Untreated Parkinson's Disease Research Articles

Cognitive impairment in incident, untreated Parkinson disease

Little is known regarding the cognitive impairment in subjects with early, drug-naïve Parkinson disease (PD). The aim of this study was to explore the proportion with mild cognitive impairment (MCI) and subtypes in an incidence cohort of untreated PD in Southern and Western Norway. A total of 196 non-demented, drug-naive patients who were recruited after an extensive search of all new cases of PD in the area and 201 healthy control subjects completed a battery of neuropsychological tests of verbal memory, visuospatial, and attentional-executive functioning. Subjects were classified as MCI if the age- and education-corrected z-score was falling 1.5 standard deviations below the mean for at least one of the cognitive domains. The PD group was more impaired on all neuropsychological tests than controls, but the effect sizes were small. The largest effect size was found for verbal memory. A total of 18.9% of the patients with PD were classified as MCI, with a relative risk of 2.1 (1.2-3.6) in PD compared to the control group. Patients with PD with and without MCI did not differ significantly regarding demographic and motor features. Among PD-MCI patients, nearly two-thirds had a non-amnestic MCI subtype, and one third had an amnestic MCI subtype. The findings demonstrate a twofold increase in the proportion with cognitive impairment in subjects with early, untreated Parkinson disease (PD) compared to controls. This has implications for diagnosis and management of PD. AD = Alzheimer disease; aMCI-MD = amnestic multiple-domain MCI; aMCI-SD = amnestic single-domain MCI; CVLT-2 = California Verbal Learning Test II; IQCode = Informant Questionnaire on Cognitive decline in the elderly; MADRS = Montgomery and Aasberg Depression Rating Scale; MCI = mild cognitive impairment; MMSE = Mini-Mental State Examination; naMCI-MD = non-amnestic multiple-domain MCI; naMCI-SD = non-amnestic single-domain MCI; PD = Parkinson disease; RR = relative risks; UPDRS = Unified Parkinson's Disease Rating Scale; VOSP = Visual Object and Space Perception Battery.

Effects of nigral stimulation on locomotion and postural stability in patients with Parkinson's disease

The physiopathology of gait and balance disorders in Parkinson's disease patients is still poorly understood. Levodopa treatment and subthalamic nucleus (STN) stimulation improve step length and walking speed, with less effect on postural instability. These disorders have been linked to dysfunction of the descending basal ganglia outputs to brainstem structures. In this study, we evaluated the effects of stimulation of the substantia nigra pars reticulata (SNr), on locomotion and balance in Parkinson's disease patients. Biomechanical parameters and leg muscle activity were recorded during gait initiation in seven selected patients operated for bilateral STN stimulation, out of 204 stimulated patients, with one contact of each electrode located within the SNr. Step length, anteroposterior and vertical velocities of the centre of gravity were studied, with special reference to the subjects' ability to brake the centre of gravity fall before foot-contact, and compared to seven controls. In Parkinson's disease patients, five treatment conditions were tested: (i) no treatment, (ii) levodopa treatment, (iii) STN stimulation, (iv) SNr stimulation and (v) combined levodopa treatment and STN stimulation. The effects of these treatments on motor parkinsonian disability were assessed with the UPDRS III scale, separated into 'axial' (rising from chair, posture, postural stability and gait) and 'distal' scores. Whereas levodopa and/or STN stimulation improved 'axial' and 'distal' motor symptoms, SNr stimulation improved only the 'axial' symptoms. Compared to controls, untreated Parkinson's disease patients showed reduced step length and velocity, and poor braking just prior to foot-contact, with a decrease in both soleus (S) and anterior tibialis (AT) muscle activity. Step length and velocity significantly increased with levodopa treatment alone or in combination with STN stimulation in both natural and fast gait conditions, and with STN stimulation alone in the fast gait condition. Conversely, SNr stimulation had no significant effect on these measures in either condition. In the natural gait condition, no fall in the centre of gravity occurred as step length was low and active braking was unnecessary. In the fast gait condition, braking was improved with STN or SNr stimulation but not with levodopa treatment, with an increase in the stance leg S muscle activity. These results suggest that anteroposterior (length and velocity) and vertical (braking capacity) gait parameters are controlled by two distinct systems within the basal ganglia circuitry, representing respectively locomotion and balance. The SNr, a major basal ganglia output known to project to pontomesencephalic structures, is postulated as being particularly involved in balance control during gait.

Long-term outcome in Parkinson disease: no advantage to initiating therapy with dopamine agonists

This Practice Point commentary discusses long-term follow-up of a treatment intervention study on Parkinson disease (PD). Katzenschlager et al. report on 166 of 302 survivors of a randomized open-label study that compared initial therapy with levodopa, with levodopa plus selegiline, or with bromocriptine, in early untreated PD. The primary study publication, from 1993, suggested that bromocriptine-treated participants were less likely than levodopa-treated participants to develop motor complications during the subsequent 4 years, although levodopa was more effective at relieving symptoms of parkinsonism. The current publication presents data after a median follow-up of 14 years and suggests that protection from motor complications does not persist over the long term. Furthermore, participants who were randomly allocated to initial treatment with levodopa showed better relief of disability and better quality of life over the long term. More than 60% of the original PD cohort had died over the 14-year time interval, underscoring the continued poor prognosis of late-stage PD. The Katzenschlager studies and other recent publications underscore the need to develop newer treatment strategies that consider the multisystem nature of the illness and expand treatment horizons beyond the single neurotransmitter dopamine.

Intact presupplementary motor area function in early, untreated Parkinson's disease

Although motor symptoms of Parkinson's disease (PD) are initially responsive to dopamine replacement therapy, nonresponsive features develop over time, suggesting that impaired dopaminergic function alone may not be wholly responsible for all the motor features of the disease. Previous studies suggest impaired function in the presupplementary motor area (pre-SMA) in PD. Our objective was to determine whether pre-SMA abnormalities are present in untreated patients with early disease. We measured N-acetyl aspartate (NAA)/creatine (Cr) and choline (Cho)/Cr ratios in pre-SMA in 26 untreated patients with early PD (disease duration 3.0 +/- 2.0 yr) and 15 control subjects with single voxel magnetic resonance spectroscopy. Neither NAA/Cr nor Cho/Cr ratios differed significantly between groups. These observations suggest that, although pre-SMA function is impaired in moderately advanced PD, it is relatively spared in early disease. We suggest that pre-SMA dysfunction is in part responsible for the dopamine nonresponsive features associated with disease progression.

Quantitation of non‐motor symptoms in Parkinson’s disease

Disabling non-motor symptoms (NMS) associated with Parkinson's disease (PD), such as dementia and loss of balance, do not respond well to levodopa therapy and can lead to eventual death in patients with the disease. In 2006, a multidisciplinary group of experts and patient representatives developed an NMS screening questionnaire (NMSQuest) and a unified Non-Motor Symptoms Scale (NMSS) to address the need for simple identification and comprehensive assessment of NMS in patients with PD. An international pilot study of 96 healthy controls and 123 patients with various stages of treated and untreated PD was conducted to demonstrate that the NMSQuest is a feasible, valid, and accepted tool. The majority of patients and caregivers felt that the questionnaire was clear and relevant to their daily lives. Data from 242 PD patients with no dementia were analysed in a pilot study on the clinimetric validation of NMSS. Similar to the NMSQuest study, the NMSS study revealed a significant correlation between progression of PD and increasing NMS burden. These studies suggest that the NMSQuest accurately detects the NMS, and that the NMSS closely correlates with quality of life for PD patients.

Temporal dynamics of basal ganglia under-recruitment in Parkinson's disease: transient caudate abnormalities during updating of working memory

Using hybrid-blocked/event-related fMRI and the 2-back task we aimed to decompose tonic and phasic temporal dynamics of basal ganglia response abnormalities in working memory associated with early untreated Parkinson's disease. In view of the tonic/phasic dopamine hypothesis, which posits a functional division between phasic D(2)-dependent striatal updating processes and tonic D(1)-dependent prefrontal context-maintenance processes, we predicted that newly diagnosed, drug-naïve Parkinson's disease patients, with selective striatal dopamine deprivation, would demonstrate transient rather than sustained activation changes in the basal ganglia during 2-back performance. Task-related activation patterns within discrete basal ganglia structures were directly compared between patients and healthy elderly controls. The obtained results yielded uniquely transient underactivation foci in caudate nuclei, putamen and globus pallidus in Parkinson's disease patients, which indicates suboptimal phasic implementation of striatal D(2)-dependent gating mechanisms during updating. Sustained underactivation was only seen in the anterior putamen, which may reflect initial signs of tonic control impairment. No significant changes were exhibited in prefrontal cortex. The present findings resonate well with the tonic/phasic dopamine account and suggest that basal ganglia under-recruitment associated with executive dysfunction in early Parkinson's disease might predominantly stem from deficiencies in phasic executive components subserved by striatum.

Dopaminergic modulation of cortico-cortical functional connectivity in Parkinson's disease: An MEG study

Recent studies have demonstrated increased resting-state cortico-cortical functional connectivity in untreated Parkinson's disease (PD). We set out to determine whether this connectivity can be modulated by dopamine replacement therapy (DRT) and explore the relationship of therapy-induced changes in connectivity with motor improvement in the relatively early stages of DRT in PD. Whole-head magnetoencephalography was performed in an eyes-closed resting-state condition in 37 patients with levodopa-treated PD (Hoehn and Yahr stages 1–3) both in a practically defined “OFF” and in the “ON” medication state. Data analysis involved calculation of three synchronisation likelihood (SL; a general measure of linear and non-linear temporal correlations between time series) measures which reflect functional coupling within and between ten major cortical areas in five frequency bands. The transition from the “OFF” to the “ON” state led to increases of SL in the 4–30 Hz range, most conspicuously with regard to local SL, in tandem with motor improvement. We found a negative correlation between the change in local beta SL and the reduction of parkinsonism after DRT. Patients presenting with relatively large motor responses (41% or better) actually showed decreases in local beta SL. The present study shows that the already elevated levels of resting-state cortico-cortical functional connectivity in the 4–30 Hz range in mild to moderate PD are on average increased even further by DRT. However, a strong motor response appears to be associated with decreases in local beta-band coupling, which may constitute a risk factor for the development of motor response fluctuations or dyskinesias.

Early, untreated Parkinson's disease patients show reaction time variability

While Parkinson's disease (PD) is associated with motor slowing, less attention has been paid to variability in performance on motor and cognitive tasks. To examine reaction time latencies and intraindividual variability in untreated patients with PD compared to healthy controls. Twenty-nine (19 men/10 women) patients with untreated PD and 16 controls (8 men/8 women) were examined using measures of simple reaction time (SRT) and choice reaction time (CRT) in addition to cognitive measures of executive function (Trail Making Test; adaptive digit ordering). Latencies and intraindividual variability were compared between groups. Partial correlation coefficients, adjusting for age, sex and education were used to examine the relationship between RT measures and motor or cognitive measures. Patients and controls did not differ with respect to age or sex distribution. Education and cognitive status differed between groups, but no subject was demented or clinically depressed. After adjusting for age, sex and education, significant group differences were found in latencies (2-choice RT and 8-choice RT) and intraindividual variability scores (all CRT conditions). Latencies did not differ significantly after adjusting for finger tapping rate. In the PD group neither the motor nor the executive measures correlated significantly with any of the reaction time measures. We conclude that CRT intraindividual variability and latencies are increased in untreated PD.

Quantitative measures of fine motor, limb, and postural bradykinesia in very early stage, untreated Parkinson's disease

Few studies have characterized the motor control abnormalities of very early stage Parkinson's disease (PD), when symptoms are mild and usually unilateral. However, this group is the most targeted for potential disease-modifying therapeutics. We have validated several quantitative measures of bradykinesia with the Unified Parkinson's Disease Rating Scale motor disability score (UPDRS III) and have found these useful in studies of advanced PD. In this study, we asked if quantitative measures of finger, forearm, and postural movement velocity could detect bradykinesia in 20 patients with very early stage, untreated PD. The results revealed evidence of significant finger and forearm bradykinesia of the patient group's more affected side when compared to the nondominant side of 19 age-matched control subjects (P = 0.001 and P < 0.001, respectively). Furthermore, the patient group's forearm movement velocity on the more affected side was significantly slower than their less affected side (P = 0.005), highlighting the importance of using an outcome measure that is lateralized in studies of very early stage PD. In contrast to our previous study that revealed significant postural bradykinesia in patients with advanced PD, we did not detect postural bradykinesia in patients with very early stage, untreated PD. Based on these findings, we suggest that the use of quantitative, lateralized measures of bradykinesia would be useful in studies of very early stage, untreated PD. These measures may improve a study by: increasing efficiency and objectivity of the evaluation, decreasing cost, and decreasing the number of subjects needed for statistical significance.

Dihydrotetrabenazine positron emission tomography imaging in early, untreated Parkinson's disease

To determine the sensitivity of positron emission tomography with 11C-labeled dihydrotetrabenazine (DTBZ) to the nigrostriatal changes associated with early, untreated Parkinson's disease (PD), and to determine the correlation between any regionally reduced DTBZ binding and the major motor features of PD. Untreated patients with early PD (n = 27) and age-matched control subjects (n = 33) underwent DTBZ/positron emission tomography scanning to measure binding to the presynaptic type 2 vesicular monoamine transporter site in dopaminergic neurons in basal ganglia regions. Clinical symptoms were rated with the Unified Parkinson's Disease Rating Scale. Mean striatal DTBZ binding values in the patient group were decreased as compared with control subjects (p < 0.001) in all regions examined. The difference between patients and control subjects was most marked in the midputamen, where only one patient had DTBZ binding within 3 standard deviations of the control mean. Bradykinesia and rigidity scores correlated with DTBZ binding in the contralateral midputamen region, particularly for the clinically least affected limbs. Tremor scores showed no significant correlation. Reduced striatal binding of DTBZ is associated with early PD. Tremor appears to be only partially related to presynaptic dopaminergic function and may have a mechanism differing from that of symptoms such as bradykinesia. The method appears to be most sensitive in mildly affected individuals with a possible "floor" effect that may limit the degree of additional change occurring once more severe clinical symptoms are evident.

P1.071 Longitudinal monitoring of untreated Parkinson's disease using the timed Up and Go test with and without a secondary cognitive task

P1.071 Longitudinal monitoring of untreated Parkinson's disease using the timed Up and Go test with and without a secondary cognitive task

P1.127 Dual tasking interference during mobility in untreated Parkinson's disease: a comparison between two verbal secondary tasks

P1.127 Dual tasking interference during mobility in untreated Parkinson's disease: a comparison between two verbal secondary tasks

Impairment of complex upper limb motor function in de novo Parkinson's disease

The aim of the present study was to evaluate complex upper limb motor function in newly diagnosed, untreated Parkinson's disease (PD) patients. Four different unimanual upper limb motor tasks were applied to 13 newly diagnosed, untreated PD patients and 13 age- and sex-matched controls. In a handwriting task, PD patients had significantly reduced sentence length and writing velocity, and decreasing letter height in the course of writing. Furthermore, PD patients performed an aiming task slower with than without target, and showed increased transposition in a pointing task. The results of this study extend previous observations of impaired complex upper limb movements to newly diagnosed, untreated PD patients.

Gastrointestinale Störungen bei Morbus Parkinson

Schon James Parkinson beschrieb gastrointestinale Dysfunktionen wie vermehrtes Speichelaufkommen, Schluckstörungen und chronische Obstipation. Parkinsonpatienten berichten auch über typische dyspeptische Beschwerden wie Übelkeit, Völlegefühl, frühes Sättigungsgefühl, epigastrische Beschwerden, Erbrechen, Sodbrennen und Meteorismus. Diese können auch von der gastrointestinalen Motilität mit verursacht werden. Eine reduzierte Magenentleerung wird sogar als ein prämotorisches Symptom des Morbus Parkinson diskutiert, da eine Verlangsamung der Magenentleerung auch bei unbehandelten Parkinsonpatienten gezeigt werden konnte und ebenso im Bereich des die intestinale motorische Funktion steuernden enterischen Nervensystems Lewy-Körperchen gehäuft gefunden wurden. Unklar sind die Effekte, die die Therapie mit Levodopa auf die gastrointestinale Motilität ausübt. Zu diskutieren sind neben einem Serotoninmangel, einerseits durch verminderte Aufnahme von Tryptophan oder Abbau von Levodopa zu Dopamin in gastrointestinalen serotonergen neuronalen Zellen. Dies hat vor dem Hintergrund der 5-HT-Rezeptor-gesteuerten Peristaltik einen hypothetischen Einfluss auf die häufige Manifestation einer chronischen Obstipation bei mit Levodopa behandelten Parkinsonpatienten.

The impact of depressive symptoms in early Parkinson disease

Depressive disorders may affect up to 50% of patients with Parkinson disease (PD) and are associated with increased disability and reduced quality of life. No previous study has systematically examined the impact of depressive symptoms in early, untreated PD. We administered the 15-item Geriatric Depression Scale (GDS-15) as part of two NIH-sponsored phase II clinical trials in PD, enrolling 413 early, untreated PD subjects. We used linear mixed models to examine the relationship of depressive symptoms, measured by the GDS-15, with motor function and activities of daily living (ADLs), as measured by the Unified PD Rating Scale (UPDRS). A time-dependent Cox model was used to examine the effect of demographic and clinical outcome measures as predictors of investigator-determined time to need for symptomatic therapy for PD. A total of 114 (27.6%) subjects screened positive for depression during the average 14.6 months of follow-up. Forty percent of these subjects were neither treated with antidepressants nor referred for further psychiatric evaluation. Depression, as assessed by the GDS-15, was a significant predictor of more impairment in ADLs (p < 0.0001) and increased need for symptomatic therapy of PD (hazard ratio = 1.86; 95% CI 1.29, 2.68). Clinically important depressive symptoms are common in early Parkinson disease (PD), but are often not treated. Depressive symptoms are an important contributor to disability and the decision to start symptomatic therapy for motor-related impairment in early PD, highlighting the broad importance of identifying and treating depression in this population.

Dopamine levels after repetitive transcranial magnetic stimulation of motor cortex in patients with Parkinson's disease: Preliminary results

Repeated session of repetitive transcranial magnetic stimulation (rTMS) over motor cortex have been reported to produce significant improvement of motor performance in patients with parkinson's disease (PD). In addition, it is known that a single session of rTMS over motor cortex transiently increases DA in striatum. Here, we test whether repeated sessions of rTMS increase serum dopamine in PD patients and whether this correlates with changes in clinical rating scales. Twenty untreated PD patients with moderate to severe symptoms (Hoehn & Yahr state III-V 1967) were assessed on the Unified Parkinson's Disease Rating Scale (UPDRS), and with an enzyme immunoassay for quantitative determination of plasma dopamine before and after six daily sessions of 25 Hz rTMS with 3,000 stimuli over the right and left hand and leg motor cortex. There was significant improvement in UPDRS compared with the baseline. Serum dopamine level also was significantly elevated over the same interval. There was a significant correlation between UPDRS and serum dopamine level before and after treatment. Improved motor performance in PD after repeated session of rTMS may be related to an elevation of serum dopamine concentration.

Excessive synchronization of basal ganglia neurons at 20 Hz slows movement in Parkinson's disease

Excessive synchronization of neuronal activity at around 20 Hz is a common finding in the basal ganglia of patients with untreated Parkinson's disease (PD). Correlative evidence suggests, but does not prove, that this spontaneous activity may contribute to slowness of movement in this condition. Here we investigate whether externally imposed synchronization through direct stimulation of the region of the subthalamic nucleus at 20 Hz can slow motor performance in a simple unimanual tapping task and whether this effect is frequency selective. Tapping rates were recorded on 42 sides in 22 patients with PD after overnight withdrawal of medication. Tapping was performed without stimulation and during bilateral stimulation at 20 Hz, 50 Hz and 130 Hz. We found that tapping rates were slowed by 8.2 ± 3.2% ( p = 0.014) during 20-Hz stimulation in subjects with relatively preserved baseline function in the task. This effect was frequency selective. The current data provide proof of the principle that excessive beta synchrony within the basal ganglia-cortical loop may contribute to the slowing of movements in Parkinson's disease.

A randomized clinical trial of coenzyme Q 10 and GPI-1485 in early Parkinson disease

To determine if future studies of coenzyme Q(10) and GPI-1485 in Parkinson disease (PD) may be warranted. We conducted a randomized, double-blind, calibrated futility clinical trial of coenzyme Q10 and GPI-1485 in early untreated PD using placebo data from the DATATOP study to establish the futility threshold. The primary outcome measure (change in total Unified Parkinson's Disease Rating Scale scores over 1 year) did not meet the prespecified criteria for futility for either agent. Secondary analyses using calibration controls and other more recent placebo data question the appropriateness of the predetermined definition of futility, and suggest that a more restrictive threshold may be needed. Coenzyme Q(10) and GPI-1485 may warrant further study in Parkinson disease, although the data are inconsistent. Additional factors (cost, availability of other agents, more recent data on placebo outcomes, other ongoing trials) should also be considered in the selection of agents for Phase III studies.

Abnormal susceptibility to distracters hinders perception in early stage Parkinson's disease: a controlled study

BackgroundOne of the perceptual abnormalities observed in Parkinson's disease (PD) is a deficit in the suppression of reflexive saccades that are automatically triggered by the onset of a peripheral target. Impairment of substantia nigra function is thought to lead to this reduced ability to suppress reflexive saccades.MethodsThe present study examined whether this perceptual deficit is also present in early stage PD when using hardly noticeable task-irrelevant stimuli. Eleven non-demented de novo, untreated PD patients (mean age 57 yr, range 44 – 70) participated in the study as well as 12 age-matched controls. Performance on an 'oculomotor capture' task, in which in half of the trials an irrelevant stimulus with sudden onset was added to the display, was compared between patients and controls. Analysis of variance (ANOVA) was performed with group (patients/controls) and age (< 61 yrs/≥ 61 yrs) as independent factors and type of trial (control/distracter) as repeated measurements factor. The factor sex was used as covariate.ResultsWith respect to Reaction Time (RT), a significant interaction between group and condition was found. RTs increased under the 'irrelevant stimulus' condition in both groups, the patients exhibiting a significantly larger increase in RTs than the control group. Also, a significant interaction effect between group and condition for number of correct responses was found. The number of correct responses was reduced in the onset distracter condition, the reduction being larger in the patients. In the patient group, contrary to the control group, a higher age was associated with fewer correct responses at baseline and in the onset distracter condition, suggesting that perceptual functions in PD are highly susceptible to the effects of ageing. The increased reaction times and larger number of incorrect responses of the PD patients in the onset distracter condition may be related to impairments of substantia nigra function and lower brain stem.ConclusionThe capture task seems to be a sensitive instrument to detect early perceptual deficits in PD. The magnitude of the observed deficits suggests that perceptual functions in early stage PD are so substantially impaired that this may interfere with daily activities.

TCH346 as a neuroprotective drug in Parkinson's disease: a double-blind, randomised, controlled trial

There is an important unmet medical need in Parkinson's disease for a neuroprotective treatment that slows or stops disease progression. TCH346 is a potent anti-apoptotic drug that protects against loss of dopaminergic neurons in laboratory models. Our aim was to assess TCH346 as a neuroprotective drug in patients with Parkinson's disease. Patients presenting at 45 international movement disorder clinics with early untreated Parkinson's disease were assessed as part of this parallel-group, double-blind, randomised controlled trial. 301 eligible patients were randomly assigned 12-18 months' treatment with TCH346 at a daily dose of 0.5 mg (n=78), 2.5 mg (n=79), or 10 mg (n=73), or placebo (n=71), followed by a 4 week washout period. The primary outcome measure was time to development of a disability requiring dopaminergic treatment. Secondary outcome measures were the annual rate of change in the unified Parkinson's disease rating scale (UPDRS) and the PDQ-39, a measure of quality of life. Analyses were by intention-to-treat. This study is pending registration with . 255 patients completed the study. TCH346 did not differ from placebo for any of the study outcomes. Treatment was needed in 26 (34%) patients in the TCH346 0.5 mg group, 30 (38%) in the TCH346 2.5 mg group, 24 (33%) in the TCH346 10 mg group, and 23 (32%) in the placebo group. There were no significant differences between groups. There were no differences between groups in the annual change in the UPDRS or PDQ-39 either. Few patients withdrew because of adverse events and none was judged to be related to the study intervention. TCH346 did not show evidence of a neuroprotective effect. The discrepancy between the preclinical promise of TCH346 and the clinical outcome could have arisen because of the use of laboratory models that do not accurately reflect the pathogenesis of Parkinson's disease, the doses of study drug used, insensitive clinical endpoints, and the patient population selected for study.