Parkinson Disease: Sławek J

Zabek M, Sławek J, Harat M, Koszewski W, Opala G, Friedman A. · Oddział Neurochirurgii Czynnościowej i Chorób Układu Pozapiramidowego, Klinika Neurochirurgii, Akademia Medyczna, ul Debinki 7, 80-211 Gdańsk. · Neurol Neurochir Pol. · Pubmed #16463215 links to  free full text

Abstract: The authors present the current views on the use of electrical stimulation in selected movement disorders (Parkinson's disease, dystonia) and pain syndromes (central and neuropathic pain) refractory to pharmacological therapy. Stimulation should be applied in cases with an established diagnosis (especially Parkinson's disease and dystonia) and with a lack of efficacy despite the best available medical therapy. Therefore it should be the last treatment option, except of generalized dystonia, where it seems to be nowadays the treatment of choice. Suggested selection criteria are based on experience of different centers and on current medical literature. They are published to make the procedure more rational and more available in Poland.

Sławek J. · Oddział Neurologii, Szpital Specjalistyczny św. Wojciecha w Gdońsku, Zakład Pielegniarstwa Neurologiczno-Psychiotrycznego, Akademia Medyczna w Gdańsku. · Neurol Neurochir Pol. · Pubmed #17941456 No free full text.

Abstract: Dopamine agonists are a relatively new group of medications, which are the second group after levodopa in terms of clinical efficacy in reduction of parkinsonian symptoms. When added to levodopa in patients with motor fluctuations they significantly prolong the on time with reduction of off periods. In patients with dyskinesias they may also be useful, because the reduction of levodopa may decrease the severity of dyskinesias as well. Agonists of the new generation, like the non-ergotamine derivatives ropinirol and pramipexol, but also the older ergoline derivative pergolide, fulfill the criterion of efficacy in classification according to evidence-based medicine regulations.

Wichowicz H, Sławek J, Derejko M. · Klinika Chorób Psychicznych i Zaburzeń Nerwicowych Katedry Chorób Psychicznych Akademii Medycznej w Gdańsku. · Przegl Lek. · Pubmed #15850333 No free full text.

Abstract: Depressive symptoms often occur in Parkinson' disease. They have negative influence for patients' quality of life. However, they are not sufficiently diagnosed nor correctly treated. Difficulties with the diagnosis could be a result of: partial confusion of symptoms of Parkinson's disease and depression and/or different clinical depressive symptoms, compared to "primary" affective disorder. Correlation between cognitive functions, Parkinson' disease and depression remains pretty unclear. Depression occurring during Parkinson's disease must be treated. Theoretically all kinds of treatment for depression can be applied. Nowadays, among antidepressive agents, SSRI's are preferred, mainly because of its good tolerance.

Sławek J. · Poradni Chorób Układu Pozapiramidowego, Szpitala Specjalistycznego św. Wojciecha-Adalberta w Gdańsku. · Neurol Neurochir Pol. · Pubmed #12910842 No free full text.

Abstract: The renewal of interest in the neurosurgical treatment of Parkinson's disease (PD) also in Poland results from of our improved understanding of functional anatomy of basal ganglia, developments in neurophysiological and neuroimaging techniques, as well as from advances in stereotactic surgery techniques. In view of the growing number of PD patients referred to surgical treatment and the wide variety of interventions offered, the development of clear of PD patient's selection to surgery seems necessary. Various surgical options and possible targets provide different functional benefits, but the almost 10 year's experience makes us aware also of the limitations and possible complications involved. Algorithms worked out by researchers from the most experienced centers include the following selection criteria as a minimal standard of the PD patient's evaluation before surgery: a reliable diagnosis of Parkinson's disease, at least 5 years of PD duration since the onset of symptoms, good responsiveness to L-dopa or apomorphine, exclusion of severe depression and dementia, neuroimaging (MRI) performed before the surgery, and optimal (but ineffective) attempts at available pharmacological therapy prior to the surgery.

Sławek J. · Wojewódzkiego Oddziału Neurologii, Szpitala Specjalistycznego św. Wojciecha w Gdańsku. · Neurol Neurochir Pol. · Pubmed #11105305 No free full text.

Abstract: The author presents current views on neuroprotective strategies in therapy of idiopathic Parkinson's disease. They are the result of different aetiopathogenetic concepts of Parkinson's disease. The concepts of loss of nigral cells as a result of aging, apoptosis or genetic defect (alpha-synucleine) are not sufficiently proven and their role is only hypothetic. Therapeutic use of nerve growth factors seems to be a promising novel strategy but there are technical problems how to deliver them to the brain. One of the most and widely acceptable concept is the theory of the role of oxidative stress in pathogenesis of Parkinson's disease. It was a scientific basis for clinical trials with selegiline (DATATOP, SINDEPAR, PDRG) which results were unfortunately disappointing, mostly because of symptomatic effect of selegiline. Another interesting concept seems to be the excitotoxicity of amino acids (like glutamate) and amantadine is the well known drug with recently discovered antagonism to NMDA receptors. In only one retrospective clinical trial in humans its neuroprotective effect was proven, but we need now well prepared prospective trials with this drug to confirm this result. So far, despite the hopes concerning selegiline no one effective neuroprotective agent is available in treatment of Parkinson's disease.

Sławek J, Wieczorek D, Derejko M, Dubaniewicz M, Brockhuis B, Sitek E, Wilczewska L, Roszmann A, Lass P. · Zakład Pielêgniarstwa Neurologiczno-Psychiatrycznego, Akademia Medyczna w Gdańsku, Szpital Specjalistyczny oew. Wojciecha, Al. Jana Pawła II 50, 80-462 Gdańsk. · Neurol Neurochir Pol. · Pubmed #19235103 links to  free full text

Abstract: BACKGROUND AND PURPOSE: Vascular risk factors may contribute to deterioration of cognitive functions in Alzheimer's disease and vascular (or mixed) dementia. Parkinson's disease (PD) is an age-related disorder and vascular risk factors potentially might be the main co-morbidity responsible for motor and cognitive impairment. However, only a few studies focused on this problem have been published. The aim of the study was to assess the contribution of vascular risk factors and white matter abnormalities in magnetic resonance imaging (MRI) on cognitive impairment in PD patients. MATERIAL AND METHODS: Sixty consecutive patients (M: 35, F: 25), mean age 68.36 years (SD: 7.25, range: 51-81) with diagnosis of idiopathic PD underwent a semi-structured questionnaire on demographics and vascular risks factors, neurological, neuropsychological and neuroimaging (MRI) examinations with quantitative assessment according to the scale by Wahlund et al. According to cognitive status they were divided into 3 groups: without cognitive disability (I, n=17), with mild cognitive impairment (II, n=25) and with dementia (III, n=18). RESULTS: There were no significant differences between groups in terms of the number of vascular risk factors (except for the ischaemic heart disease difference between group I and III) and severity of white matter hyperintensities in MRI studies. CONCLUSIONS: Vascular risk factors along with white matter vascular abnormalities probably do not contribute to cognitive impairment in patients with PD. This is in concordance with previously published studies.

Derejko M, Sławek J, Wieczorek D, Brockhuis B, Dubaniewicz M, Lass P. · Neurophysiology Department, Institute of Psychiatry and Neurology, Warsaw, Poland. · Nucl Med Commun. · Pubmed #17088679 No free full text.

Abstract: OBJECTIVE: To investigate the pattern of regional cerebral blood flow (rCBF) deficits in Parkinson's disease patients in relation to cognitive decline and to assess the clinical usefulness of single photon emission tomography (SPET) scanning in differentiation between Parkinson's disease patients with dementia and those without cognitive deficits. METHODS: We performed Tc-ECD SPET in 60 patients with idiopathic Parkinson's disease (F: 25, M: 35), with average age of 68.4 years (SD+/-7.3, range 51-81 years). All patients were examined neurologically with the assessment of stage and severity of Parkinson's disease (Hoehn-Yahr scale, UPDRS, Schwab-England scale). Detailed neuropsychological examination was performed in each Parkinson's disease patient. On the basis of DSM-IV criteria of dementia and the results obtained in psychological examination, the whole group was divided into three subgroups: I, with no cognitive changes (n = 17); II, with mild cognitive impairment (n = 25); and III, with dementia (n = 18). RESULTS: There was noticeable significant decrease of perfusion in all areas in Parkinson's disease patients when compared to the age-matched control group of healthy volunteers (n = 20). In group III, perfusion was significantly decreased (when compared to groups I and II), particularly in parietal and temporal areas with the predominance of the left side. Regression analysis revealed two independent factors related to dementia: decrease of perfusion within left temporal lobe and its increase within left thalamus. CONCLUSION: Parkinson's disease patients with dementia showed left temporo-parietal hypoperfusion as compared to a group of patients without dementia, which resembles perfusion deficits described in Alzheimer's disease. The hypoperfusion of the left temporal lobe with increase of rCBF within the left thalamus might be clinically useful in discrimination of Parkinson's disease patients with dementia against those without cognitive impairment.

Derejko M, Sławek J, Wieczorek D, Dubaniewicz M, Lass P. · Zakład Neurofizjologii Klinicznej, Instytut Psychiatrii i Neurologii, ul. Sobieskiego 9, 02-957 Warszawa. · Neurol Neurochir Pol. · Pubmed #16967348 links to  free full text

Abstract: BACKGROUND AND PURPOSE: The aim of the study was to assess the prevalence of vascular risk factors and white matter hyperintensities (WMH) in patients with Parkinson's disease (PD) and its impact on clinical features such as motor impairment. MATERIAL AND METHODS: 60 patients with PD [25 women and 35 men; mean age 68.4 (51-81) years, mean duration of disease 8.4 (1-27) years] with good response to L-Dopa were studied. Besides neurological examination, the degree of motor impairment was evaluated in all patients using UPDRS, Hoehn-Yahr, and Schwab-England scales. All patients underwent MRI to assess the degree of WMH using Age Related White Matter Changes (ARWMC) Wahlund scale. Moreover, the prevalence of classic vascular risk factors included arterial hypertension, diabetes mellitus t. 1 and 2; plasma cholesterol, cardiovascular diseases, alcohol abuse and smoking was assessed. RESULTS: Presence of at least one vascular risk factor was noted in 19 patients (31.7%). No significant differences were found between the groups of patients with and without vascular risk factors with regard to all clinical parameters and total ARWMC score. These factors did not differ between the groups of patients with more than 3 vascular risk factors and other patients. WMH (ARWMC > or =1) occurred in 33 patients (55%). No significant differences in all analysed clinical factors and the total number of vascular risk factors between the groups with (ARWMC > or =1) and without (ARWMC=0) WMH were found. The group of patients with at least one focus with score of 2 in the Wahlund scale did not differ significantly in all analysed clinical parameters from the rest of the patients. CONCLUSIONS: Our data suggest that the severity of WMH and incidence of vascular risk factors are not significantly related with the degree of motor disability in PD.

Wichowicz HM, Sławek J, Derejko M, Cubała WJ. · 1st Department of Psychiatry, Medical University, Gdańsk, Debinki 7 St. 80-952 Gdańsk, Poland. · Eur Psychiatry. · Pubmed #16531018 No free full text.

Abstract: OBJECTIVE: The aim of this study was to assess the prevalence and factors influencing depression in PD patients in a cross-sectional outpatient clinic - based Polish patients sample. MATERIALS AND METHODS: One hundred consecutive PD patients were included in this study; 35 of them fulfilled DSM-IV criteria for Major Depression and its severity was assessed with Montgomery-Asberg Depression Rating Scale (MADRS). A structured interview and a neurological examination, including Hoehn and Yahr scale (H-Y), Schwab-England disability scale, II, III, IV parts of Unified Parkinson's Disease Rating Scale (UPDRS), and Mini-Mental State Examination (MMSE) were performed. The parameters obtained were analysed between the depressed and non-depressed PD patients. RESULTS: The prevalence of depression in PD in Polish population was established at the level of 35%. PD patients with depression scored significantly higher in all UPDRS scales (except for the subscale of clinical fluctuation) and in H-Y scale. PD with depression was also associated with longer PD duration, higher doses of L-dopa equivalents, patients' age, general impairment of daily living in Schwab and England disability scale, lower MMSE and higher clinical fluctuations. However, those six differences were insignificant. CONCLUSIONS: Depression prevalence rate among PD patients in Polish population is slightly lower than in most of other published studies. This may result from strict selection criteria, use of specific outcome measures and restricted criteria for depression that were applied.

Sławek J, Derejko M, Lass P. · Neurosurgery Department, Division of Functional Neurosurgery and Movement Disorders, Medical University of Gdańsk, Debinki 7 Str., Gdańsk, Poland. · Parkinsonism Relat Disord. · Pubmed #16154794 No free full text.

Abstract: PURPOSE: To determine the factors associated with poor quality of life (QoL) in patients with idiopathic Parkinson's disease (PD) in a clinic-based sample. SCOPE: One hundred patients were included in this study. To assess the quality of life the Parkinson's Disease Questionnaire (PDQ-39) was used. A structured questionnaire interview and a complete neurological examination, including the Hoehn and Yahr scale (H-Y), the Schwab and England disability scale, II, III, IV parts of the unified Parkinson's disease rating scale (UPDRS part II, III, IV), Montgomery-Asberg depression rating scale (MADRS) and the Mini-Mental state examination (MMSE) were performed. RESULTS AND CONCLUSIONS: The most important predictive factor was MADRS score, followed by clinical fluctuations as measured by UPDRS part IVB and the H-Y stage of disease, which account for 79% of the variance of QoL scores. Therefore, recognition of depression should become an important part of treatment of PD.

Sławek J, Derejko M, Lass P, Dubaniewicz M. · Department of Neurosurgery, Division of Functional Neurosurgery and Movement Disorders, Medical University, ul. Debinki 7, 80-211 Gdańsk, Poland. · Clin Neurol Neurosurg. · Pubmed #16112411 No free full text.

Abstract: Although a mild stooped posture is a hallmark of parkinsonism, extreme trunk forward flexion is not common. This phenomenon was described in different etiological entities and called camptocormia. Other similar presentations called Pisa syndrome and antecollis were described mainly in extrapyramidal disorders. Authors present two cases of probable multiple system atrophy (MSA) with predominant parkinsonism and Pisa syndrome (or camptocormia). Both of them were previously misdiagnosed as idiopathic Parkinson's disease (PD) and one was reported 1 year earlier. The typical clinical presentation fulfilling the diagnostic criteria for multiple system atrophy, rapid progression with lack of responsiveness to L-DOPA and apomorphine and typical MRI putaminal pathology observed in both cases allowed us to make a diagnosis. Accuracy of clinical diagnosis in multiple system atrophy is still very poor. Therefore, unusual or rare clinical presentations may support the final diagnosis. The camptocormia, Pisa syndrome and antecollis may represent the continuum of the same motor phenomenon and most of the authors refer them to unusual form of axial dystonia. According to many clinical presentations on different forms of camptocormia/Pisa syndrome authors conclude that not etiology, but the localization of specific lesion, probably within putamen is responsible for that form of dystonia. In cases of parkinsonism and severe forward flexion of trunk multiple system atrophy, diagnosis should be considered.

Zach M, Friedman A, Sławek J, Derejko M. · Department of Neurology, Medical University of Warsaw, Warsaw, Poland. · Mov Disord. · Pubmed #15197705 No free full text.

Abstract: The objective of this study was to evaluate possible relationships between quality of life (QoL) of Polish patients with long-lasting Parkinson's disease and various demographic and clinical factors. The study comprised 141 patients of Movement Disorders outpatient clinics in Warsaw and Gdansk with at least 5 years of the disease duration. Mean age of patients was 68.09 +/- 8.51 years, mean duration of disease was 11.87 +/- 5.14 years. To assess the quality of life, the Parkinson's Disease Questionnaire (PDQ-39) was used. Additional questions concerned duration of disease, initial and current treatment and expenses associated with therapy. Self-perceived symptoms of depression were in our study the most important factor determining QoL. Duration of the disease and expenses related to the treatment also have a significant impact on the QoL. Patient's age and presence of dyskinesia seem to be irrelevant to the quality of life.

Sławek J, Derejko M. · Klinika Neurochirurgii-Oddział Neurochirurgii Czynnościowej i Chorób Układu Pozapiramidowego, Akademia Medyczna w Gdańsku. · Neurol Neurochir Pol. · Pubmed #15098337 No free full text.

Abstract: The aim of our study was to assess the frequency, risk factors, and interrelations between depression and dementia in P.D. MATERIAL AND METHODS: 100 consecutive patients with P.D. with good response to L-dopa and normal CT/MRI scans, mean age: 66 (41-81) years, mean disease duration 6.7 (0-24) years. Rating scales: for stage of disease and motor disability: Hoehn-Yahr (HY), Schwab-England (SE), Unified Parkinson's Disease Rating Scale (UPDRS), for depression: Montgomery-Asberg Depression Rating Scale (MADRS), for dementia: Mini Mental State Examination (MMSE), for quality of life: Parkinson's Disease Questionnaire (PDQ-39) and own questionnaire (demographic data and treatment). RESULTS: Depression (MADRS > 19) was revealed in 35% and dementia (MMSE < or = 23) in 19% of patients. Depressed and demented patients had significantly more advanced motor disability (UPDRS, HY, SE) and poor quality of life (PDQ-39). In group with dementia disease duration was longer (9.4 vs 6.0 years; p < 0.009), mean age was higher (71.3 vs 64.7 years; p < 0.002) and sleep disturbances, depression and hallucinations more frequent (p < 0.04). Groups with and without depression did not differ significantly in terms of dementia (MMSE). CONCLUSIONS: Depression and dementia are more frequent in patients with greater motor disability and correlated significantly with poor quality of life. Old age, longer disease duration, hallucinations and sleep disturbances are risk factors for dementia in P.D. In demented patients with P.D. depression is more frequent.

Friedman A, Harat M, Opala G, Sławek J, Zabek M. · Klinika Neurochirurgii-Oddział Neurochirurgii Czynnościowej i Chorób Układu Pozapiramidowego Akademia Medyczna w Gdańsku ul. Debinki 7, 80-211 Gdańsk. · Neurol Neurochir Pol. · Pubmed #15098326 No free full text.

Abstract: Renewed interest (also in Poland) in the neurosurgical treatment of Parkinson's Disease is the main cause of referring patients to stereotactic surgery. It is the result of our improved understanding of functional anatomy of basal ganglia and development of neurophysiological, neuroimaging and neurosurgical techniques. Various surgical options and possible targets offer different functional benefits, but due to almost 10 years experience we are aware of limited results and possible complications as well. There is a need of minimal standard of patient's evaluation before selection to surgery. The selection criteria include: good diagnosis of Parkinson's Disease, at least 5 years from the onset of symptoms, good responsiveness to L-dopa or apomorphine, exclusion of severe depression and dementia, neuroimaging (MRI) before surgery and optimal (but ineffective) pharmacological therapy before surgery.

Derejko M, Sławek J, Lass P, Nyka WM. · Department of Nuclear Medicine, Medical University, Gdańsk, Poland. · Nucl Med Rev Cent East Eur. · Pubmed #14600899 No free full text.

Abstract: Dementia is one of the main non-motor symptoms of Parkinson's disease (PD) and it is diagnosed in about 30% of cases. Its aetiology remains unclear and contributing factors are controversial. Dementia may be more common in old patients with severe motor symptoms and mild cognitive impairment. Clinico-pathological studies show the association between dementia in PD and the age-related group of dementias, such as AD and VaD. A valuable aid in the assessment of dementia in PD is cerebral blood flow (CBF) brain SPECT scanning. It shows three different patterns of rCBF reduction, including frontal lobe hypoperfusion, Alzheimer-like type of hypoperfusion and multiple, vascular defects. The heterogeneity of rCBF reduction may reflect the multifactorial pathophysiology of dementia in PD. It may result from concomitant AD pathology, cerebrovascular disease, destruction of nigro-striato-frontal projection or may be a distinct disease of different aetiology.

Sławek J, Derejko M, Lass P. · Szpitala Specjalistycznego św. Wojciecha-Adalberta w Gdańsku. · Neurol Neurochir Pol. · Pubmed #14558483 No free full text.

Abstract: The aim of our study was to assess the frequency of depression in group of patients with Parkinson's disease (PD) who fulfilled the diagnostic criteria of PD, had normal CT scans and responded well to L-dopa treatment. The sample consisted of 73 consecutive patients (34 women and 39 men), mean age 65.7 (41-81) years, mean duration of disease 6.7 years. Besides neurological examination, in all the patients the degree of motor impairment was evaluated using the UPDRS, H-Y, and SE scales. Moreover, a sociodemographic questionnaire, psychological tests (MADRS, MMSE), and a quality of life scale (PDQ-39) were used. Depression (MADRS scores > 19) was found in 25 (34.2%) of the patients, with major depression (scores > 28) diagnosed in 7 patients (9.5%) and moderate depression (scores between 20 and 28)--in 18 cases (24.6%). In comparison to non-depressed patients, those with depression were older by 0.9 years on the average, their onset of the disease occurred later by 1.7 years, and their mean duration of the disease was longer by 2.6 years. These differences were not statistically significant. Dementia (MMSE scores < or = 23) did not differentiate between the two groups: it was found in 27 depressed patients (37.4%) and in 26 (35.6%) of those without depression. Patients in the depressed group suffered statistically more often from sleep disorders (19 vs. 14; p < 0.001). In this group motor impairment was significantly more marked, as measured by the UPDRS (32.2 vs. 46.8; p < 0.001) and H-Y (2.54 vs 2.98; p < 0.007), and their quality of life as measured by PDQ-39 questionnaire was significantly lower (36.4 vs. 82.24; p < 0.00002). Our data indicate the presence of depression in 34.2% of the sample, i.e. a somewhat lower prevalence rate than that reported in other studies. This may be due to the fact that only outpatient population was analysed, and outpatients are seldom categorized as degree 4 and 5 on the H-Y scale. Depression on PD patients was correlated with their more severe motor disability and considerably lower quality of life. This may suggest a relationship with progression of the disease and more pronounced changes in cerebral neurotransmitters (i.e. endogenous origin), or PD patient's response to their limited mobility and isolation in later stages of the disease (i.e. reactive origin). However, the two factors--endogenous and reactive--may be overlapping, since a majority of PD patients suffer from mild to moderate depression.

Sławek J, Derejko M. · Wojewódzkiego Oddziału Neurologii Szpitala Specjalistycznego św. Wojciecha-Adalberta w Gdańsku. · Neurol Neurochir Pol. · Pubmed #11987708 No free full text.

Abstract: Camptocormia is characterized by pronounced forward flexion of the thoracolumbar spine, which increases while walking and disappears in recumbent position. The clinical spectrum of the described disorders with concomitant camptocormia is heterogenous. It was described for the first time in idiopathic Parkinson's disease in 1999. The pathophysiology of this phenomenon remains unclear but seems to be not related to antiparkinsonian treatment. The authors present the case of a 54 years old woman, with idiopathic Parkinson disease diagnosed 5 years ago. The rapid progression of the disease was associated with good response to Levodopa therapy, although the dose had to be increased up to 1400 mg/d (with peripheral decarboxylase and COMT inhibitor). After 5 years she developed painful spasms of paraspinal muscles which resulted in trunk flexion. The clinical picture resembled the described cases of camptocormia. There was no correlation between the appearance of camptocormia and the regime of levodopa administration (time or dosage). Therefore, one can conclude, that presumably camptocormia is not a form of dystonia of the trunk but, the result of till now unclear other factors (dysfunction in other non-dopaminergic nigrostriatal projections?).

Sławek J, Bojko E, Szady J. · Wojewódzkiego Oddziału Neurologii Szpitala Specjalistycznego św. Wojciecha w Gdańsku. · Neurol Neurochir Pol. · Pubmed #11783401 No free full text.

Abstract: The aim of our study was to assess the frequency of dementia in a highly selected (according to diagnostic criteria of Parkinson's disease and other causes of dementia) group of patients. MATERIAL AND METHODS: 46 patients (F 18, M 28), mean age--63.9 (39-80) years, with good response to L-Dopa. Besides the neurological examination, all patients underwent CT and psychological tests (Wechsler-Bellevue, Mini Mental and Hamilton test--to exclude severe depression as cognitive problem cause). In the group with dementia thyroxine and cholesterol tests and EEG were performed. RESULTS: Within the whole group the features of dementia (the index of deterioration in Wechsler test > 25% and/or 23 or less points in Mini-Mental) were recognized in 11 (23.9%) patients. In comparison to the rest of the patients, in the group with dementia the mean age was 8.1 years higher, mean age at onset of the disease was 6.4 years higher, mean time of the disease 1.5 years longer and the severity of the disease measured in Hoehn-Yahr rating scale was 0.76 points higher (2.20 vs 2.96). In the whole group severe depression (> 18 points in Hamilton test) was revealed in 6%, whereas moderate (8-17 points) occurred in 71%. CONCLUSIONS: Older age, later onset of symptoms and more advanced disease are the risk factors of dementia. Other causes--like dementia of Alzheimer's type may be suspected or two distinctive forms of Parkinson's Disease with and without dementia exist.

Sławek J, Derejko M, Lass P. · No affiliation provided · Eur J Neurol. · Pubmed #12535006 No free full text.

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