (PD) in many studies, and with Alzheimer's disease (AD) in a few. METHODS: We conducted screening tests for neurologic disease and occupational pesticide use in a population-based sample of 400 elderly subjects at two government-run clinics in Costa Rica; 361 subjects who failed the initial screen were given both the mini-mental states exam (MMSE) and a modified version of a 10-item united Parkinson's disease rating motor subscale (UPDRS). Among subjects who failed either test, 144 were then examined by a neurologist. RESULTS: Past occupational pesticide exposure was reported by 18% of subjects. Exposed subjects performed worse on the MMSE than the non-exposed (mean 24.5 versus 25.9, p=0.01, adjusted for age, sex, and education). The exposed had significantly elevated risks of abnormal scores on two UPDRS items, tremor-at-rest (OR 2.58, 1.28-5.23), and finger-tapping (OR=2.94, 95% CI 1.03-8.41). Thirty-three (23%) of those examined by the neurologist were diagnosed with possible/probable PD, 3-4 times the expected based on international data; 85% of these cases had not been previously diagnosed. Among subjects who took the UPDRS, the exposed had an increased risk of PD (OR=2.57, 95% CI 0.91-7.26). No excess risk was found for a diagnosis of AD or mild cognitive impairment. CONCLUSIONS: Elderly subjects with past occupational pesticide exposure performed significantly worse on screening tests for dementia and PD, and had an increased risk of an eventual PD diagnosis. Screening may be particularly appropriate among elderly subjects with past pesticide exposure.

Behavioral therapy to treat urinary incontinence in Parkinson disease.

OBJECTIVE: To assess the feasibility and efficacy of exercise-based behavioral therapy to treat urinary incontinence (UI) in older adults with Parkinson disease (PD). METHODS: Participants with PD ≥50 years with ≥4 UI episodes on a 7-day bladder diary were recruited from movement disorders clinics. In 5 visits over 8 weeks, participants learned pelvic floor muscle exercises using computer-assisted EMG biofeedback, and bladder control strategies including urge suppression. Bladder diaries were used to reinforce techniques and monitor the primary outcome of UI frequency. Secondary outcomes included additional reporting of lower urinary tract symptoms, symptom bother, and quality of life (QOL) using the International Consultation on Incontinence Questionnaire for overactive bladder (ICIQ-OAB). RESULTS: Twenty participants were enrolled (90% male, age 66.5 ± 6.2 [mean ± SD], with PD for 6.9 ± 5.4 years) and 17 completed the study. The median (interquartile range) weekly frequency of baseline UI episodes was 9 (4-11) and following intervention was 1 (0-3), representing an 83.3% reduction (45.5-100.0, p = 0.0001). QOL scores on the ICIQ-OAB improved from 71.1 ± 23.9 to 54.7 ± 15.4 (p = 0.002). CONCLUSIONS: In this uncontrolled pilot study of an exercise-based, biofeedback-assisted behavioral intervention, older participants with PD demonstrated statistically significant and clinically meaningful reductions in frequency of UI and improvement in QOL. Randomized controlled trials to assess behavioral therapies for UI in patients with PD are warranted. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that exercise-based, biofeedback-assisted behavioral intervention can reduce UI frequency in patients >50 years old with PD.

Therapeutic efficacy of unilateral subthalamotomy in Parkinson's disease: results in 89 patients followed for up to 36 months.

BACKGROUND: Stereotactic thermocoagulative lesions of the subthalamic nucleus (STN) have been shown to induce significant motor improvement in patients with Parkinson's disease (PD). PATIENTS AND METHODS: 89 patients with PD were treated with unilateral subthalamotomy. 68 patients were available for evaluations after 12 months, 36 at 24 months and 25 at 36 months. RESULTS: The Unified Parkinson's Disease Rating Scale (UPDRS) motor scores improved significantly contralaterally to the lesion in the "off" and "on" states throughout the follow-up, except for the "on" state at the last evaluation. Axial features and signs ipsilateral to the lesion progressed steadily throughout the study. Levodopa daily doses were significantly reduced by 45%, 36% and 28% at 12, 24 and 36 months post-surgery. 14 patients (15%) developed postoperative hemichorea-ballism which required pallidotomy in eight. These 14 patients had significantly higher dyskinesia scores (levodopa induced) preoperatively than the entire cohort. CONCLUSION: Unilateral subthalamotomy was associated with significant and sustained motor benefit contralateral to the lesion. Further work is needed to ascertain what factors led to severe, persistent chorea-ballism in a subset of patients. Subthalamotomy may be considered an option in circumstances when deep brain stimulation is not viable.

Treatment of imbalance with varenicline Chantix(R): report of a patient with fragile X tremor/ataxia syndrome.

We describe the case of a man with Fragile X tremor/ataxia syndrome, whose ataxia and imbalance improved with the use of varenicline (Chantix) and reverted to baseline 10 days after varenicline was discontinued. Varenicline was started as part of a smoking cessation program.

Bilateral subthalamotomy in Parkinson's disease: initial and long-term response.

We conducted an open label pilot study of the effect of bilateral subthalamotomy in 18 patients with advanced Parkinson's disease. In seven patients, the first subthalamotomy pre-dated the second by 12-24 months ('staged surgery'). Subsequently, a second group of 11 patients received bilateral subthalamotomy on the same day ('simultaneous surgery'). Patients were assessed according to the CAPIT (Core Assessment Program for Intracerebral Transplantation) protocol, a battery of timed motor tests and neuropsychological tests. Evaluations were performed in the 'off' and 'on' drug states before surgery and at 1 and 6 months and every year thereafter for a minimum of 3 years after bilateral subthalamotomy. Compared with baseline, bilateral subthalamotomy induced a significant (P < 0.001) reduction in the 'off' (49.5%) and 'on' (35.5%) Unified Parkinson's Disease Rating Scale (UPDRS) motor scores at the last assessment. A blind rating of videotape motor exams in the 'off' and 'on' medication states preoperatively and at 2 years postoperatively also revealed a significant improvement. All of the cardinal features of Parkinson's disease as well as activities of daily living (ADL) scores significantly improved (P < 0.01). Levodopa-induced dyskinesias were reduced by 50% (P < 0.01), and the mean daily levodopa dose was reduced by 47% at the time of the last evaluation compared with baseline (P < 0.0001). Dyskinesias occurred intraoperatively or in the immediate postoperative hours in 13 patients, but were generally mild and short lasting. Three patients developed severe generalized chorea that gradually resolved within the next 3-6 months. Three patients experienced severe and persistent postoperative dysarthria. In two, this coincided with the patients exhibiting large bilateral lesions also suffering from severe dyskinesias. No patient exhibited permanent cognitive impairment. The motor benefit has persisted for a follow-up of 3-6 years. This study indicates that bilateral subthalamotomy may induce a significant and long-lasting improvement of advanced Parkinson's disease, but the clinical outcome was variable. This variability may depend in large part on the precise location and volume of the lesions. Further refinement of the surgical procedure is mandatory.

Clinical and neuropathologic variation in neuronal intermediate filament inclusion disease.

BACKGROUND: Recently described neuronal intermediate filament inclusion disease (NIFID) shows considerable clinical heterogeneity. OBJECTIVE: To assess the spectrum of the clinical and neuropathological features in 10 NIFID cases. METHODS: Retrospective chart and comprehensive neuropathological review of these NIFID cases was conducted. RESULTS: The mean age at onset was 40.8 (range 23 to 56) years, mean disease duration was 4.5 (range 2.7 to 13) years, and mean age at death was 45.3 (range 28 to 61) years. The most common presenting symptoms were behavioral and personality changes in 7 of 10 cases and, less often, memory loss, cognitive impairment, language deficits, and motor weakness. Extrapyramidal features were present in 8 of 10 patients. Language impairment, perseveration, executive dysfunction, hyperreflexia, and primitive reflexes were frequent signs, whereas a minority had buccofacial apraxia, supranuclear ophthalmoplegia, upper motor neuron disease (MND), and limb dystonia. Frontotemporal and caudate atrophy were common. Histologic changes were extensive in many cortical areas, deep gray matter, cerebellum, and spinal cord. The hallmark lesions of NIFID were unique neuronal IF inclusions detected most robustly by antibodies to neurofilament triplet proteins and alpha-internexin. CONCLUSION: NIFID is a neuropathologically distinct, clinically heterogeneous variant of frontotemporal dementia (FTD) that may include parkinsonism or MND. Neuronal IF inclusions are the neuropathological signatures of NIFID that distinguish it from all other FTD variants including FTD with MND and FTD tauopathies.

Pseudobulbar crying induced by stimulation in the region of the subthalamic nucleus.

We describe a case of pseudobulbar crying associated with deep brain stimulation (DBS) in the region of the subthalamic nucleus (STN). Patients with pseudobulbar crying show no other evidence of subjective feelings of depression such as dysphoria, anhedonia, or vegetative signs. This may be accompanied by other symptoms of pseudobulbar palsy and has been reported to occur with ischaemic or structural lesions in both cortical and subcortical regions of the brain. Although depression has been observed to result from DBS in the region of the STN, pseudobulbar crying has not been reported. A single patient who reported the symptoms of pseudobulbar crying after placement of an STN DBS was tested in the off DBS and on DBS conditions. The patient was tested using all four DBS lead contacts and the observations and results of the examiners were recorded. The Geriatric Depression Scale was used to evaluate for depression in all of the conditions. The patient exhibited pseudobulbar crying when on monopolar stimulation at all four lead contacts. The pseudobulbar crying resolved off stimulation. This case describes another type of affective change that may be associated with stimulation in the region of or within the STN. Clinicians should be aware of this potential complication, the importance of differentiating it from stimulation induced depression, and its response to a serotonin reuptake inhibitor, such as sertraline.

Complications of gamma knife surgery for Parkinson disease.

BACKGROUND: Many medical centers throughout the world offer radiosurgery with the gamma knife (GK) for pallidotomy and thalamotomy as a safe and effective alternative to radiofrequency ablative surgery and deep brain stimulation for Parkinson disease (PD). The reported incidence of significant complications varies considerably, and the long-term complication rate remains unknown. DESIGN: We describe 8 patients seen during an 8-month period referred for complications of GK surgery for PD. RESULTS: Of the 8 patients, 1 died as a result of complications, including dysphagia and aspiration pneumonia. Other complications included hemiplegia, homonymous visual field deficit, hand weakness, dysarthria, hypophonia, aphasia, arm and face numbness, and pseudobulbar laughter. In all patients, lesions were significantly off target. CONCLUSIONS: The 8 patients with PD seen in referral at our center for complications of GK surgery highlight a spectrum of potential problems associated with this procedure. These include lesion accuracy and size and the delayed development of neurological complications secondary to radiation necrosis. Gamma knife surgery may have a higher complication rate than has been previously appreciated due to delayed onset and underreporting. We believe that the risk-benefit ratio of the GK will require further scrutiny when considering pallidotomy or thalamotomy in patients with PD. Physicians using this technique should carefully follow up patients postoperatively for delayed complications, and fully inform patients of these potential risks.

Transdermal dopaminergic D(2) receptor agonist therapy in Parkinson's disease with N-0923 TDS: a double-blind, placebo-controlled study.

N-0923 is a non-ergot, dopaminergic D(2) agonist designed to be transdermally available. It has anti-parkinsonian effects when infused intravenously. An adhesive matrix patch was developed to deliver N-0923 transdermally (N-0923 TDS). In this phase II trial, we evaluated the effectiveness of various doses of N-0923 TDS at replacing levodopa. Eighty-five Parkinson's disease (PD) patients were randomized to placebo or one of four doses of N-0923 TDS for 21 days. Change in daily levodopa dose was the primary efficacy measure. Significantly greater reductions in levodopa dose were achieved as compared to placebo for the two highest doses of N-0923 TDS. Patients treated with 33.5 mg and 67 mg N-0923 TDS decreased levodopa use by 26% and 28%, vs. 7% for placebo. N-0923 TDS was safe and well tolerated.

Management of psychotic aspects of Parkinson's disease.

Psychotic symptoms have become increasingly common in patients with idiopathic Parkinson's disease and other parkinsonian syndromes. This increased prevalence of psychoses is in part a reflection of the greater longevity of people with Parkinson's disease and, to a certain extent, is a consequence of our success in treating the motor symptoms of these syndromes. The psychotic symptoms associated with Parkinson's disease can be as varied as the motor symptoms. They stem from interactions between the underlying neuropathologies of the syndromes and the adverse effects associated with chronic antiparkinsonian drug administration. In patients with advanced Parkinson's disease, there is also a high prevalence of affective comorbidity. This increase in affective symptoms and the relatively high incidence of cognitive and affective side effects of the antiparkinsonian medications contribute to the increase in psychoses observed in these older patients. The most significant risk factors for developing psychosis in Parkinson's disease are (1) coexistence of dementia, (2) protracted sleep disturbances, and (3) nighttime use of long-acting dopaminomimetics. This article reviews the phenomenology, pathophysiology, and treatment of psychosis associated with parkinsonism and discusses how atypical antipsychotic medications have revolutionized the management of the symptoms and improved the quality of life of those affected.

Depression and disability in Parkinson's disease.

The relationship between depression and disability in idiopathic Parkinson's disease (PD) was examined in 31 outpatients. Thirteen percent had current major depression (MD), 10% dysthymia, and 32% a lifetime history of MD. Depression was significantly related to both illness severity and functional impairment. Male patients with early-onset PD (before age 55) had more mood and anxiety disorders than late-onset male patients. Patients with right-sided PD had significantly more depressive symptoms than those with left-sided PD. On multiple regression analyses, depression predicted impaired social, role, and physical functioning for men (but not for women), independent of the impact of illness severity. The results suggest that treatment of depression may improve function; however, findings of gender differences will require replication.

Individual differences in behavior following amphetamine, GBR-12909, or apomorphine but not SKF-38393 or quinpirole.

Subjects that respond more to a novel environment show a greater locomotor response to drugs of abuse such as cocaine and amphetamine. The current study was performed to examine differences between high (HR) and low (LR) responding rats to a novel environment following administration of amphetamine, a selective dopamine uptake blocker (GBR-12909), a nonselective dopamine agonist (apomorphine), and selective dopamine D1 and D2/D3 agonists. A behavioral checklist and a rating scale were used to determine the behavioral arousal caused by administration of amphetamine (0, 0.5, 2.0, and 8.0 mg/kg), GBR-12909 (0, 1.25, 5.0, and 20.0 mg/kg), apomorphine (0, 0.1, 0.3, and 1 mg/kg), SKF 39393 (0, 2.5, 10, and 40 mg/kg), or quinpirole (0, 0.05, 0.5, and 5.0 mg/kg). The five drugs produced behavioral activation profiles distinct from each other. Following amphetamine administration, both HR and LR subjects showed dose dependent increases in behavioral arousal. The behaviors primarily affected were sniffing, locomotor activity, rearing, and oral activity. HR rats showed a greater overall behavioral response to amphetamine administration compared with LR rats and there were differences in specific behaviors between the two groups. Following GBR-12909 administration, all subjects showed dose dependent increases in sniffing, locomotor activity, and rearing. Differences between HR and LR were observed in sniffing, locomotor activity, and rearing behaviors. HR and LR both showed dose dependent increases in behavior following apomorphine administration. HR showed greater behavioral activation after apomorphine than LR.(ABSTRACT TRUNCATED AT 250 WORDS)

Individual locomotor response to novelty predicts selective alterations in D1 and D2 receptors and mRNAs.

Rats that have a greater locomotor response to novelty (high responders, HR) have differences in measures of presynaptic dopamine transmission compared to low responders (LR) to a novel environment, including altered dopamine release and behavioral response to indirect dopamine agonists. This study examined the role of three dopamine terminal fields, the nucleus accumbens, striatum, and medial prefrontal cortex, in differences between HR and LR. In the first experiment, dopamine was infused directly into the nucleus accumbens (0, 3, 10, and 30 micrograms/side) or the striatum (0, 10, 30, and 100 micrograms/side). HR showed a greater behavioral response to both the 3 and 30 micrograms/side doses infused into the nucleus accumbens compared to LR. No differences between HR and LR were revealed by dopamine infusion into the striatum. In the second experiment, radioligand binding assays were performed to determine if differences exist between high and low responder rats in the Bmax and/or KD of radiolabeled antagonist ligands for the dopamine D1 and/or D2 receptors. There were fewer D2 binding sites in the nucleus accumbens and fewer sites in the striatum in HR compared to LR. High responders showed a greater Bmax for D1 binding sites in the nucleus accumbens than LR. No differences in number of binding sites for D1 receptors were observed between HR and LR in the striatum. No differences between HR and LR in D2 or D1 receptor binding were observed in the medial prefrontal cortex. There were no differences in KD for any of the dopamine receptors in the regions examined.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of cocaine microinjections into the nucleus accumbens and medial prefrontal cortex on schedule-induced behaviour: comparison with systemic cocaine administration.

The effects of cocaine HCl infusions into either the nucleus accumbens (NACC) or medial prefrontal cortex (PFC) were compared on the performance of schedule-induced polydipsia (SIP) and related behaviours. Food-deprived rats were exposed to a fixed-time 60-s schedule of food delivery in daily 30-min sessions until stable levels of behaviour were obtained (14 days). Rats were then bilaterally infused with cocaine into either the NACC or PFC via chronically indwelling guide cannulae. Each subject received a sequence of five cocaine infusions (0, 12.5, 25, 50, 100 micrograms) according to a Latin Square design. For comparison, following these intracranial infusions each rat received a sequence of five IP injections of cocaine (0, 2.5, 5, 10, 20 mg/kg) also in a counterbalanced order. NACC and PFC infusions of cocaine and IP cocaine dose-dependently reduced SIP. Cocaine infusions into the NACC, but not the PFC, increased locomotor activity but the characteristic temporal profile of locomotor activity during SIP was retained. IP cocaine also increased locomotor activity in a dose-dependent manner, but the temporal profile of activity was flattened following 20 mg/kg cocaine. NACC and PFC infusions of cocaine had little effect on the total number of panel presses to gain access to the food pellets, but did slightly decrease the high rates of responding immediately prior to the pellet delivery. IP cocaine increased the total number of panel presses at the higher doses, mainly by increasing the low rates of responding. The effects of cocaine infusions into the PFC were behaviourally the most selective, as they reduced SIP without having substantial effects either on locomotor activity or panel pressing.(ABSTRACT TRUNCATED AT 250 WORDS)

Individual differences in schedule-induced and conditioned behaviors.

Previous experiments have shown that subjects which exhibit a high locomotor response to novelty (HR) also show a greater locomotor response to psychomotor stimulants than subjects which have a low locomotor response to a novel environment (LR). The current experiments were designed to examine in more detail the behavioral differences between HR and LR rats in non-drug paradigms. In the first experiment HR rats acquired schedule-induced polydipsia (SIP) more readily than LR rats. Panel pressing to gain access to the food pellets, however, was greater in LR rats compared to HR rats, especially after stable levels of SIP had been attained. In the second experiment one group of rats were fed daily after a 30-min period in photocell-cages (food conditioning; FC) while a control group was fed in the home-cage (non-conditioned; NC). FC subjects developed heightened locomotor activity in anticipation of feeding in the initial 30 min in the test-cage compared to NC rats. This anticipatory locomotor activity developed more rapidly and to a greater level in HR rats than in LR rats. The concentrations of dopamine, dihydroxyphenylacetic acid, homovanillic acid, serotonin, 5-hydroxyindoleacetic acid, and norepinephrine were determined at the completion of behavioral testing in both the food conditioned and non-conditioned rats. The food conditioned experiment showed that variations in both the dopaminergic and serotoninergic systems may underlie individual differences in behavioral responsiveness. However, no clear pattern of neurochemical differences emerged. The current set of experiments have demonstrated differences between HR and LR rats in non-drug related paradigms and that HR rats appear to show a greater motivational excitement induced by periodic food delivery than LR rats.

Individual differences in basal and cocaine-stimulated extracellular dopamine in the nucleus accumbens using quantitative microdialysis.

The current experiment examined the role of nucleus accumbens (NACC) dopamine in individual differences. Subjects were divided into high responders (HR) and low responders (LR) based on their locomotor response to a novel environment. HR rats were subjects which had a locomotor response to novelty in the upper third of the population screened and LR rats in the bottom third of the population. A new method of microdialysis was then used that allowed determination of the extracellular dopamine concentration. This was accomplished by adding various dopamine concentrations (0.0, 5.0 and 20.0 nM) to the perfusate. The concentration of dopamine in the dialysate was subsequently determined. The difference in the dialysate and perfusate dopamine was regressed on the perfusate dopamine. The regression yielded the in vivo recovery and the extracellular concentration. HR rats exhibit a 250% higher basal dopamine concentration (6.45 +/- 1.01 nM, n = 6) than LR rats (2.58 +/- 0.16 nM, n = 7). The in vivo microdialysis recovery was used to estimate the extracellular dopamine following cocaine challenge (15 mg/kg) in the two groups. Following i.p. cocaine administration, HR rats had both a greater locomotor response and increase in absolute dopamine concentration compared to LR rats. The maximum dopamine concentration in the HR group was 23 +/- 2.9 nM, while that in the LR group was only 8.6 +/- 1.1 nM. The maximum in the LR group is comparable to the basal level in the HR group. However, there were no difference in percent change in dopamine following cocaine.(ABSTRACT TRUNCATED AT 250 WORDS)

Levodopa: pharmacology, pharmacokinetics, and pharmacodynamics.

The success of L-dopa therapy in patients with Parkinson's disease and the concepts discussed in this article are summarized in Figure 6. Even in advanced stages of disease, 80% of parkinsonian disability remains responsive to L-dopa therapy. The 50% of the response contaminated by response fluctuations should be viewed, at least in part, as a hopeful sign that the system is still responding to L-dopa therapy. Unfortunately suboptimal control of response fluctuations is still a source of consternation for patient and treating physicians alike. Response fluctuations notwithstanding, it should be emphasized that patients actually do better at every stage of disease for having been on L-dopa, as recently confirmed in a retrospective study of the relationship between response fluctuations and the timing of initiation of therapy. To the extent that the increasing frequency, amplitude, and complexity of response fluctuations add to the overall parkinsonian disability, the phenomenon demands a better understanding that will hopefully lead to better corrective or preventive measures.