الفهرس 
Introduction
EPIDEMIOLOGY OF PDOnly 14 pages are availabe for public view
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Abstract
Parkinson’s Disease (PD) is a progressive neurodegenerative disease that affects 1–2% of people older than 60 years of age (Launer et al., 2000) Although PD has long been considered predominantly motor disorder, non-motor signs and symptoms have recently gained increasing recognition as part of PD (Löhle et al., 2009) Patients with PD have an almost six-fold increased risk of developing dementia compared with age-matched individuals without PD (Aarsland and Kurz, 2010) Aim of the work 1-Detailed study of the cognitive profile of patients with Parkinson’s disease. 2-Identification of the risk factors of cognitive impairement in PD patients. Study design It is Prospective Descriptive Study that extended from 1st of May 2017 till the end of April 2018 Subjects The current study is a multicenter study and patients were recruited from outpatient neurology clinic of AUH and Sohag university hospital. The included 48 patients with PD who were recruited ,36 from AUH and 12 from Sohag University Hospital. selection criteria of the Patients: Inclusions criteria The study included 48 patients of both sexes (38 males and 10 females) diagnosed as Parkinson’s disease according to Queen Square Brain Bank criteria (Hughes et al.,1992). Step (1) Diagnosis of Parkinsonian Syndrome Bradykinesia plus At least one of the following Muscular rigidity 4-6 Hz rest tremor postural instability not caused by primary visual, vestibular, cerebellar, or proprioceptive affection Step (2) Exclusion criteria for Parkinson’s disease history of repeated strokes with stepwise progression of parkinsonian features history of repeated head injury history of definite encephalitis oculogyric crises neuroleptic treatment at onset of symptoms more than one affected relative sustained remission strictly unilateral features after 3 years supranuclear gaze palsy cerebellar signs early severe autonomic involvement early severe dementia with disturbances of memory, language, and praxis Babinski sign presence of cerebral tumor or communication hydrocephalus on imaging studynegative response to large doses of levodopa in absence of malabsorption MPTP exposure Step (3) supportive prospective positive criteria for Parkinson’s disease Three or more required for diagnosis of definite Parkinson’s disease in combination with step one Unilateral onset Rest tremor present Progressive disorder Persistent asymmetry affecting side of onset most Excellent response (70-100%) to levodopa Severe levodopa-induced chorea Levodopa response for 5 years or more Clinical course of ten years or more All Patients were subjected to the following: 1-History taking and thorough general medical and neurological examination according to neurological examination special sheet of Asyut university hospital. Diagnosis of PDD according to MDS Task Force carried as follow First step: diagnosis of PD according to queen square brain bank criteria to exclude other alternative causes of Parkinsonism. Second step: diagnosis of dementia by the following A :MMSE< 26 for literate patients and < 24 for illiterate ones Impairment of at least two of the following domains attention -executive function -visuo –spatial ability -memoryOther criteria: 1- PD developed prior to the onset of dementia (1-year role) to be distinguished from DLB. 2- cognitive deficiency severe enough to impair daily life 3- Assessment of motor symptoms and signs using MDS_ UPDRS (part II and III). 4- Assessment of non-motor symptoms using (part I) of MDS_ UPDRS 5- Assessment of cognitive function of PD patients Using: A-UPDRS , part IB-MMSEC-WAIS 6- laboratory studies: serum level estimation of: -vitamin D3-uric acid-cholesterol level The present study shows: from 1st of May 2017 to end of April 2018, 48 patients diagnosed as Parkinson’s disease according to Queen Square Brain Bank criteria were included with mean age of 61.3 ±10.8 years, 58.3 % were over 60 years of age and 79.2% were males. Nearly all studied PD patients had a variety of non-motor symptoms where 79.2 % of them had cognitive impairment and depressed mood with different degrees and 89.6 % were apathetic. Urinary problems were found in 95.8 % of the studied sample and 97.9% had constipation problems. Furthermore, easy fatigability was reported by 95.8% of the studied patients and 66.7 % had sleep problems. As regarding the study of motor experiences of daily living, all of the studied patients suffered from problems in dressing, hygienic tasks, practicing their hobbies and activities and turning in bed with different degrees of severity . Most of the patients had troubles in eating tasks (97.8%) and in maintaining balance during walking ( 93.7%). Moreover, resting tremors were found in 95.8% of the studied sample and 85.4 % reported slight to moderate speech difficulties. Motor examination of the studied sample revealed that all of them suffered from global body bradykinesia with different degrees . Different degrees of rigidity and rest tremors constancy were found in 95.8% with the same percentage for each while 91.7% had Walking difficulties and abnormal posture. Maintaining posture and freezing during walking were observed in 71 % and 63 % of the studied patients respectively. Based on Hoehn and Yahr staging of PD , most of the studied patients were classified between stage 2 and 3 with 37.5% for each one. With the study of motor complications of medical treatment , 80.4% of patients suffered from variable off-state periods while only 19.6 % had dyskinesia with the exclusion of two patients who weren’t under therapy. As regarding the study of patients according to MDS_UPDRS, most of them had mild to moderate affection on part I (77.1%) ,II (75%) and IV (93.8%) while the majority of them (83.3%) suffered from moderate to severe affection on part III. With the study of mini-mental state examination of the sample, the mean of total MMSE score was 22.3 ± 3.1 with the majority of the studied patients (79.2%) had impaired cognitive function. Moreover, 75 % of them had affection in two or more of the studied cognitive domains ( visuospacial ability , free-recall and the attention score ) according to MDS task force criteria. . The mean total Wechsler score was 80.2 ± 7.6 with the majority of the studied patients had between low average to border line intelligence (IQ) score with 41.7% for each one. Moreover, the study of the laboratory data reported that , the mean serum cholesterol level was 160.6 ± 38.2 mg/dl while the mean serum level of uric acid was 4.3 ± 1.8 mg/dl . The majority of the studied patients had low serum vitamin D level (89.6 %) with mean serum vitamin D level of 9.8 ± 6.5 ng/ml. More than two thirds (68.8 %) of the studied PD patients had vitamin D deficiency and further fifth (20.8%) had vitamin D insufficiency in comparison to only 46.2 % of controls ( 7.7 % deficiency and 38.5 % insufficiency ) (p=0,03) . As regarding the comparison between patients with PDD and PD without dementia , it was found that part I , part II and part III scores of MDS-UPDRS were significantly higher in the demented in comparison to the non-demented patients (p<0,05) . Also, bradykinesia was more severe in the demented group with the majority of them had mild (44.7%) to moderate (42.2%) degree while the non-demented group had just slight (30%) to mild (70%) degree of affection. Furthermore, rigidity score was significantly higher in the demented group (P< 0.05).Moreover ,the demented group was classified in more advanced stages than the non-demented one on Hoen and Yahr staging with significant difference (p = 0,01) . Attention was the most frequently encountered impaired cognitive domain among patients with PDD (table 16) . Also, Non-demented group had significantly higher total Wechsler adult intelligence scale score in comparison to the demented one (p <0.001). Moreover, serum vitamin D level was significantly lower in the demented group compared to non-demented PD patients with (p < 0.001). On the other hand, both groups of patients had insignificant differences as regarding part IV of MDS_UPDRS ,the severity of resting tremors or its constancy , off –state time ,serum cholesterol and uric acid level (p>0.05). The study also reported that total Wechsler score had positive significant correlation with serum vitamin D level and it had negative significant correlation with the total scores of part I , part II and part III of MDS-UPDRS. On the other hand, total Wechsler score had no correlation with serum cholesterol level and insignificant correlation with serum uric acid level, body rigidity score, body resting tremors score and part IV score of MDS-UPDRS. Moreover, total Wechsler score was significantly decreasing with the increase in Hoehn and Yahr staging and with the severity of bradykinesia. Presence of variety of non-motor symptoms among PD patients is a common presentation . Cognitive impairement as studied by MMSE is one of the commonest non-motor symptom among PD patients (79.2 %) . Moreover, Most of PD patients have affection in two or more of the studied cognitive domains (75 %) (visuospacial ability, the free recall and the attention ). PDD patients have more advanced scores on part I ,II and III of MDS_UPDRS and more advanced Hoen and Yahr stages as compared to PD patients without dementia . Bradykinesia and rigidity are more severe in PDD patients when compared to the non-demented group. Serum vitamin D level is significantly lower in PDD patients as compared to PD patients without dementia (p<0,001). Low educational level and deficient vitamin D were found to be predictive risk factors for dementia in PD patients. Limitations of the study1-Two thirds of the studied patients were illiterate , so clock drawing test which is the diagnostic tool for executive dysfunction described by MDS task force couldn’t be done. 1-Every PD patient should be routinely assessed by MDS_UPDRS on first diagnosis and on follow up visits in the out-patient neurology clinic. 2- cognitive profile including MMSE and assessment of the main four cognitive domains ( visuospacial ability,attention ,free- recall and executive function) should be assessed in every newly diagnosed PD patient and on routine follow up visits to determine early signs of mild cognitive impairment (MCI) before progression to dementia. 3-Serum vitamin D level should be measured in every PD patient and monitored carefully. Moreover vitamin D supplement should be added to PD medical treatment in case of deficiency or insufficiency, which might ameliorate or slowdown the cognitive decline among PD patients.