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Disease Complications and Healthcare Use More Common in Women Than Men, Dutch Study Finds

gender differences

Women with Parkinson’s are more likely than men to have disease-related complications within five years of diagnosis and more likely to access healthcare services sooner, findings from a Dutch study suggest.

The study, “Sex-Specific Patient Journeys in Early Parkinson’s Disease in the Netherlands,” was published in Frontiers in Neurology.

Throughout their disease’s course, Parkinson’s patients need to rely on various healthcare providers, from general practitioners to therapists and neurologists, to maintain a quality of life.

“This ‘journey through the healthcare system’ varies per individual because of heterogeneity of symptoms, differences in disease progression rate, and the occurrence of PD-related complications. One important source of this variation might be sex differences in the presentation of PD [Parkinson’s disease],” the researchers wrote.

Evidence indicates that Parkinson’s affects more men than women, and that the disease starts at earlier ages and progresses faster in men. Women are known to have more tremor-dominant Parkinson’s, while men most often experience the akinetic-rigid kind — that typified by a slowness of movement, accompanied by muscle stiffness, postural instability and gait difficulties.

Nonetheless, it remains to be understood if these sex differences translate into “patient journeys” distinct to Parkinson’s. Knowing these journeys can help to improve access to services, and enhance coordination and quality of care.

Medical data today are routinely collected and stored in administrative healthcare databases, and typically cover both a patient’s health status and healthcare-related services. Such information can be found through electronic health records, medical claims, and drug and disease registries.

Investigators at Radboud University Medical Center used national medical claims data to reconstruct the sex-specific journey of Dutch Parkinson’s patients over the first five years after a diagnosis. (The study notes that the Netherland has “compulsory health insurance … [and] comparatively low out-of-pocket payments.”)

The claims database chosen for analysis contained data of all people diagnosed with Parkinson’s disease between 2012 and 2016 in the Netherlands. Researchers analyzed the time it took for patients to receive care from neurologists, allied healthcare therapists, or primary care physicians. They also studied the occurrence of Parkinson’s-related hospitalizations, incidences of pneumonia, orthopedic injuries, enrollment in a nursing home, and death.

In total, 22,293 medical claims regarding early Parkinson’s were analyzed: 13,518 (60.6%) involving male patients and 8,775 (39.4%) for females. At the time of diagnosis, men had a mean age of 71.6 years, and women 72.5.

The first Parkinson’s-related complications, such as pneumonia, orthopedic injuries, and hospitalization, began to be reported at a median of 1.8 years for women and 2.3 years for men.

Five years post-diagnosis, 68.7% of the men had at least one Parkinson’s disease-related complication, 22.5% lived in a nursing home, and 18.3% had died. Among the women, a greater percentage had at least one Parkinson’s complication ( 73%) and lived in a nursing home (27.2%), but a lesser percentage (14.6%) had died.

Female patients were more likely to visit their general practitioners earlier and more often than did male patients, starting about one month after diagnosis. Women began to doctor visits 31 days post-diagnosis and returned for checks-ups ever six weeks, men made a first visit at 41 days post-diagnosis and returned every eight to nine weeks.

Women also started their physiotherapy treatment earlier and returned more often: five months after diagnosis and once every five to six weeks thereafter; among men, physiotherapy started at eight months and continued once every seven to eight weeks.

“After 5 years, 37.9% … of women had visited an occupational therapist and 18.5% … a speech and language therapist at least once,” compared to 33.1% and 23.7%, respectively, for men, the researchers wrote. These differences were statistically significant.

Overall, gender differences among Parkinson’s patients were found to be related not only disease manifestations or progression, but also with the use of healthcare services.

“[O]ur findings suggest that women experience complications and access most healthcare services sooner after diagnosis and more frequently than men,” the researchers wrote.

“We hope these insights can lead to better and more personalized care for [Parkinson’s disease] patients of both sexes,” they concluded.

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Women with Parkinson’s Who are Homebound Face Greater Barriers to Access Support, Study Finds

homebound women

Women with advanced Parkinson’s disease who are homebound are more likely to live alone and may face greater barriers to accessing support.

That finding comes from the study, “Sex-related differences in homebound advanced Parkinson’s disease patients,” which was published in Clinical Interventions in Aging.

Parkinson’s motor and non-motor symptoms negatively affect patients’ quality of life. Caregivers play an important role in keeping Parkinson’s patients engaged in daily activities, which can improve their quality of life.

“The combination of advanced PD [Parkinson’s disease], older age, and its associated accumulation of comorbidities are negatively reinforcing, rendering many people homebound. Once homebound and disconnected from routine care, this population is at further risk of deterioration and adverse events,” the researchers wrote.

Parkinson’s duration appears to be similar between the sexes. However, and in comparison to men, studies indicate that women tend to be older, have greater disease severity, other diseases aside from Parkinson’s (comorbidities), and are less likely to be monitored by a neurologist or receive surgical interventions like deep brain stimulation.

A recent study also has shown that women are at greater risk of having poor access to caregivers.

To further explore the associations between sex, homebound status and access to care, researchers studied the characteristics of men and women who were unable to leave their home and who were enrolled in a home visitation program for people with advanced Parkinson’s and related disorders. The study was a collaboration among nine institutions, including universities and medical centers.

Patients were seen between February 2014 and July 2016. Researchers analyzed the subjects’ data, which was either collected through in-person interviews or medical chart review.

Of the 85 enrolled patients, 52% (44 people) were women. At the first program-related home visit, individuals had an average age of 79.6 years and no differences were found between sexes.

Among the women, 32 had Parkinson’s disease, eight had dementia with Lewy bodies, one had Parkinson’s disease dementia, and the remaining nine had different types of parkinsonism-like disorders.

Overall, in the entire group of 85 patients, Parkinson’s was the most common diagnosis (79%). A diagnosis of Parkinson’s dementia was more frequent in men (17.1%) than in women (2.3%).

Men were found to have greater caregiving assistance, compared to women. “Comparing caregiver types, 70.7% of men identified a spouse, partner, or significant other serving as a caregiver compared to only 27.3% of women,” the researchers noted.

Women were more frequently single or widowed, which could be explained by the fact that women have a longer life expectancy than men.

About 18.1% of women lived alone and had no caregiver, compared to 2.4% in the male subsample.

“This study highlights the relative lack of caregivers among homebound women with advanced PD [Parkinson’s disease] and emphasizes the vulnerability of this group of patients to interruptions in continuity of care. With additional understanding of barriers to care, clinicians can further individualize treatment strategies, counseling, and care planning based on these sex-related differences,” the researchers concluded.

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Women with Depression and Anxiety Are Largest Parkinson’s Group with Fibromyalgia, Study Finds

Parkinson's and fibromyalgia

A distinct population of people are diagnosed with both Parkinson’s disease and fibromyalgia, a study in Israel found, noting they tend to be women with mental health issues, such as depression and anxiety, who rely on painkillers more than other Parkinson’s patients.

The study, “Fibromyalgia-Like Syndrome Associated with Parkinson’s Disease—A Cohort Study,” was published in the Journal of Clinical Medicine.

Fibromyalgia is a chronic condition characterized by widespread pain in various parts of the body. Parkinson’s and fibromyalgia share clinical features like muscle stiffness, unusual pelvic and rectal discomfort, poor sleep, fatigue, and depression. Nonetheless, only one case study to date has detailed a patient with both diseases, the researchers said.

“Since PD [Parkinson’s disease] and FM [fibromyalgia] are two relatively common disorders, it is not uncommon for a neurologist, rheumatologist, or a pain specialist to encounter a patient suffering from both illnesses,” they added.

Investigators at the Ben Gurion University sought to retrospectively characterize this specific group of patients, looking at their demographics, comorbidities, and medication use.

The team searched the Clalit Health Services database between the years 2000 and 2015 for people diagnosed with Parkinson’s and fibromyalgia. Researchers identified Parkinson’s patients through the application of a medication tracer algorithm, and those with fibromyalgia based on medical records.

During this 15-year period, 2,606 people (1,220 women and 1,386 men; mean age 67.9) were diagnosed with Parkinson’s and 60 (2.3%) of them also had fibromyalgia (a fibromyalgia-like syndrome associated with Parkinson’s disease, referred to as FLISPAD).

The majority of those with both the neurodegenerative and rheumatic disorders were women (88.3%) diagnosed at a mean age of 63.95 for Parkinson’s, while their age at fibromyalgia diagnosis varied from 51.68 to 76.22 years. A majority — 77% — also received a fibromyalgia diagnosis after that of Parkinson’s disease.

This particular patient population also had a higher prevalence of depression, anxiety, dementia, hypertension, and heart failure.

Compared to those with Parkinson’s, patients with both conditions used different analgesics (painkillers) at higher rates as well as more antidepressants.

“This FLISPAD subgroup of patients are mostly female, younger at PD diagnosis with a higher rate of cigarette smoking, anxiety, and depression,” the researchers wrote. And they “consume more analgesic drugs, both over-the-counter (OTC) and prescription medications, including opioids.”

A diagnosis of depression or use of antidepressants tended to come a mean 3.5 years before a fibromyalgia diagnosis.

Results also showed that Parkinson’s and fibromyalgia patients purchased 21.3% more anti-parkinsonian medications than those who did not have fibromyalgia. Although not significant, this finding achieved borderline statistical significance.

“These patients present a challenge for physicians as they use more analgesics, psychotropic medications, and tend to also use more APDs [anti-parkinsonian drugs] over time. More research is needed to determine the etiology and determinants of this syndrome, the needs of patients and course of treatment, both for PD [Parkinson’s disease] and FM [fibromyalgia] symptoms,” the researchers concluded.

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Female Counselors, Teachers and Healthcare Workers at Higher Disease Risk, Study Suggests

women and work risks

Women working in fields that include teaching, healthcare, and — especially — social work “defined broadly” may be at a higher risk of Parkinson’s disease, a large observational study has found.

The study, “Occupation and Parkinson disease in the Women’s Health Initiative Observational Study,” was published in the American Journal of Industrial Medicine.

An individual’s risk of developing Parkinson’s is influenced by a variety of factors. Among these are workplace exposures, the most obvious being pesticides and other chemicals used in a job and linked to Parkinson’s risk.

Most studies into workplace-related risks for Parkinson’s involve men, and these data do not necessarily hold for other populations, both due to biological differences and because of differences among people drawn to specific fields.

Researchers used data from the Women’s Health Initiative Observational Study (WHI-OS) to assess Parkinson’s risk as a factor of career choice in 80,646 postmenopausal (ages 50 to 79) female workers in the United States who were followed for an average of 11 years after enrollment.

After adjusting for possible confounding factors like smoking history, income or ethnicity, they divided participants into broad career categories, like teaching (preschool through post-secondary), sales, counseling and social work, cleaning and maintenance, top executives, nurses, doctors and other healthcare professionals, etc.

They then determined whether any of these categories were significantly linked to Parkinson’s by calculating relative risk (RR; a value that is significantly higher or lower than 1 suggests an increased or decreased risk, respectively).

In total, 2,590 women (3.21%) in the study had Parkinson’s; 186 cases at its start and the rest diagnosed over the course of study follow-up.

There was a statistically significant increase in Parkinson’s risk among “counselors, social workers, and other community and social service specialists,” with a relative risk of 1.18, the researchers wrote, calling it an “excess risk.”

“Resonating with our findings, social work, defined broadly, has been associated with PD in studies of diverse designs, including an excess risk among white female religious workers,” the study said. “[A]lso there is evidence that women with PD are more likely to have a history of work that requires complex interpersonal interactions.”

Trends toward a higher Parkinson’s risk was found among “top executives” (RR of 1.18), “postsecondary teachers” (RR of 1.17), and workers in “building and grounds cleaning and maintenance” (RR of 1.21). But none of these associations reached statistical significance.

There was also a non-significant trend toward a lower Parkinson’s risk among people in sales, particularly “retail salespersons” (RR 0.87).

Researchers also looked at these risks broken down by how long participants had worked in these fields. For “counselors, social workers, and other community and social service specialists,” Parkinson’s risk increased with longer time spent on the job (from RR of 1.09 at 1–5 years of work to RR of 1.27 with 20 or more years). There was no consistent trend for time spent on the job for other career categories.

Based on 39 cases, they also noted evidence of an excessive risk among “health technologists and technicians” with more than 20 years of employment (RR of 1.46).

“Our findings paint a largely reassuring picture of occupational risks for PD [Parkinson’s disease] among U.S. women,” the researchers concluded.

They propose that future studies more closely examine the identified career paths to more specifically determine what factors might be influencing Parkinson’s risk for people in these fields.

As this study focused on older individuals, it may not be reflective of risks encountered by younger workers, particularly in fields with rapidly changing technology like healthcare, the researchers added.

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Study Outlines Risk Factors for Levodopa-induced Dyskinesia in Newly Diagnosed PD Patients

Parkinson's levodopa-induced dyskinesia

Severe motor, functional, and gait impairment; cumulative levodopa exposure; anxiety, and sex are among the risk factors for developing levodopa-induced dyskinesia (LID) in people newly diagnosed  with Parkinson’s disease, according to results from the Parkinson’s Progression Markers Initiative (PPMI).

The research, “Risk factors of levodopa-induced dyskinesia in Parkinson’s disease: results from the PPMI cohort,” was published in the journal npj Parkinson’s Disease.

Long-term dopamine repletion therapy in Parkinson’s patients can lead to motor fluctuations, including dyskinesia — involuntary, jerky movements. According to observational studies, over 50% of Parkinson’s patients on levodopa — the gold-standard treatment for Parkinson’s — for more than five years develop LID.

Proposed risk factors for LID include levodopa dosage — associated with the loss of dopamine-producing neurons in the brain — treatment duration, low body weight, and being a woman. However, available studies have employed different methodological approaches and follow-up duration.

The PPMI is an ongoing, large-scale, collaborative study initiated in 2010 to identify markers of disease progression in de novo patients — newly diagnosed and still untreated. Patients’ clinical, neuroimaging and cerebrospinal fluid (the liquid surrounding the brain and the spinal cord)/blood biomarkers are collected yearly in this international study.

Analyzed biomarkers include the total amount of the tau protein as well as its altered (phosphorylated) version — which forms tangles inside neurons in Parkinson’s patients — total alpha-synuclein (the main component of Lewy bodies), and amyloid-beta (1-42), a protein that is also relevant in Alzheimer’s disease.

Researchers from Ospedale S. Maria della Misericordia, in Perugia, Italy, wanted to define factors predictive of LID development in de novo Parkinson’s patients.

Data from 423 patients were analyzed. Median follow-up duration was 4.6 years and average time to start dopaminergic therapy was one year.

A combination of factors, such as disease duration, anxiety — assessed with the State-Trait Anxiety Inventory (STAI) — and higher (worse) score on the Movement Disorder Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) part III, which assesses motor function, predicted the initiation of dopaminergic therapy.

Overall, 109 of 390 patients analyzed experienced LID (27.9%), 33 of whom lacked data regarding levodopa treatment and/or LID onset. The median time to LID was 3.6 years (range 0.8-7.1 years), with a mean onset time of 5.81 years from Parkinson’s diagnosis, and an incidence rate of 64 per 1,000 person-years. This measure comprises actual follow-up duration in each patient and is higher with the length of the study.

Individual risk factors for LID development included being a woman, not being completely functional independent as measured by the modified Schwab & England Activities of Daily Living scale, higher MDS-UPDRS part III score, postural instability-gait disturbance (PIGD) or intermediate phenotype, higher DaTscan caudate asymmetry index — which reflects the difference in the levels of dopamine transport between two areas of the brain involved in motor control — higher genetic risk score, and anxiety.

Of note, no cerebral spinal fluid biomarker predicted LID development.

Researchers also found that the onset of dyskinesia was associated with depression and anxiety.

Combining all factors with an additional variable of 1,000 mg/day of levodopa equivalent daily dose — the amount of levodopa with a similar effect as the medication taken — was also found to be fairly accurate to predict dyskinesia onset.

“In summary, our findings indicate that data deriving from a large cohort of de novo PD patients monitored longitudinally are useful in understanding the composite aspects involved in the progression of disease,” researchers stated.

The team also said the findings may help “future design of both biomarker studies and randomized clinical trials.”

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Lifetime Risk of Developing Parkinson’s Similar Between Women and Men, Study Reports

lifetime risk

One in two women and one in three men older than 45 will develop Parkinson’s disease, dementia or stroke during their lifetime, a new study suggests.

Preventive strategies to delay disease onset can reduce this risk by up to half.

The study with those findings, “Lifetime risk of common neurological diseases in the elderly population” was published in the Journal of Neurology, Neurosurgery & Psychiatry.

Parkinson’s disease, dementia and stroke are among the leading causes of mortality and disability in older individuals. In fact, the diseases often co-occur. Parkinson’s disease and stroke patients are at increased risk of dementia, and patients with dementia at increased risk of stroke.

Researchers from the University Medical Center Rotterdam, The Netherlands, assessed the lifetime risk for dementia, stroke and parkinsonism in middle-aged and elderly men and women between 1990 and 2016.

They followed 12,102 individuals (57.7% women) aged 45 or older who were free from these diseases at baseline (beginning), and enrolled in the Rotterdam Study, a prospective population-based group. Participants participated in full medical check-ups every four years.

After 26-years of follow-up, 1,489 individuals were diagnosed with dementia, 1,285 with stroke, and 263 with Parkinson’s disease. A total of 438 individuals were diagnosed with more than one disease.

The overall lifetime risk to develop any of these conditions for a 45-year-old was 48.2% in women and 36.3% in men.

This difference was due to a higher risk of dementia as the first manifesting disease in women rather than men (25.9% vs 13.7%, respectively), while the risk for stroke (19.0% vs 18.9%) and parkinsonism (3.3% vs 3.6%) was similar between the sexes.

Moreover, this risk increased with age – between the ages of 45 to 65 years this risk ranged from 2.6% for women and 3.2% for men. After that, and until the age of 95, up to 45.8% of women and 35.3% of men were at risk.

“At age 45, first manifestation of stroke posed the highest lifetime risk for men (18.9%). Dementia posed the largest risk for women (25.9%), which was significantly higher compared with that for men (13.7%),” researchers wrote.

The lifetime risk for Parkinson’s was similar between women (4.3%)  and men (4.9%).

Strategies that delay disease onset between one to three years could reduce the lifetime risk for developing any of these diseases by 20% in individuals 45 and older, and by more then 50% in the oldest members of that group.

“Even a delay in onset for a few years of only one disease could already result in substantial reductions for the combined lifetime risk of developing any of these diseases,” researchers wrote.

“These findings strengthen the call for prioritizing the focus on preventive interventions at population level which could substantially reduce the burden of common neurological diseases in the aging population,” they concluded.

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