Abbreviations & Acronyms A = adrenergic/noradrenergic BBB = blood-brain barrier DA = dopamine DLTN = dorsolateral tegmental nucleus DO = detrusor overactivity GABA = gamma-amino-butyric acid Glu = glutamate. GPi = globus pallidus internus IML = intermediolateral cell column L = lumbar LC = locus ceruleus LUT = lower urinary tract LUTS = lower urinary tract symptoms MPOA = medial preoptic area MSA = multiple system atrophy NBM = nucleus basalis Meynert OAB = overactive bladder PAG = periaqueductal gray matter PBN = parabrachial nucleus PD = Parkinson's disease PMC = pontine micturition center PVN = paraventricular nucleus S = sacral SNc = substantia nigra pars compacta SNr = substantia nigra pars reticulata STN = subthalamic nucleus T = thoracic TUR-P = transurethral prostate resection of the prostate VTA = ventral tegmental area ZI = zona incerta Abstract: Bladder function of patients with Parkinson's disease alters significantly: the majority of patients have overactive bladder (urinary urgency/frequency) with little or no post-void residuals. This seems to be the result of an altered brain-bladder relationship, as in Parkinson's disease, the frontal-basal ganglia D1 dopaminergic circuit that normally suppresses the micturition reflex is altered. The pathophysiology of the bladder dysfunction in Parkinson's disease differs from that in multiple system atrophy; therefore, it might also aid in differential diagnosis. The effects of levodopa, the major drug to treat motor dysfunction, on the bladder in Parkinson's disease vary significantly; therefore, add-on therapy is often required. Anticholinergic drugs are the first-line treatment, with particular care for cognitive function in elderly patients. The second-line treatment includes serotonergics drug, desmopressin and others. Newer modalities include deep brain stimulation that improves the bladder in Parkinson's disease; and botulinum toxin is promising, particularly in difficult cases. These treatments might be beneficial in maximizing the patients' quality of life.
In MSA patients, 18.2% presented with bladder dysfunction as the sole initial manifestation, and the mean interval from the onset of urinary to the onset of motor symptoms was 2.8 years. It is clinically important to avoid unnecessary prostatic surgery when MSA patients see urologists before neurologists.
Objectives Neuroimaging markers for Parkinson's disease (PD)/dementia with Lewy bodies (DLB) include dopamine transporter (DAT) scanning and metaiodobenzylguanidine (MIBG) myocardial scintigraphy. It is unknown which marker is useful to identify the premotor phase PD/DLB. We reported four patients who, during a negative DAT scan period, had a positive MIBG result that suggested premotor PD/DLB. Here we report 18 additional patients. Methods This study was a prospective cohort study. The recruiting period was five years; prospective follow‐up period, 5.5 ± 3.0 years; and a once a year (minimum) follow‐up visit. We recruited 745 referred subjects. The inclusion criteria were having at least one of the following known PD nonmotor features: (1) autonomic: postural hypotension (pure autonomic failure [PAF]), constipation, bladder dysfunction; (2) sleep: REM sleep behavior disorder (RBD); and (3) cognitive: mild cognitive impairment or psychiatric symptoms. Also, the patient had to have undergone both DAT and MIBG tests. Results Only 18 patients fulfilled these criteria. Their characteristics were: elderly (mean age 75.5 years), with long histories (onset 61.0 years; duration 14.5 years), and predominately male (14 men, four women). The patients' neurologic diagnoses were constipation/RBD in 10, constipation/RBD/PAF in six, and constipation/PAF in two. During the follow‐up period, seven patients developed PD or DLB. An abnormal MIBG result was noted in 94%, and an abnormal DAT result was noted in 56%. Conclusions MIBG has the potential to be a useful marker during the DAT scan negative period to identify premotor PD/DLB, but further studies are needed.
Objective: Alzheimer's disease (AD), Lewy body disease (LBD), and white matter disease (WMD) are common in the elderly. Although these diseases are observed together pathologically, the extent to which these diseases occur together clinically is uncertain. To address this question, we analyzed the clinical neuroimaging data of Japanese patients. Patients and Methods:This was a prospective study with a 3.0-year recruiting period, a prospective follow-up period of 2.0 ± 1.5 years, and ≥1×/year visits. We recruited 770 referred subjects who had undergone three neuroimaging markers: brain magnetic resonance imaging (MRI), dopamine transporter (DAT) scanning, and metaiodobenzylguanidine (MIBG) myocardial scintigraphy.Results: Among the 770 patients, 731 fulfilled the criteria of some of or all of the three diseases as follows: WMD (n = 46), WMD + AD (n = 110), WMD + LBD (n = 89), WMD + AD +LBD (n = 86), AD (n = 118), LBD (n = 239), and AD + LBD (n = 43). In total, there were patients with WMD (n = 331), AD (n = 357), and LBD (n = 414) (with overlap); dual diseases (n = 242; 33%) and triple diseases (n = 86; 12%). Clinically, pure WMD showed overactive bladder but mild gait/cognitive disorder. Pure AD showed cognitive disorder alone. Pure LBD showed cognitive, gait, and sleep/autonomic disorders. Triple/dual diseases showed combined clinical features, depending on the underlying diseases. However, these differences did not reach statistical significance. Conclusion:Forty-five percent of the patients who visited dementia/movement disorder/sleep-autonomic disorder clinics showed either triple or dual diseases. It is important to follow such patients from the viewpoint of disease progression and necessary care.
Objective Delirium/dementia (collectively called cognitive spectrum disorder [CSD]) is a major issue in hospital wards. However, few reports are available on the incidence of CSD on multi‐faculty wards or on the factors contributing to it. The aim of this study was to address these issues by a neurogeriatric team (neurologists, psychiatrists, specialist nurses, and link nurses from all wards). Patients and Methods This was a retrospective study with a 12‐month recruiting period, a prospective follow‐up period of 3.0 ± 2.5 weeks, and ≥1×/week visits. We diagnosed acute‐onset delirium by the Confusion Assessment Method and analyzed underlying conditions. We also diagnosed premorbid dementia by neurocognitive examination and neuroimaging following published criteria. Results Our subjects were 723 CSD from 15 faculties, accounting for 6.5% of admissions, 393 men and 330 women, mean age 81 years. CSD was prevalent in cardiology/cardiac surgery (CAR), orthopedic surgery (OP), and neurology/neurosurgery (N), with dementia alone in ophthalmology and a combination of delirium/dementia in the other faculties. Premorbid dementia were diagnosed with Alzheimer's disease (AD), white matter disease, dementia with Lewy bodies (DLB), or some combination of these. Delirium was accompanied by worsening of gait difficulty. The ratio of brain (N) versus extra‐brain was 105 (14.5%):618 (85.5%). Severe CSD was common in DLB than AD but without statistical significance. Conclusion Total 6.5% of hospital admissions showed CSD, with CAR, OP, and N being prevalent. The ratio of brain versus extra‐brain was 14.5%:85.5%. Severe CSD was more prevalent in DLB patients than in AD patients, but without statistical significance.
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