A multicenter assessment of nonmotor symptoms and their impact on quality of life in Parkinson's disease


Movement Disorders
Volume 24, Issue 11, Pages 1641-1649
Published Online: 9 June 2009

Paolo Barone, MD, Angelo Antonini, MD, Carlo Colosimo, MD, Roberto Marconi, MD, Letterio Morgante, MD, Tania P. Avarello, MD, Eugenio Bottacchi, MD, Antonino Cannas, MD, Gabriella Ceravolo, MD, Roberto Ceravolo, MD, Giulio Cicarelli, MD, Roberto M. Gaglio, MD Rosa M. Giglia, MD, Francesco Iemolo, MD, Michela Manfredi, MD, Giuseppe Meco, MD, Alessandra Nicoletti, MD, Massimo Pederzoli, MD, Alfredo Petrone, MD, Antonio Pisani, MD, Francesco E. Pontieri, MD, Rocco Quatrale, MD, Silvia Ramat, MD, Rosanna Scala, MD, Giuseppe Volpe, MD, Salvatore Zappulla, MD, Anna Rita Bentivoglio, MD, Fabrizio Stocchi, MD, Giorgio Trianni, MD, Paolo Del Dotto, MD, on behalf of the PRIAMO study group.

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We performed a multicenter survey using a semistructured interview in 1,072 consecutive patients with Parkinson's disease (PD) enrolled during 12 months in 55 Italian centers to assess the prevalence of nonmotor symptoms (NMSs), their association with cognitive impairment, and the impact on patients' quality of life (QoL). We found that 98.6% of patients with PD reported the presence of NMSs. The most common were as follows: fatigue (58%), anxiety (56%), leg pain (38%), insomnia (37%), urgency and nocturia (35%), drooling of saliva and difficulties in maintaining concentration (31%). The mean number of NMS per patient was 7.8 (range, 0-32). NMS in the psychiatric domain were the most frequent (67%). Frequency of NMS increased along with the disease duration and severity. Patients with cognitive impairment reported more frequently apathy, attention/memory deficit, and psychiatric symptoms. Apathy was the symptom associated with worse PDQ-39 score but also presence of fatigue, attention/memory, and psychiatric symptoms had a negative impact on QoL. These findings further support a key role for NMS in the clinical frame of PD and the need to address them specifically in clinical trials using dedicated scales.

© 2009 Movement Disorder Society

Received: 19 January 2009; Revised: 30 March 2009; Accepted: 4 April 2009

Podcast Summary by Joaquim Ferreira, MD, PhD, Neurological Clinical Research Unit , Institute of Molecular Medicine, Lisbon, Portugal

The PRIAMO study (Parkinson and non Motor symptoms) is a multicentre, observational study with both cross-sectional and longitudinal components (conducted in Italian movement disorders centres) designed to evaluate the prevalence and incidence of non-motor symptoms (NMS) in patients with parkinsonism.

The paper published in The Movement Disorders Journal only reports on the baseline assessment of patients with idiopathic Parkinson's Disease in terms of NMS. The secondary objectives were to evaluate the association of NMS with cognitive impairment and the impact on patients' quality of life (QoL). 1,072 PD patients were evaluated using a semi-structured interview based on the NMS questionnaire for PD (NMSQuest).

The study concluded that almost all patients (99%) reported complaints corresponding to NMS. The most commonly reported symptoms were fatigue (58%), anxiety (56%), leg pain (38%), insomnia (37%), urgency and nocturia (35%), drooling and difficulties in maintaining concentration (31%). In the secondary analysis a tendency to an increase in the frequency of NMS along with disease duration and severity, and cognitive dysfunction was identified.

The appraisal of this study deserves the following comments:

1. The generalization of the conclusions must take in consideration that the study sample included mostly early and intermediate stage PD patients (mean disease duration of 5 years and 80% without motor fluctuations);

2. Though the PRIAMO study design also includes a prospective follow-up of these patients, the cross-sectional nature of the published analysis limits the value of the correlations generated as measures of disease progression;

3. The definition of NMS was based on the response (yes/no) to a semi-structured interview which in practice corresponded to the patient's perception of the presence or absence of specific complaints and not the assessment by a dedicated scale or an objective measure of a predefined event;

4. The discrepancies with the results reported in past "NMS papers" regarding the frequency of NMS, might reflect methodological issues (e.g. recruitment criteria, screening tools for NMS) and not true differences.

The PRIAMO study constitutes the largest ever published study designed specifically to evaluate the frequency of NMS in PD. The very high frequency of NMS complaints in a large sample of PD patients, even in an early disease stage, has clear implications for our clinical practice. However, besides the need to recognize its presence, we cannot conclude from this study on the severity of these same complaints nor on the frequency of similar symptoms in the general population if measured with the same instruments. The true association between NMS, disease progression and QOL will have a more suitable assessment once the longitudinal data is available.

The conclusions from the PRIAMO study highlight the growing relevance of NMS for the management of PD and the need to recognize symptoms like fatigue, anxiety and pain in patients with PD. It also reinforces the role of non-dopaminergic systems in the pathology of PD.

About Prof. Joaquim Ferreira, MD, PhD

Joaquim Ferreira, MD, PhD, is an attending physician in Neurology at the University Hospital of Santa Maria and Assistant of Pharmacology and Therapeutics at the Lisbon School of Medicine, Portugal.

He became interested in movement disorders during his medical degree and obtained neurological training at the University Hospital of Santa Maria. From 1999-2000, Dr Ferreira undertook a Clinical Pharmacology fellowship with Professor Olivier Rascol in Toulouse, France.

Dr. Ferreira is currently Coordinator of the Movement Disorders Unit of the Neurological Clinical Research Unit of the Institute of Molecular Medicine, Lisbon, and has served as Principal Investigator for multiple clinical trials. He is also Coordinator of the Movement Disorders Cochrane Review Group. In addition, Dr Ferreira serves chair of the Education Sub-committee of the European Movement Disorders Section. His major research interests are Parkinson's disease, dystonia, botulinum toxin and neuropharmacology.