The Monthly Transmitter (March 2012)
Prepared by Dr. Jayne Wilkinson, Dr. Daniel Weintraub & Dr. Amy Hellman Philadelphia VA PADRECC
Review of Cognitive Decline in PD
Atrophy in the hippocampus, the region of the brain known for memory formation and storage, is evident in Parkinsons disease (PD) patients with cognitive impairment, including early decline known as mild cognitive impairment (MCI), according to two studies by researchers at the Perelman School of Medicine at the University of Pennsylvania and the Philadelphia PADRECC. The studies were published in recent issues of the Archives of Neurology and Brain. In one study, researchers found that PD with MCI had more atrophy in the hippocampus, basal ganglia, amygdala, and insula compared with Parkinsons patients with normal cognition, whereas Parkinsons patients with normal cognition showed no significant loss of brain volume compared with healthy controls. Then researchers generated the first structural pattern of classifying brain atrophy associated with dementia in PD by analyzing the scans of PD with either dementia or normal cognition. In the second manuscript, a method of classifying brain atrophy patterns in Alzheimers disease (AD) patients using MRIs can also detect cognitive decline in PD, and a higher baseline AD pattern of atrophy predicted long-term cognitive decline in cognitively normal PD patients. On the basis of a simple neuroimaging study, we may be able to predict which patients with Parkinsons disease will experience long-term cognitive decline or develop dementia in the future, said the studies lead author, Daniel Weintraub, MD, associate professor of Geriatric Psychiatry with Penns Perelman School of Medicine and the Philadelphia Veterans Affairs Medical Center. Diagnostic tests like this can help us determine which patients would benefit from future clinical trials of medications aiming to stave off or prevent dementia progression in Parkinsons disease. This research raises the possibility that both AD and PD pathology contribute to cognitive decline in PD, although researchers are still uncertain whether the neurodegeneration seen in these patients is caused by primary PD pathology, AD pathology, or a combination of the two.
Brain. 2012, 135; 170180; "Alzheimers disease pattern of brain atrophy predicts cognitive decline in Parkinsons disease" http://brain.oxfordjournals.org/content/early/2011/11/18/brain.awr277.full.pdf
Archives of Neurology. (2011), 68 (12): 1562-1568; " Neurodegeneration Across Stages of Cognitive Decline in Parkinson Disease" http://archneur.ama-assn.org/cgi/content/full/68/12/1562
Deep brain stimulation of the subthalamic nucleus improves sense of well-being in parkinson's disease
As noted in the abstract: Deep brain stimulation of the subthalamic nucleus is an effective treatment for the motor symptoms of Parkinson's disease. A range of psychiatric and behavioral problems have been documented following deep brain stimulation, however, the short-term effects of subthalamic nucleus stimulation on patients' mood have only been investigated in a few studies. The aim of this study was to compare self-reported mood in Parkinson's patients with deep brain stimulation of the subthalamic nucleus ON versus OFF. Twenty-three Parkinson's patients with bilateral deep brain stimulation of the subthalamic nucleus and 11 unoperated Parkinson's patients completed a mood visual analogue scale twice. Operated patients were tested with deep brain stimulation of the subthalamic nucleus both ON and OFF. All were assessed on medication. The operated Parkinson's group reported feeling significantly better coordinated, stronger, and more contented with deep brain stimulation ON compared to OFF. Fourteen of the 16 mood scales changed in a positive direction when deep brain stimulation of the subthalamic nucleus was ON. When changes in motor scores were taken into account, the operated patients still reported feeling better-coordinated, but also less gregarious with stimulation ON. Unoperated Parkinson's patients showed no differences on any of these measures between their 2 ratings. Short-term changes in deep brain stimulation of the subthalamic nucleus have a small and mostly positive effect on mood, which may be partly, or even completely related to improvements in motor symptoms. The implications for day-to-day management of patients with deep brain stimulation of the subthalamic nucleus are discussed in this article. It would be interesting to see if these findings correlate to longer term mood changes. Additionally, to compare these results to patients who underwent DBS with globus pallidus interna, as the target nucleus.
Impaired Olfaction and Other Prodromal Features in the Parkinson At-Risk Syndrome Study
Olfactory dysfunction in Parkinsons Disease (PD) precedes the onset of motor features, suggesting that olfactory testing could be used as a screening test. Combining testing for olfaction with testing for other prodromal nonmotor features may be more efficient than using hyposmia alone for detecting the risk of developing PD. Individuals with no neurological diagnosis completed a mail survey, including the 40-item University of Pennsylvania Smell Identification Test and questions on prodromal features of PD. The frequency of nonmotor features reported on this survey was compared across individuals with and without hyposmia. Of the 4,999 subjects who completed and returned the survey and smell test, 669 were found to be hyposmic. Hyposmic subjects were more likely to endorse nonmotor features of PD, including anxiety and depression, constipation, and symptoms of REM sleep behavior disorder, as well as changes in motor function. Of the subjects who reported 4 or more nonmotor features, 26% were found to be hyposmic compared to 12% of those who reported 3 or fewer nonmotor features. The authors concluded that hyposmia is associated with other nonmotor fatures of PD in undiagnosed individuals, and further assessment of hyposmic subjects using more specific markers for degeneration will evaluate whether combining hyposmia and other nonmotor features is useful in assessing the risk of future neurodegeneration.
Mov Disord. 2012 Mar;27(3):406-412. doi: 10.1002/mds.24892. Epub 2012 Jan 11.
Clinical Care Committee
· Rotation of Committee Chair: Leadership for the clinical care committee rotates amongst the PADRECCs. San Francisco leads the committee for March/April. Committee meets the first Tuesday of the month at 12pm ET.
· Patient Education Materials: In response to the Needs Assessment performed after the 2010 National PD Consortium Conference, the Clinical Care Committee is developing simplified- 1-2 page patient education materials that are clinically based but geared towards patients and families that can be given out during clinic visits. Topics include: exercise, medications, motor symptoms, non motor symptoms, agent orange and fall prevention. Once developed the materials will be available on the National PADRECC & VA Consortium website for reproduction.
· Standardize Clinical Care: Continues to discuss a variety of clinical issues, provide clinical support to the Consortium network, and work on measures to standardize clinical care across the PADRECC network. Recent agenda issues discussed:
o Use and benefits of Rasagaline
o Tetrabenazine use in HD, Tourettes, management of tics
o DAT scan usage
o Increased use of GPi site for DBS
o Use of CVT (clinical video teleheath)/telemed for movement disorders
· PD Handbook: A handbook for the VHA that addresses such things as definition of PD, purpose, authority and scope, system of care, population served, etc. is in the final stage of completion. An appendix is being added that includes publications by PADRECC staff.
· PADRECC Transmitter: PADRECC clinicians provide reviews of recent movement disorder publications that are included in the PADRECC Transmitter
· PADRECC/EES Movement Disorder Series: The FY 2012 series is underway. The 3rd audio conference for this series was held on March 8th titled: "Mood Disorders in Parkinson's Disease: What's New." The audio conferences will be archived on the website www.parkinsons.va.gov under the Movement Disorder Series tab. All evaluations for CMEs will now be done electronically through EES. Please take a look at the Dates To Remember section for a listing of upcoming audio conferences.
· Patient Education Video Project: 8 videos were taped for FY 2011. The videos are in the final stage of editing and once completed they will be available on DVD, the PADRECC & Consortium website and You Tube. Request was accepted by EES for taping of 8 more videos in FY2012 which are currently underway.
· PADRECC Transmitter: The committee continues to assemble and distribute this e-newsletter every other month.
· National Newsletter: The committee is in the process of assembling the Annual National Newsletter which will be distributed in 2012.
· PADRECC Facebook Page: The committee is exploring the possibility of developing a National PADRECC & PD Consortium Facebook page.
Philadelphia PADRECC Service Area Updates
Cincinnati VAMC (Phone: 513-558-1107)
Director: Fredy Revilla, MD
The Movement Disorders Clinic at the Cincinnati VAMC, part of the VA consortium, currently cares for about 750 patients. It has witnessed an increase of 20 to 25% each year in last four to five years in total number of patients and a similar increase in the number of outpatient visits. Extra efforts are made to accommodate the urgent and non-urgent consult requests from other clinical services. Our Clinic attracts patients from nearby VA Centers for evaluation and guidance. Specialized services, such as chemodenervation, DBS surgeries, and stimulation programming follow-ups are routinely offered. The quantity and quality of exposure to a variety of movement disorders in the clinic make it very attractive for students, residents, and geriatric fellows, who rotate in the Movement Clinics to gain clinical experience in such disorders.
The attending staff neurologists, Dr. Fredy J. Revilla and Dr. Alok Sahay, routinely give presentations and educational lectures to residents and medical students. They participate in collaborative Grand Rounds on topics of clinical interest. The faculty members also actively participate in monthly educational teleconferences in collaboration with the VA PADRECC Philadelphia, which are always well attended by Movement Disorders clinicians from the VA and also from the University of Cincinnati (Drs. Alberto Espay and Andrew Duker). The Cincinnati VAMC is very proud to have a VA approved and funded Fellowship Program in Movement Disorders.
Dates to Remember
April 21-28, 2012
American Academy of Neurology Annual Conference
New Orleans, LA
May 10, 2012
EES/PADRECC Movement Disorder Series
Pharmacy and Therapeutics
June 17-21, 2012
16th International Congress of Parkinson's Disease and Movement Disorders
July 12, 2012
EES/PADRECC Movement Disorder Series
Rehab Issues in PD
September 13, 2012
EES/PADRECC Movement Disorder Series
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