The results suggested that elevated serum levels of triglycerides (TG), low density cholesterol (LDL) and total cholesterol (TC) may be protective factors for the pathogenesis of PD.
And here’s another meta analysis that bottom lines the results in the title:
Fifteen cohort studies with 9740 participants, including 2032 PD patients and 7708 controls were analyzed, and the analysis found that lipid levels in the PD patients was significantly lower than that of healthy controls. So dyslipidemia might have a predictive value.
As a Person With PD (PwP), this sort of information could have been useful, say, oh, between 50 or 60 years ago. Of course, it would have taken general practitioners with a broad knowledge of factors affecting the prodromal symptoms and signs of PD to pick up on it. (And that information wasn’t available at that time).
As it so happened, I had essential tremors, and could feel resting tremors oscillating away, even though they were not visible to the human eye. And other prodromal symptoms were present, too, and at an early age. Fortunately, I did not have the LRRK or PARK gene variations that cause early onset PD that can not be denied (Michael J. Fox’s case comes to mind). Unfortunately, my particular set of symptoms did not result in an actual diagnosis of PD until after I had been retired early due to one of my other prodromal symptoms (MDD) put me on disability leave for over 9 months, and I was unable to hold down a steady job for a couple of years. Fortunately, the Social Security Administration provided me with retroactive disability benefits to the day following the date the insurance company gave up on trying to recoup their losses by representing my case to the OASDI. Fortunately, I have been able to find folks who have supported me through the years, intellectually and socially, as my continuing journey with PD has become a larger part of my life.
Perhaps the future of medicine lies in something like the application of IBM’s Big Blue computer (or other advanced Artificial Intelligence systems) to assimilating the huge (not just big) data residing in the NIH and other medical libraries, so that correlations among various signs could be identified and point to diagnostic criteria and effective treatment modalities, so that until there is a cure for Parkinson’s (and other diseases), we can do what we can to identify the probability of an eventual diagnosis (provided decent medical information and observations) and then to defer or delay and to mitigate the symptoms.
And until then, I will do my best to forgive those who have caused me harm, whether through omission or commission, while asking forgiveness of those against whom I have “trespassed,” to use the word in the KJV.
(Didn’t mean to take an ethical/religious tangent at the end, but there it is. I’ve said too much, I haven’t said enough… I was sentenced to twenty years of boredom, for trying to change the system from within…[insert your favorite poplar song phrase here]).
Here’s a few studies that came up in my news feed from PubMed Central (PMC) or elsewhere for articles recently published on the topics in which I’m interested – namely, prodromal symptoms related to PD, the relationship of REM sleep disorder and depression to PD, and, of course, the use of singing and dance therapies as complementary approaches to dealing with the symptoms of PD.
The prevalence and duration of non-motor symptoms (NMS) in prodromal Parkinson’s disease (PD) has not been extensively studied. The aim of this study was to determine the prevalence and duration of prodromal NMS (pNMS) in a cohort of patients with recently diagnosed PD.
…subtracted the duration of the presence of each individual NMS reported from the duration of the earliest motor symptom. NMS whose duration preceded the duration of motor symptoms were considered a pNMS. Individual pNMS were then grouped into relevant pNMS clusters based on the NMSQuest domains. Motor subtypes were defined as tremor dominant, postural instability gait difficulty (PIGD) and indeterminate type according to the Movement Disorder Society Unified Parkinson’s Disease Rating Scale revision.
Results: Prodromal NMS were experienced by 90.3% of patients with PD. … males reporting more sexual dysfunction, forgetfulness and dream re-enactment, whereas females reported more unexplained weight change and anxiety. There was a significant association between any prodromalgastrointestinal symptoms and urinary symptoms and the PIGD phenotype.[n.b.: phenotype includes inherent traits or characteristics that are observable]. [Emphases added].
Citation: Durcan R, Wiblin L, Lawson RA, Khoo TK, Yarnall AJ, Duncan GW, Brooks DJ, Pavese N, Burn DJ; ICICLE-PD Study Group. Prevalence and duration of non-motor symptoms in prodromal Parkinson’s disease. Eur J Neurol. 2019 Jul;26(7):979-985. doi: 10.1111/ene.13919. Epub 2019 Mar 1. PMID: 30706593; PMCID: PMC6563450.
Purpose: To explore the effect of sleep disorders, including the probable rapid eye movement (REM) sleep behavior disorder (pRBD) and the daytime sleepiness, on depressive symptoms in patients with early and prodromal PD.
5-year follow-up study showed that sleep disorders, including pRBD and daytime sleepiness, were associated with the increased depressive-related score in individuals with early and prodromal PD.
Conclusion: … Sleep disorders, including pRBD and daytime sleepiness, are associated with depression at baseline and longitudinally, … partially mediated by the autonomic dysfunction in early and prodromal PD, … implication that sleep management is of great value for disease surveillance.
Citation: Ma J, Dou K, Liu R, Liao Y, Yuan Z, Xie A. Associations of Sleep Disorders With Depressive Symptoms in Early and Prodromal Parkinson’s Disease. Front Aging Neurosci. 2022 Jun 10;14:898149. doi: 10.3389/fnagi.2022.898149. PMID: 35754965; PMCID: PMC9226450.
Abstract Background Previous reports suggest that group therapeutic singing (GTS) may have a positive effect on motor symptoms in persons with Parkinson’s disease (PD).
Objective To determine the effect of a single session of GTS on clinical motor symptoms.
Methods Clinical motor symptom assessment was completed immediately before and after 1 hour of GTS in 18 participants.
Results A significant decrease in average scores for gait and posture and tremor, but not speech and facial expression or bradykinesia was revealed.
Conclusion These results support the notion that GTS is a beneficial adjuvant therapy for persons with PD that warrants further research.
Citation: Stegemoller E, Forsyth E, Patel B, et al. Group therapeutic singing improves clinical motor scores in persons with Parkinson’s disease BMJ Neurology Open 2022;4:e000286. doi: 10.1136/bmjno-2022-000286
What research has found its way into the email inbox recently?
Although singing is a nearly universal human behavior, many adults consider themselves poor singers and avoid singing based on self-assessment of pitch matching accuracy during singing (here referred to as singing accuracy), in contrast to the uninhibited singing exhibited by children. In this article, I report results that shed light on how singing accuracy changes across the lifespan, using data from a large online sample, including participants ranging from 6 to 99 years old. Results suggest that singing accuracy improves dramatically from childhood to young adulthood, unperturbed by voice changes during adolescence, and remain at a similarly high level for the remainder of life, exhibiting no strong tendency toward age-related decline. Vocal or instrumental musical training has significant positive effects on singing accuracy, particularly in childhood, though there was no evidence for gender differences. Finally, pitch discrimination varied with age similarly to singing accuracy, in support of views that singing accuracy reflects sensorimotor learning. Taken together, these results are consistent with the view that singing accuracy is a learned motor skill that benefits from engagement and can remain a fruitful endeavor into old age. (emphasis added).
Basically, this says that if you learned how sing accurately when you were young, you can probably sing well into your later years. And, since singing is a learned motor skill, one might assume that it can be learned even as one gets older.
Relevance to folks with Parkinson’s Disease (PD)?
Vocal strength exercises, such as those provided by Power for Parkinson’s as free YouTube video classes, can help with specific Parkinson’s related symptoms:
Many people with PD speak quietly and in one tone; they don’t convey much emotion. Sometimes speech soundsbreathy or hoarse. People with Parkinson’s might slur words, mumble or trail off at the end of a sentence.Most people talk slowly, but some speak rapidly, even stuttering or stammering.
Parkinson’s motor symptoms, such as decreased facial expression, slowness and stooped posture, may add to speech problems. These can send incorrect non-verbal cues or impact the ability to show emotion. Source: https://www.michaeljfox.org/news/speech-swallowing-problems accessed June 20, 2022 (emphasis added).
Since our vocal cords are muscles, and singing is a learned motor skill, we can strengthen those muscles and push against the progressive, degenerative symptoms of PD through exercises that:
remind us to breathe deeply to sustain vocal volume,
improve our posture in order to enable deep breathing,
exercise the muscles of the face and mouth
to enable crisp diction instead of slurring and mumbling, and that
support emotional expression through inflection and singing.
And “Everybody Knows” that if exercise is fun, one is more likely to continue doing it.
Full disclosure: The author has attended Power for Parkinson’s ® vocal exercise classes since their inception in 2016, and co-founded a participant organized singing group (with the late Jeff Berke) in 2015. Therefore, he might be (definitely is) biased in favor of this modality of treatment for vocal and speech related symptoms of PD.
And from the abstract and significance statement of the original (non-open access) article:
Physical exercise improves motor performance in individuals with Parkinson’s disease and elevates mood in those with depression. Although underlying factors have not been identified, clues arise from previous studies showing a link between cognitive benefits of exercise and increases in brain-derived neurotrophic factor (BDNF). (emphasis added).
and:
Exercise has been shown to improve movement and cognition in humans and rodents. Here, we report that voluntary exercise over 30 days leads to an increase in evoked dopamine (DA) release throughout the striatum, and an increase in BDNF in the dorsal (motor) striatum. The increase in DA release appears to require BDNF, indicated by the absence of DA release enhancement with running in BDNF+/- mice. Activation of BDNF receptors using a pharmacological agonist was also shown to boost DA release. Together these data support a necessary and sufficient role for BDNF in exercise-enhanced DA release, and provide mechanistic insight into the reported benefits of exercise in individuals with dopamine-linked neuropsychiatric disorders, including Parkinson’s disease and depression. (emphasis added).
The citation:
Voluntary exercise boosts striatal dopamine release: evidence for the necessary and sufficient role of BDNF, Guendalina Bastioli, Jennifer C. Arnold, Maria Mancini, Adam C. Mar, Begoña Gamallo-Lana, Khalil Saadipour, Moses V. Chao, Margaret E. Rice,Journal of Neuroscience 16 May 2022, JN-RM-2273-21; DOI: 10.1523/JNEUROSCI.2273-21.2022
So that covers why exercise is good for all. But what about what is good for the one?
… there is growing recognition that PD is not a single entity but instead reflects multiple diseases, in which different combinations of environmental, genetic and potential comorbid factors interact to direct individual disease trajectories… The clear consequence of there being distinct diseases that collectively form PD, is that there is no single biomarker or treatment for PD development or progression. We propose that diagnosis should shift away from the clinical definitions, towards biologically defined diseases that collectively form PD, to enable informative patient stratification. N-of-one type, clinical designs offer an unbiased, and agnostic approach to re-defining PD in terms of a group of many individual diseases. . (emphasis added).
The citation links to PubMed where you can download the full article, should you be so inclined. The next citation also links to an open access free article.
In this article, Riggare reports on self tracking done in 2012 (as a Person with Parkinson’s), and the offer the possibility that self-tracking of symptoms and medications can help to inform the physician’s decisions over the course of treatment. In other words, one should be a self-advocate as a patient and work with your physician to achieve the best combination of treatments to address Parkinson’s and its comorbidities. (At least that’s my takeaway from the article. Others might differ).
Another look at PD aims to categorize it into various sub-types:
This article is a “desk review”of other studies, using specific criteria to either include/exclude each study in the results. Their conclusion:
Conclusion: Subtyping studies undertaken to date have significant methodologic shortcomings and most have questionable clinical applicability and unknown biological relevance. The clinical and biological signature of PD may be unique to the individual, rendering PD resistant to meaningful cluster solutions. New approaches that acknowledge the individual-level heterogeneity and that are more aligned with personalized medicine are needed. (emphasis added).
Among the articles cited in the bibliography is this one (another open access article):
In this, the authors describe their methodology and results from the Oxford cohort (one of several cohorts of PwPs and controls that have been used for research. (I would take the time and effort to locate the original publication describing the different cohorts involved in the effort to find biomarkers, but I am currently experiencing a wave of Parkinson’s related apathy. Check my past posts, or do a search on PubMed – I do remember that Oxford and Boston were two of the cohorts of PwPs. But I digress).
Results: Apolipoprotein A1 and C-reactive protein levels differed across our PD subtypes, with severe motor disease phenotype, poor psychological well-being, and poor sleep subtype having reduced apolipoprotein A1 and higher C-reactive protein levels. Reduced apolipoprotein A1, higher C-reactive protein, and reduced vitamin D were associated with worse baseline activities of daily living (MDS-UPDRS II).
In other words: Close, but no cigar. But I, for one, certainly could have benefited from this knowledge had it been available 60 years ago. (don’t get me started – I’ve played that tape many times before).
I don’t have access to the content of this book, but I was struck by the abstract to this chapter:
ABSTRACT
The right to an education is an important human right and is regulated in considerable detail in Articles 13 and 14 of the International Covenant on Economic, Social and Cultural Rights as well as in Articles 28 and 29 of the UN Convention on the Rights of the Child. With the sole exception of the United States,all United Nations member States have accepted the right to education as a legally binding human right that needs to be implemented in their domestic systems. (emphasis added)
What’s wrong with education in the United States? The U.S.A. hasn’t accepted it as a legally binding human right. No wonder that (well, I won’t go there today).
Chapter: Music Education Child Development and Human Rights By Steven J. Holochwost, Elizabeth Stuk
The book citation is: Fifer, J., Impey, A., Kirchschlaeger, P.G., Nowak, M., & Ulrich, G. (Eds.). (2022). The Routledge Companion to Music and Human Rights (1st ed.). Routledge https://doi.org/10.4324/9781003043478 eBook ISBN 9781003043478
Book Description The Routledge Companion to Music and Human Rights is a collection of case studies spanning a wide range of concerns about music and human rights in response to intensifying challenges to the well-being of individuals, peoples, and the planet. It brings forward the expertise of academic researchers, lawyers, human rights practitioners, and performing musicians who offer critical reflection on how their work might identify, inform, or advance mutual interests in their respective fields. The book is comprised of 28 chapters, interspersed with 23 ‘voices’ – portraits that focus on individuals’ intimate experiences with music in the defence or advancement of human rights – and explores the following four themes: 1) Fundamentals on music and human rights; 2) Music in pursuit of human rights; 3) Music as a means of violating human rights; 4) Human rights and music: intrinsic resonances.
The book is scheduled for publishing on May 31, 2022. $250 for print, under $50.00 USD for ebook format.
I really gotta look into becoming a student or getting associated with an organization or library that would allow me to access research articles, journals, ans books. It’s the one thing I miss most about IBM: access to technical journals through the library. That, and the IBM Club band, aka the Blue Diamonds Jazz Orchestra (BDJO).
While not exactly fitting in with music, but maybe under basic human rights (free speech, anyone?), here is an open access article reporting on the results of the Parkinson’s Voice initiative:
Conclusion first:
Sustained vowels may provide an objective, robust and streamlined approach towards informing PwP subtype assignment. The current study’s findings corroborate part of the PD research literature indicating the presence of four PD subtypes having been thoroughly validated on a large PwP cohort and externally validated on two additional PwP cohorts. There are important practical implications of defining PD subtypes using data that is easy to self-collect remotely such as speech signals and in particular sustained vowel /a/ phonations: they enable large-scale investigations and may bring us a step closer towards more personalized medicine approaches and targeted clinical management. The key limitation of the study is that we do not have additional clinical labels (e.g. UPDRS) or other self-reported outcome measures to map the resulting PD subtypes onto something that would be more tangible and comparable to related PD subtype studies. Future work could explore the extent subtypes form useful markers of symptom severity progression and conversely how PD progression might affect subtype membership for individual PwP. Similarly, further work could integrate additional modalities to speech to incorporate longitudinal passively collected modalities and self-reports which could be capturing PD-related symptoms, e.g. via using smartphones and wearables along the lines we have explored for mental disorders [64], [67]–[70]. Collecting additional modalities at scale using increasingly affordable technologies may provide new insights towards understanding PD subtypes which may translate into understanding individual PwP similarities, related PwP symptom trajectories, and ultimately lead to better symptom management strategies.
and from the abstract:
Purpose People diagnosed with Parkinson’s (PwP) exhibit a diverse manifestation of heterogeneous symptoms which likely reflect different subtypes. However, there is no widely accepted consensus on the criteria for subtype membership assignment. We explored clustering PwP using a data-driven approach mining speech signals. … Results We selected 21 dysphonia measures and found four main clusters which provide tentative insights into different dominating speech-associated characteristics (cophenetic coefficient=0.72, silhouette score=0.67). The cluster findings were consistent across the three PVI cohorts, strongly supporting the generalization of the presented methodology towards PwP subtype assignment, and were independently visually verified in 2D projections with t-SNE.
The citation (and the link to access) this open access article are:
Tsanas, T & Arora, S 2022, ‘Data-driven Subtyping of Parkinson’s using Acoustic Analysis of Sustained Vowels and Cluster Analysis: Findings in the Parkinson’s Voice Initiative Study’, SN Computer Science, vol. 3, 232. https://doi.org/10.1007/s42979-022-01123-y
And there you have it. A bunch of research or reviews over the last year and a half involving dance and Parkinson’s Disease. I did a search and haven’t had enough time to read any of these yet, but That’s part of the reason for this blog: to serve as a repository of links to articles. All of these are open access articles so the full text should be available.
Or not. Instead, I’ll do my best not to violate the NDA we signed about the trial, and look instead at oh, say, humor and Parkinson’s Disease (PD).
As one of my graduate professors mentioned to our class, humor is best when it is “in the moment,” spontaneous, and not planned, often helping to release the tension of what could be an awkward moment.
I’ll refer to the interview conducted by Power for Parkinson’s earlier this month with the PhD. candidate who was conducting the trial noted above. In it, he lays out the concepts and the parameters of the studies, and the three folks in the interview play some of the exercises.
I actually participated in the clinical trial noted in the previous post and felt that it helped me recognize some things about myself as a Person With Parkinson’s and my interactions with the rest of the world. Still have the same issue of people of thinking I’m serious when I’m jesting, and vice versa, though. And knowing just how far to go with it and when to shut my mouth (or press delete instead of send). It’s a work in progress… or an abandoned house/wisecrack house/fixer-upper. Take your pick.
and, just for today, we’ll end in a prayer:
Forgive, O Lord, my little jokes on Thee
And I’ll forgive Thy great big one on me.
The evidence that rhythm, movement, and making music continues to accumulate as a therapeutic approach to address the symptoms and Quality of Life issues related to Parkinson’s Disease (PD).
Today we look at an article just out in Frontiers of Human Neuroscience, titled
Over the last quarter of a century, increasing research results point to rhythm and music as effective and useful tools for treatment and rehabilitation of people with neurological disorders. This article reviews the evidence for four different approaches, what the consensus is at the present time, and, of course, suggests future directions.
The authors look at four different approaches:
Rhythmic Auditory Stimulation (RAS)
Music-Supported Therapy (MST)
Therapeutic Instrumental Music Performance therapy (TIMP) and
Patterned Sensory Enhancement (PSE)
The consensus of recent meta-analyses and systematic reviews is that, for Parkinson’s Disease (PD), is that RAS is an effective tool for improving gait, stride, and speed – folks walk faster and with longer steps with RAS. Additionally, evidence is showing that it also reduces freezing of gait (FOG), improves balance and reduces the occurrence of falls.
Neither MST nor TIMP have been studied much beyond the rehabilitation of stroke patients. They involve practicing on a keyboard or drums, beginning with the patient’s comfort level and increasing in difficulty. Some studies have begun to be used to investigate effectiveness as treatments for PD. Some have shown improvements in motor dexterity. More research is needed, but in the meantime, learning to play drums or keyboards can’t hurt, and may enrich one’s quality of life (QOL).
Growing evidence in neurological and brain imaging have shown increased activity in the auditory and motor areas of the brain, indicating that brain plasticity might be achieved through music and rhythmic interventions. The authors note that RAS has been well studied with stroke and PD populations, but not with other movement disorders and Alzheimer’s populations. In addition MST and TIMP have only begun to be investigated as a means of restoring fine motor coordination.
The authors also call for neuroimaging use in studies, to better understand the physiological basis of the rehabilitation process. They point out the gaps in research and hope to provide a framework for future research – not so much a roadmap, I would think, but a laying out of what we know and what we don’t know, and what kinds of studies are needed to answer the questions about what we don’t know.. They state that “musical rhythm is a powerful tool” for therapy, and our understanding and exploration of how it modulates brain networks is in the initial stages.
In other words, “We’ve only just begun.”
Meanwhile: Don’t stop moving to the music.
Citation: Braun Janzen T, Koshimori Y, Richard NM and Thaut MH (2022) Rhythm and Music-Based Interventions in Motor Rehabilitation: Current Evidence and Future Perspectives. Front. Hum. Neurosci. 15:789467. doi: 10.3389/fnhum.2021.78946
Diagnosis of PD is often not made until a person is in their 60s. With all the attention that has been focused on the disease(s) in the last 20 years or so, I suspect that more people are getting diagnosed at an earlier age, although most cases of young onset PD are likely to be genetic in origin.
However, an “early” diagnosis may not be a timely diagnosis, as the title of one opinion piece I read some time ago said (see link below).
It is now becoming apparent that “Parkinson’s”includes several categories of symptoms, not just rigidity, tremors, and gait, as shown in the table below::
The problem is that treatment and diagnosis are often delayed until PD has already reduced Quality of Life for many folks.
Good evidence for the quality-of-life benefits of existing symptomatic treatment supports the argument for earlier diagnosis at a time when symptoms are already present (emphasis added). This argument would be significantly bolstered by the development of disease-modifying treatments. Benefits of early diagnosis and treatment would affect not only the individual (and their families) but also the wider society and the research community. Ultimately, however, shared decision-making and the principles of autonomy, beneficence, and non-maleficence will need to be applied on an individual basis when considering a “timely” diagnosis.
Therefore, the earlier one can predict the probability or inevitability of PD the sooner one can use treatments – whether pharmacological, surgical, nutritional, or lifestyle in nature – that can either reduce, delay, or defer (and possibly reverse?) the symptoms of PD.
Of all the symptoms associated with PD: tremors, bradykinesia, depression & anxiety, posture, gait issues (difficulties walking), REM Sleep Behavior Disorder (RBD), anosmia (loss of ability to smell), cognitive issues, facial masking, and micrographia (small handwriting) – RBD is the one which is most highly predictive of a later PD diagnosis.
The predictive ‘specificity’ is so strong that if someone has RBD, the chance of being diagnosed with Parkinson’s or related conditions over the next 15 years or more is over 80%
If an 18-21 year old person walked into a physician’s office with RBD, essential tremors, and depression as main symptoms, what would happen? In 1970, probably nothing – one might get treated for depression, but essential tremors are also called “benign”tremors, and were ignored, even if the patient reported being able to feel the tremors while resting, though invisible to the external observer. As for RBD, it would probably also be ignored.
By “a physician,” we are talking about a General Practitioner, or “family doctor,” and not s specialist like a Movement Disorders Specialist who would be trained to identify varied symptoms, including those that are prodromal. And, of course, the identification of prodromal symptoms has only been investigated within the last decade or so, and are identified as for “research only” purposes – not for clinical diagnosis. A recent survey article (not referenced below) indicated that a majority of general practitioners were either unaware of the Movement Disorders Society’s list of prodromal symptoms, or were not using them to make referrals to Movement Disorders Specialists.
But thanks to the dedication and generosity of folks like Michael J. Fox and others, PD has become a respectable disease for which the person who has it has no reason to be apologetic or ashamed, and can hold their head up (and they ought to, since one symptom is to walk with shoulders stooped down) and proudly proclaim that they have Parkinson’s, which is why they walk funny. And so it goes.
Articles that were quoted above or which contributed to this article are found in the links below.
This paper (or rather a chapter in a thesis) landed in my newsfeed recently. In it, the authors describe a study done to see whether people with Parkinson’s in the later stages are getting adequate treatment and whether they could benefit from more specific treatment. (A link to the PDf file is at the end of this post).
A person in Late Stage Parkinson’s has more than one of the following:
Motor symptoms not controlled despite medication.
Levadopa-related dyskinesias or dystonia,
PD dementia (defined according to MDS Task Force definition (Dubois et al. 2007), and not treated with cholinesterase inhibitors,
Depression not adequately treated,
Neuropsychiatric symptoms, such as agitation/ aggression; anxiety and irritability,
Orthostatic hypotension, pain, constipation, urinary symptoms, insomnia or daytime sleepiness (autonomic systems degeneration),
Falls on a regular basis,
Other symptoms related to risk of choking, speech issues, or producing too much saliva,
Inadequate Home environment.
Basically, the study provided a list of recommended activities and treatment on a sheet of paper (the control group) and actually providing the treatments and activities recommended, (the treatment group).
Not surprisingly, the treatment group did better at the end of the study than the controls. The conclusions were that people in late-stage Parkinson’s are often undertreated and could benefit from implementation of movement disorder specialists’ recommendations. (One would hope that the control group would also be provided with the treatments after the study ended. Perhaps, leading to another report)?
I’ve paraphrased the table used to describe late stage Parkinsonism in order not to infringe on their copyright. The title of the entire thesis is “Impairment and Disability in Late Stage Parkinsonism” and the overall author is Danny Hommel. I couldn’t find an email to ask for permission in writing to reproduce anything verbatim.
Other chapters include:
The late-stage of parkinsonism’s – motor and non-motor complications
The prevalence and determinants of neuropsychiatric symptoms in late-stage parkinsonism
Prevalence and prescribed treatments of orthostatic hypotension in institutionalized peoples with Parkinson’s disease (the chapter discussed in this post)
Optimizing treatment in undertreated late-stage parkinsonism: a pragmatic randomized trial
