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Idiopathic parkinsonism: epidemiology and clinical characteristics of a population-based incidence cohort
Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Idiopathic parkinsonism is a neurodegenerative syndrome of unknown cause and includes Parkinson’s disease (PD) and atypical parkinsonian disorders. The atypical parkinsonian disorders are: Multiple system atrophy (MSA), progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD). The incidence rates of these diseases in Sweden are largely unknown. The diagnosis of each disease relies mainly on clinical examination although several imaging and laboratory parameters may show changes. A diagnosis based on clinical examination is especially difficult early in the course of each disease; diagnosis is easier later on when disease-charactersistic signs have evolved and become more prominent. However, even in later stages it is not uncommon that patients are misdiagnosed. PD can be divided into subgroups based on the main clinical symptoms, i. e. tremor dominant, postural instability and gait difficulty (PIGD), and indeterminate. The PIGD subtype has worse prognosis including higher risk of dementia. The aims were to study the incidence of idiopathic parkinsonism and the different specific parkinsonian disorders in the Umeåregion and to investigate the patients early in the course of the disease with brainmagnetic resonance tomography (MRI), external anal sphincterelectromyography (EAS-EMG) and oculomotor examination. Can these methods improve the differential diagnostic work-up and/or differentiate between the subtypes of PD?

Methods: We examined all patients in our catchment area (142,000 inhabitants) who were referred to us due to a suspected parkinsonian syndrome. Our clinic is the only clinic in the area receiving referrals regarding movement disorders. During the period (January 1, 2004 through April 30,2009) 190 patients fulfilled the inclusion criteria and were included in the study. Healthy volunteers served as controls. 

Results: Incidence: We found the highest incidences reported in the literature: PD (22.5/100,000/year), MSA(2.4/100,000/year), and PSP (1.2/100,000/year). No CBD patients were encountered. Brain MRI: Degenerative changes were common both in controls and PD. There were no differences between the PD subtypes. EAS-EMG: Pathological changes in EAS-EMG examination were common in PD, MSA and PSP. It was not possible to separate PD, MSA and PSP by the EAS-EMG examination. Oculomotor examination: Pathological results were common in all diagnosis groups compared to controls. It was not possible to separate PD, MSA and PSP or the PD subtypes with the help of oculomotor examination.

Conclusions: The incidences of idiopathic parkinsonism, PD, MSA and PSP were higher than previously reported in the literature. It is not clear weather this is due to a true higher incidence in the Umeå region or a more effective casefinding than in other studies. MRI, EAS-EMG and oculomotor examination could not contribute to the differential diagnostic work-up between PD, MSA and PSP nor differentiate between PD subtypes early in the course of the disease.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2012. , 51 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1436
Keyword [en]
Parkinsonism, Parkinson's disease, Multiple system atrophy, Progressive supranuclear palsy, Incidence, Magnetic resonance tomography, Electromyography, Oculomotor
National Category
Neurology
Identifiers
URN: urn:nbn:se:umu:diva-50976ISBN: 978-91-7459-251-1 (print)OAI: oai:DiVA.org:umu-50976DiVA: diva2:471763
Public defence
2012-01-27, Hörsal E04, byggnad 6E, Norrlands Universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2012-01-05 Created: 2012-01-02 Last updated: 2012-04-27Bibliographically approved
List of papers
1. Incidence of Parkinson's disease and parkinsonism in northern Sweden: a population-based study
Open this publication in new window or tab >>Incidence of Parkinson's disease and parkinsonism in northern Sweden: a population-based study
2010 (English)In: Movement Disorders, ISSN 0885-3185, E-ISSN 1531-8257, Vol. 25, no 3, 341-348 p.Article in journal (Refereed) Published
Abstract [en]

The differential diagnosis of parkinsonian disorders is difficult, especially early in the course of the diseases. The clinical subtypes of Parkinson's disease (PD) have not so far been described in newly diagnosed patients. We present a prospective incidence cohort study of patients with idiopathic parkinsonian syndromes in the Umeå region in northern Sweden identified over a 4-year period. The clinical diagnoses were re-evaluated at follow-up visits at 12 months. We found 138 patients with parkinsonism: 112 PD, 12 multiple system atrophy with predominant parkinsonism (MSA-P), six progressive supranuclear palsy (PSP) and eight unclassifiable patients. The crude incidences for all age ranges per 100,000 were: PD 19.7 (95% confidence interval 16.1-23.3); MSA-P 2.1 (1.1-3.7); PSP 1.1 (0.4-2.4); idiopathic parkinsonism 24.3 (20.2-28.4). Age-standardized to the average Swedish population 2004-2007: PD 22.5 (18.3-26.7); MSA-P 2.4 (1.2-4.2); PSP 1.2 (0.4-2.6); idiopathic parkinsonism 27.5 (22.9-32.1). The crude annual incidence rate for PD, with exclusion of patients with normal dopamine receptor uptake (FP-CIT-SPECT), was 18.8 per 100,000 (95% confidence interval 15.2-22.4), age-adjusted to the average Swedish population 2004 to 2007: 21.5 (17.4-25.6). The incidence rates did not differ significantly between men and women. The cumulative incidence of PD up to 89 years of age was for men 3.4%, for women 2.6%, and for both sexes combined 2.9%. The annual incidence rates found for PD, idiopathic parkinsonism, MSA-P and PSP are among the highest reported.

Keyword
Parkinson's disease; parkinsonism; incidence; population-based; epidemiology
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-39348 (URN)10.1002/mds.22987 (DOI)20108376 (PubMedID)
Available from: 2011-01-24 Created: 2011-01-24 Last updated: 2017-12-11Bibliographically approved
2. Degenerative changes were common in brain magnetic resonance imaging in patients with newly diagnosed Parkinson's disease in a population-based cohort
Open this publication in new window or tab >>Degenerative changes were common in brain magnetic resonance imaging in patients with newly diagnosed Parkinson's disease in a population-based cohort
Show others...
2009 (English)In: Journal of Neurology, ISSN 0340-5354, E-ISSN 1432-1459, Vol. 256, no 10, 1671-1680 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to investigate newly diagnosed patients with Parkinson's disease (PD) with structural magnetic resonance imaging (MRI), to compare them with healthy controls, to relate the findings to clinical subtypes - tremor dominant (TD) or postural instability and gait difficulty (PIGD) - and to investigate the relationship between both the duration from onset of symptoms to diagnosis and the severity of symptoms and the MRI findings. Patients with a definite PD diagnosis were compared to patients with a probable PD diagnosis. We hypothesized that the PIGD subtype, the probable PD group, a greater symptom severity and a longer symptom duration would all be associated with more frequent pathological findings. Sixty-six PD patients were included and examined with MRI, 35 with the PIGD subtype and 23 with the TD subtype. Fifty-three had definite PD and 13 probable PD. Thirty healthy individuals, matched for age and sex, served as controls. Degenerative changes in the cerebellar cortex and the superior cerebellar peduncle were significantly more common in the probable PD group than in the controls, suggesting the possibility of an emerging atypical parkinsonian disorder. No significant MRI differences were found between definite PD and controls, between definite PD and probable PD, nor between PIGD and TD. No significant associations were found between duration to diagnosis and MRI results, nor between severity of symptoms and MRI results. Thus, although pathological MRI findings were common they can not be used to separate subgroups of PD in newly diagnosed patients.

Place, publisher, year, edition, pages
Berlin: Springer, 2009
Keyword
MRI, parkinsonism, diagnosis, parkinson’s disease
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-30092 (URN)10.1007/s00415-009-5177-4 (DOI)19484399 (PubMedID)
Available from: 2009-12-04 Created: 2009-12-04 Last updated: 2017-12-12Bibliographically approved
3. Anal sphincter electromyography in patients with newly diagnosed idiopathic parkinsonism
Open this publication in new window or tab >>Anal sphincter electromyography in patients with newly diagnosed idiopathic parkinsonism
Show others...
2012 (English)In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 126, no 4, 248-255 p.Article in journal (Refereed) Published
Abstract [en]

Objectives The differential diagnosis of patients with idiopathic parkinsonism is difficult, especially early in the course of the disease. External anal sphincter electromyography has been reported to be of value in the differential diagnosis between Parkinson’s disease and multiple system atrophy. Patients with multiple system atrophy are reported to have pathological external anal sphincter electromyography and patients with Parkinson’s disease are reported to have significantly less pathological external anal sphincter electromyography results. Comparisons between patients with parkinsonian disorders have usually been made many years into the disease, and thus it is largely unknown if the results of external anal sphincter electromyography can be used to distinguish the different diagnoses in the early phase of the disease.

Material and methods We investigated 148 newly diagnosed patients with idiopathic parkinsonism from a population-based incidence cohort (100 definite Parkinson’s disease, 21 probable Parkinson’s disease, 16 multiple system atrophy, eleven progressive supranuclear palsy, and 40 controls) with external anal sphincter electromyography within three months of their first visit and, in the majority of patients, before start of treatment with dopaminergic drugs. The clinical diagnoses were made using established clinical diagnostic criteria after a median follow-up of three years.

Results All patient groups had more pathological external anal sphincter electromyography results than controls. No external anal sphincter electromyography differences were found between the patient groups, especially not between Parkinson’s disease and multiple system atrophy.

Conclusions External anal sphincter electromyography examination cannot separate the different parkinsonian subgroups from each other in early course of the diseases.

Place, publisher, year, edition, pages
Hoboken, NJ: Wiley-Blackwell, 2012
Keyword
Electromyography, Multiple system atrophy, Parkinson’s disease.
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-50975 (URN)10.1111/j.1600-0404.2011.01633.x (DOI)000308205500006 ()
Available from: 2012-01-04 Created: 2012-01-02 Last updated: 2017-12-08Bibliographically approved
4. Impaired oculomotor function in a community-based patient population with newly diagnosed idiopathic parkinsonism
Open this publication in new window or tab >>Impaired oculomotor function in a community-based patient population with newly diagnosed idiopathic parkinsonism
2012 (English)In: Journal of Neurology, ISSN 0340-5354, E-ISSN 1432-1459, Vol. 259, no 6, 1206-1214 p.Article in journal (Refereed) Published
Abstract [en]

The differential diagnosis of idiopathic parkinsonism can be very challenging, especially early in the course of the disease. Oculomotor function has been reported to differ between the diseases constituting idiopathic parkinsonism. A detailed examination of the oculomotor functions could thus possibly be useful in the early differential diagnostic procedure. Oculomotor function could also differ between subgroups of patients with Parkinson's disease (PD). We examined the oculomotor function in a population-based incidence cohort with newly diagnosed idiopathic parkinsonism and 38 controls. We examined 135 patients with parkinsonism 105 PD, 11 progressive supranuclear palsy (PSP), and 19 multiple system atrophy with predominant parkinsonism (MSA-P)] within 3 months of their first visit to our clinic and before initiation of dopaminergic medication. The oculomotor measurements were repeated after 12 months. The clinical diagnosis was that of the latest clinical follow-up (median follow-up was 3 years). All patients were examined with (123)I-N-(omega)-fluoropropyl-2-β-carbomethoxy-3-β-(4-iodophenyl) nortropane single-photon emission computed tomography (FP-CIT SPECT), and only patients with pathological uptake of the ligand were included. Pathological changes in the oculomotor function were found in all patient groups compared to controls at the baseline examination. In PD, there were correlations between total axial motor scores and vertical saccade velocity and precision, horizontal saccade velocity and precision, and smooth pursuit gain at 20 and 30°/s. Oculomotor test results could not separate the different forms of idiopathic parkinsonism in the early phase from each other. Few changes in the oculomotor functions were observed between the baseline and the 12-month follow-up examinations. No correlations were found between the oculomotor measurements and disease severity or duration.

Keyword
parkinson’s disease, parkinsonism, oculomotor, gaze palsy, eye movements
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-50804 (URN)10.1007/s00415-011-6338-9 (DOI)000304859300027 ()22173951 (PubMedID)
Available from: 2011-12-22 Created: 2011-12-22 Last updated: 2017-12-08Bibliographically approved

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