Parkinson Disease: Shulman LM

Miyasaki JM, Shannon K, Voon V, Ravina B, Kleiner-Fisman G, Anderson K, Shulman LM, Gronseth G, Weiner WJ, Anonymous00046. · University of Toronto, Canada. · Neurology. · Pubmed #16606910 No free full text.

Abstract: OBJECTIVE: To make evidence-based treatment recommendations for patients with Parkinson disease (PD) with dementia, depression, and psychosis based on these questions: 1) What tools are effective to screen for depression, psychosis, and dementia in PD? 2) What are effective treatments for depression and psychosis in PD? 3) What are effective treatments for PD dementia or dementia with Lewy bodies (DLB)? METHODS: A nine-member multispecialty committee evaluated available evidence from a structured literature review using MEDLINE, and the Cochrane Database of Health and Psychosocial Instruments from 1966 to 2004. Additional articles were identified by panel members. RESULTS: The Beck Depression Inventory-I, Hamilton Depression Rating Scale, and Montgomery Asberg Depression Rating Scale should be considered to screen for depression in PD (Level B). The Mini-Mental State Examination and the Cambridge Cognitive Examination should be considered to screen for dementia in PD (Level B). Amitriptyline may be considered to treat depression in PD without dementia (Level C). For psychosis in PD, clozapine should be considered (Level B), quetiapine may be considered (Level C), but olanzapine should not be considered (Level B). Donepezil or rivastigmine should be considered for dementia in PD (Level B) and rivastigmine should be considered for DLB (Level B). CONCLUSIONS: Screening tools are available for depression and dementia in patients with PD, but more specific validated tools are needed. There are no widely used, validated tools for psychosis screening in Parkinson disease (PD). Clozapine successfully treats psychosis in PD. Cholinesterase inhibitors are effective treatments for dementia in PD, but improvement is modest and motor side effects may occur.

Robottom BJ, Mullins RJ, Shulman LM. · Department of Neurology, University of Maryland School of Medicine, 22 South Greene Street N4W46, Baltimore, MD 21201, USA. · Expert Rev Neurother. · Pubmed #19086876 No free full text.

Abstract: Pregnancy in Parkinson's disease (PD) is an uncommon occurrence. Available reports suggest that there may be a worsening of PD symptom severity related to pregnancy. In this special report, medical literature on pregnancy in PD will be reviewed with regard to disease progression and the safety of antiparkinsonian medications. A case report of pregnancy in a woman with PD will be described. It is speculated that the symptoms of PD may be affected by changing hormone levels.

Shulman LM. · University of Maryland School of Medicine, Baltimore, MD 21201, USA. · Gend Med. · Pubmed #17584622 No free full text.

Abstract: Because estrogen has numerous effects on dopamine neurotransmission, many researchers are interested in its possible use to either slow the progression or reduce the risk of Parkinson's disease (PD). The incidence of PD is greater in men than in women. Gender differences in neurotoxicity have been observed, and basic research in experimental animals indicates that estrogen protects neurons from various forms of injury. However, the results of retrospective surveys of the neuroprotective effects of estrogen replacement in PD have been mixed, with some showing no effect on risk and others showing a reduction in risk. A mildly significant gender difference in disability and quality-of-life reporting has been noted, with women citing greater disability and reduced quality of life. Gender differences have been shown in response to treatment of PD, for example, in how levodopa is metabolized--women have greater levodopa bioavailability. In the Parkinson's Disease on Estrogen Therapy Replacement in the Menopause Years (POETRY) study, participants were found to have improved scores on the Unified Parkinson Disease Rating Scale. Based on the POETRY results, it is hypothesized that estrogen replacement therapy (ERT) may lead to improvement in PD symptoms and provide an opportunity to reduce the dosage of antiparkinsonian medication in women.

Shulman LM, Bhat V. · Maryland Parkinson's Disease & Movement Disorders Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA. · Expert Rev Neurother. · Pubmed #16533144 No free full text.

Abstract: Parkinson's disease is a chronic neurodegenerative disorder of unknown etiology. There are sparse data on gender differences in this disorder, but it is clear that there are gender discrepancies in incidence, symptoms, medication effects and treatments. There also appear to be lifecycle fluctuations in the disease course of female Parkinson's disease patients. The effect of estrogen in this disorder is multifold and its role in the development and treatment of PD will be discussed.

Shulman LM. · The Rosalyn Newman Scholar of Clinical Research in Parkinson's Disease, University of Maryland School of Medicine, 22 South Greene Street N4W46, Baltimore, MD 21201, USA. · Parkinsonism Relat Disord. · Pubmed #15177058 No free full text.

Abstract: Increasing evidence suggests that estrogens may protect the nigrostriatal dopaminergic pathway affected in Parkinson's disease (PD). Animal studies show that estrogens influence the synthesis, release, and metabolism of dopamine and can modulate dopamine receptor expression and function. Some clinical studies suggest that PD symptoms may be exacerbated after menopause and delayed or alleviated with hormone replacement therapy, but others have failed to observe positive estrogenic effects. The conflicting findings suggest that several variables, including age, estrogen dose and formulation, and timing and length of dosing period, may determine whether benefits are seen and the nature of these benefits. Further investigation is therefore needed for the relationship between estrogens and the nigrostriatal dopaminergic system.

Shulman LM. · University of Miami School of Medicine, Miami, Florida 33136, USA. · Eur J Neurol. · Pubmed #11054153 No free full text.

Abstract: Dopamine receptor agonists are assuming increased importance in the treatment of both early and advanced symptoms of Parkinson's disease (PD). However, tolerability of these drugs can be a problem. Identifying patients who are at increased risk of adverse effects is central to using dopamine agonists in PD. The newer agonists, pramipexole and ropinirole, are generally adequate without levodopa for early symptoms and carry the hope for a more acceptable profile of long-term side-effects. In the patient with advanced disease, all four dopamine agonists significantly augment the response to levodopa, which reduces the problems of motor fluctuations and drug related dyskinesia. Understanding the common pitfalls when prescribing these drugs will facilitate their safety and efficacy.

Weiner WJ, Shulman LM, Oertel WH. · Department of Neurology, University of Miami School of Medicine, Florida, USA. · Adv Neurol. · Pubmed #10410759 No free full text.

This publication has no abstract.

Hauser RA, Shulman LM, Trugman JM, Roberts JW, Mori A, Ballerini R, Sussman NM, Anonymous00024. · Department of Neurology, University of South Florida, Tampa, Florida 33606, USA. · Mov Disord. · Pubmed #18831530 No free full text.

Abstract: The objective of this study was to evaluate the efficacy, safety, and tolerability of istradefylline 20 mg once daily versus placebo as an adjunct to levodopa in subjects with Parkinson's disease (PD) who have motor fluctuations. Istradefylline (KW-6002) is an adenosine A(2A) receptor antagonist that in primate models of PD improves motor function without causing or worsening dyskinesia. This 12-week, multicenter, double-blind, placebo-controlled, randomized, Phase 3 study of istradefylline was conducted in subjects experiencing an average daily OFF time of at least 3 hours (116 randomized to istradefylline; 115 to placebo). All were on stable levodopa regimens; 90% were also on stable regimens of other anti-Parkinson's medications. Istradefylline-treated subjects had significant placebo-corrected reductions in daily OFF time from baseline to endpoint: 4.6% (P = 0.03) and 0.7 hours (P = 0.03). For ON time with troublesome dyskinesia, the changes between istradefylline and placebo were not significant. Istradefylline was well tolerated, with 6 (5.2%) istradefylline-treated and 7 (6.1%) placebo-treated subjects withdrawing from the study because of adverse events. Dyskinesia, lightheadedness, tremor, constipation, and weight decrease were reported more often with istradefylline than placebo. We conclude that istradefylline is well tolerated and significantly reduces OFF time as an adjunct to levodopa in PD subjects with motor fluctuations.

Skidmore FM, Mackman CA, Pav B, Shulman LM, Garvan C, Macko RF, Heilman KM. · Department of Neurology, University of Florida College of Medicine, 100 S. Newell Drive, Gainesville, FL 32610, USA. · J Rehabil Res Dev. · Pubmed #19319758 No free full text.

Abstract: Patients with Parkinson disease (PD) may have decreased physical activity due to motor deficits. We recently validated the reliability of step activity monitors (SAMs) to accurately count steps in PD, and we wished to use them to evaluate the impact of disease severity on home activity levels in PD. Twenty-six subjects with PD (Hoehn and Yahr disease stage 2-4) were recruited to participate in a study of activity levels over 48 hours. Ability to achieve 95% device accuracy was an entry requirement. A Unified Parkinson Disease Rating Scale (UPDRS) evaluation was performed on all subjects, subjects were monitored for 48 hours, and total number of steps per day and maximum steps taken per hour were calculated. Out of 26 subjects, 25 met entry requirements. We calculated the number of steps taken per day, as well as maximal activity levels, and correlated these with UPDRS total score, the activity of daily living subscale, and the UPDRS motor function subscale off and on medication (all p < 0.01). Transition from Hoehn and Yahr stage 2 to stage 3 was associated with a decline in functional mobility (p < 0.005). A microprocessor-linked SAM accurately counted steps in subjects with PD. The number of steps taken correlated highly with disease severity. SAMs may be useful outcome measures in PD.

Tanji H, Anderson KE, Gruber-Baldini AL, Fishman PS, Reich SG, Weiner WJ, Shulman LM. · Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. · Mov Disord. · Pubmed #18759355 No free full text.

Abstract: To assess the association between mutuality of the marital relationship in Parkinson's disease with disease severity, disability, mental health, quality of life, and caregiver burden. Spouses of patients with PD completed questionnaires assessing mutuality of the marital relationship (Mutuality Scale) and caregiver strain (Caregiver Strain Index). Patients and spouses completed scales assessing their mental health (Brief Symptom Inventory-18), medical co-morbidity (Cumulative Illness Rating Scale) and health-related QoL (SF-12v2). PD severity and disability were assessed with the Unified Parkinson's Disease Rating Scale and the Older Americans Resource and Services Disability Scale. The relationships between mutuality and patient and spousal variables were analyzed with univariate correlations and multiple regression. Ninety-six spouse-patient pairs were assessed. Increased mutuality, as reported by the spouse was associated with reduced caregiver burden, less depression of both spouse and patient, and less PD severity. Mutuality was inversely correlated with gait impairment, with lesser correlations for balance, urinary incontinence and motor fluctuations. Greater mutuality between spouses and patients with PD is associated with better mental health of both partners, reduced caregiver burden and improved spousal quality of life. PD severity, especially gait, balance, urinary incontinence and motor fluctuations are particular stressors on the marital relationship.

Tanji H, Gruber-Baldini AL, Anderson KE, Pretzer-Aboff I, Reich SG, Fishman PS, Weiner WJ, Shulman LM. · Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA. · Mov Disord. · Pubmed #18709681 No free full text.

Abstract: The objective of this study is to compare physical performance measures for their ability to discriminate between levels of disability and disease severity in Parkinson's disease (PD). Disability in PD is commonly assessed by patient self-report, which may be limited by patient insight. METHODS: Seventy-nine patients with PD were tested with seven performance measures: Physical Performance Test (PPT), modified Physical Performance Test (mPPT), Short Physical Performance Battery (SPPB), Performance Test of Activities of Daily Living (PADL), Berg Balance Scale (BBS), Timed Up and Go (TUG), and Functional Reach (FR). These measures were compared with patient-reported disability on the Older Americans Resource and Services Disability subscale (OARS) and disease severity on the Unified Parkinson's Disease Rating Scale (UPDRS). The performance measures were more sensitive to levels of disease severity than disability. Four measures discriminated across quartiles of disability (PPT, mPPT, BBS, TUG: P < 0.05), whereas all seven measures discriminated across quartiles of the Total UPDRS (PPT, mPPT, BBS, TUG, FR: P < 0.01; SPPB, PADL: P < 0.05). However, no measure consistently discriminated between subgroups with a range of early and advanced disease severity. The seven physical performance measures showed different profiles of strengths and weaknesses in assessing disability and disease severity. The results of this study will facilitate choosing performance measures for clinical care and clinical trials in PD.

Skidmore FM, Patterson SL, Shulman LM, Sorkin JD, Macko RF. · Department of Neurology, Baltimore Department of Veterans Affairs Medical Center (VAMC), Baltimore, MD 21201, USA. · J Rehabil Res Dev. · Pubmed #18566930 No free full text.

Abstract: This pilot study evaluated the safety and feasibility of a 3-month progressive treadmill aerobic exercise (TM-AEX) program for persons with Parkinson disease with gait impairment. Eight subjects underwent a treadmill stress test to determine eligibility. Of these subjects, three were referred for further cardiac evaluation and five were enrolled. In 136 TM-AEX sessions, 11 falls or near falls and 9 episodes (8 asymptomatic) of systolic blood pressure drops >20 mmHg occurred. Harness supports prevented injury from falls. TM-AEX significantly improved the subjects' total Unified Parkinson's Disease Rating Scale scores and peak ambulatory workload capacities. This study suggests that an aerobic exercise program is feasible for persons who have Parkinson disease with gait impairment; however, precautions must be taken to prevent falls. Systolic blood pressure instability during exercise points to the need for autonomic dysfunction monitoring. Our data indicate that TM-AEX may reduce symptom severity and improve fitness. Further studies are needed for a better understanding of the risks and benefits of TM-AEX in this population.

McDade E, Weiner WJ, Shulman LM. · Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA. · Parkinsonism Relat Disord. · Pubmed #18457984 No free full text.

Abstract: We report a 45-year-old man with a 4-year history of Parkinson's disease complicated by the development of left-foot dystonia resulting in a fracture of the fifth metatarsal. Orthopedic injuries are common in Parkinson's disease, but they are usually secondary to falls. Although drug-induced dystonia is a common side effect of pharmacological treatment of Parkinson's disease, this is the first report of a fracture related to these abnormal movements.

Price MD, Shulman LM. · Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA. · Menopause Int. · Pubmed #18380960 No free full text.

Abstract: Elderly women with Parkinson's disease (PD) represent a specific patient population that may benefit from individualized treatment strategies. PD has been shown to occur approximately twice as often in men than in women, resulting in theories regarding estrogen being protective against the disease and as a potential treatment strategy. Given women's longer life expectancy, they are more likely to reach an age where antiparkinsonian medications are associated with side-effects. This paper will review medical and surgical treatments as well as the relationship of gender and age with respect to the management of PD.

Shulman LM, Gruber-Baldini AL, Anderson KE, Vaughan CG, Reich SG, Fishman PS, Weiner WJ. · Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA. · Mov Disord. · Pubmed #18361474 No free full text.

Abstract: The objectives of this study are to assess the level of disease severity associated with disability in Parkinson disease (PD) and the sequence of loss of independence in basic and instrumental activities of daily living (ADLs and IADLs). Six hundred eighteen patients with PD were evaluated for disease severity with the Unified PD Rating Scale (UPDRS) and for disability with the Older Americans Resource and Services Disability Subscale (OARS). The association between patient-reported disability on ADLs and IADLs and level of disease severity on the total UPDRS was examined cross-sectionally. Disability, with loss of independent function is reported between total UPDRS scores 30 to 40, and HY stages II to III. Difficulty with daily activities, without loss of independent function is reported earlier, at UPDRS <20 and HY I to II. Difficulty with walking is initially reported, followed by problems with a number of gait-dependent activities including housework, dressing, transferring in and out of bed, and traveling in the community. The transition from HY stage II to III marks a pivotal milestone in PD, when gait and balance impairment results in disability in many gait-dependent activities. The onset of disability in PD can be identified by asking patients about their walking, housework, dressing, and traveling. While individual patients vary in progression, the benchmarks of disability in this study provide guidance when counseling patients about prognosis. Better understanding of the stages of disability may facilitate the development of novel outcome measures in clinical trials in PD.

Anderson KE, Gruber-Baldini AL, Vaughan CG, Reich SG, Fishman PS, Weiner WJ, Shulman LM. · Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA. · Mov Disord. · Pubmed #17876850 No free full text.

Abstract: Patients with psychogenic movement disorders (PMD) often report severe impairment, yet the impact of PMD on disability and quality of life has not been examined. We compared 66 patients with PMD and 704 patients with Parkinson's disease (PD) on measures of disability (Older Americans Resources and Services Scale, OARS); quality of life (QOL; SF-12v2 Health Survey) and psychiatric symptomatology (Brief Symptom Inventory 18, BSI-18). On the total OARS, PMD and PD patients reported similar levels of disability (17.6 +/- 6.6, 19.8 +/- 10.9, P = 0.490 at "best" function and 24.1 +/- 11.2, 26.2 +/- 14.3, P = 0.497 at their "worst" function). PMD patients reported similar Physical Health QOL to PD patients (38.9 +/- 14.5, 39.8 +/- 11.6, P = 0.652) but worse mental health QOL (41.6 +/- 13.4 vs. 48.9 +/- 11.0, P < 0.001). On the BSI-18, PMD patients reported higher levels of distress on the Global Symptom Index (62.03 +/- 9.6 vs. 53.7 +/- 9.9, P < 0.001) and on Anxiety, Depression and Somatization subscales (PMD vs. PD scores: Anxiety 58.9 +/- 12.0 vs. 52.3 +/- 10.1, P < 0.001; Depression 58.8 +/- 11.9 vs. 51.3 +/- 10.3, P < 0.001; Somatization 60.5 +/- 11.0 vs. 54.7 +/- 8.7, P < 0.001). Thus, severity of disability reported by the PMD group was equal to that seen in a progressive neurodegenerative condition. Quality of life and mental health implications of PMD were also evident. PMD impacts several aspects of patient function and daily life.

Haines S, Chen H, Anderson KE, Fishman PS, Shulman LM, Weiner WJ, Reich SG. · Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA. · Neurology. · Pubmed #16894111 No free full text.

Abstract: The authors surveyed 101 patients with Parkinson disease (PD) about their experiences disclosing the diagnosis. Ninety percent disclosed early to family; more than 25% waited at least 1 year to disclose at work. The main concerns about disclosure were fear of reflecting negatively on themselves and fear of upsetting others. Patients who delayed disclosure were more likely male, younger, and employed. There is considerable variability among patients with PD in the time to disclose their diagnosis.

Shulman LM, Pretzer-Aboff I, Anderson KE, Stevenson R, Vaughan CG, Gruber-Baldini AL, Reich SG, Weiner WJ. · Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. · Mov Disord. · Pubmed #16482533 No free full text.

Abstract: We compared subjective self-reports with objective performance ratings of activities of daily living (ADLs) and instrumental ADLs (IADLs) in patients with Parkinson's disease (PD) and identified variables associated with discordance of ratings between these two methods. Seventy-six PD patients completed a modified Older Americans Resources and Services scale, assessing ADLs and IADLs. These results were compared with structured performance tests of walking, eating, dressing, money, and medicine management administered in the clinic. Patient performance was rated on a five-point Likert-type scale, ranging from 1 = no difficulty to 5 = completely unable to perform task. Significant differences were found between patients and clinicians' ratings on all tasks except walking. On the other four tasks, paired group t tests showed that patients reported better function compared with the clinician rating of medication management (1.33 vs. 2.80), eating (1.53 vs. 1.76), dressing (1.64 vs. 1.86), and managing money (1.44 vs. 2.06). A discrepancy was found between patients subjective reporting of ADL and IADL function and objective ratings. Patients overestimated their function on four of five tasks. Further study is necessary to identify whether subjective or objective performance ratings are more reflective of actual daily function.

Shulman LM, Wen X, Weiner WJ, Bateman D, Minagar A, Duncan R, Konefal J. · Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. · Mov Disord. · Pubmed #12210879 No free full text.

Abstract: Interest in alternative medical treatments, including acupuncture, is increasing. Alternative treatments must be subjected to the same objective standards as all medical treatments. A non-blinded pilot study of the safety, tolerability, and efficacy of acupuncture (ACUPX) for the symptoms of (PD) was performed. Twenty PD patients (mean age, 68 years; disease duration, 8.5 years; Hoehn and Yahr [H&Y] stage, 2.2; Unified Parkinson's Disease Rating Scale score [UPDRS], 38.7) each received acupuncture treatments by a licensed acupuncturist. All patients were treated with two acupuncture treatment sessions per week. The first seven patients received 10 treatments and the last 13 patients 16 treatments. Patients were evaluated before and after ACUPX with the Sickness Impact Profile (SIP); UPDRS; H & Y; Schwab and England (S & E); Beck Anxiety Inventory (BAI); Beck Depression Inventory (BDI); quantitative motor tests, including timed evaluations of arm pronation supination movements, finger dexterity, finger movements between two fixed measured points, and the stand-walk-sit test; and a patient questionnaire designed for the study. Following ACUPX, there were no significant changes in the UPDRS, H&Y, S&E, BAI, BDI, quantitative motor tests, total SIP or the two SIP Dimension scores. Analysis of the 12 SIP categories not corrected for multiple comparisons revealed a post-ACUPX improvement in the sleep and rest category only (P = 0.03). On the patient questionnaire, 85% of patients reported subjective improvement of individual symptoms including tremor, walking, handwriting, slowness, pain, sleep, depression, and anxiety. There were no adverse effects. ACUPX therapy is safe and well tolerated in PD patients. A range of PD and behavioral scales failed to show improvement following ACUPX other than sleep benefit, although patients reported other discrete symptomatic improvements. A broad battery of tests in PD patients suggested that ACUPX resulted in improvement of sleep and rest only. This finding needs to be verified using more in-depth and controlled evaluation of ACUPX for PD-related sleep disturbance.

Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. · Department of Neurology, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD 21201, USA. · Parkinsonism Relat Disord. · Pubmed #12039431 No free full text.

Abstract: BACKGROUND: Depression, anxiety, fatigue and sleep disorders occur commonly in patients with Parkinson's disease (PD). These non-motor symptoms often contribute to the reduction of functional abilities in PD patients. OBJECTIVE: This study was designed to evaluate the diagnostic accuracy of the treating neurologist for a variety of behavioral symptoms commonly associated with PD. METHODS: A prospective evaluation of 101 patients with PD selected in no particular order was conducted. All patients were evaluated with the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn & Yahr Stage (H/Y), and the Schwab & England Scale (S/E). The patients completed a brief screening questionnaire for depression and anxiety followed by the administration of a battery of standardized tests including the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Fatigue Severity Scale (FSS), and the Pittsburgh Sleep Quality Inventory (PSQI). RESULTS: Standardized testing showed evidence of a problem with depression in 44% of patients, anxiety in 39%, fatigue in 42% and sleep disturbance in 43%. The prevalence of these conditions, identified by the treating neurologist was lower: 21% with depression, 19% with anxiety, 14% with fatigue and 39% with sleep disturbance. The diagnostic accuracy for the treating neurologists was 35% for depression, 42% for anxiety, 25% for fatigue, and 60% for sleep disturbance. CONCLUSION: This study demonstrates that during routine office visits, neurologists failed to identify the presence of depression, anxiety, and fatigue more than half of the time and failed to recognize sleep disturbance in 40% of patients. Awareness of the likelihood of underrecognition of behavioral symptoms in PD should generate approaches to improve diagnostic accuracy and facilitate timely therapeutic interventions.

Shulman LM, Taback RL, Bean J, Weiner WJ. · Department of Neurology, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD 21201, USA. · Mov Disord. · Pubmed #11391746 No free full text.

Abstract: Many patients with Parkinson's disease (PD) have clinically significant anxiety, depression, fatigue, sleep disturbance, or sensory symptoms. The comorbidity of these nonmotor symptoms and their relationship to PD severity has not been extensively evaluated. Ninety- nine nondemented PD patients were evaluated with the following battery of tests: Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), a sensory symptom questionnaire, Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn & Yahr (H/Y) Stage, and the Schwab & England ADL scale (S/E). The comorbidity of the nonmotor symptoms and their relationship to PD severity was analyzed. Thirty-six percent of the study population had depression (BDI > or =10), 33% had anxiety (BAI > or =10), 40% had fatigue (FSS > 4), 47% had sleep disturbance (PSQI > 5), and 63% reported sensory symptoms. Only 12% of the sample had no nonmotor symptoms. Fifty-nine percent of the patients had two or more nonmotor symptoms, and nearly 25% had four or more. Increased comorbidity was associated with greater PD severity (P < 001). This study reveals that the nonmotor symptoms of PD frequently occur together in the same patients. Increased comorbidity of the five nonmotor symptoms was associated with greater PD severity. These results suggest that recognition of these diverse nonmotor symptoms may be enhanced by looking for others when one nonmotor symptom has been identified.

Landy HJ, Weiner WJ, Calancie B, Harris W, Shulman LM, Singer C, Abrams L, Bowen B. · Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL 33136, USA. · Stereotact Funct Neurosurg. · Pubmed #11124661 No free full text.

Abstract: In stereotactic pallidotomy for Parkinson's disease, care must be taken to avoid internal capsule injury while maximizing improvement of rigidity and tremor. In 21 patients, intraoperative electromyography (EMG) was used to assess stimulation thresholds required for capsular responses and to monitor muscle tone and tremor. Surface EMG electrodes were placed on the face and multiple muscle groups of the extremities. The stimulation and lesion electrode was introduced via MRI-guided stereotaxis toward a point 2-3 mm anterior to the midcommissural point, 5-6 mm inferior to the AC-PC plane, and 21-22 mm lateral to the midline. Exact targets were modified according to MRI-visualized anatomy. With stimulation at 5 and 50 Hz, thresholds for detection of EMG responses were usually seen at 4-5 mA. EMG responses were consistently seen prior to visual observation of muscle activity. Timing of EMG response relative to stimulus aided in differentiating stimulus-related movement from spontaneous tremor. Resting spontaneous EMG activity was seen to decrease as rigidity was improved by incremental lesion production. EMG activity related to tremor was recorded; tremor decrease by lesion production was documented by EMG recording. Patient cooperation with physiologic testing during stimulation and lesion production may become limited. Intraoperative EMG monitoring provides an adjunct to improve reliability of assessment of capsular stimulation and rigidity while providing documentation of lesion impact on rigidity and tremor.

Shulman LM, Minagar A, Rabinstein A, Weiner WJ. · Department of Neurology, University of Miami School of Medicine, Florida 33136, USA. · Mov Disord. · Pubmed #10928576 No free full text.

Abstract: BACKGROUND: Controversy exists regarding the use of dopamine receptor agonists in elderly patients with Parkinson's disease because of concern about a high rate of intolerable side effects. METHODS: A retrospective chart review was used to examine our experience with dopamine agonist use in the very elderly by identifying patients in our Parkinson's disease database who were over the age of 80 years and who had received agonists. Sixty-nine patients were identified who had 120 separate trials of agonist therapy. Successful treatment with the agonist was defined as maintenance of the agonist for a minimum of 6 months. RESULTS: The overall success rate among the very elderly for an agonist trial was 46%. Success rates for individual agonists were 15 of 27 (56%) bromocriptine, 18 of 34 (53%) pergolide, 17 of 43 (40%) pramipexole, and 5 of 16 (31%) ropinirole. In successful trials with bromocriptine, the mean daily dose was 12.8 mg, mean duration of treatment was 40 months, and mean age at drug initiation was 82 years; for pergolide it was 1.8 mg, 32 months, and 83 years; for pramipexole 2.7 mg, 14 months, and 83 years, and for ropinirole 10.6 mg, 11 months, and 83 years. CONCLUSION: This study demonstrated that therapeutic dosages of dopamine agonists were well tolerated by 46% of very elderly patients who received a trial of an agonist. These results indicate that dopamine receptor agonist therapeutic trials are warranted in selected very elderly patients.

Weiner WJ, Minagar A, Shulman LM. · Department of Neurology, University of Miami School of Medicine, FL 33136, USA. · Neurology. · Pubmed #10751276 No free full text.

This publication has no abstract.

Shulman LM. · Department of Neurology, University of Miami School of Medicine, Fla 33136, USA. · Arch Neurol. · Pubmed #10714670 links to  free full text

This publication has no abstract.