The late stage of Parkinson's -results of a large multinational study on motor and non-motor complications.

INTRODUCTION: There is little information on the late stages of parkinsonism. METHODS: We conducted a multicentre study in 692 patients with late stage parkinsonism in six European countries. Inclusion criteria were disease duration of ≥7 years and either Hoehn and Yahr stage ≥4 or Schwab and England score of 50 or less. RESULTS: Average disease duration was 15.4 (SD 7.7) years and mean total UPDRS score was 82.7 (SD 22.4). Dementia according to MDS-criteria was present in 37% of patients. Mean levodopa equivalence dose was 874.1 (SD 591.1) mg/d. Eighty two percent of patients reported falls, related to freezing (16%) or unrelated to freezing (21% of patients) or occurring both related and unrelated to freezing (45%), and were frequent in 26%. Moderate-severe difficulties were reported for turning in bed by 51%, speech by 43%, swallowing by 16% and tremor by 11%. Off-periods occurred in 68% and were present at least 50% of the day in 13%, with morning dystonia occurring in 35%. Dyskinesias were reported by 45% but were moderate or severe only in 7%. Moderate-severe fatigue, constipation, urinary symptoms and nocturia, concentration and memory problems were encountered by more than half of participants. Hallucinations (44%) or delusions (25%) were present in 63% and were moderate-severe in 15%. The association with overall disability was strongest for severity of falls/postural instability, bradykinesia, cognitive score and speech impairment. CONCLUSION: These data suggest that current treatment of late stage parkinsonism in the community remains insufficiently effective to alleviate disabling symptoms in many patients.

Promising non-pharmacological therapies in PD: Targeting late stage disease and the role of computer based cognitive training.

Non-pharmacological interventions are increasingly being acknowledged as valuable treatment options to overcome or reduce functional problems in patients with Parkinson's disease (PD). There is a wide range of such non-pharmacological treatments for which the supportive evidence is emerging. Physiotherapy is one good example in this domain. However, there are also several promising non-pharmacological treatment strategies that have thus far received less research attention. Here, we describe two relatively new, but encouraging approaches. First, we focus on a hitherto largely overseen subgroup of PD, namely those with late-stage disease, a population that is often excluded from clinical studies. Importantly, the aims and therapeutic strategies in late-stage PD differ considerably from those in early-stage PD, and an emphasis on non-pharmacological management is particularly important for this vulnerable subgroup. Second, we focus on computer-based cognitive training, as an example of a relatively new intervention that includes innovative elements such as personalized training, artificial intelligence, and virtual reality. We review the latest evidence, practical considerations and future research perspectives, both for non-pharmacological approaches in late-stage PD and for computer-based cognitive training.