Professor K Ray Chaudhuri

Transcription

1 Centre of excellence Parkinson s Care and Research The Spectrum of Non Motor Symptoms in Parkinson s Evolving concepts Professor K Ray Chaudhuri St Thomas Hospital Guy s Hospital National Parkinson Foundation International Centre of Excellence Kings College Hospital, Kings College London

2 Why are NMS important? The evidence

3 Dr James Parkinson ( ) Politician, Geologist, Artist, Doctor The NMS of PD were recognized by James Parkinson himself. Thus, in his Essay on the Shaking Palsy in 1817, he referred to sleep disturbance, constipation, dysarthria, dysphonia, dysphagia, sialorrhoea, urinary incontinence and, at the last, constant sleepiness with slight delirium. Chaudhuri and Quinn. NMS of PD Oxford Univ Press. 2010

4 What is Parkinson s? The traditional view! Parkinson s disease is one of the most common neurodegenerative diseases First described by James Parkinson in 1817 in An Essay on the Shaking Palsy The main pathological feature is the degeneration of neuromelanin-containing neurones in the pars compacta of the substantia nigra; resulting in depleted levels of dopamine within the brain PARKINSON S DISEASE NORMAL 18 Images taken from Fast Facts: Parkinson s Disease Third Edition 2010; K Ray Chaudhuri, C G Clough, K D Sethi

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6 NMS Phenomenology PD is more than just a motor disorder Parkinson s disease (PD), one of the most frequent neurodegenerative disorders, is no longer considered a complex motor disorder characterized by extrapyramidal symptoms, but a progressive multisystem or more correctly multiorgan disease with variegated neurological and nonmotor deficiencies. K Jellinger. Mov Disord 2012

7 What are the NMS of Parkinson s Todorova et al. 2014

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11 NMS prevalence (holistic) Highly prevalent 98.6% Barone et al. (n = 1072) % Chaudhuri et al (n =935) 2013

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13 NMS are typically thought to occur in advanced PD but now recognised as frequently in untreated and premotor stage

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17 Chaudhuri KR, Yates L, Martinez-Martin P. The non motor symptom complex of Parkinson s disease: time for a comprehensive assessment. Current Neurol Neurosci Reports ;5 :

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19 PrePhysiological Genetics Preclínical: neuroimáging Premotor: Prediagnóstic:

20 NMS Poor quality of life

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22 Martinez-Martin et al. Mov Disord 2011; 26: Correlations NMSS with PDQ-39 and EQ-5D N=411

23 N=411 * Mann-Whitney test. Benajmini-Hochberg adjustment, p < 0.026

24 NMS Subtypes

25 There are different types of Parkinson s Motor vs Non Motor Parkinson s

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27 NM Endophenotypes/Subtypes Chaudhuri et al. PLOS One Chaudhuri et al. MDS Sydney 2013 Park Cognitive Park Depression/Anxiety Park Sleep Park Pain Park Fatigue Park Autonomic

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29 Detection of NMS is useless if we do not recognize the problem

30 Table 3: Potentially treatable NMS of PD undeclared to health care professionals across several European centres. NMS % Undeclared Potentially Treatable Dribbling saliva 45.5 BTx, Atrovent, oral atropine, swallow timer Vomiting 42.1 Domperidone ConstipatioN 46.1 Macrogol Hallucinations 41.5 Drug modifications/neroleptic Anxiety 39.6 Anxiolytics EDS 52.4 Modafinil, sleep hygiene, caffeine RBD 44.1 Clonazepam, melatonin Insomnia 43.9 Hypnotics, nighttime CDD None of these symptoms were treated prior to NMSQuest use even in major PD centres Chaudhuri KR et al. Mov Disord 2010;25(6):704 9.

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32 National Parkinson s Audit (Parkinson s UK 2011,) over 6,000 people with PD from 325 services across the UK, highlighted a number of failings in PD patients experience, including: 39% of newly diagnosed patients were not provided with written information about PD A third of newly diagnosed patients waited longer than six weeks to see a specialist Around a third of physiotherapists, speech and language therapists, and occupational therapists working in specialised neurological services did not receive updated training on the management of PD Many > 40% had no NMS assessment All-Party Parliamentary Group on Parkinson s Disease in 2009 revealed major inequalities across the country in access : Significant shortfalls in access to Parkinson s disease nurse specialists, particularly across Northern Ireland and Wales Poor access to therapy services Poor information provision and signposting, especially with regard to social care Lack of integrated working between the range of services involved in the different aspects of care for people with Parkinson s disease and carers Parkinson s UK, National Parkinson s Audit Summary 2011, 2011 All-Party Parliamentary Group for Parkinson's Disease, Please mind the gap: Parkinson's disease services today - Inquiry into access to health and social care services for people with Parkinson's disease and their carers, July 2009

33 NMS The first holistic tools to be scientifcally validated

34 FIRST MULTIDISCIPLINARY PARKINSON S DISEASE (PD) NON-MOTOR SYMPTOM (NMS) MEETING FOR DEVISING A NON MOTOR SCALE FOR ASSESSMENT OF PD (Supported by Parkinson s UK, MDS, Industry) PENNYHILL PARK, SURREY, UK 5,6 FEB 2004

35 The first validated sleep scale for PD: PDSS (Chaudhuri et al 2002/2011) Now used worldwide Translated to 32 languages PDSS 2 (2011) The first validated NMS questionnaire NMSQuest Empowering patients across the world to declare NMS to HCP Worldwide use Chaudhuri et al 2006 The first validated NMS scale (NMSS) Worldwide use for clinical trials and epidemiology Chaudhuri et al 2007/2009

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37 Holistic assessment of NMS is now possible

38 For prevalence studies NMSQ & PRIAMO Quest Yes / No MDS-UPDRS & NMSS 0 = No >0 = Yes Mov Disord 2006; 21: Mov Disord 2007; 22: Mov Disord 2008; 23: Mov Disord 2009; 24:

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41 Non-Motor Symptom Assessment Scale for Parkinson s disease Symptoms assessed over the last month Each symptom scored with respect to: Severity: 0 = None 1 = Mild (symptom present but cause little distress or disturbance) 2 = Moderate (some distress or disturbance to patient) 3 = Severe (major source of distress or disturbance to patient) Frequency: 1 = Rarely (< 1/ week) 2 = Often (1/week) 3 = Frequent (several times per week) 4 = Very frequent (daily or all the time) Total score - Possible range: 0 12 points

42 The MDS-UPDRS I. Non-Motor Aspects of Experiences of Daily Living (nm-edl)

43 Now used worldwide Translated to 14 languages Recommended by MDS Parkinson s UK DH UK EPDA

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45 NMSQ score 5/30, untreated PD HY 2 NMSQ score 19/30, untreated, HY 2

46 Table 4. Classification of PD using NMS burden levels. Staging by NMSQuest (can be performed by HCP based on patient responses using NMSQ) Chaudhuri et al (Kings-ISCIII classification) Stage 1 NMSQ 0-5 Stage 2 NMSQ 6-12 Stage 3 NMSQ Highly significant correlation with HrQol Inverse relationship Stage 4 NMSQ Grading by NMSS (to be used for clinical and research based studies) (PLOS ONE) Chaudhuri et al 2013 Stage 1 NMSS 1-20 Stage 2 NMSS Stage 3 NMSS Stage 4 NMSS - 71

47 Non Motor Symptoms Questionnaire Levels No Mild Moderat e Severe Very sev. NMSQuest Score Age (ys.) n.s Sex (males) n (%) 2 (0.8) 44 (18.6) 61 (25.7) 51 (21.5) 79 (33.3) n.s. PD Duration (ys.) Motor examination Motor complications NMSS Total HADS-Anxiety HADS-Depression Fatigue VAS n.s. PDQ8-Index summary p

48 Key Messages Any PD patient will have 6-8 different NMS NMSQuest is the only patient completed validated tool and still not widely used in the UK leading to sub optimal mamagement NMS burden is one of the key determinants of quality of life of PwP and carer NMS burden can be easily graded according to severity Aspects of NMS are likley to emerge as clinical biomarkers for pre-motor PD and early PD (NMSQ + Scopa aut + imaging) Robust animal models are lacking Holistic assessment in clinic is essential for optimal care

49 Acknowledgments Kings Parkinson s Centre of Excellence Research Team Prof K Ray Chaudhuri Director Dr A Todorova Clin Res Fellow Dr A Sauerbier Clin Res Fellow Dr N Dimitrov Clin Fellow Dr L Kilngelhoefer Visiting Res Fellow Dr Z Panaogtis Visiting Res Fellow Dr P Reddy. Res Fellow and consultant Statistical and Data support Prof P Martinez-Martin and team (Madrid) KCL Collaborators: Prof Richard Brown Prof Clive Ballard Prof Anthony David KCH: Dr M Samuel, Mr K Ashkan, Dr D Martino Ms Alexandra Rizos : European Research Manager Ms Louise Gallagher Research Nurse Ms Emma Ekins Research Nurse Ms Miriam Parry : PDNS and part time research nurse Ms Rona Iniss : PDNS and and part time research nurse Ms Anne Martin : PDNS Ms S Bassi: data coordinator Animal Model Team: Prof Peter Jenner Dr Sarah Salvage Dr Erika Colletto We also acknowledge support from Europar, MDS Non Motor Study Group, NIHR BRC and Parkinson s UK

50 Thank you for your attention! Acknowledgements: Parkinson s and MDS non motor study group Kings Parkinson s Centre of Excellence Research Team Academic Grant from Biomedical Research Centre (Kings College), National Institute of Health Research Parkinson s UK EPDA UCB, AbbVie, Britannia