PracticeUpdate Neurology Best of 2018

EDITOR’S PICKS 17

Functional Neurological Disorders in

Parkinson’s Disease Journal of Neurology, Neurosurgery, and Psychiatry Take-home message • Functional neurologic disorders (FNDs) are common and underrecognized. They frequently occur together with a different, organic disorder, posing diagnostic and therapeutic challenges. This is a multicenter case–con- trol study in several countries, assessing the clinical and demographic features of FNDs in patients with Parkinson’s disease (PD). Functional symptoms preceded PD onset or occurred at the same time in 34% of cases and were typically seen on the most affected side. Patients with coexisting FNDs had longer delay to PD diagnosis and received a DAT scan to assist diagnosis more frequently. Psychiatric disorders and family history of PD were more common when FNDs were associated. PD-FND patients had higher mean scores on the Beck Depression Inven- tory (34 vs 17) and the Beck Anxiety Inventory (21 vs 14). Healthcare utilization was higher, including more hospi- talizations (mean, 1.2 vs 0.9). The most common functional symptoms were gait/balance dysfunction and tremor. • This article draws attention to the prevalence of FNDs in PD and offers useful information on clinical details. Codrin Lungu MD Abstract OBJECTIVE To ascertain demographic and clinical features of Parkin- son disease (PD) associated with functional neurological features. METHODS A standardised form was used to extract data from electronic records of 53 PD patients with associated functional neurological disorders (PD-FND) across eight movement disorders centres in the USA, Canada and Europe. These subjects were matched for age, gender and disease duration to PD patients without functional fea- tures (PD-only). Logistic regression analysis was used to compare both groups after adjusting for clustering effect. RESULTS Functional symptoms preceded or co-occurred with PD onset in 34% of cases, nearly always in the most affected body side. Com- pared with PD-only subjects, PD-FNDwere predominantly female (68%), had longer delay to PD diagnosis, greater prevalence of dyskinesia (42% vs 18%; P=0.023), worse depression and anxiety (P=0.033and 0.025, respectively), higher levodopa-equivalent daily dose (972±701 vs 741±559mg; P=0.029) and lower motor severity (P=0.019). These patients also exhibited greater healthcare resource utilisation, higher use of [(123)I]FP-CIT SPECT and were more likely to have had a pre-ex- isting psychiatric disorder (P=0.008) and family history of PD (P=0.036). CONCLUSIONS A subtype of PD with functional neurological features is familial in one-fourth of cases and associated with more psychiat- ric than motor disability and greater use of diagnostic and healthcare resources than those without functional features. Functional manifes- tations may be prodromal to PD in one-third of patients. Functional Neurological Disorders in Parkinson Disease. J Neurol Neurosurg Psychiatr 2018 Jun 01;89(6)566-571, BDWissel, AK Dwivedi, A Merola, et al. www.practiceupdate.com/c/68819

compared between treatment groups by analysis of variance. Linear regression compared change in perfusion against change in BP. Mag- netic resonance imaging scan analysis was masked to treatment group. RESULTS Among 62 analyzable patients, the mean age was 69.3 years, and 60% (n=37) were male. The mean (SD) systolic BP decreased by 8 (12) mm Hg in the standard group and by 27 (17) mm Hg in the intensive group (P< .001), with mean (SD) achieved pressures of 141 (13) and 126 (10) mm Hg, respectively. Change in global perfusion did not differ between treatment groups: the mean (SD) change was -0.5 (9.4) mL/min/100 g in the standard group vs 0.7 (8.6) mL/min/100 g in the intensive group (partial η2, 0.004; 95% CI, -3.551 to 5.818; P= .63). No differences were observed when the analysis examined gray or white matter only or was confined to those achieving target BP. The number of adverse events did not differ between treatment groups, with a mean (SD) of 0.21 (0.65) for the stand- ard group and 0.32 (0.75) for the intensive group (P= .44). CONCLUSIONS AND RELEVANCE Intensive BP lowering did not reduce cere- bral perfusion in severe small vessel disease. Effect of Standard vs Intensive Blood Pressure Control on Cerebral Blood Flow in Small Vessel Disease: The PRESERVE Randomized Clinical Trial. JAMA Neurol 2018 Mar 05;[EPub Ahead of Print], ID Croall, DJ Tozer, B Moynihan, et al. www.practiceupdate.com/c/65082 in relatively rare cases of severe large-vessel stenosis, in which the perfusion in the territory of the affected vessel is severely compromised. " " This study adds to accumulating evidence that lowering blood pressure only has negative effects

VOL. 3 • NO. 4 • 2018