Background: Compulsive behavior, dyskinesias, motor fluctuations, and hallucinations are common Parkinson’s disease (PD) medication side effects. These are yet to be examined in relation to race and level of education. The goal of this analysis was to identify socioeconomic or clinical variables that are associated with compulsive behavior, dyskinesias, motor fluctuations, and hallucinations in patients in a safety-net hospital. Methods: A movement disorder patient database containing 452 patients with idiopathic PD was analyzed for differences in PD medication side effects using univariate and multivariate logistic regression analysis. Race, sex, and level of education were evaluated as possible confounders. Results: A greater proportion of the patients in this study were Caucasian males. The only variable associated with compulsive behavior was age, with higher age having a protective effect ( p = 0.0336). Disease duration (defined as time since the onset of symptoms), diagnosis duration (time since formal diagnosis), and level of education were significantly associated with dyskinesia inunivariate analysis ( p =< 0.0001, <0.0001, 0.1236 respectively). However, diagnosis duration was the only variable significantly associated with dyskinesia in multivariate analysis ( p = 0.0038), in addition to a borderline significant association when comparing individuals with graduate degree to those who had completed high school education or less ( p = 0.0599), with a protective effect of higher education. Disease duration, diagnosis duration, and use of monoamineoxidase inhibitors were also significantly associated with motor fluctuations in the univariate analysis, while only diagnosis duration was significantly associated with motor fluctuations in multivariate analysis ( p = 0.0035) with longer diagnosis duration associated with higher risk of motor fluctuations. Age, disease duration, and diagnosis duration were associated with an increased risk of hallucinations in univariate analysis ( p =< 0.0001, <0.0001, <0.0001 respectively), but age and disease duration were the only variables associated with hallucinations in multivariate analysis ( p = 0.0009, 0.1196 respectively). Race was not associated with a higher risk of compulsive behavior, dyskinesias, motor fluctuations, or hallucinations. Conclusion: Compulsive behavior, dyskinesias, motor fluctuations, and hallucinations in our PD population may be associated with differences in socioeconomic status and access to care, but not with differences in race.
The pharmacological therapy of Parkinson’s Disease (PD) is commonly associated with side effects, such as compulsive behavior, dyskinesias, motor fluctuations and hallucinations, which can have a significant impact on the quality of life of the patient [
A recent study suggests that motor fluctuations and dyskinesias are associated with disease progression rather than the duration of L-dopa therapy [
This analysis studies a population of PD patients at Boston Medical Center (BMC), an urban safety-net hospital in Boston, MA and aims to identify socioeconomic or clinical variables that are associated with compulsive behavior, dyskinesias, motor fluctuations, and hallucinations in patients in a safety-net hospital.
Patients were recruited from the neurology department at Boston Medical Center (BMC) in Boston, Massachusetts between 2007 and 2012. Movement disorder specialists at Boston Medical Center evaluated the patients and only those who were diagnosed with idiopathic PD were eligible for this study. The Institutional Review Board (IRB) at BMC gave approval for this research.
During the clinical encounter, the clinicians evaluated the patients for history or physical exam elements consistent with compulsive behavior, dyskinesias, motor fluctuations, and hallucinations. This data was collected by the clinician using a standardized clinical characteristics data form and then entered into a de-iden- tified database. The form included sections for demographic and clinical information as well as the medications used by the patient. Demographical information collected included the patients’ year of birth, sex, ethnicity, and education level. Clinical information included the self-reported date of symptom onset, date of diagnosis, and the presence or absence of potential disease complications such as compulsive behavior, dyskinesias, motor fluctuations, and hallucinations.
The main clinical outcomes of interest in this study were the four major side effects of compulsive behavior, dyskinesia, motor fluctuations, and hallucinations. The clinical variables included disease duration (number of years since the onset of symptoms), diagnosis duration (number of years since the diagnosis of PD as a measure of treatment duration), medication groups (carbidopa-levodopa, COMTI, DAs, MAOI), the total number of medications and total number of medication groups. The covariates of interest included age, gender, race (Caucasian vs. non-Caucasian), education (high school and lower, college or some college, graduate degree).
For evaluation of demographics, sample size, mean and standard deviation were calculated and reported for continuous variables. Frequency and relative frequency are reported for dichotomous and categorical variables (
Four hundred and fifty-two (452) patients were included in the analysis. Their
Patient Demographics (Total: 452 patients) | Mean (SD) |
---|---|
Age in years | 76.25 (10.66) |
Disease Duration (in years) | 17.23 (7.57) |
Diagnosis Duration (in years) | 15.74 (7.51) |
Total Number of PD Medications Used | 1.73 (1.54) |
Frequency (%) | |
Sex (Male) | 227 (50.22) |
Race (Caucasian) | 375 (83.33) |
College Education or Higher | 265 (58.63) |
Medication Groups | Frequency (%) |
Carbidopa-Levodopa | 284 (62.83) |
COMT Inhibitors | 78 (17.47) |
Dopamine Agonists | 160 (35.40) |
MAO Inhibitors | 76 (16.81) |
Categories | Unadjusted | Multivariate | ||||
---|---|---|---|---|---|---|
OR | CI | P-Value | OR | CI | P-Value | |
Age in years | 0.964 | 0.932 - 0.997 | 0.0336** | 0.964 | 0.932 - 0.997 | 0.0336** |
Disease Duration (in years) | 1.018 | 0.967 - 1.073 | 0.4963 | |||
Diagnosis Duration (in years) | 1.017 | 0.967 - 1.070 | 0.5037 | |||
Gender | 1.239 | 0.587 - 2.617 | 0.5740 | |||
Race | 0.689 | 0.202 - 2.351 | 0.5514 | |||
Education | ||||||
College | 1.636 | 0.603 - 4.444 | 0.3340 | |||
Graduate | 0.865 | 0.256 - 2.922 | 0.8159 | |||
Medication Groups | ||||||
Carbidopa-Levodopa | 1.123 | 0.495 - 2.548 | 0.7809 | |||
COMT Inhibitors | 1.265 | 0.495 - 3.232 | 0.6229 | |||
Dopamine Agonists | 0.800 | 0.353 - 1.813 | 0.5929 | |||
MAO Inhibitors | 1.309 | 0.512 - 3.347 | 0.5736 | |||
Total Number of Medications | 1.038 | 0.814 - 1.324 | 0.7648 | |||
Total Number of Medication Groups | 1.042 | 0.747 - 1.453 | 0.8082 |
**P-Value <0.05, *P-Value <0.2.
Categories | Unadjusted | Multivariate | ||||
---|---|---|---|---|---|---|
OR | CI | P-Value | OR | CI | P-Value | |
Age in years | 1.005 | 0.988 - 1.023 | 0.5518 | |||
Disease Duration | 1.173 | 1.128 - 1.220 | <0.0001** | 0.989 | 0.861 - 1.135 | 0.8701 |
Diagnosis Duration | 1.162 | 1.118 - 1.207 | <0.0001** | 1.239 | 1.072 - 1.432 | 0.0038** |
Gender | 1.160 | 0.792 - 1.698 | 0.4461 | |||
Race | 1.071 | 0.626 - 1.833 | 0.8027 | |||
Education | ||||||
College | 1.091 | 0.669 - 1.776 | 0.7278 | 0.876 | 0.445 - 1.722 | 0.7000 |
Graduate | 0.650 | 0.376 - 1.125 | 0.1236* | 0.989 | 0.861 - 1.135 | 0.0599* |
Medication Groups | ||||||
Carbidopa-Levodopa | 1.264 | 0.842 - 1.897 | 0.2576 | |||
COMT Inhibitors | 1.064 | 0.650 - 1.754 | 0.7969 | |||
Dopamine Agonists | 1.148 | 0.773 - 1.705 | 0.4945 | |||
MAO Inhibitors | 1.056 | 0.639 - 1.744 | 0.8308 | |||
Total Number of Medications | 1.036 | 0.915 - 1.173 | 0.5786 | |||
Total Number of Medication Groups | 1.081 | 0.915 - 1.278 | 0.3592 |
**P-Value < 0.05, *P-Value < 0.2.
Categories | Unadjusted | Multivariate | ||||
---|---|---|---|---|---|---|
OR | CI | P-Value | OR | CI | P-Value | |
Age in years | 0.999 | 0.982 - 1.016 | 0.8954 | |||
Disease Duration | 1.140 | 1.099 - 1.183 | <0.0001** | 0.934 | 0.813 - 1.073 | 0.3353 |
Diagnosis Duration | 1.149 | 1.106 - 1.193 | <0.0001** | 1.241 | 1.074 - 1.434 | 0.0035** |
Gender | 1.126 | 0.774 - 1.637 | 0.5360 | |||
Race | 1.151 | 0.677 - 1.958 | 0.6028 | |||
Education | ||||||
College | 1.189 | 0.733 - 1.927 | 0.4837 | |||
Graduate | 1.053 | 0.623 - 1.781 | 0.8467 | |||
Medication Groups | ||||||
Carbidopa-Levodopa | 1.071 | 0.721 - 1.591 | 0.7328 | 1.571 | 0.830 - 2.971 | 0.1650 |
COMT Inhibitors | 1.041 | 0.638 - 1.699 | 0.8728 | |||
Dopamine Agonists | 1.010 | 0.684 - 1.492 | 0.9583 | |||
MAO Inhibitors | 1.753 | 1.055 - 1.910 | 0.0301** | 1.571 | 0.830 - 2.971 | 0.1650 |
Total Number of Medications | 1.002 | 0.887 - 1.133 | 0.9738 | |||
Total Number of Medication Groups | 1.083 | 0.918 - 1.277 | 0.3449 |
**P-Value < 0.05, *P-Value < 0.2.
Categories | Unadjusted | Multivariate | |||||
---|---|---|---|---|---|---|---|
OR | CI | P-Value | OR | CI | P-Value | ||
Age in years | 1.057 | 1.034 - 1.081 | <0.0001** | 1.051 | 1.020 - 1.082 | 0.0009** | |
Disease Duration | 1.097 | 1.061 - 1.134 | <0.0001** | 1.097 | 0.976 - 1.232 | 0.1196* | |
Diagnosis Duration | 1.098 | 1.062 - 1.135 | <0.0001** | 0.983 | 0.872 - 1.108 | 0.7764 | |
Gender | 1.127 | 0.737 - 1.725 | 0.5809 | ||||
Race | 0.708 | 0.376 - 1.334 | 0.2857 | ||||
Education | |||||||
College | 1.315 | 0.765 - 2.260 | 0.3221 | ||||
Graduate | 0.918 | 0.499 - 1.689 | 0.7837 | ||||
Medication Groups | |||||||
Carbidopa-Levodopa | 0.935 | 0.581 - 1.504 | 0.7813 | ||||
COMT Inhibitors | 1.214 | 0.695 - 2.118 | 0.4959 | ||||
Dopamine Agonists | 1.070 | 0.665 - 1.721 | 0.7813 | ||||
MAO Inhibitors | 1.160 | 0.646 - 2.083 | 0.6182 | ||||
Total Number of Medications | 1.025 | 0.881 - 1.193 | 0.7473 | ||||
Total Number of Medication Groups | 1.042 | 0.885 - 1.270 | 0.6863 | ||||
**P-Value < 0.05, *P-Value < 0.2.
demographics are outlined in
Of the 452 patients enrolled in this study, 284 used carbidopa-levodopa, 160 used DAs, 78 used COMTI, 76 used MAOBI.
In this sample, 30 (6.64%) patients had demonstrated compulsive behavior, 184 (40.71%) suffered from dyskinesia, 227 (50.22%) experienced motor fluctuations, and 122 (27.00%) experienced hallucinations.
Tables 2-5 demonstrate the results of the multivariate logistic regression analysis. As seen in
Previous studies have suggested that the use of PD medications, in particular DAs and to a lesser extent L-dopa, are associated with the development of compulsive behavior in the general population [
In our cohort, dyskinesias were not associated with any specific medication groups, but they were associated with the time since diagnosis and were less likely to occur in patients with a graduate degree. A study in 2006 estimated that the 5-year risk of L-dopa induced dyskinesias was 50% in patients with disease onset between 50 - 59 years and 16% in those with onset after 70 years [
Fifty percent of the patients in the study had motor fluctuations. Previous studies had estimated the prevalence of motor fluctuations to be closer to 40% [
Several studies have demonstrated that dopaminergic medications influence hallucinations in PD and that they are associated with increased age and longer disease duration [
In our study, race was not associated with a higher risk of compulsive behavior, dyskinesias, motor fluctuations, or hallucinations. Racial differences in the incidence of complications of PD, especially compulsive behavior, dyskinesias, motor fluctuations, and hallucinations have not been specifically studied. A previous study found that the incidence of Parkinson’s disease was higher among Hispanics, followed by non-Hispanic whites, Asians, and Blacks [
This was a cross-sectional study with limited information on temporality, impacting conclusions about causality. We did not have access to data regarding the dosage of medications and the duration they had been taken for, making us unable to evaluate dose-response associations. The data on disease duration was collected by asking the patients about the start of their symptoms, which might be subject to recall inaccuracy and recall bias. Studies have shown that non-motor symptoms of PD can manifest up to 10 years before formal diagnosis is made [
Compulsive behavior was associated with younger age, but not use of L-dopa. Dyskinesias were not associated with any medication group, but were associated with a longer time since diagnosis. In addition, patients with a graduate degree were less likely to have dyskinesias. Motor fluctuations were associated with longer duration of disease and use of MAOBI. Hallucinations were not associated with L-dopa. In conclusion, our study suggests that compulsive behavior, dyskinesias, motor fluctuations, and hallucinations in our PD population may be associated with differences in socioeconomic status and access to care, but not with differences in race.
The authors would like to thank Boston University School of Medicine and the Boston Medical Center Department of Neurology for the guidance and support received for this project.
Sisniega, D.C., Madhusudhan, D., Rahmani, E., McInnis, R., Weinberg, J., Saint-Hilaire, M.-H. and Hohler, A.D. (2017) Medication Side Effect Profiles in PD Patients in a Safety-Net Hospital. Advances in Parkinson’s Disease, 6, 101-112. https://doi.org/10.4236/apd.2017.64011