Available evidence on the practice of acute pharmacological challenge tests in parkinsonian patients was reviewed by a committee of experts, which achieved a general consensus. The published data deal mainly with the acute administration of levodopa and apomorphine in Parkinson's disease. Such challenge may serve different purposes, e.g., research, diagnosis, or tailoring of treatment. Unique protocols describing the clinical setting and practice parameters are not available. The present paper describes the scientific background and supplies practical guidelines, whenever possible, to perform and evaluate acute challenge tests in parkinsonian syndromes. With the appropriate indication and setting, acute challenge tests are useful in diagnosis and therapy of Parkinson's disease and related disorders. © 2001 Movement Disorder Society.

We used a computational analysis of open loop handwriting movements and a clinical rating scale for monitoring the effect of apomorphine in 16 patients with early untreated parkinsonism [subsequently L-DOPA responsive, probable Parkinson's disease (PD)], six patients with long-standing PD with L-DOPA associated motor fluctuations, and seven patients with known L-DOPA unresponsive parkinsonism. Subjects were instructed to write fluently concentric circles of approximately 12 mm in diameter. Movements were recorded for two periods of 3 s each, using a digitizing tablet. Mean peak velocity (Vmax) and mean peak acceleration (Amax) were determined. In addition, two sensitive indices describing the degree of automation of handwriting were derived: (a) NCV, calculated as the mean Number of Changes in direction of Velocity per half circle, and (b) NCA, the mean Number of Changes in the direction of Acceleration. Clinical rating was performed according to the Unified Parkinson's Disease Rating Scale part III (UPDRS III). After apomorphine injection, the patients with early untreated probable PD showed significant improvement of Vmax, Amax, NCV, NCA, and UPDRS III scores. Likewise, the patients with long-standing PD improved significantly in all kinematic parameters and UPDRS III scores. Patients with L-DOPA unresponsive parkinsonism failed to change significantly in any of the parameters tested. These observations suggest that the computer-assisted analysis of automated handwriting movements can be used as an objective quick method for quantifying dopamimetic effects on the kinematics of handwriting movements in parkinsonian patients.

Current management guidelines for the treatment of patients with Parkinson's disease (PD) are limited due to the lack of knowledge of factors that influence health-related quality of life (HRQL). To assess the HRQL of people with PD, and to systematically identify and evaluate those factors (other than disease severity and medication, which could have an impact), we undertook a cross-sectional, randomized selection, multicenter international survey of patients with PD, caregivers, and clinicians. Face-to-face interviews were conducted with subjects in six countries. Disease severity, medication, and other factors hypothesized to influence HRQL were assessed using a combination of specially developed questionnaires and validated instruments including the Parkinson's Disease Questionnaire-39 (HRQL), Hoehn and Yahr Stage (disease severity), and Beck's Depression Inventory (BDI; depression). Multiple linear regression models were used to demonstrate whether the factors investigated contribute significantly to HRQL. The results obtained indicated that Hoehn and Yahr stage and medication explained only 17.3% of the variability in HRQL of patients with PD, although both were significant (R(2) = 0.173, P < 0.05). Other factors increased the explanatory power to adjusted R(2) = 0.597, with BDI being the most significant predictor of variability in HRQL (adjusted R(2) = 0.582; P < 0.001), followed by "Satisfaction with the explanation of the condition at diagnosis" and "Current feelings of optimism" (both P < 0.05). These factors, in addition to disease severity and medication, explain 59.7% of the variability in HRQL across the population. In conclusion, depression (as measured by the BDI) in PD, "satisfaction with the explanation of the condition at diagnosis" and "current feelings of optimism" have a significant impact on HRQL. The completion of this initial analysis is the first step towards developing management guidelines that truly influence the HRQL of patients with PD.

Parkinson's disease (PD) has a major socioeconomic impact on society. The chronic, progressive course of the disease, which often leads to severe disability, results in high expenses for the medical resources used for treatment, care, and rehabilitation of patients as well as reduced or lost productivity as a result of illness or premature death. In Great Britain, it has been estimated that the National Health Service spends up to 383 million pound sterling (1992) annually for the care of PD. This emphasizes the importance of assessing the costs related to this disease. A detailed knowledge of the cost allocation would provide a solid basis on which health care priorities can be rationally set. Next to hospitalization, drug treatment accounts for the highest expense for direct medical costs of PD. Therefore, this analysis focuses on the costs of drug treatment for PD. The cost analysis was based on a retrospective study of 409 patients with PD who were seen over a 1-year period in our movement disorders clinic. The cost of therapy varied considerably depending on the severity of the condition (assessed in the "off" phase), the incidence of motor fluctuations, and the type of PD. In the early stage of the disease (Hoehn and Yahr stage I [HY I]), mean daily costs for therapy were DM (German marks) 6.60, which increased in later stages of the disease (HY V) to DM 22.00. If rare cases requiring continuous subcutaneous apomorphine infusion were included, mean daily costs of patients in HY V rose to DM 32.50 (the mean daily costs of subcutaneous apomorphine-treated patients in HY V: DM 74.30). Patients with motor fluctuations accounted for higher costs (DM 16.50) compared with those without motor fluctuations (DM 7.80). With respect to the three subtypes of PD, the mean daily expenditure was DM 7.00 for the tremor-dominant type, DM 12.40 for the akinetic-rigid type, and DM 10.80 for the mixed type. In the group of 409 PD patients included in this analysis, the average daily expenditure for drug treatment totaled DM 10.70 per patient (including patients on subcutaneous apomorphine).