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Prepared by: James Morley, MD, PhD, Shital Shah, DO, Alexander Pantelyat, MD & Eileen Hummel, RN, BSN Philadelphia VA PADRECC
Predictors of Cogntive Impairment in an Early Stage Parkinson’s Disease Cohort
Cognitive impairment is common in all stages of PD and accurate measurement scales are important. Prior studies have indicated that the Montreal Cognitive Assessment (MoCA) is more sensitive than the Mini-Mental State Examination (MMSE) in identifying early PD cognitive impairment. In this study, the researchers studied cognitive impairment in a sample of more than 400 early PD patients (duration< 3.5 years) compared to controls (N=141), and evaluated the ability of the MoCA and MMSE to identify change over time. PD patients had significantly lower scores on the MoCA and MMSE compared to the controls (adjusting for age, sex, and years of education). The fraction of patients classified with normal cognition, mild cognitive impairment (MCI) and dementia varied significantly, depending on the scoring criteria used. Using the “screening” threshold for the MoCA (normal 26-30, MCI 21-25, dementia < 20), 47.7% of the PD patients were classified as having normal cognition, 40.5% with MCI, and 11.7% with dementia, compared to 63.8% in the control group with normal cognition, 19.9% with MCI and 16.3% with dementia. With the MMSE at screening threshold, 37.4%, 32.1%, and 30.5% of patients were classified as having normal cognition, MCI, and dementia respectively. Eighteen months later, the assessments were repeated in 155 of the patients with PD; MoCA scores decreased significantly while the MMSE scores did not. Cognitive impairment was associated with lower education, increased age, male sex, and quantitative motor and nonmotor (smell, depression, and anxiety) measures. The authors conclude that the MoCA may be more sensitive in identifying early, as well as longitudinal, cognitive impairment in patients with PD.
Mov Disord. 2014 Jan 6. Doi: 10.1002/mds/mds.25748. [Epub ahead of print]
PMID: 24395708 [PubMed – as supplied by publisher]
Randomized Trial of Safinamide Add-On to Levodopa in Parkinson’s disease with Motor Fluctuations
Levodopa is an effective treatment for motor symptoms in Parkinson’s disease (PD), but chronic use is associated with complications including motor fluctuations and dyskinesias. A recent phase III randomized, double-blind, placebo-controlled trial studied the effects of safinamide (a novel drug that is of particular interest because it effects multiple pathways besides dopamine regulation) as add-on therapy on motor fluctuations and dyskinesias in PD. Subjects were randomized to safinamide 100 mg/day (N=224), safinamide 50 mg/day (N=223) or placebo (N=222) for 24 weeks. In the primary analysis, subjects on either dose of safinamide reported approximately ½ hour per day more “on” time without troublesome dyskinesias. In addition, there was a similar reduction in off time. The UPDRS-III motor exam was improved in subjects on 50 mg and 100 mg safinamide and the UPDRS-II (measuring patient-reported symptom severity) was improved only in patients taking 100 mg safinamide. This study suggests that safinamide may be beneficial as add-on therapy to dopaminergic treatment in patients with motor fluctuations and disabling dyskinesias.
Borgohain R, Szasz J, Stanzione P, et al. Randomized Trial of Safinamide Add-On to Levodopa in Parkinson’s Disease with Motor Fluctuations. Movement Disorders 2014:29; 229-237
Pimavanserin for patients with Parkinson's disease psychosis: a randomised, placebo-controlled phase 3 trial.
Parkinson's disease (PD) psychosis, which includes hallucinations and delusions, is common and often disabling but treatment options are limited. This study aimed to assess safety and treatment effects of pimavanserin, an investigational drug, on symptoms including illusions, visual hallucinations and paranoid delusions. Patients with PD psychosis were randomly assigned to receive either the study drug (N=95) or a placebo (N=90). Their symptoms were evaluated at the beginning of the study, and 2, 4 and 6 weeks later using several methods, including the PD-adapted scale for assessment of positive symptoms (SAPS-PD). Antipsychotic treatments were not permitted during the study, but controlled PD medications, or deep brain stimulation was allowed. Patients taking pimavanserin had a significant decrease in their symptoms compared with patients taking placebo as indicated by SAPS-PD scores, doctors’ clinical global impression of change scores and decreased caregiver burden. Importantly, pimavanserin was well tolerated overall, and did not worsen motor function. 10 patients in the pimavanserin group stopped the drug because of a side effect compared with 2 in the placebo group. The QT interval was prolonged in some patients, making baseline electrocardiogram assessments necessary when using pimavanserin. The authors concluded that pimavanserin may benefit patients with PD psychosis who otherwise have few treatment options. Further study is needed because patients in this study were only followed for a relatively short time and the primary outcome scale (SAPS-PD) differs from prior studies of PD psychosis. Additionally, the pharmaceutical company that makes pimavanserin sponsored the study and employees helped analyze the results and write the article. It is possible that this degree of involvement in the study may have affected its reported outcome.
Lancet. 2014 Feb 8;383(9916):533-40.
· Rotation of Committee Chair: Leadership for the clinical care committee rotates amongst the PADRECCs. The San Francisco PADRECC leads the committee for March/April. Committee meets via conference call the first Tuesday of the month at 12pm (EST)
· Standardize and Optimize Clinical Care: Continues to discuss a variety of clinical issues to enhance patient care, the committee continues to provide clinical support to the Consortium network, and work on measures to standardize clinical care across the PADRECC network. Recent agenda items have included ongoing discussion on:
Review of applications in clinical arena for subset of patients, and ways to expand access to CBOCs and remote areas where subspecialty expertise is not available. Research ideas pertaining to the use of home monitoring devices in movement disorders patients.
Development of PMB guideline for clinical use of various toxins
Applications and pitfalls of use
Philadelphia PADRECC Service Area Updates
Director: John Duda, MD
Upcoming Patient Education Events
This program is for newly diagnosed patients and/or new patients to the PADRECC clinic. The latest information on Parkinson’s disease and treatment will be provided. This program will be held on April 23rd, at the Philadelphia VA and at the VA Fort Dix and Gloucester Clinics via video connection.
This is a collaborative patient education program for people diagnosed with Parkinson’s Disease or Multiple Sclerosis. Presentations and demonstrations on nutrition, yoga, general exercise and dance will be done to highlight the importance of taking care of the mind and body. Program will be held on May 13th at the Philadelphia VA.
The group will meet the 1st Monday of each month at l:30 pm starting April 7st. The group will be held in the 4th Floor PADRECC Conference Room and at the VA Fort Dix and Horsham CBCOs via video connection.
Director: Ruth Walker, MD
1. Zhu X, Cho E-S, Sha Q, Peng J, Oksov Y, Kam SY, Ho M, Walker RH, Lee S (2014) Giant axon formation mice lacking Kell, XK, or Kell and XK; animal models of McLeod neuroacanthocytosis American Journal of Pathology 184(3):800-807 PMID:24405768
2. Walker RH (2013) Thoughts on selected movement disorder terminology and a plea for clarity Tremor and other Hyperkinetic Movements 3:1-3 PMID:24396709
3. Paucar M, Xiang F, Moore, R, Walker RH, Winnberg E, Svenningsson P (2013) Genotype-phenotype analysis in inherited prion disease with eight octapeptide repeat insertional mutation Prion 7.6:1-10
4. Walker RH, Fink JK (2013) Morphea and Parry-Romberg syndrome associated with a mixed movement disorder Parkinsonism and Related Disorders 19:1169-1170 PMID:23968650
5. Miquel M, Spampinato U, Latxague C, Aviles-Olmos I, Bader B, Bertram K, Bhatia K, Burbaud P, Burghaus L, Cho JW, Cuny E, Danek A, Foltynie T, Garcia Ruiz PJ, Gimenez-Roldan S, Guehl D, Hariz M, Jarman P, Kefalopoulou Z, Limousin P, Lipsman N, Lozano A, Moro E, Ngy D, Rodriguez-Oroz MC, Shang HF, Walker RH, Yokochi F, Zrinzo L, Tison F (2013) Bilateral pallidal stimulation in chorea-acanthocytosis: a multi-center retrospective study PLoS ONE 8(11);e79241 PMID:24223913
West Haven VA
Director: Diana Richardson
Parkinson’s Awareness Month Events and More
Dates to Remember
April 24-25, 2014
National VA PD Consortium
2013 East Coast Regional Meeting
April 26-May 3, 2014
American Academy of Neurology-Annual Meeting
May 8, 2014
EES/PADRECC Movement Disorder Series
Topic: Drug Induced Parkinsonism
June 8-12, 2014
18th International Congress of Parkinson’s Disease and Movement Disorders
Movement Disorder Society
September 11, 2014
EES/PADRECC Movement Disorder Series
Topic: Sleep Disorders in PD
November 13, 2014
EES/PADRECC Movement Disorder Series
Topic: Exercise and PD
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