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Endurance Exercise May Help Manage Cortisol Levels in Parkinson’s Patients, Study Suggests

cortisol exercise PD

Doing high-intensity endurance exercise reduces morning cortisol levels in patients with Parkinson’s disease, which may have an impact on the progression of non-motor signs and symptoms, a pilot study suggests.

While other studies are needed to confirm if lowering cortisol with physical exercise works for delaying disease worsening, this data supports the further exploration of the role played by the hormone in non-motor symptoms of Parkinson’s.

The study, “Endurance Exercise Reduces Cortisol in Parkinson’s Disease With Mild Cognitive Impairment,” was published in the journal Movement Disorders.

Parkinson’s disease is a complex disorder associated with both motor and non-motor symptoms including sleep problems, depression, and cognitive impairment.

There is evidence that a malfunction of the hypothalamic-pituitary-adrenal axis (HPA) is involved in the progression of non-motor symptoms of Parkinson’s due to an overproduction of the hormone cortisol.

HPA is a system in the body crucial for stress management. It involves a set of complex interactions between two parts of the brain — the hypothalamus and the pituitary glands — and the adrenal glands located at the top of each kidney, which are regulated by different hormones.

After a stressful or threatening event, the HPA axis is activated and several “stress hormones,” primarily cortisol and adrenaline, are released by the adrenal glands into the bloodstream. As the blood levels of cortisol rise, they start to block the release of other hormones from the hypothalamus and the pituitary that, in turn, will induce a drop in cortisol levels.

This type of negative feedback loop is one mechanism by which HPA regulates itself to avoid excessive and sustained production of cortisol.

Beside this natural stress management process, cortisol is also important for a wide range of vital processes, including metabolism and the immune response. There has been a long-standing association between raised or impaired regulation of cortisol levels and a number of psychiatric conditions such as anxiety and depression, even though this is not yet fully understood.

Elevated morning cortisol levels have been reported in Parkinson’s patients. Accordingly, there is evidence that elevated cortisol in Parkinson’s patients is linked to symptoms such as depression and risk behavior.

Physical exercise is associated with a lower production of cortisol in healthy individuals, and there is evidence that it may also reduce the risk and rate of Parkinson’s progression.

Based on this data, the researchers reasoned that doing exercise could lower daytime production of cortisol in Parkinson’s patients, with possible implications for delaying the progression of their non-motor symptoms.

To test this theory, they conducted a small study in which they measured the levels of cortisol in saliva samples collected from eight Parkinson’s patients with mild cognitive impairment (ages 53 to 79). Over six months, participants were asked to perform high-intensity treadmill endurance exercise.

The exercise program included five to 10 minutes of warm-up, 30 minutes of exercise at 80-85% maximum heart rate, followed by five to 10 minutes of cool-down. Participants exercised an average of 2.5 days per week, and over the first eight weeks of training, exercise duration and intensity were gradually increased to target levels.

Saliva samples were collected before and after completing the program, and at specific times immediately after waking up (0, 0.25, 0.50, and 0.75 hours after awakening) and at periods throughout the day (three, six, nine, and 12 hours after awakening).

Overall, cortisol secretion of Parkinson’s patients more closely resembled that of healthy people after they had completed the training program.

Results showed there was an average 19% reduction in cortisol secretion, compared with the pre-training period. In addition, while cortisol reduction was significant during the times immediately after waking up, it was not in the periods later in the day.

“These data support the need for further exploration of HPA axis dysregulation in Parkinson’s disease,” the researchers wrote. “To understand not only its potential role in the mechanisms underlying non-motor symptoms of Parkinson’s, but also its responsiveness to intervention studies such as physical exercise that can improve non-motor symptoms.”

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Specific BDNF Mutation May Be Linked to Higher Risk of Cognitive Impairment in Parkinson’s, Study Suggests

BDNF gene mutation

One amino acid change in the brain-derived neurotrophic factor (BDNF) gene, which provides instructions for a protein important to neuronal survival, may be associated with cognitive impairment in Parkinson’s disease patients, a study has found.

The study, “BDNF Val66Met polymorphism and cognitive impairment in Parkinson’s disease—a meta-analysis,” was published in the journal Neurological Sciences.

BDNF protein is produced inside brain cells and is crucial for their function as well as supporting their growth and protecting them against premature cell death. When its coding sequence is changed, this can have a major impact on brain cell outcomes.

Previous studies have suggested that one specific BDNF gene mutation called Val66Met that results in the change of a valine (Val) by a methionine (Met) at position 66 — both amino acids, also known as the protein’s building blocks — could be linked to cognitive impairment in Parkinson’s disease. However, there is no consensus on the relevance of this genetic mutation on outcomes of Parkinson’s patients.

Chinese researchers searched for available literature on this matter, and analyzed pooled data from six studies involving a total of 1,467 patients with Parkinson’s disease. These studies had been carried out in Italy, Spain, Poland, Brazil, Belgrade (Serbia), and the Netherlands.

Results revealed a significant association between the Val66Met BDNF mutation and risk of Parkinson’s disease-related cognitive impairment. Patients who had two copies of the BDNF gene with methionine (mutated version) were found to have a 3.82 times higher risk of developing cognitive impairment than those who had two BDNF copies with valine (non-mutated version).

However, it’s worth mentioning that the studies in this analysis only included Caucasian study samples, so these results should not be generalized to other ethnicities.

Parkinson’s disease affects people of all races and ethnicity worldwide. Some studies indicate that neurodegenerative disorders affect more white people than any other ethnicity, but a solid conclusion cannot be drawn from available research as they tend to vary widely regarding diagnostic criteria, sample sizes, and methodology.

“Future studies should verify our findings in larger populations, particularly in other ethnicities,” the researchers wrote.

Still, the team believes that this study provides evidence that mutated BDNF “may be associated with increased risk of cognitive impairment of Parkinson’s disease, at least among Caucasians.”

In addition, this Val66Met change in the BDNF sequence should be studied in different Parkinson’s patients presenting tremor dominant or postural instability gait disorders. Further understanding of the impact of genetics on the long-term outcomes of these patients “may better guide clinical treatments and judge the prognosis,” they said.

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Aptinyx to Launch Phase 2 Study of NYX-458 to Treat Cognitive Impairment

NYX-458

Positive preclinical and Phase 1 clinical data support further assessmentof Aptinyx‘s investigational compound NYX-458 for the treatment of cognitive impairment associated with Parkinson’s disease in new Phase 2 studies.

Aptinyx expects to launch a new Phase 2 clinical study in Parkinson’s patients this year, the company announced in a press release.

“So far, 2019 has been marked by the achievement of key milestones and important clinical study results that form the basis for several of our upcoming Phase 2 studies,” said Norbert Riedel, PhD, president and CEO of Aptinyx.

“[W]e reported highly encouraging data from a non-human primate study of NYX-458 … showing its ability to reverse cognitive deficits. We also observed a favorable safety, tolerability, and pharmacokinetic profile with NYX-458 in our healthy volunteer Phase 1 study,” he said.

NYX-458 is a small molecule compound that controls the activity of N-methyl-D-aspartate (NMDA) receptors in the brain. These receptors are involved in the communication between nerve cells, which occur at a structure located at the junction between two nerve cells, called a synapse.

It is thought that loss of dopamine-producing neurons — a hallmark feature of Parkinson’s disease — also impairs the function of NMDA receptors in the brain, leading to cognitive impairment. By controlling their activity, NYX-458 has the potential to restore the function of NMDA receptors and reverse cognitive impairment associated with Parkinson’s.

Preclinical studies have shown that treatment with NYX-458 could lead to fast, strong, and long-lasting improvements in the cognition of animals that had been treated with low doses of a neurotoxin that destroys dopaminergic neurons and induces Parkinson’s symptoms.

Also, treatment with NYX-458 did not interfere with levodopa, a standard therapy for the treatment of motor symptoms associated with Parkinson’s, and did not contribute to worsening of motor symptoms.

These preclinical findings were recently discussed at the 14th International Conference on Alzheimer’s & Parkinson’s Diseases in Lisbon, Portugal.

To explore further explore the potential of the investigational therapy, Aptinyx launched a Phase 1 clinical trial in healthy volunteers. This study was designed to assess the safety, tolerability, and overall stability and metabolism (pharmacokinetics) of NYX-458 in the body.

The randomized, double-blind, placebo-controlled, Phase 1 trial involved 62 healthy volunteers who were treated with NYX-458 administered orally at doses ranging from 10 to 200 mg.

Results showed that NYX-458 was in general safe and well-tolerated by study participants. No serious adverse events associated with the treatment were reported.

Additional analysis also showed that the compound could successfully cross the blood-brain barrier (a semipermeable membrane that isolates the brain from the blood that circulates in the body), behaving as expected in a dose-proportional manner.

Supported by these positive preclinical data and favorable Phase 1 safety and tolerability profiles, the company plans to launch a Phase 2 trial to assess NYX-458 in patients with Parkinson’s disease in the second half of 2019.

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Early Involvement of Caudate Brain Region Linked to Worse Prognosis in Parkinson’s Patients, Study Finds

caudate involvement

Almost half of people in the early stages of Parkinson’s disease already have signs of neurodegeneration in a brain region called the caudate, which was previously thought to affect mostly those at advanced disease stages, a study reports.

Early caudate involvement on both sides of the brain, as seen by DaTscan imaging of the brain, appeared to predict the risk for worse outcomes, including cognitive impairment, depression, and gait problems, over a four-year follow-up period.

These findings suggest that caudate involvement detected through DaTscan neuroimaging may serve as an early biomarker to identify patients at a greater risk of faster disease progression in the near future.

The study, “Clinical implications of early caudate dysfunction in Parkinson’s disease,” was published in the Journal of Neurology, Neurosurgery & Psychiatry.

Parkinson’s disease is believed to be caused by the impairment or death of dopamine-producing nerve cells (neurons) in a region of the brain called the substantia nigra, which controls the body’s balance and movement.

When the disease is established, or advanced, the degeneration of dopaminergic neurons and nerve fibers frequently extends to a brain region called the caudate nucleus. This region plays important roles in motor control as well as in various other non-motor tasks, such as learning and sleep.

In fact, the loss of dopaminergic function in this region is known to contribute to the hallmark symptoms of Parkinson’s including cognitive impairment, depression, sleep disorders, and gait problems.

Although less common, caudate dopaminergic dysfunction may also emerge in the early stages of the disease, in which case it could also contribute to the onset of non-motor symptoms. However, the frequency of this specific brain impairment in early Parkinson’s is unknown as are its clinical implications for patients.

To address this lack of knowledge, a team, led by researchers at the University of Milan in Italy and Newcastle University in England, investigated the prevalence of caudate dopaminergic dysfunction in people who were still in the very early stages of Parkinson’s.

By comparing the participants’ state at the beginning of the study and four years later, they also looked for associations between caudate involvement and an increased risk of disease progression.

They analyzed clinical data from 397 patients who had had a Parkinson’s diagnosis for two years or less, and were participating in the Parkinson’s Progression Markers Initiative (PPMI), an ongoing study attempting to identify biomarkers of disease progression. The team compared the collected clinical data from Parkinson’s patients with that of 177 healthy volunteers.

Caudate dysfunction was detected using 123I-FP-CIT single-photon emission computed tomography, commonly known as DaTscan. This is an imaging technique that depicts the levels of dopamine transporters in the brain that is often used to confirm a Parkinson’s diagnosis.

Based on DaTscan imaging data, the participants were divided into three groups: those who had no reduction of dopamine transporters, those who showed reduction in just one side of the brain, and those who had involvement of both sides of the brain.

Initial data showed that 51.6% of the patients had signs of normal caudate dopamine function, while 26% had caudate dopaminergic dysfunction on one side of the brain (unilateral), and 22.4% on both sides (bilateral).

Four years later, the patients who initially had bilateral caudate involvement were found to experience more frequent and worse cognitive impairment and depression, and more severe gait disability.

In general, after four years of follow-up, more patients showed a loss of dopaminergic nerve fibers in the caudate, compared with the study start, affecting 83.9% of patients (unilateral 22.5%, bilateral 61.4%).

“In this study, we have demonstrated a high frequency of early caudate dopaminergic dysfunction in patients with recently diagnosed [Parkinson’s disease],” the researchers wrote.

“Our study suggests that early bilateral caudate dopaminergic dysfunction is associated with an increased frequency of clinically significant depression and to worse depressive symptoms, regardless of age,” they added.

DaTscan parameters used to define the presence of early caudate dysfunction may be a “valid indicator of more rapid onset of such symptoms,” they said, which may help in “identifying patients at risk of clinical progression to cognitive impairment, depression, and gait problems in the near future.”

Assessment of caudate dopaminergic denervation may also assist clinicians in better predicting disease course at an early stage and identifying patients who may benefit the most from early, targeted disease-modifying therapies.

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Treatment with Intranasal Insulin May Improve Verbal Fluency and Motor Function, Early Study Shows

Intranasal insulin

Treatment with intranasal insulin — which is atomized into a spray and inhaled through the nose — may ease Parkinson’s disease-related cognitive impairment and motor symptoms without dangerously lowering blood sugar levels, according to a proof-of-concept trial.

The study, “Safety and preliminary efficacy of intranasal insulin for cognitive impairment in Parkinson disease and multiple system atrophy: A double-blinded placebo-controlled pilot study,” was published in PLoS ONE.

Insulin, which regulates sugar (glucose) levels in the blood, is known to have potent effects in the brain, including on cognition. Intranasal insulin treatment has been shown to increase functional connectivity in the brain in type 2 diabetes without changing serum glucose levels.

Evidence also indicates that intranasal insulin improves visuospatial (visual perception of the spatial relationships between objects) and verbal short-term memory in people with mild cognitive impairment due to Alzheimer’s disease.

Cognitive impairment is a common non-motor complication of Parkinson’s disease. However, the effects of intranasal insulin on this particular complication remain to be understood.

In this study, researchers from Harvard Medical School and University of Massachusetts designed a randomized, placebo-controlled, single-center Phase 2 trial (NCT02064166) to evaluate the effectiveness of intranasal insulin as a treatment for individuals with Parkinson’s and multiple system atrophy (MSA). The symptoms of MSA are similar to those seen in Parkinson’s, but the disorder has a quicker progression and a much shorter survival rate.

A total 14 patients, comprised of nine men and five women, were randomly assigned to receive 40 international units (IU) of intranasal insulin or saline once daily for four weeks. Nine individuals were included in the insulin group and the remaining six were allocated to the placebo group.

Participants were diagnosed and treated for Parkinson’s disease, with one subject in the insulin group also treated for possible multiple system atrophy.

During the trial, participants completed a screening visit, a baseline assessment, two follow-up visits, and an end-of-treatment assessment. Researchers performed neuropsychological testing, and evaluated patients’ motor function — using several disease severity scales and a walking test — and disease progression.

Participants kept taking their usual medications. The last intranasal insulin or placebo dose was given on the day of post-treatment assessment.

The intranasal therapy was safe and well-tolerated and there were no treatment-related side effects. Importantly, blood glucose levels remained normal in treated individuals.

Results revealed patients who received the insulin had better verbal fluency than those given the placebo. Compared with their pre-treatment assessments, individuals given insulin also had decreased disease severity and motor scores — indicating their motor symptoms were eased by treatment and that the Parkinson’s did not progress as fast.

Interestingly, the patient with probable multiple system atrophy, who was included in the insulin group, remained stable during the study and showed a tendency toward improvement of motor skills.

“Although this is a single case of INI [intranasal insulin] treatment in MSA [multiple system atrophy], it warrants further investigation as there are no therapies available to modify disease progression,” the researchers said.

No changes were observed in cognitive, depression, or gait assessments within and between groups.

“Our study provided preliminary data that suggested an improvement of functional skills after four weeks of daily INI [intranasal insulin] treatment that paves the way toward a larger cohort study to evaluate long-term safety and potential efficacy of intranasal insulin administration for potential treatment and prevention of functional decline in patients with Parkinson disease,” the study concluded.

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Apathy and Depression Linked to Sleep Disorder in Parkinson’s Patients, Study Finds

apathy

Symptoms of apathy and depression are more frequent and severe in Parkinson’s patients with rapid eye movement sleep behavior disorder (RBD) than in patients without this disorder, according to a study.

Findings also showed that women with Parkinson’s and RBD are more likely to experience apathy than men.

The study, “Apathy in Parkinson’s disease with REM sleep behavior disorder,” was published in the Journal of the Neurological Sciences.

RBD affects up to half of Parkinson’s patients and often appears several years before motor symptoms. People with Parkinson’s and RBD typically experience more non-motor symptoms such as cognitive impairment, daytime sleepiness, and depression than those without RBD.

Apathy is very common in Parkinson’s patients and affects the treatment and long-term outcomes of the disease. Recent evidence showed a high prevalence of apathy in people with RBD and depression, but studies on the association between these disorders in Parkinson’s patients are still lacking.

Researchers at the University of Bern in Switzerland addressed this shortcoming by analyzing the motor function of 64 Parkinson’s patients, using the modified Hoehn & Yahr stage and the Unified Parkinson’s Disease Rating Scale (on and off dopaminergic medication), prior to deep brain stimulation from 2012 to 2016.

Non-motor assessments included the Starkstein apathy scale (SAS), the Hamilton depression rating scale, the Epworth sleepiness scale, and the mini-mental state examination of cognitive impairment. No patient had relevant cognitive deterioration or dementia.

Of the patients, 26 (40%) fulfilled the criteria for RBD (mean age of 62.6 years, Parkinson’s duration of 12.8 years), while 38 did not (mean age of 63 years, disease duration of 11.4 years). Motor function of the two groups only differed in the UPDRS part 2 score, related to daily living activities. This score was higher in patients with RBD when specifically analyzing the periods they were off medication.

Among the patients with RBD, 52% had apathy, defined as a score of 14 or higher on the SAS, while 50% had more symptoms of depression. In the group without RBD, apathy was observed in 42% of patients and depressive symptoms in 20% of them.

Patients with RBD had significantly higher mean apathy and depression scores, indicating greater severity, than those without this disorder. Higher apathy scores were especially seen in women. In contrast, the results of sleepiness and cognitive function were similar between the two groups.

“In [Parkinson’s], RBD is associated with isolated apathy and increased severity of depressive symptoms, independent of medication, motor and other non-motor symptoms,” the researchers wrote.

As for patients without depression, an increased apathy score was found in 53% of those with RBD and 29% of those without RBD. The data also showed that 58% of those with RBD and 64% of those without RBD had increased depressive symptoms but not an increased apathy score.

According to the researchers, this finding means that although their overlap is well-known, “apathy should not be considered as a mere symptom of depression.”

In the group with RBD, women showed more frequent and more severe apathy, as well as more frequent use of antidepressants than men, but these were not statistically significant. However, gender was the only independent predictor of apathy in the group with RBD, with women having a higher risk. No other gender difference was found.

This study suggests that patients with Parkinson’s and RBD “should receive targeted medical attention to improve diagnosis, monitoring and management of neuropsychiatric symptoms and their consequences,” the researchers concluded.

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New DBS Method Eases Both Cognitive and Motor Symptoms in Parkinson’s Patient, Study Shows

DBS patient expectations

A new approach to deep brain stimulation (DBS) was able to reduce both motor and cognitive impairments in a patient with Parkinson’s disease, a case study reports.

Described by the researchers in Spain who conducted the study, this alternative to conventional DBS involves a single electrode that is placed in each side of the brain, which is able to stimulate two different regions at the same time.

The study, “Simultaneous Stimulation of the Globus Pallidus Interna and the Nucleus Basalis of Meynert in the Parkinson-Dementia Syndrome,” was published in the journal Dementia and Geriatric Cognitive Disorders.

DBS is a type of surgery recommended for Parkinson’s patients who fail to respond to other medications. The procedure involves implanting a device that sends electrical signals produced by a battery to stimulate specific regions of the patient’s brain.

Although previous studies have shown that DBS can effectively reduce Parkinson’s motor symptoms, the same cannot be said regarding cognitive deficits, which may affect up to 60 percent of recently diagnosed patients.

“In fact, patients with dementia or significant cognitive impairment are often excluded from DBS studies … based on reports of irreversible cognitive worsening after DBS surgery in patients with preexisting cognitive impairment,” the researchers wrote.

Now, these researchers have explored the therapeutic potential of a new type of DBS that is able to target two brain regions simultaneously.

The single-case study focused on a 68-year-old patient with six years of clinical history, showing signs of mild cognitive impairment, who underwent DBS targeting two different regions of the brain with a single electrode placed on each hemisphere (half): the globus pallidus interna (GPi), to treat motor symptoms; and the nucleus basalis of Meynert (NBM), to treat cognitive deficits.

Two months after starting GPi stimulation, the patient started showing signs of motor improvement, reflected by a reduction of 61.37% in the Unified Parkinson’s Disease Rating Scale (UPDRS-III) score and in a performance improvement of 80% during the Up and Go test, compared with before the treatment. The UPDRS-III assesses the severity of motor symptoms, while the Up and Go test assesses mobility according to the time it takes an individual to rise from a chair, walk 3 meters, turn around, walk back to the chair, and sit down.

Moreover, the levodopa equivalent dose (a rough technique to compare different medications; LED) score decreased by 16.81% following GPi stimulation.

Motor improvement at two months was accompanied by a general decline in cognitive performance. However, minor cognitive improvements were found three months after the patient began receiving NBM stimulation together with GPi stimulation, namely in the capacity for abstraction, non-verbal memory (our visual memory system), verbal memory retrieval, and speed processing (the time it takes a person to do a mental task).

“The follow-up conducted 1 year after starting the combined GPi + NBM stimulation confirmed the improvement in UPDRS-III scores, along with a 20% reduction in LED compared to baseline. No visual side effects were recorded during the follow-up,” the researchers wrote.

“This approach showed no significant side effects and resulted in improvements in certain cognitive functions in a patient with baseline mild cognitive impairment, which would have excluded this patient from undergoing DBS under most current protocols. Further research is necessary before offering this surgical alternative to a wider range of patients,” they concluded.

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Genetic Variant Predetermines Risk of Cognitive Decline in Parkinson’s, Research Suggests

genetic variant

Researchers have found that Parkinson’s patients whose cognitive ability is intact, but who have a specific genetic variant, have significantly less gray matter in the regions of their brain that are related to dementia.

The study with that finding, “Reduced gray matter volume in cognitively preserved COMT 158Val/Val Parkinson’s disease patients and its association with cognitive decline,” was published in Brain Imaging and Behavior.

Several mutations in the COMT gene have been associated with the risk of developing Parkinson’s disease. This gene provides instructions for making catechol-O-methyltransferase (COMT), an enzyme that helps break down certain chemical messengers like dopamine.

The most common alteration in the DNA sequence that makes up the COMT gene is the Val158Met mutation in which a valine (Val) is replaced by a methionine (Met) at position 158. Val and Met are both amino acids, also known as the protein’s building blocks.

Every individual has two copies of each gene, one inherited from each parent. Therefore, a person can have two Val’s in the same position at both COMT gene copies (also known as the Val/Val genotype), a Val in one gene and a Met in the other (Val/Met genotype), or two Met’s (Met/Met genotype). Scientists use the word “genotype” to describe a person’s genetic constitution.

Changes in COMT’s molecular structure, lead to high (Val/Val), intermediate (Val/Met) and low (Met/Met) enzymatic activity.

The Val158Met mutation in the COMT gene has been associated with an increased risk of cognitive decline in Parkinson’s disease, particularly in people with greater COMT activity. When this happens, there is too much neurotransmitter degradation, thus leading to reduced levels of dopamine and affecting basic brain functions such as motor coordination and memory.

Evidence suggests a correlation between cognitive impairment, one of Parkinson’s non-motor features, and reduced gray matter volume.

The brain is composed of gray and white matter. The first consists of cell bodies — the control center of neurons — while the latter is made up of nerve cell projections, known as axons or fibers, connecting distinct parts of gray matter.

A Spanish team of researchers used magnetic resonance imaging (MRI), a non-invasive imaging technology, to investigate a possible structural brain compromise in Parkinson’s patients with highly active COMT activity that could explain their increased risk for subsequent cognitive impairment.

The study included 120 newly diagnosed Parkinson’s patients with normal cognition (who were not previously treated for the disease) and 48 healthy controls from the Parkinson’s Progression Markers Initiative database.

Results showed that there was a widespread, significant reduction in cerebral gray matter volume in patients with the Val/Val genotype. They observed alterations in the fronto-subcortical and posterior-cortical brain regions, where motor and cognitive functions originate.

Gray matter volume at some of the identified regions was associated with cognitive decline in a four-year follow-up period, suggesting that gray matter volume reduction during the early stages of disease predisposes Val/Val patients to cognitive impairment.

Nonetheless, gray matter volume analysis at one-year follow-up was not increased in Val/Val subjects, in comparison to Val/Met and Met/Met participants, indicating a somewhat stable atrophy in the Val/Val subset and that those brain changes might already be present prior to diagnosis.

The team believes their research “sparks the need to further characterize the association between a modified COMT enzymatic effect and a structural brain compromise in the early stages of [Parkinson’s disease].”

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US Study Shows Patterns of Prescription Errors for Dementia Therapies to Parkinson’s Patients

dementia prescription errors

Women and Hispanic patients with Parkinson’s disease, as well as those living in Southern and Midwestern U.S. states, are most often prescribed inappropriate dementia therapies, a nationwide study reveals.

The study, “Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease,” appeared in the journal JAMA Neurology.

Cognitive impairment in Parkinson’s patients is a major reason behind their loss of independence, as well as nursing home placement and healthcare costs. About 1 in 4 Parkinson’s patients has objective cognitive impairment at the time of diagnosis, and dementia affects about 80-90% of patients by 12 years after diagnosis.

Despite the high incidence of cognitive impairment in Parkinson’s patients, there is little information on dementia medication use.

University of Pennsylvania researchers reviewed the clinical records of 268,407 Medicare beneficiaries with a Parkinson’s diagnosis who had 12 consecutive months of inpatient, outpatient, and prescription medicine coverage from January to December 2014. Medicare is the primary insurer for 97 percent of the U.S. population ages 65 years or older.

According to Medicare Services data, about 27.2% of the Parkinson’s patients included in the study had filled at least one prescription for a dementia medication in 2014. The most commonly prescribed therapy was Aricept (donepezil), followed by Namenda (memantine) and Exelon (rivastigmine), while Razadyne (galantamine) use was uncommon.

Women were found to be 15% less likely to use dementia medication than men. Black patients were 38% more likely and Hispanic patients 28% more likely to use these therapies than white patients, while Native Americans were about 38% less likely.

“Female sex was associated with lower odds of dementia medication use … Dementia medication use was positively associated with black and Hispanic race/ethnicity, and it was negatively associated with Native American,” the researchers wrote.

Use of a dementia medicine was associated with a dementia diagnosis, but also depression, hip or pelvic fracture, and stroke or transient ischemic attack.

Approximately 66.4% of patients were only prescribed a single dementia medicine during the year, while 26.7% had prescription fills for both Namenda and an acetylcholinesterase inhibitor (AChEI), most frequently Aricept or Exelon.

“Coadministration of a drug with high anticholinergic activity [such as Namenda] and an AChEI represents a frank prescribing error because these drugs have opposing pharmacologic effects,” the researchers wrote.

“In patients with Parkinson disease, who bear additional risks of cognitive impairment and vulnerability to anticholinergic activity, coprescribing of an ACHEI and a high-potency anticholinergic medication can be considered a never event because it is a medication error likely to contribute to disability,” they said.

Almost 45% of Medicare beneficiaries with Parkinson’s and a clinical diagnosis of dementia filled a prescription for a medication that could further worsen their cognitive impairment over the course of a single year.

The records revealed that black beneficiaries were 17% less likely to be prescribed both a high-potency anticholinergic agent and AChEI than white Parkinson’s patients. In contrast, Hispanics and women had an 11% and 30% increased chance of experiencing this so-called never event, defined as a serious medical error or occurrence that should never happen to a patient and can cause harm.

Dual prescriptions of an anticholinergic agent and AChEI were found to be more frequent among patients with secondary conditions, including depression, chronic obstructive pulmonary disease (COPD), hypertension, chronic kidney disease, diabetes, and heart failure.

Clusters of high prevalence of inappropriate prescribing were found in the Southern and Midwestern U.S. regions, while clusters of low prevalence of inappropriate dual-prescribing were reported in the Northwest and Northeast.

“We identified unique patterns of dementia medication use among individuals with Parkinson disease, along with racial/ethnic, sex, and geographic disparities in potentially inappropriate prescribing habits,” the researchers said.

Further studies are warranted to explore the potential contributing role of anticholinergic agents in the development of dementia among Parkinson’s patients.

“Future studies may take a clinical trial approach, in which high-potency anticholinergic medications are replaced with lower-potency alternatives, and the change in cognitive testing and cognitive trajectory are measured,” the researchers suggested.

Additionally, improvements in practitioner education may “lessen negative patient outcomes in the future,” they added.

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Poor Sense of Smell Evident in Parkinson’s Patients in Small Study, But Not Linked to Dementia

Olfactory deficits — a diminished sense of smell — affected 95% of Parkinson’s disease patients in a small study, but such problems did not appear to be linked to cognitive impairment or disease-related dementia.
The study, “Association between olfactory loss and cognitive deficits in Parkinson’s disease,” was published at the journal Clinical Neurology and Neurosurgery.
Previous research has suggested that a poor sense of smell is a non-motor symptom of Parkinson’s disease experienced by many patients — about 90% — during its initial and moderate stages.
Researchers have also found possible associations between olfactory dysfunction and a patient’s risk of developing dementia, with recent studies indicating a three times higher risk of cognitive deficits appearing in 10 years in these patients.
A research team in Brazil compared the cognitive and olfactory capacity of 42 Parkinson’s patients and 38 age- and sex-matched healthy volunteers.
Patients had lower cognitive scores compared to the control group, as determined by the Scales for Outcomes in Parkinson’s Disease-Cognition (SCOPA-Cog) and Mini-Mental State Examination (MMSE) tests. Thirty-four, or 81%, of them were diagnosed with dementia based on the International Parkinson and Movement Disorder Society criteria.
This high number of Parkinson’s dementia patients “can be partly explained by the fact that the study was carried out in a reference center for Parkinson’s disease treatment, where patients had longer disease duration and more complications,” the researchers said.
Patients’ sense of smell was assessed using the Sniffin’ Sticks Screening 12 Test, in which the participants are asked to identify each stick’s respective scent from among four options.

Based on the number of correct answers, the prevalence of olfactory dysfunction in Parkinson’s patients was 95.24% — 40 out of 42 patients were classified has having an impaired sense of smell.

Further analysis found no association between olfactory and cognitive impairment among patients, regardless of their age (although older patients had worse results — an expected finding as sense of smell is known to diminish with age, especially in men, the study noted). The only exception was in attention, the one cognitive domain that correlated with a loss or diminishment of olfactory abilities.
Among volunteers, cognitive and olfactory scores strongly correlated, both in the SCOPA-Cog and MMSE results.
A possible explanation for these results, the researchers said, could be a difficulty recognizing odors due to poor cognitive ability.

This mean a study limitation might be “the choice of the instrument to measure olfaction, because although olfaction can be evaluated in several ways (…) the Sniffin ‘Sticks Screening Test only evaluates odor identification,” the researchers wrote. “Because odor identification requires more cognitive processing and memory use than the other two ways of assessing smell (odor threshold and discrimination), it would be possible that cognitive impairment at the time olfaction was assessed affected the olfactory scores.”

Collectively, this study revealed that “patients with advanced Parkinson’s disease have cognitive and olfactory deficits more commonly than other elderly patients,” the researchers wrote.
But a link between olfactory deficit and the onset of Parkinson’s dementia could not be established. Further studies are necessary to assess sense of smell in a larger Parkinson’s population, and to

Source: Parkinson's News Today