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There have been few incidence studies of vascular parkinsonism (VP), progressive supranuclear palsy (PSP), and parkinsonian-type multiple system atrophy (MSA-P). We measured the age-, gender- and socioeconomic-specific incidence rates for these conditions in north-east Scotland.Incident non drug-induced parkinsonian patients were identified prospectively over three years by several overlapping methods from a baseline primary care population of 311,357. Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Patients had yearly follow-up to improve diagnostic accuracy. Incidence rates using the diagnosis by established research criteria at latest follow-up were calculated for each condition by age, gender, and socioeconomic status.Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD 9.8; 61% men). The crude annual incidence was 3.2 per 100,000 (95% confidence interval (CI) 2.2-4.3) for VP, 1.7 per 100,000 (95% CI 1.0-2.4) for PSP, and 1.4 per 100,000 (95% CI 0.8-2.1) for MSA-P. VP and MSA-P were more common in men (age-adjusted male to female ratios 2.58 (95% CI 1.65-3.83) and 8.65 (95% CI 4.73-14.5) respectively). Incidence did not vary with socioeconomic status.This is the first community-based, prospective study to report the incidence of vascular parkinsonism and the third to report the incidence of PSP and MSA-P. Further follow-up and comparison with similar studies in different populations will yield valuable prognostic and aetiological information on these conditions.

This study was undertaken to perform a systematic review and meta-analysis of studies of mortality in Parkinson's disease (PD) and to investigate which factors were associated with mortality. We conducted comprehensive searches of studies reporting a ratio of mortality in PD versus controls, descriptive survival measures, or factors predicting survival; assessed study quality; and extracted relevant data. Descriptive analysis, meta-analysis, and meta-regression were performed as appropriate. Eighty-eight studies were included in the review with variable study methods and quality. Almost all studies reported increased mortality in PD (vs. controls), with mortality ratios ranging from 0.9 to 3.8, with major between-study heterogeneity. Inception cohorts were more consistent with a pooled mortality ratio of approximately 1.5. Inception cohorts, measurements at longer follow-up duration, and older study recruitment year were associated with lower mortality ratios, but these findings were not robust in sensitivity analyses. Within studies, mortality ratios increased over time. No robust evidence was found that mortality has decreased after the introduction of levodopa (L-dopa). On average, PD survival reduced by approximately 5% every year of follow-up, although there was significant heterogeneity. In post-mortem studies, mean duration until death ranged from 6.9 to 14.3 years. Increasing age and presence of dementia were most commonly associated with increased mortality. Parkinson's disease is associated with increased mortality, but major heterogeneity is seen in estimates of mortality, which is probably explained by variable methodology and patient selection. Individual-patient-data meta-analysis of high-quality inception studies with long-term follow-up would be the optimal way to investigate the factors influencing mortality.

Purpose The purpose of this study was to show the viability and performance of a shape-based pattern recognition technique applied to I-N-omega-fluoropropyl-2-beta-carbomethoxy-3beta-(4-iodophenyl) nortropane single-photon emission computed tomography (FP-CIT SPECT) in patients with parkinsonism. Methods A fully automated pattern recognition tool, based on the shape of FP-CIT SPECT images, was written using Java. Its performance was evaluated and compared with QuantiSPECT, a region-of-interest-based quantitation tool, and observer performance using receiver operating characteristic analysis and kappa statistics. The techniques were compared using a sample of patients and controls recruited from a prospective community-based study of first presentation of parkinsonian symptoms with longitudinal follow up (median 3 years). Results The shape-based technique as well as the conventional semiquantitative approach was performed by experienced observers. The technique had a high level of automation, thereby avoiding observer/operator variability. Conclusion A pattern recognition approach is a viable alternative to traditional methods of analysis in FP-CIT SPECT and has additional advantages.

Objective During a prospective community-based incidence study of parkinsonism, a control group was recruited for comparison with the incident patients. This study compared the demographic and health status of recruited vs. nonrecruited controls. Study Design and Setting For each incident patient, attempts were made to recruit an age–gender matched control from the same general practice or, failing that, from a previously identified community cohort of people aged over 64 years who had expressed an interest in taking part in future research. Recruited controls were compared with those who were approached but not recruited in terms of age, socioeconomic status, gender, several measures of health status, and survival. Results A total of 74 controls (40%) were recruited out of 186 potential controls who were approached. Recruited controls scored slightly worse than nonrecruited controls on every measure of health status, which reached statistical significance for numbers of acute prescriptions and major surgical procedures. There were no significant differences in age, gender, socioeconomic status, or survival. Conclusion The control cohort was affected by recruitment bias, which suggested that recruited controls had slightly poorer health compared to nonrecruited controls. This bias may reduce differences in health when comparisons are made between the controls and the parkinsonian patients.

Objective To assess the effect of the colors of the envelope and ink on the response rate to a postal questionnaire in a study screening for undiagnosed parkinsonism in people aged 65 years and over in the community. Study Design and Setting A total of 2,524 people aged 65 years and over from five general practices in Aberdeen were randomized to receive a questionnaire about the symptoms of parkinsonism printed in either colored (green) or black ink, and sent out in either a brown or white envelope. Results The overall response rate was 63.5%. There was no significant interaction between envelope and ink color. The use of green ink compared to black significantly increased the response rate from 61.4% to 65.7% (OR 1.20, 95% confidence interval 1.02, 1.41). There was no overall effect of envelope color on response rate (62.3% brown and 64.8% white, OR 0.90, 95% confidence interval 0.76, 1.06) but there was significant heterogeneity between the general practices. When this general practice–envelope interaction was accounted for, brown envelopes had a significantly lower response rate than white ones (OR 0.49). Conclusion This study, along with existing evidence, has shown that the use of certain ink colors in postal questionnaires is likely to increase response rates relative to black ink. The effect of envelope color was inconsistent both within this study and between previous studies.

Making the diagnosis of Parkinson’s disease (PD) is a common clinical situation faced by neurologists, geriatricians, and general physicians. In the UK, about 30 to 40 patients are diagnosed with PD every day.1 However, the diagnosis is not always easy. The diagnostic reference standard for idiopathic PD is still histopathology, based on the loss of dopaminergic neurons in the substantia nigra, with Lewy bodies in the surviving neurons (fig 1).2 But clearly any reference standard that requires postmortem examination is not very helpful to a clinician faced with a living patient. Unfortunately, there is no antemortem equivalent of the Lewy body. Figure 1 Lewy body (arrow): haematoxylin & eosin stain, original objective magnification ×40 (courtesy of Dr James MacKenzie). The diagnosis, therefore, remains a clinical one in which laboratory and radiological investigations play only a small part. Clinicians must rely on interpreting a combination of clinical features, their onset, symmetry, progression, and response to treatment. This diagnostic process is subjective and so, unsurprisingly, is liable to error; two hospital based studies in the early 1990s found that only about three quarters of patients with a final clinical diagnosis of PD had it confirmed at postmortem (fewer when the clinical diagnosis at presentation was considered).3,4 Although more recent studies suggest that the accuracy of diagnosis has improved, to perhaps 90% or more,5,6 these came from highly specialised units, which may not be representative of most departments that see parkinsonian patients. Several attempts have been made to improve diagnostic accuracy by developing better clinical criteria for parkinsonism and PD. Two of the most commonly used are the UK Parkinson’s Disease Society (PDS) Brain Bank criteria,2 and the Gelb criteria7 (see boxes 1 and 2). These may improve the accuracy of the diagnosis of PD, …

The objective of this study was to test the methods for a large study of the incidence and prognosis of Parkinson's disease and other degenerative parkinsonian disorders and provide provisional incidence figures. This was a community-based prospective study to identify patients with newly diagnosed non-drug-induced Parkinsonism (>or=2 of tremor, rigidity, bradykinesia, postural instability) from a population of 148,600 people in Aberdeen, Scotland, over 18 months. Multiple search strategies were used to identify patients, including some population screening. Incident patients and age/sex-matched controls had assessments of impairment, disability, quality of life, mood, and cognition and are being followed up yearly. Two hundred and two people with possible parkinsonian symptoms were assessed, and 82 incident patients were identified, 50 with probable Parkinson's disease. The crude incidences of probable Parkinsonism and probable Parkinson's disease were 31.4/100,000/year (95% CI: 24.5-39.7) and 22.4/100,000/year (95% CI: 16.6-29.6), respectively. The mean age of diagnosis of Parkinson's disease was 76.1 +/- 10.0 years and the incidence was greater in men. The methods were generally successful. Provisionally, we found a higher incidence of Parkinson's disease than other comparable studies, and our patients were considerably older. This may reflect better case ascertainment in the elderly. A larger study is planned.

Background: The issue of whether to adopt a “wait and watch” strategy or to initiate drug therapy soon after diagnosis in Parkinson’s disease (PD) has been the subject of some debate. A recent observational study supported early treatment by demonstrating deterioration in self-reported health status in those left untreated, but not those who received therapy. We aimed to replicate this observation. Methods: People with PD from a prospective incidence study underwent follow-up with yearly clinical assessment of parkinsonian impairment (Unified Parkinson’s Disease Rating Scale (UPDRS)) and self-reported health status (Parkinson’s Disease Questionnaire (PDQ-39)). Two year outcomes were compared with those who started treatment within 1 year of diagnosis and those left untreated. Results: 42 patients with PD were followed-up for 2 years, of whom 26 started treatment during the first year and 16 remained untreated. Those receiving treatment had significantly higher UPDRS and PDQ-39 scores at baseline. There was no significant deterioration in PDQ-39 score in either group (median change untreated 0.8 vs treated 4.0; p = 0.47), despite a significant difference in the change in motor UPDRS scores (untreated 6.0 vs treated −6.0; p = 0.03). Conclusion: Given the lack of significant deterioration in the PDQ-39 in untreated patients, we believe a “wait and watch” strategy for the treatment of newly diagnosed PD remains a credible approach unless randomised trials prove otherwise.

There have been few high quality incidence studies of Parkinson's disease (PD). We measured age-, gender- and socioeconomic-specific incidence rates for parkinsonism and PD in north-east Scotland, and compared our results with those of previous high quality studies. Incident patients were identified prospectively over three years by several overlapping methods from primary care practices (total population 311,357). Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Drug-induced parkinsonism was excluded. Patients had yearly follow-up to improve diagnostic accuracy. Incidence rates using clinical diagnosis at latest follow-up were calculated for all parkinsonism and for PD by age, gender and socioeconomic status. Meta-analysis with similar studies was performed. Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD 9.8; 61% men). The crude annual incidence of parkinsonism was 28.7 per 100,000 (95% confidence interval (CI) 25.7-31.8) and PD 17.9 per 100,000 (95% CI 15.5-20.4). PD was more common in men (age-adjusted male to female ratio 1.87:1, 95% CI 1.55-2.23) but there was no difference by socioeconomic status. Meta-analysis of 12 studies showed an incidence of PD (adjusted to the 1990 Scottish population) of 14.6 per 100,000 (95% CI 12.2-17.3) with considerable heterogeneity (I(2) 95%), partially explained by population size and recruitment duration. The incidence of PD was similar to other high quality studies. The incidence of PD was not affected by socioeconomic status.

Parkinson’s disease (PD) is a neurodegenerative disease, the clinical features of which are usually asymmetrical at presentation. This can lead to difficulty in differentiating it from other asymmetric neurological disorders. We present two cases where idiopathic PD was initially misdiagnosed as stroke, leading to a delay in appropriate symptomatic therapy. Physicians involved in diagnosis and treatment of people with strokes should consider PD when formulating their differential diagnosis.

We read with interest the recent meta-analysis of seven studies that reported that the age-adjusted incidence of Parkinson’s disease was 1.5 times greater in men than in women.1 However, this meta-analysis excluded several informative studies (such as those with