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 2Pure 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 REFERENCES, |. Patkinson J An Essay on the Shaking Palsy, Sherwood, Neely, and Jones London 1817 2 Stacy M. Nonmator symptoms in Parkinson's disease Int J Neurosci 2011; 121 Suppl2:9-17. 3. Martinez Matin P, Schapira AH, Stocchi Fetal: Prevalence of nonmetor symptoms in Parkinson's esease in an international setting study using nonmotor symptoms questionnaire in $45 Patents. Mov Disord, 2007; 2: 1623-1629. 4. Barone P, Antonini A, Colosimo C. Roberto Marconi et a. The PRIAMO study: a. multicenter assessment of nonmotor symptoms and thelr impact on qualty of life in Parkinson's disease Mov Disord, 2009; 24 1641-1649, Ju0Y-SETENBER 2076 | VOLUME 13 NUMBER 31, 8 4. 16. u. 18. 19. 2, 2. 2, Santamaria J, Tolosa E, Valles A. Parkinsons disease with 4epresson: a possibe Subgroup of iiopathc Parkinsonism, Neurology. 1986;36:1130-1133, Sulvan $5, Wiliams DR, Galagher DA, Massey LA, Moriyama 1S, Lees Al. Non motor symptoms as presenting complains in Peskinsons disease: a cinicpathological study. Movement Disorders, 2008;23(1) 101-106 Shulman UM, Taback Rl, Bean J, Weiner W Comority ofthe onmotor symptoms of Parkinson's disease. Movement Disorders.2001;16(3:507-510. De Souza Varun R, Kakode P et a. Non_motor symptoms in lian patients with Parkinson's eens. Basal gangla, 2015; 5489-93, Lee HM, Koh 8, Many Faces of Parkinson's Disease: Non Motor ‘ymptomsof Parkins s Disease. Mov Disord 2015.May 82) 92-97 AatslandD, Larsen J, Tandberg, Lake K Predictors of nursing home placement in Parkinson's disease: a population-based, prospectivestudy.JAm GeriatSoc 2000 Aug: 481) 938-42. Muerengl 5, Lewis H, Edwards M Ks E eta. Non-motor symptomsin Parkinson's disease: An under diagnosed problem. ‘Aging Health. 2006; 216 967-98, Rana AQ, AhmedUS,Chaudry 2M, VasanS Parkinson sdsease:2 review of nor-motor symptoms. Expert Rev Neurother, 2015 May; 1515): 549.62. ‘Abbas N, Jahangeer 5, Rashid S. Frequency of ansety, depression and cognitive impairments in PD.PAFMU, Dec 2003; 5302519347 Hughes Al, Daniel SE, KfordL, Lees Al Accuracy of clinical diagnosis of idiopathic Parkinson's disease: 2 lniopathologial study of 100 cases. J Neurol Neurosurg Psychiat. 192:55:181-188 Chaudhuri KR, Jucynsta CP Naidu etal. The Non declaration ‘of Non mator Symptoms of Parkinson’ disease to HealthCare Professionals: An Intemational Study Using the Non motor ‘Symptoms Questionnaire. Movement Disorders. 2010; 256): 704-708. Sakakibara R, Uchiyama T,YamanishT, Kishi M. Genitourinary fysfuncton in Parkinson's dsease, Movement Disorders. 2010, 25(0e2-12 FILA, Cano-de-le-Cuerda R, Mufor Helin E. Pain in Parkinson dlsease: A review of the Ieratue, Parkinsonism & Related Disorders March 2013;193):285-294 Koler WC Sensory symptomsin Parkinson’ sdisease Neurology. 1984; 34(7; 957-95. Lee MA, Walker RW, Hirth T) Prentice WM, survey ofpain in idiopathic arkinso's ease. Joumal of Pain and Symptom Management 206; 32(5:462-469, ‘AaminS, Mana, Anuar, Tan etal Non motor Symptoms in Malaysian Parkinson sDisease Population. Patkinson'scsease. 2014 Api 2014(2:472157,DOL10.1155/2014/472157 Sakakibara, Shinotoh H, Uchiyama T et al. Questionnaie- based assessment of pec organ dysfunction in Parkinson's disease Autonomic Neuroscience. 2001;92(1-21.76-85. Ga0X.chenH Schwarzschild MA etal Erectile function and isk of Parkinsons disease. American Joumalof ideology, 2007; 166125 1446-1450, Senara JM, Rai S, Lapeyre-Mese M et al Prevalence of omhostatic hypotension in Parkinsons disease. Journal of NeurologyNeurosurgeryandPsychiaty.1997:63(5):584-589, Non motor Symptoms Questionn: Parkinson disease (NMSQuest) ‘Nom motor symptoms in Parkinsonism for patients of ate Se Age Duration of Parkinsonism Contact No Lact Have you experienced anyone ofthe following last month? [ay ined fine 2 [St ae aio oF snipes Bonen eT aT Tle veep en a ri voi i psig ee TE Pie wich arena yay ian Tae 1 Fete ng res or is Tr Las finer dos a PP a Te Fs ow Ho 8] ing wk TT a | bin mapas anew vE NTS 5 [ng ie pia wn PsP Ezra eg PT se tapas Es ecate Jy SePrEMeER 2016 VOLUME 13 NuMBER 3