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Background The International Parkinson and Movement Disorder Society-sponsored UPDRS (MDS-UPDRS) is a powerful clinical outcome measure. Objectives To evaluate the feasibility of various MDS-UPDRS-based composite scores and determine their minimal clinically important difference threshold values. Methods Overall, 1,113 paired investigations of 452 patients were reviewed implementing three different techniques simultaneously. Results Based on the ordinal regression modeling, the MDS-UPDRS II+III, MDS-UPDRS I+II+III, and the total score of MDS-UPDRS are clinically applicable outcome measures. Any improvement greater than 4.9 points or any worsening more than 4.2 points on MDS-UPDRS II+III represent a minimal, yet clinically meaningful, change. In reference to MDS-UPDRS I+II+III, the smallest changes considered clinically relevant were 6.7 and 5.2 points for improvement and deterioration, respectively. The thresholds for the total score of MDS-UPDRS were 7.1 points for improvement and 6.3 points for worsening. Conclusions Our findings support the application of various MDS-UPDRS-based composite scores. © 2018 International Parkinson and Movement Disorder Society.

Background: The minimal clinically important difference is the smallest change of scores clinically meaningful to patients. Objectives: We aimed to calculate these threshold values in association with the International Parkinson and Movement Disorder Society UPDRS (MDS-UPDRS) Parts I and II and to evaluate the feasibility of the composite score of Part I and II (MDS-UPDRS I+II) as an outcome. Methods: Nine hundred eighty-five paired investigations of 365 patients were reviewed, implementing three different techniques simultaneously. Results: Based on the ordinal regression modeling, the MDS-UPDRS I+II score is an applicable outcome measure. Any improvement greater than 2.64 points or any worsening more than 2.45 points on MDS-UPDRS Part I represent a minimal, yet clinically meaningful change. In reference to Part II, the smallest changes considered clinically relevant were 3.05 and 2.51 points for improvement and deterioration, respectively. The thresholds for MDS-UPDRS I+II were 5.73 points for improvement and 4.70 points for worsening. Conclusions: Our minimal clinically important difference thresholds can be utilized in clinical practice in judging clinical relevance. © 2016 International Parkinson and Movement Disorder Society

Quality of Life in Essential Tremor Questionnaire (QUEST) was specially developed for essential tremor population to measure the health-related quality of life. Besides the development of the Hungarian version, we performed an independent testing of the scale adding further information on its clinimetric properties.In this study 133 ET patients treated at University of Pécs, Hungary, were enrolled. Besides QUEST, we assessed Patient's Global Impression-Severity (PGI-S) and Fahn-Tolosa-Marin Tremor Rating Scales. After the independent validation in accordance to the Classic Theory of Tests, we evaluated cut-off values for detecting clinically meaningful ET-related disabilities based on receiver operating characteristics analysis.Cronbach's a was 0.897. QUEST demonstrated high convergent validity with PGI and divergent validity with disease-duration, positive family history, need for deep brain stimulation surgery, and the presence of depression and anxiety. Presence of moderate ET-related disabilities was identified by scores11.25 points on QUEST-SI (sensitivity: 77.4%, specificity: 83.3%); whereas scores20.35 points indicated severe ET-related disabilities (sensitivity: 83.3%, specificity: 59.1%).We demonstrated that the fundamental clinimetric properties of the QUEST are satisfactory.Az Életminőség Esszenciális Tremorban Skálát (Quality of Life in Essential Tremor Questionnaire, QUEST) az esszen-ciális tremoros populáció egészséggel kapcsolatos életminőségének méréséhez fejlesztették ki. A magyar nyelvi verzió kidolgozása mellett egy olyan független validációt is elvégeztünk, ami a skála klinimetrikus tulajdonságainak kibővítését is megcélozta.Jelen vizsgálatunkba a Pécsi Tudományegyetemen kezelt 133 esszenciális tremoros beteg került bevonásra. A QUEST mellett a Beteg által Értékelt Globális Összbenyomás-súlyosság (Patient’s Global Impression-Severity, PGI-S) és a Fahn-Tolosa-Marin Tremor Pontozóskála került felvételre. A klinikai tesztek klasszikus elmélete szerinti független validációt követően hatásfokmérő karakterisztika eljárás alapján meghatároztuk a különböző mértékű korlátozottsági fokokra jellemző határértékeket.A skálára jellegzetes Cronbach-a értéke 0,897 volt. A QUEST szoros konvergens validitást mutatott a PGI-S skálával, míg divergens validitást a betegségtartammal, a pozitív családi anamnézissel, a mély agyi stimulációt igénylő súlyossággal, illetve a depresszióval és szorongással. Eredményeink alapján a 11,25 pontot meghaladó értékek a közepes fokú (szenzitivitás: 77,4%, specificitás: 83,3%), míg a 20,35 pontot meghaladó értékek súlyos fokú (szenzitivitás: 83,3%, specificitás: 59,1%) korlátozottságra utalnak.Eredményeink szerint a magyar nyelvű QUEST skála megfelelő klinimetrikus tulajdonságokkal rendelkezik.

Background Apathy is a syndrome characterized primarily by lack of motivation which may be associated with cognitive, affective and behavioral changes. Although the Lille Apathy Scale (LARS) has been extensively utilized in PD for detecting apathy and testing the effectiveness of specific therapeutic interventions, the highly variable cut-off values (between -11 and -22 points) ensures the applicability of the LARS degree of difficulty as a superb screening tool. Objective The aim of this study is to determine more reliable threshold values based on the neuropsychiatric status of patients. Methods Depression was assessed utilizing the Montgomery-Asberg Depression Rating Scale and neurocognitive status by Addenbrooke's Cognitive Examination. The presence of apathy was assessed by the proposed diagnostic criteria of Drijgers et al, and graded by both LARS and the 'Apathy' item of MDS-UPDRS. Results Based on multivariate regression analysis, we revealed the neurocognitive status, severity of depression, and also gender while applying dosage of dopamine agonists to determine the degree of patient apathy. Based on whether or not depression and neurocognitive disorders were indeed present, we established four different threshold values for the LARS: patients with normal cognition and without depression: -22.5; patients with normal cognition and with depression: -18.5; patients with NCD and without depression: -19.5; patients with NCD and with depression: -14.5. Conclusions The LARS and the 'Apathy' item of MDS-UPDRS were confirmed to be potentially operational, beneficial and easy-to-assess instruments for detecting apathy syndrome in PD. However, there is no universal threshold value for the LARS suitable in all types of Parkinson's patients.

Background. Impulse control disorders in Parkinson’s disease (PD) represent emerging problems with potentially devastating consequences. The standard screening methods for impulse control disorders are clinically imperfect. Although it is rarely reported, many patients utilize the Internet to fulfill their compulsive behaviors because of its easy accessibility. We designed a study to test the hypothesis that an active screening for excessive Internet use and Internet addiction might improve the sensitivity of identification of impulse control disorders. Methods. The standard screening method included the Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease and the modified Minnesota Impulsive Disorders Interview. In the second round, the Problematic Internet Use Questionnaire was also assessed for detecting excessive Internet use. Results. While the standard approach identified 19 patients out of 106 (17.9%) with any type of impulse control disorders, screening for the problematic Internet use detected 29 patients with impulse control disorders (27.4%) having significantly better efficacy over the standard method (p=0.004, the McNemar test). Conclusions. Our study suggests that the screening for problematic Internet use by the Problematic Internet Use Questionnaire is an effective, feasible, and easy-to-use add-on method for identifying PD patients with impulse control disorders more efficiently and probably at earlier stages.

Background Motor complications represent an important clinical problem in the treatment of Parkinson's disease (PD). The Motor Complications Part of the Movement Disorder Society-sponsored Unified Parkinson's Disease Rating Scale (MDS-UPDRS Part IV) and the Unified Dyskinesia Rating Scale (UDysRS) are among the most reliable instruments to evaluate these problems. The minimal clinically important difference thresholds are the smallest changes in the outcome measures that are clinically meaningful. Aims The aim of our study was to calculate the minimal clinically important difference thresholds for the MDS-UPDRS Part IV and the historic parts of the UDysRS. Methods A total of 1044 paired investigations of 436 patients were analyzed. Changes in the respective outcome measures (MDS-UPDRS Part IV, UDysRS Parts I and II) were compared to the Patient-rated Global Impression of Improvement scores (anchors). Subsequently, we applied receiver-operating characteristic analysis to ascertain the MCID thresholds with optimal sensitivity and specificity. Results Any improvement greater than 2.1 points or any worsening greater than 1.8 points on UDysRS Part I represents a minimal, yet clinically meaningful change. In reference to UDysRS Part II, the smallest changes considered clinically relevant are 1.8 and 1.7 points for improvement and deterioration, respectively. The thresholds for the MDS-UPDRS Part IV are 0.9 points for improvement and 0.8 points for worsening. Conclusions Our estimates may allow the judgment of the clinical relevance of numeric changes in the dyskinesia scales.

Background: A recent evidence-based guideline demonstrated that bilateral repetitive transcranial magnetic stimulation (rTMS) over the motor cortex (M1) can improve motor symptoms of Parkinson's disease (PD). We conducted a randomized, double-blind, placebo-controlled study to evaluate the impact of bilateral M1 rTMS on depression in PD. Methods: Forty-six patients with PD and mild-to-moderate depression were randomly assigned to active (n = 23) and sham (n = 23) rTMS. Two patients in the sham group did not complete the protocol because of reasons unrelated to the study. High-frequency rTMS was applied over the primary motor cortex bilaterally for 10 days. An investigator blinded to the treatment performed three video-taped examinations on each patient: before stimulation (baseline), and 1 day (short-term effect) and 30 days after the treatment session ended (long-term effect). The primary end point was the changes in depression, while secondary end points included health-related quality of life scales and Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS). Results: In the actively treated group, not only did the severity of depression improve (from 17 to 7 points, Montgomery-Åsberg Depression Rating Scale, median values, p < 0.001), but also the health-related quality of life (from 25.4 to 16.9 points, PDQ-39 summary index, median values, p < 0.001). Besides, we could also demonstrate an improvement in MDS-UPDRS Motor Examination (from 26 to 20 points, median values, p < 0.05). In the sham-treated group, none of the examined tests and scales improved significantly after treatment. Conclusions: Our results demonstrate the beneficial effects of high-frequency bilateral M1 rTMS on depression and health-related quality of life in PD. However, this effect of rTMS should also be confirmed in patients with severe depression by further clinical trials.

Background: Sleep problems are among the most common non-motor symptoms of Parkinson’s disease (PD). The PD Sleep Scale 2nd version (PDSS-2) improved the original PDSS by adding more items on different aspects of sleep problems, making it a more robust tool to evaluate the severity of sleep disturbances. However, previous studies on deep brain stimulation (DBS) have not used the PDSS-2. Objective: To determine if the PDSS-2 could detect improvement reliably in sleep problems after bilateral subthalamic nucleus DBS for PD. Methods: In this prospective study, 25 consecutive patients undergoing DBS implantation were enrolled. Patients were examined twice: 1 week prior to the DBS implantation (baseline) and 12 months postoperatively. Severity of PD symptoms were assessed by the Movement Disorders Society Unified PD Rating Scale (MDS-UPDRS) and the Non-Motor Symptoms Scale (NMSS). Presence and severity of sleep disturbances were specifically measured by PDSS-2. Results: Total score of MDS-UPDRS improved from 81 (median, interquartile-range: 63–103) to 55 points (median, IQR: 46–75, p < 0.001). Health-related quality of life, measured by PDQ-39, also improved from 29 (IQR: 18–40) to 15 (IQR: 9–28) points (p = 0.002). Most domains of NMSS also improved. At baseline 13 patients reported sleep problems, but 1 year after DBS implantation only 3 did (p = 0.012). Although only 6 out of 15 items showed a significant decrease after DBS implantation, the total score of PDSS-2 decreased from 24 (IQR: 17–32) to 10 (IQR: 7–18) points (P < 0.001). Conclusions: Based on our results, PDSS-2 can detect improvements in sleep quality reliably after DBS implantation.

In the present review the recent developments in the definitions of neurocognitive disorders associated with Parkinson’s disease are summarized including the possibilities for screening and treating. For a long time, the recognition of neurocognitive disorders associated in patients with Parkinson’s disease was unsatisfactory due to the heterogeneity of definitions. The recently developed Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) introduced the definitions of mild and major neurocognitive disorders instead of mild cognitive impairment and dementia. The new DSM-5 definitions are clinically well applicable; therefore, the validation of the most frequent screening tests (Mini-Mental State Examination; Addenbrooke’s Cognitive Examination; Montreal Cognitive Assessment; Mattis Dementia Rating Scale) is warranted. Based on a Hungarian sample of 295 patients with Parkinson’s disease, the cut-off scores having the best discriminative values are highly dependent on education years (Addenbrooke’s Cognitive Examination: 0–8 years of education: 82.5 points, 9–12 years of education: 83.5 points, and ≥13 years of education: 84.5 points; Mini-Mental State Examination: 26.5–27.5–28.5 points, Montreal Cognitive Assessment: 23.5–24.5–24.5 points, Mattis Dementia Rating Scale: 138.5–139.5–139.5 points, respectively). Orv. Hetil., 2015, 156(23), 915–926.

The International Parkinson and Movement Disorder Society-sponsored UPDRS (MDS-UPDRS) is a powerful clinical outcome measure.To evaluate the feasibility of various MDS-UPDRS-based composite scores and determine their minimal clinically important difference threshold values.Overall, 1,113 paired investigations of 452 patients were reviewed implementing three different techniques simultaneously.Based on the ordinal regression modeling, the MDS-UPDRS II+III, MDS-UPDRS I+II+III, and the total score of MDS-UPDRS are clinically applicable outcome measures. Any improvement greater than 4.9 points or any worsening more than 4.2 points on MDS-UPDRS II+III represent a minimal, yet clinically meaningful, change. In reference to MDS-UPDRS I+II+III, the smallest changes considered clinically relevant were 6.7 and 5.2 points for improvement and deterioration, respectively. The thresholds for the total score of MDS-UPDRS were 7.1 points for improvement and 6.3 points for worsening.Our findings support the application of various MDS-UPDRS-based composite scores. © 2018 International Parkinson and Movement Disorder Society.

Background: Minimal clinically important difference (MCID) is the smallest change in an outcome, which a patient identifies as meaningful. Although the 2 most frequently applied Parkinson's disease (PD) “quality of life” questionnaires (the PDQ-39 and PDQ-8) provide encouragingly similar results, their MCID thresholds appear to be vastly different. Our aim was to calculate the MCID estimates for both PDQ-39 and PDQ-8 Summary Indices (PDQ-39-SI and PDQ-8-SI) by the utilization of both anchor- and distribution-based techniques. Methods: Nine hundred eighty-five paired investigations of 365 patients were included. Three different techniques were used simultaneously to calculate the MCID values. Results: First, we replicated the previously published results demonstrating how both PDQ-39-SI and PDQ-8-SI provide similar values and respond in a similar way to changes. Subsequently, we calculated the MCID thresholds. The most optimal estimates for MCID thresholds for PDQ-39-SI were -4.72 and +4.22 for detecting minimal clinically important improvement and worsening. For PDQ-8-SI, these estimates were -5.94 and +4.91 points for detecting minimal clinically important improvement and worsening respectively. Conclusions: Our study is the first one that directly compared the MCID estimates for both PDQ-39-SI and PDQ-8-SI on a large pool of patients including all disease severity stages. These MICD estimates varied across PD severity.

Background: Dyskinesia is among the most troublesome symptoms of advanced Parkinson's disease (PD). The recently developed Unified Dyskinesia Rating Scale (UDysRS) can simultaneously measure several subjective and objective aspects of dyskinesia, irrespective of the other motor symptoms of PD. Despite the advantages of deep brain stimulation (DBS), previous studies on DBS have not used the UDysRS yet. Methods: In this prospective study, 71 consecutive patients undergoing DBS implantation were enrolled. Patients were examined twice: 1 week prior to the DBS implantation (baseline) and 12 months postoperatively. The severity of PD-related symptoms was assessed by the Movement Disorders Society Unified PD Rating Scale (MDS-UPDRS). The presence and severity of dyskinesia were specifically measured by the UDysRS and patient diaries. Results: At baseline, all 71 patients had dyskinesia, but 1 year after DBS implantation, 25 patients were dyskinesia-free, and an additional 19 had only mild dyskinesia. The total score on the UDysRS decreased from 38.0 ± 17.8 to 10.8 ± 13.0 (p < 0.001). Besides this, all parts of the UDysRS showed significant improvement after STN DBS treatment, and the magnitude of these changes had a large effect size. The total score of MDS-UPDRS improved from 76.5 ± 24.3 to 60.4 ± 21.4 points (p < 0.001). Conclusions: Based on our results, UDysRS can reliably detect improvements in dyskinesia after DBS implantation.

Background Levodopa/carbidopa intestinal gel therapy (LCIG) can efficiently improve several motor and non-motor symptoms of advanced Parkinson's disease (PD). The recently developed Movement Disorder Society-sponsored Unified Parkinson's Disease Rating Scale (MDS-UPDRS) improved the original UPDRS making it a more robust tool to evaluate therapeutic changes. However, previous studies have not used the MDS-UPDRS and the Unified Dyskinesia Rating Scale (UDysRS) to assess the efficacy of LCIG. Objectives Our aim was to determine if the MDS-UPDRS and UDysRS could detect improvement in the experiences of daily living following 1-year LCIG treatment. Methods In this prospective, multicenter, open-label study, 34 consecutive patients undergoing LCIG treatment were enrolled. Patients were examined twice: prior to LCIG initiation and 12 months later. Impact of PD-related symptoms and dyskinesia was assessed by the MDS-UPDRS and UDysRS. Results Non-motor Experiences of Daily Living part of MDS-UPDRS improved from 20 (median, interquartile-range, IQR:14–23) to 16 points (median, IQR:12–20, p = 0.044) and the Motor Experiences of Daily Living ameliorated from 24 (median, IQR:20–29) to 18 points (median, IQR:13–25, p = 0.025). Health-related quality of life, measured by PDQ-39, also improved from 35.4 (median, IQR:26.9–50.3) to 27.0 (median, IQR:21.3–31.4) points (p = 0.003). The total score of UDysRS decreased from 47 (median, IQR:36–54) to 34 (median, IQR:21–45) points (p = 0.003). Conclusions As far as the authors are aware of, our paper is the first to evaluate the impact of LCIG on dyskinesia by the means of UDysRS. Changes in MDS-UPDRS and UDysRS confirm that LCIG treatment can efficiently improve experiences of daily living in advanced PD.

The minimal clinically important difference is the smallest change of scores clinically meaningful to patients.We aimed to calculate these threshold values in association with the International Parkinson and Movement Disorder Society UPDRS (MDS-UPDRS) Parts I and II and to evaluate the feasibility of the composite score of Part I and II (MDS-UPDRS I+II) as an outcome.Nine hundred eighty-five paired investigations of 365 patients were reviewed, implementing three different techniques simultaneously.Based on the ordinal regression modeling, the MDS-UPDRS I+II score is an applicable outcome measure. Any improvement greater than 2.64 points or any worsening more than 2.45 points on MDS-UPDRS Part I represent a minimal, yet clinically meaningful change. In reference to Part II, the smallest changes considered clinically relevant were 3.05 and 2.51 points for improvement and deterioration, respectively. The thresholds for MDS-UPDRS I+II were 5.73 points for improvement and 4.70 points for worsening.Our minimal clinically important difference thresholds can be utilized in clinical practice in judging clinical relevance. © 2016 International Parkinson and Movement Disorder Society.

In the present review the recent developments in the definitions of neurocognitive disorders associated with Parkinson's disease are summarized including the possibilities for screening and treating. For a long time, the recognition of neurocognitive disorders associated in patients with Parkinson's disease was unsatisfactory due to the heterogeneity of definitions. The recently developed Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) introduced the definitions of mild and major neurocognitive disorders instead of mild cognitive impairment and dementia. The new DSM-5 definitions are clinically well applicable; therefore, the validation of the most frequent screening tests (Mini-Mental State Examination; Addenbrooke's Cognitive Examination; Montreal Cognitive Assessment; Mattis Dementia Rating Scale) is warranted. Based on a Hungarian sample of 295 patients with Parkinson's disease, the cut-off scores having the best discriminative values are highly dependent on education years (Addenbrooke's Cognitive Examination: 0-8 years of education: 82.5 points, 9-12 years of education: 83.5 points, and ≥13 years of education: 84.5 points; Mini-Mental State Examination: 26.5-27.5-28.5 points, Montreal Cognitive Assessment: 23.5-24.5-24.5 points, Mattis Dementia Rating Scale: 138.5-139.5-139.5 points, respectively).

Introduction. Among the nonmotor features of Parkinson’s disease (PD), cognitive impairment is one of the most troublesome problems. New diagnostic criteria for mild and major neurocognitive disorder (NCD) in PD were established by Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5). The aim of our study was to establish the diagnostic accuracy of widely used screening tests for NCD in PD.Methods. Within the scope of our study we evaluated the sensitivity and specificity of different neuropsychological tests (Addenbrooke’s Cognitive Examination (ACE), Mattis Dementia Rating Scale (MDRS), Mini Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA)) in 370 PD patients without depression.Results. MoCA and ACE feature the finest diagnostic accuracy for detecting mild cognitive disorder in PD (DSM-5) at the cut-off scores of 23.5 and 83.5 points, respectively. The diagnostic accuracy of these tests was 0.859 (95% CI: 0.818–0.894, MoCA) and 0.820 (95% CI: 0.774–0.859, ACE). In the detection of major NCD (DSM-5), MoCA and MDRS tests exhibited the best diagnostic accuracy at the cut-off scores of 20.5 and 132.5 points, respectively. The diagnostic accuracy of these tests was 0.863 (95% CI: 0.823–0.897, MoCA) and 0.830 (95% CI: 0.785–0.869, MDRS).Conclusion. Our study demonstrated that the MoCA may be the most suitable test for detecting mild and major NCD in PD.

Objectives There is a debate on the potential advantageous effects of bilateral subthalamic deep brain stimulation (DBS) in the treatment of Parkinson’s disease (PD) with early fluctuations. Our investigation aimed to evaluate if DBS therapy could preserve working capability. Materials & methods We reviewed the data of 40 young ( Results Although similar (approximately 50%) improvement was achieved in the severity of motor and major non-motor symptoms in both groups, the postoperative quality of life was significantly better in the ‘Active job’ group (0.687 vs. 0.587, medians, p Conclusions Although our study has several limitations, our results suggest that in patients with active job the appropriately ‘early’ usage of DBS might help preserve working capability in a two-year time-frame and gain higher improvement in quality of life.