Accepted Manuscript Impulse control and related disorders in Mexican Parkinson´s disease patients Mayela Rodríguez-Violante , Paulina González-Latapi , Amin Cervantes-Arriaga , Azyadeh Camacho-Ordoñez , Daniel Weintraub PII:
S1353-8020(14)00217-X
DOI:
10.1016/j.parkreldis.2014.05.014
Reference:
PRD 2353
To appear in:
Parkinsonism and Related Disorders
Received Date: 10 March 2014 Revised Date:
29 April 2014
Accepted Date: 27 May 2014
Please cite this article as: Rodríguez-Violante M, González-Latapi P, Cervantes-Arriaga A, CamachoOrdoñez A, Weintraub D, Impulse control and related disorders in Mexican Parkinson´s disease patients, Parkinsonism and Related Disorders (2014), doi: 10.1016/j.parkreldis.2014.05.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Impulse control and related disorders in Mexican Parkinson´s disease patients Mayela Rodríguez-Violante a,b*, Paulina González-Latapi a, Amin Cervantes-
a
Clinical Laboratory of Neurodegenerative Diseases, National Institute of
Neurology and Neurosurgery. Mexico City. Mexico.
Movement Disorders Clinic, National Institute of Neurology and Neurosurgery.
SC
b
Mexico City. Mexico.
Departments of Psychiatry and Neurology, Perelman School of Medicine at the
M AN U
c
RI PT
Arriaga a, Azyadeh Camacho-Ordoñez a, Daniel Weintraub c
University of Pennsylvania, and Parkinson's Disease Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania. USA.
*Correspondence:
TE D
Mayela Rodríguez-Violante.
Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery.
Insurgentes Sur #3877 Col. La Fama 14269 México, D.F. México.
EP
E-mail: [email protected]
AC C
Tel: (55)5606-3822 Ext. 5018. Fax: (55)51716456.
1
ACCEPTED MANUSCRIPT
Abstract Background: Impulse control disorders (ICDs) are a relatively recent addition to the behavioral spectrum of PD-related non-motor symptoms. Social and
RI PT
economic factors may play a role on the ICD phenotype of PD patients. Objective: The aim of this study is to determine the prevalence and characterize the clinical profile of ICDs in a sample of low-income, low-education PD patients
SC
with no social security benefits from a Latin American country. Methods: We included 300 consecutive PD patients and 150 control subjects. The presence of
M AN U
ICD and related disorders was assessed using a structured interview. After the interview and neurological evaluation were concluded, all subjects completed the Questionnaire for Impulsive-compulsive Disorders in Parkinson´s Disease-Rating Scale (QUIP-RS). Results: Regarding ICDs and related disorders (hobbyism-
TE D
punding), 25.6% (n=77) of patients in the PD group and 16.6% (n=25) in the control group fulfilled criteria for at least one ICD or related disorder (p=0.032). There was a statistically significant difference in the QUIP-RS mean score
EP
between PD and control subjects (5.6 ± 9.7 and 2.7 ± 4.21, p=0.001). The most common ICD was compulsive eating for both PD (8.6%) and control (2.6%)
AC C
groups. Conclusions: The results of this study confirm that for this population, symptoms of an ICD are significantly more frequent in PD subjects than in control subjects. Nevertheless, socioeconomic differences may contribute to a lower overall frequency and distinct pattern of ICDs in PD patients compared with what has been reported in other countries. Key words: Impulse control disorder, Parkinson’s disease, Mexico, QUIP-RS
2
ACCEPTED MANUSCRIPT
1. Introduction.
RI PT
Non-motor symptoms contribute significantly to Parkinson´s disease (PD) related disability. Impulse control disorders (ICDs) are a relatively recent addition to the behavioral spectrum of PD-related non-motor symptoms. ICDs are characterized
SC
by a failure to resist an impulse to perform an activity that is harmful to the person or to others, due to its excessive nature1. Hypersexuality, compulsive
M AN U
shopping, pathological gambling and compulsive eating are considered the most frequent ICDs in PD [1-3]. Punding, hobbyism and dopamine dysregulation syndrome are considered disorders that overlap with ICDs [4]. Patients with PD are reported to be at higher risk of developing these disorders [5], likely due to
TE D
drug class association between dopamine agonist drugs and ICDs, which is considered the primary risk factor for the development of ICD in PD [6]. Levodopa and amantadine use have also been proposed as risk factors for ICDs
EP
[7].
The DOMINION study identified an ICD in 13.6% of 3090 US-Canadian patients;
AC C
compulsive buying (5.7%) and gambling (5.0%) were the most frequent [8]. A recent study reported an 8.1% prevalence of ICDs in Italian PD patients, with gambling and hypersexuality as the most frequent disorders [9]. On the other hand, among Indian population the prevalence of ICD and related disorders was 31.6% with punding, compulsive buying and compulsive eating being the most frequent [10]. Another recent study in the United States reported compulsive eating as the most frequent ICD and gambling as the least frequent [11]. In a 3
ACCEPTED MANUSCRIPT
study assessing Chinese population, an overall prevalence of 3.53% was reported (male to female ratio of 10:1), with hypersexuality as the most frequent behavior (1.92%) [12]. It should be pointed out that the percentage of subjects on
RI PT
a dopamine agonist on these studies ranged from 28% to 84%. These data suggests that social and economic factors may play a role on the ICD phenotype of PD patients.
SC
The aim of this study is to determine the prevalence and characterize the clinical profile of ICDs in a sample of low-income PD patients from Mexico.
M AN U
2. Methods.
We included 300 consecutive PD patients attending the Movement Disorders Clinic at the Neurology and Neurosurgery National Institute in Mexico City. PD was diagnosed according to the Queen Square Brain Bank Criteria [13]. One
TE D
hundred fifty control subjects from a similar age group and without any known neurological disease were recruited among visitors to the outpatient clinic. Subjects with a family history of a neurodegenerative disease were excluded.
EP
Relatives of PD patients were not included as controls due to the possibility of shared habits regarding ICDs.
AC C
Demographic data including age, years of schooling (as a surrogate for education) and smoking status was collected for both groups. Clinical data regarding age at PD onset, predominant symptoms at PD onset, and current treatment and dose was collected. Levodopa equivalent daily dose (LEDD) and dopamine agonist levodopa equivalent daily dose (DA-LEDD) were calculated [14]. PD patients were evaluated by a neurologist with expertise in movement
4
ACCEPTED MANUSCRIPT
disorders using the Spanish version of the Movement Disorder Society-Unified Parkinson Disease Rating Scale (MDS-UPDRS) [15]. Item 1.6 (features of dopamine dysregulation syndrome) from the MDS-UPDRS Part I was excluded
RI PT
from total scores calculations.
Socioeconomic data was collected as a composite index routinely used in Mexican national institutes of health [16]. Socio-economical levels (1 to 6) are
SC
defined taking into account the monthly income, employment status, social security, number of households, geographic area and house characteristics. For
M AN U
both groups (PD and control subjects), only subjects belonging to level 1 and 2 (average household income of 500 USD/monthly or lower and no social security) were included. This population represents most of the patients attending our center.
TE D
The presence of ICD and related disorders was assessed using a structured interview based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and Minnesota Impulsive Disorders Interview. After the interview
EP
and neurological evaluation were concluded, all subjects completed the Questionnaire for Impulsive-compulsive Disorders in Parkinson´s Disease-Rating
AC C
Scale (QUIP-RS) [4]. The QUIP-RS is designed to measure the presence and severity of ICD symptoms (hypersexuality, compulsive shopping, pathological gambling and compulsive eating) and related disorders (punding, hobbyism and dopamine dysregulation syndrome) in the previous four weeks. It uses a 5-point Likert scale to rate the frequency of behaviors. Scores for each ICD and related disorders range from 0 to 16, with a higher score indicating greater severity.
5
ACCEPTED MANUSCRIPT
Optimal cutoff values for individual ICDs have been previously reported as follows: score ≥ 6 for pathological gambling, ≥8 for compulsive shopping, ≥8 for hypersexuality and ≥7 for compulsive eating. Due to overlap, hobbyism and
RI PT
punding were combined, with a cutoff score ≥7. To reduce bias, the structured interview and the QUIP-RS were applied in separate rooms by different raters
the patient without the assistance of an informant.
SC
blinded to each other assessment. In all cases, the QUIP-RS was completed by
The local ethics and research committee approved this study. All participants
2.1 Statistical analysis
M AN U
provided written informed consent as determined by the local ethics committee.
Demographic data was reported in terms of percentages, mean and standard deviation. Bivariate analysis was performed to compare treatment between PD
TE D
non-ICD and ICD patients. Chi square test or Fisher´s exact test were used to compare ICD frequency between PD and control subjects. Mean QUIP-RS scores were compared using an independent samples T test. A step-wise logistic
EP
regression analysis was done using the presence of ICD symptoms as the dependent variable. Independent variables included in the bivariate analysis
AC C
were based on previously known risk factors for ICD in Parkinson’s disease. Independent variables found to be significant in the bivariate analysis (p
S1353-8020(14)00217-X
DOI:
10.1016/j.parkreldis.2014.05.014
Reference:
PRD 2353
To appear in:
Parkinsonism and Related Disorders
Received Date: 10 March 2014 Revised Date:
29 April 2014
Accepted Date: 27 May 2014
Please cite this article as: Rodríguez-Violante M, González-Latapi P, Cervantes-Arriaga A, CamachoOrdoñez A, Weintraub D, Impulse control and related disorders in Mexican Parkinson´s disease patients, Parkinsonism and Related Disorders (2014), doi: 10.1016/j.parkreldis.2014.05.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Impulse control and related disorders in Mexican Parkinson´s disease patients Mayela Rodríguez-Violante a,b*, Paulina González-Latapi a, Amin Cervantes-
a
Clinical Laboratory of Neurodegenerative Diseases, National Institute of
Neurology and Neurosurgery. Mexico City. Mexico.
Movement Disorders Clinic, National Institute of Neurology and Neurosurgery.
SC
b
Mexico City. Mexico.
Departments of Psychiatry and Neurology, Perelman School of Medicine at the
M AN U
c
RI PT
Arriaga a, Azyadeh Camacho-Ordoñez a, Daniel Weintraub c
University of Pennsylvania, and Parkinson's Disease Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania. USA.
*Correspondence:
TE D
Mayela Rodríguez-Violante.
Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery.
Insurgentes Sur #3877 Col. La Fama 14269 México, D.F. México.
EP
E-mail: [email protected]
AC C
Tel: (55)5606-3822 Ext. 5018. Fax: (55)51716456.
1
ACCEPTED MANUSCRIPT
Abstract Background: Impulse control disorders (ICDs) are a relatively recent addition to the behavioral spectrum of PD-related non-motor symptoms. Social and
RI PT
economic factors may play a role on the ICD phenotype of PD patients. Objective: The aim of this study is to determine the prevalence and characterize the clinical profile of ICDs in a sample of low-income, low-education PD patients
SC
with no social security benefits from a Latin American country. Methods: We included 300 consecutive PD patients and 150 control subjects. The presence of
M AN U
ICD and related disorders was assessed using a structured interview. After the interview and neurological evaluation were concluded, all subjects completed the Questionnaire for Impulsive-compulsive Disorders in Parkinson´s Disease-Rating Scale (QUIP-RS). Results: Regarding ICDs and related disorders (hobbyism-
TE D
punding), 25.6% (n=77) of patients in the PD group and 16.6% (n=25) in the control group fulfilled criteria for at least one ICD or related disorder (p=0.032). There was a statistically significant difference in the QUIP-RS mean score
EP
between PD and control subjects (5.6 ± 9.7 and 2.7 ± 4.21, p=0.001). The most common ICD was compulsive eating for both PD (8.6%) and control (2.6%)
AC C
groups. Conclusions: The results of this study confirm that for this population, symptoms of an ICD are significantly more frequent in PD subjects than in control subjects. Nevertheless, socioeconomic differences may contribute to a lower overall frequency and distinct pattern of ICDs in PD patients compared with what has been reported in other countries. Key words: Impulse control disorder, Parkinson’s disease, Mexico, QUIP-RS
2
ACCEPTED MANUSCRIPT
1. Introduction.
RI PT
Non-motor symptoms contribute significantly to Parkinson´s disease (PD) related disability. Impulse control disorders (ICDs) are a relatively recent addition to the behavioral spectrum of PD-related non-motor symptoms. ICDs are characterized
SC
by a failure to resist an impulse to perform an activity that is harmful to the person or to others, due to its excessive nature1. Hypersexuality, compulsive
M AN U
shopping, pathological gambling and compulsive eating are considered the most frequent ICDs in PD [1-3]. Punding, hobbyism and dopamine dysregulation syndrome are considered disorders that overlap with ICDs [4]. Patients with PD are reported to be at higher risk of developing these disorders [5], likely due to
TE D
drug class association between dopamine agonist drugs and ICDs, which is considered the primary risk factor for the development of ICD in PD [6]. Levodopa and amantadine use have also been proposed as risk factors for ICDs
EP
[7].
The DOMINION study identified an ICD in 13.6% of 3090 US-Canadian patients;
AC C
compulsive buying (5.7%) and gambling (5.0%) were the most frequent [8]. A recent study reported an 8.1% prevalence of ICDs in Italian PD patients, with gambling and hypersexuality as the most frequent disorders [9]. On the other hand, among Indian population the prevalence of ICD and related disorders was 31.6% with punding, compulsive buying and compulsive eating being the most frequent [10]. Another recent study in the United States reported compulsive eating as the most frequent ICD and gambling as the least frequent [11]. In a 3
ACCEPTED MANUSCRIPT
study assessing Chinese population, an overall prevalence of 3.53% was reported (male to female ratio of 10:1), with hypersexuality as the most frequent behavior (1.92%) [12]. It should be pointed out that the percentage of subjects on
RI PT
a dopamine agonist on these studies ranged from 28% to 84%. These data suggests that social and economic factors may play a role on the ICD phenotype of PD patients.
SC
The aim of this study is to determine the prevalence and characterize the clinical profile of ICDs in a sample of low-income PD patients from Mexico.
M AN U
2. Methods.
We included 300 consecutive PD patients attending the Movement Disorders Clinic at the Neurology and Neurosurgery National Institute in Mexico City. PD was diagnosed according to the Queen Square Brain Bank Criteria [13]. One
TE D
hundred fifty control subjects from a similar age group and without any known neurological disease were recruited among visitors to the outpatient clinic. Subjects with a family history of a neurodegenerative disease were excluded.
EP
Relatives of PD patients were not included as controls due to the possibility of shared habits regarding ICDs.
AC C
Demographic data including age, years of schooling (as a surrogate for education) and smoking status was collected for both groups. Clinical data regarding age at PD onset, predominant symptoms at PD onset, and current treatment and dose was collected. Levodopa equivalent daily dose (LEDD) and dopamine agonist levodopa equivalent daily dose (DA-LEDD) were calculated [14]. PD patients were evaluated by a neurologist with expertise in movement
4
ACCEPTED MANUSCRIPT
disorders using the Spanish version of the Movement Disorder Society-Unified Parkinson Disease Rating Scale (MDS-UPDRS) [15]. Item 1.6 (features of dopamine dysregulation syndrome) from the MDS-UPDRS Part I was excluded
RI PT
from total scores calculations.
Socioeconomic data was collected as a composite index routinely used in Mexican national institutes of health [16]. Socio-economical levels (1 to 6) are
SC
defined taking into account the monthly income, employment status, social security, number of households, geographic area and house characteristics. For
M AN U
both groups (PD and control subjects), only subjects belonging to level 1 and 2 (average household income of 500 USD/monthly or lower and no social security) were included. This population represents most of the patients attending our center.
TE D
The presence of ICD and related disorders was assessed using a structured interview based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and Minnesota Impulsive Disorders Interview. After the interview
EP
and neurological evaluation were concluded, all subjects completed the Questionnaire for Impulsive-compulsive Disorders in Parkinson´s Disease-Rating
AC C
Scale (QUIP-RS) [4]. The QUIP-RS is designed to measure the presence and severity of ICD symptoms (hypersexuality, compulsive shopping, pathological gambling and compulsive eating) and related disorders (punding, hobbyism and dopamine dysregulation syndrome) in the previous four weeks. It uses a 5-point Likert scale to rate the frequency of behaviors. Scores for each ICD and related disorders range from 0 to 16, with a higher score indicating greater severity.
5
ACCEPTED MANUSCRIPT
Optimal cutoff values for individual ICDs have been previously reported as follows: score ≥ 6 for pathological gambling, ≥8 for compulsive shopping, ≥8 for hypersexuality and ≥7 for compulsive eating. Due to overlap, hobbyism and
RI PT
punding were combined, with a cutoff score ≥7. To reduce bias, the structured interview and the QUIP-RS were applied in separate rooms by different raters
the patient without the assistance of an informant.
SC
blinded to each other assessment. In all cases, the QUIP-RS was completed by
The local ethics and research committee approved this study. All participants
2.1 Statistical analysis
M AN U
provided written informed consent as determined by the local ethics committee.
Demographic data was reported in terms of percentages, mean and standard deviation. Bivariate analysis was performed to compare treatment between PD
TE D
non-ICD and ICD patients. Chi square test or Fisher´s exact test were used to compare ICD frequency between PD and control subjects. Mean QUIP-RS scores were compared using an independent samples T test. A step-wise logistic
EP
regression analysis was done using the presence of ICD symptoms as the dependent variable. Independent variables included in the bivariate analysis
AC C
were based on previously known risk factors for ICD in Parkinson’s disease. Independent variables found to be significant in the bivariate analysis (p
