IMRAN AHMAD’, USAMA BIN ZUBAIR™
‘aritant rote of Nelo Svs Unaersy Media ané Dental Coleg, PAS Sls Kaa Faitan
"Medea fea Mk RP Paton
ORIGINAL ARTICLE
‘Submitted: May 10,2016
‘Accepted: August 15,2016
‘CORRESPONDENCE: USAMA BIN ZUBAIR, &-mai drusamabinaubaieyhoo com Contact: 0321-5209950
ABSTRACT
OBJECTIVE
Toscreen the patients of Parkinson disease for presence
cofnonmotorsymptoms
STUDY DESIGN
Crosssectionalstudy.
PLACE AND DURATION OF STUDY
Three months curation observational study was cried
‘tat Miltary Hospital Rawalpindi ftom October 2015t0
December2015.
SUBJECTS AND METHODS
‘Althe patient of Parkinson's disease (PO) presenting in
rnewology department filed 3 sef administered Non
Motor System questionnaire (NMS Ques} comprising of
30-tmes. Patients had to respond as "es of “no” to
teachitem Frequency ofeach symptom wascaleulatedto
lookforthecommonnNMSexperiencedby patients.
RESULTS,
1 total of 62 patients were screened though NMS
‘questionaire, Mean age of patients was 645 (ange
34-91 year). 9353 were male. The mean of total
Symptoms postive on NMS Quest was 118. Most
commonly experianced NMSincluded nocturia (80.61%)
and unexplained pains (60.51%) followed by gency
(70.9%) and constipation (67.790). NMS least reported
were dificult during sex(1.61%) andchangein sexcrive
(8.06%) followed by diplopie (12.9%) and incomplete
bowel emptying(16.1%).
CONCLUSION
The study concluded that prevalence of NMS among
patients of PD was high 50 these symptoms shouldbe
assessed carefully by physicians at the time of
onsutation 50 that overall qualty of ie of patients s
improved.
INTRODUCTION
In 1817 JamesParkinson described Parkinson disease PD} forthe estima
his famous essay. Ics @ commen, idlopathic lsorder associated with
inadequate dopamine in brainstem due da degeneration of neurons inthe
substantianigra,
“Traitionall only motor symptomatology was associated with PD, now itis
considered as abroad spectrum disorder with multiple features induding
psychiatric and nor-motor manifestations (NMS. These include cognitive
Sysfuncion, anhedonia, hallucinosis and other csordes related to mood
and behavior. Hyposmia, pain, bad sleep quality and other sensory
disturbances like numbness, coldness, burning and paasthesis ae aso
common. Majority of PD patients have complains related to autonomic
system as well including constipation, postural hypotension and urogenital
problems.
NMS may be related to neurodegenerativ changes affecting several neural
systems andor caused by drugs employed in treatment of PD-The clinical
Picture of PD may be considered as iceberg, The visible part presents the
‘motor symptoms andthe largernon visible part represents the several NMS,
Martinez Matinetal performed multicetricintemational cross sectional
study using the NMS Questonnaie and reported that NMS were presenta
98.4% ofthe patients. The PRIAMO study showed similar resus hat NMS
were resentinthevastmajoiyof PD patents
Previously ony lateor advanced PD wasassociatedith presenceofNMSbut
a study done in recent past fed ths myth revealed that non-mator
‘manifestations may occur ealer than motor disturbances and cause more
18 who gave writen
‘consent were included in the study regardless of the duration of
clsease Pediatric patients patients already on psychiatric eatment
and those whe didnot iveconsent or were unable to understand or
‘complete the questonnaire were excluded frm the study. UKBrain
Bank citron was used to dlagnose the patients of PD he Patents
presenting with tremor, bredyknesa wth or without rigity and
posturainstabilty wereincudedintheanahsis
Instruments
Non motor Symptoms Questionnave (The NMSOuest) is 230 item
screening tool used to look or non tormanfestationsofPD..tsa
sel eporting instrument comprising of 12 NMS domains wich
include GIT, urinary, CVS, respiratory, neuropsychiatric, cutaneous
and sensory symptoms, Disorders of sleep, apathy, fatigue and
attention are also part these domains. ach domain includes 208,
specficquesionfeaturingansnersasyesorno,
Procedure
‘After ethical approval from ethical committe Miltary Hospital
Rawapinl this cross sectional study was cad rom October 2015
to December 2015. The patients were provided with a detalles
description of the study Inclusion was sity based on informed
‘writen consent. All consenting PO patients completed the NMS
‘Questionnaire in outpatient department (OPO) while waiting for
their tun to meet the treating physician. Help of caregivers was
acquited where necessary. Routine history Including information|
about drugs and the demographic profile were entered in a
Structured form, The NMSQvest used nthe study ee annexure Al
Frequency ofthe individual non motor symptoms was abtaines by |
adding all the “yes” responses. Percentage was calculated by
transforming the fequenciesrelatedt the numberof patientsinthe
sample. Prevalence ofeach domain was obtained by vansforming
the sum of item postive responses on the maximum possible
numberof postive responses inthe domain. All statistical analysis
was performed using Statistics Package for Social Sciences version
200.
RESULTS
[Ate the application of incision and exclusion criteria total 62
patients wereincludednthe analysis Mean age of patients was645
(range 34-91 years) 93.5% were male. Table 1 and ? showed the
‘frequency and percentage of invdual symptoms and domains
respectively The mean oftotalsymptomspostiveon NMS Quest as
11.8 Most commonly experienced NMS included nocturia (80.51%)
and uneepained pains (80.61%) folowed by urgency (709%) and
Constipation (67.79. NMS least reported were ifclty during sex
(1.61%) andchangein sexdrve (8.053) followed diplopia 12955),
and incomplete bowel emptying (16.18). Domain most commonly
affected is urinary (75.75% of the individuals eporced) followed by
‘depression andanxiety (asreportedby6605%findividuas
Frequeney and percents of poste reponse
Wei
Renenbsing
Cons
Seiten
Dayne
‘ain ing re
‘Seating
22 EEE EEEEEE RE
‘rate
ostvempms anal accofing to NMS Quest di
a SOT
Deon
suey Serene 2016 | WOLUME 1 mune 2Pure 1
‘Spec of NMS presented by th punts in ou std.
TREE
eit
Bey
DISCUSSION
Rests ofourstudy show thata wide spectrum ofNMS exists among
all the patents suffering frm Parkinsonism. Simla resus were
reported ina study done on more than 1000 patents that NMS were
present among ll the patients of PD regardless of stage of disease’
Ranging from urinary problems to neuropsychiatic symptoms,
variety of NMS may be present in one patient so this demands the
requirement for a detailed asseszment at the time of patient
presentatoninOPD.
LUsinary problems were the commenestamong most f the patients
Noctua was present in 806% patients and urgency in 70.9%. n an
international study done by K.Ray Chaudhur et l these symptoms
ere 6594 and 605% respectively”. Hyperactivity of detrusor due to
dysfunction of dopaminebsasalganglaccut maybe respoasibiefor
urinary problems As the disease advances and there srse in motor
‘symptoms, lower urinary tract problems also increase. Degeneration
‘of neurons producing dopamine may be the cause. Use of
lntichalinergicagent toreduce detrusor hyperactivity mustbe very
vigilant
Unexplained pains not elated oaths a other systemic problem
were reported in 805% of te cases which sin accordance with the
results ofrevew ate that painisthemost frequent complaintwith
‘which patients of PD present. Iti often neglected and treated
inadequately de to more focus on motor symptomatology” and its
prevalenceincreaseswith thedurationfeisease™”.
Gastrointestinal symptoms were also present in considerable
number of patents especially constipation was reported in 67.7%
‘cases. Sila results were shown ina study done in Malaysia that
dsabling constipation was the commonest NMS experienced by
61.9% ofthe patients”
Sexual symptoms were ver rarely reportedinour study as compared
With other studies which showed high frequency of Sexual
dysfunction amang patent of PO” Previous research showed that
‘men suffering from PO are also at inereased risk of develoing
cerecle dysfunction” Under reportinginourstudy may ede tothe
Socal baer that patients hesitate in teling these symptoms to
physician in out set up oF usually people here think that sexual
acttyconcernsonlyof youngage grup.
Neuropsychiatric symptoms also make major bulk of NMS in PD
patients. Chronic diseases involving Welong medication cause
signicantpsychiatic morbidity. In cae of PD abnoxmal neuronal
pathways and neurotransmitter imbalances may add to the
Situation. 6.05% of ourpatients showed anxiety and depression like
features. Astudydonein thesamehospitalby psychiatry department
Inthe past showed that depression and anwety were present n 38%
cfthepatients". MajrtyofPD patent presentwithsleep disorders.
(Our data showed 41.2% patients complaining of sie disturbances
(ut of which intense viv dreams was commonest followed by
insomnia and acting out of dreams similar to results of The PRAMO
Study showing insomnia and RED as chief lep disorders present in
PD patient.
Postural hypotension sa common symptom in many patents with
parkinsonism” Faure of autonomic system n these patients is main
‘cause of drop in blood pressure an changing the posture. 27.94 of|
the patients in our study complained of dizziness on change of
osture which is very much in accordance with the avalabe data.
COurstudyhasfew limitations. NMSQuestissubjectiveandit doesnot
cover certain areassuch asspeech,gaitand dopamine dysregulation
syndrome. The sample size and use of self administered
questionnaires pose methodological issues as well. The findings
cannot be generalized a or study population wasmot selected fom
‘andomized patients of PD from all neurology units of Pakstan, We
suggest further studies ona broader based and a more
‘epresentativesamplesie preferably case controlstudesthat would
be hepfulin giving true prevalence of some ofthe commoner NMS.
‘CONCLUSION
‘The study concluded that prevalence of NMS among patients of PD
was high 50 these symptoms shouldbe assessed careful by the
‘hysicians atthe ime of consultation sa that overall quality of feof
patients maybe improved
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Non motor Symptoms Questionn:
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