Does Cognitive Impairment Affect Rehabilitation Outcome in Parkinson's Disease?

Davide Ferrazzoli,Paola Ortelli,Giuseppe Frazzitta,Nir Giladi,Roberto Maestri,Rossana Bera,Maria Felice Ghilardi,Gianni Pezzoli

doi:10.3389/fnagi.2016.00192

Abstract

Background: The cognitive status is generally considered as a major determinant of rehabilitation outcome in Parkinson’s disease (PD). No studies about the effect of cognitive impairment on motor rehabilitation outcomes in PD have been performed before.Objective: This study is aimed to evaluate the impact of cognitive decline on rehabilitation outcomes in patients with PD.Methods: We retrospectively identified 485 patients with PD hospitalized for a 4-week Multidisciplinary Intensive Rehabilitation Treatment (MIRT) between January 2014 and September 2015. According to Mini Mental State Examination (MMSE), patients were divided into: group 1—normal cognition (score 27–30), group 2—mild cognitive impairment (score 21–26), group 3—moderate or severe cognitive impairment (score ≤ 20). According to Frontal Assessment Battery (FAB), subjects were divided into patients with normal (score ≥13.8) and pathological (score <13.8) executive functions. The outcome measures were: Unified Parkinson’s Disease Rating Scale (UPDRS), Parkinson’s Disease Disability Scale (PDDS), Six Minutes Walking Test (6MWT), Timed Up and Go Test (TUG) and Berg Balance Scale (BBS).Results: All scales had worse values with the increase of cognitive impairment and passing from normal to pathological executive functions. After rehabilitation, all the outcome measures improved in all groups (p < 0.0001). Between groups, the percentage of improvement was significantly different for total UPDRS (p = 0.0009, best improvement in normal MMSE group; p = 0.019, best improvement in normal FAB group), and BBS (p < 0.0001, all pairwise comparisons significant, best improvement in patients with worse MMSE score; p < 0.0001, best improvement in patients with pathological FAB). TUG (p = 0.006) and BBS (p < 0.0001) improved in patients with pathological FAB score, more than in those with normal FAB score.Conclusions: Patients gain benefit in the rehabilitative outcomes, regardless of cognition. Our data suggest that rehabilitation could be effective also in Parkinsonian subjects with cognitive impairment, as well as with dysexecutive syndrome.

Highlights

MATERIALS AND METHODSEven with optimal pharmacological or surgical therapies, patients with Parkinson’s disease (PD) experience disabling symptoms that do not respond to these treatments
To test whether the effectiveness of rehabilitation was dependent on the level of cognitive state at baseline, we considered the difference in outcome variables between the discharge and admission values and run a one-factor non-parametric analysis of variance (ANOVA) (Kruskal-Wallis) on the cognition factor
Mini Mental State Examination (MMSE) scores were negatively related to age (R = −0.38, p < 0.0001) and Hoehn and Yahr (H&Y) (R = −0.24, p < 0.0001) and positively related to years of education (R = 0.15, p = 0.0007)

Summary

Introduction

MATERIALS AND METHODSEven with optimal pharmacological or surgical therapies, patients with Parkinson’s disease (PD) experience disabling symptoms (such as postural instability or freezing of gait) that do not respond to these treatments. Even if implicit learning mechanisms are defective in Parkinsonian patients in comparison to normal subjects, motor learning is feasible in PD (Nieuwboer et al, 2007) and this is crucial for rehabilitation. In this context, literature data indicate that training the patients to use cognitive strategies allows the execution of correct movements (Morris et al, 2009) under executive/volitional control. Poynter et al (2013) in an observational study of 241 patients demonstrated that even patients with moderate cognitive impairment were able to make significant gains in grooming, dressing, toileting, transferring and mobility (as measured with Barthel Index Score) after rehabilitation treatment. No studies about the effect of cognitive impairment on motor rehabilitation outcomes in PD have been performed before

Methods

Results

Conclusion