Nonmotor PD Symptoms Bolster Disease Severity Assessment

Kate Johnson

October 07, 2013

MONTREAL, Quebec, Canada — The staging of nonmotor Parkinson's disease (PD) symptoms should be an integral part of disease severity assessment and treatment decisions because such symptoms can severely impair a patient's quality of life even when motor symptoms are mild, researchers reported at the World Parkinson Congress here.

"This nonmotor staging that we are proposing is a novel way of prioritizing how to refer patients early for proper care and treatment," senior investigator Ray Chaudhuri, DSc, told Medscape Medical News.

"Many doctors rely only on motor symptoms missing advanced nonmotor symptoms, such as depression, pain, sleep problems, sexual problems, as well as apathy and constipation, for instance, in a patient who may have very early motor PD, such as a slight hand tremor," said Professor Chaudhuri, who is a researcher at King's College London's Institute of Psychiatry and director of the National Parkinson Foundation-accredited International Centre of Excellence at King's College Hospital in London, United Kingdom.

Professor Chaudhuri and his team recently published (PLoS One. 2013;8:e57221) a proposed method of staging nonmotor symptoms based on patient scores on the NonMotor Symptoms Scale (NMSS).

Scores of 1 to 20 (mild) are classified as a nonmotor symptom burden (NMSB) of 1, scores of 21 to 40 (moderate) are classified as NMSB 2, scores of 41 to 70 (severe) are NMSB 4, and scores greater than 71 (very severe) are NMSB 5.

In this observational, cross-sectional international study, researchers looked at the relation of NMSB stage to motor symptoms staged on the Hoehn and Yahr (H&Y) scale in 933 consecutive patients and found little correlation in the severity of both scales, reported Elisaveta Sokolov, MBBS, also from King's College London, who presented the results at the congress.

Table. Motor and Nonmotor Symptoms in the PD Cohort

H&Y Stage NMSB 0 NMSB 1 NMSB 2 NMSB 3 NMSB 4 Total
H&Y 1 3 45 48 19 9 124
H&Y 2 2 104 144 77 77 404
H&Y 3 0 34 77 75 94 280
H&Y 4 0 6 17 24 59 106
H&Y 5 0 0 1 1 17 19
Total 5 189 287 196 256 933


This pattern held true in a subsequent cohort of 517 patients with a mean age of 68 years.

"More than 70% of the patients had a nonmotor symptom burden that was severe or very severe," she said, even though the median motor symptom burden was H-Y stage 2. "Even at a very mild or relatively mild motor stage, such as H-Y 2 to 2.5, the nonmotor symptom burden can be great."

Specifically, 70% of patients had an NMSB of 3 or 4, while roughly 29% had NMSB 2 and 1% had NMSB 1. However, for motor symptoms, roughly 30% had H-Y grade 2, 23% had H-Y grade 2 to 2.5, and 20% had more severe symptoms.

"In the diagnosis of Parkinson's patients, we should consider not only the motor symptoms…but must take into consideration the nonmotor symptoms especially because of the key impact on their quality of life," she concluded.

The average patient with PD has 6 to 8 nonmotor symptoms, said Professor Chaudhuri. "This is the new face of Parkinson's and integral to PD," he told Medscape Medical News. But he said this aspect of PD is largely neglected in clinical practice.

"We have found that up to 68% of clinic consultations do not address nonmotor problems," he said during a plenary symposium at the congress.

"It is the combination of motor and nonmotor symptoms that determines a patient's quality of life, and so the challenge is to come up with a global management strategy. Our grading system correlates very closely with QOL [quality of life] and addresses the need for treatment."

Asked for comment on these findings, Serge Przedborski, MD, PhD, chair of the congress's program committee, said the recognition of nonmotor symptoms is transforming the definition of PD.

"Before, when we didn't have very effective treatments for the motor aspects of PD, the nonmotor symptoms were masked because the motor symptoms were so bad," he told Medscape Medical News. "Now we have a much longer time frame during which the motor manifestations are under control, and because of that the nonmotor symptoms interfere with quality of life."

But Dr. Przedborski said staging nonmotor symptoms is only the first step.

"We need scales targeted towards measuring nonmotor manifestations but also towards the treatment of them," he said. "We need to have objective measures of response to treatment, otherwise we're going on observation and patient feedback and that is not reliable enough to inform the community, patient and physician about the quality of a treatment strategy."

The study was funded by the United Kingdom National Institute of Health Research and the Department of Health. None of the speakers have disclosed any relevant financial relationships.

3rd World Parkinson Congress (WPC). Abstract #P12.29. Presented October 3, 2013.


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