Pizzamiglio, G

Rounis, E

Rounis, Elisabeth

Oxford University Research Archive

Praxis deficits in patients with Parkinson’s disease: A neuropsychological studyGloria Pizzamiglio1,2 Elisabeth Rounis11Nuffield Department of Clinical Neurosciences, University of Oxford 2 Wellcome Centre for Human Neuroimaging, Institute of Neurology, University College London, London, UKLimb apraxia is a higher motor dysfunction, comprising deficits in volitional learned and/orskilled movements despite intact motor, cognitive and sensory faculties (1,2). It has beendescribed in a number of acquired brain disorders, such as in stroke and neurodegenerativediseases, including basal ganglia disorders and Idiopathic Parkinson’s Disease (IPD) (2,3).The role of praxis deficits in the latter remains unclear. In particular the extent to whichthese overlap and the relationship of praxis deficit and motor deficits in IPD others remainsunknown.In this study:1. We sought to identify praxis deficits and subtypes in a group of 19 Idiopathic Parkinson’sdisease (IPD) patients, with no known cognitive impairment o dementia.2. We investigated how these deficits correlate with measures of dexterity, PD (usingUPDRS -3), cognitive deficits (using MOCA) and deficits in activities of daily living (UPDRS- 2), controlling for time since levodopa use and multiple comparisons1) The study demonstrated deficits in limb praxis in a group of IPD patients. In addition to identifying idemotor and ideational apraxia in subgroups of these patients, praxis deficits were entered as continuous variables to identify their relationship to PD deficits in these patients2) With the exception of one measure, namely Imitation, praxis deficits do not seem to correlate with cognitive dysfunction (MOCA). However they do correlate with motor PD deficits measured on the UPDRS 3 scale. 3) Our results should encourage further studies of higher-order motor impairments in Idiopathic Parkinson’s disease. These motor deficits may supplement work on non-motor deficits, in allowing to predict response to treatments and prognosis.(1) Leiguarda and Marsden (2000) Limb apraxias: higher-order disorders of sensorimotor integration. Brain 123, no. 5:860-879.(2) Heilman KM, Rothi LJG. 2003. Apraxia. In: Heilman KM, Valenstein E (eds) Clinical Neuropsychology. New York: Oxford University Press; pp. 215-235(3) Pramstaller and Marsden (1996) The basal ganglia and apraxia. Brain 119, Pt1: 319-40.Background & Objectives Behavioural Assessments & MethodsResultsPatient Demographics19 patients (6 Females, 13 Males), with a diagnosis of IdiopathicParkinson’s disease participated in the study.9/19 patients scored below age-adjusted cut-off for ideomotorapraxia (on Meaningless Imitation and Gesture Production tasks),2/19 scored below age-adjusted cut-off for ideational apraxia (onSingle Object Use Task).Patient Demographics are provided in the Table, below.Summary of Findings DiscussionNeuropsychologyTasksAll patients undertook the following tasks:1. Cognitive assessment with MOCA2. Assessment of hand function/impairment (9 Holepeg test)3. Apraxia tasks:Praxis tests from the Birmingham Cognitive Screen:• Meaningless Gesture Imitation• Gesture Recognition• Gesture Production• Single Object Use12Meaningless Gesture Imitation(Goldenberg, Laimgruber & Hermsdo, 2001). Using detailed neuropsychology testing we identified that over half (58%) of patients with IPD had upper limb apraxia. Most of the patients identified had ideomotor (82%), as opposed to ideational (18%), apraxia. Apraxia Scores were particularly correlated with Motor deficits on UPDRS 3. Indeed there were no correlations between these scores and either PD severity (Hoehn and Yahr Stage) or total UPDRS score.  There was also no correlation with demographic variables including  patient’s age, years of education or Levodopa treatment amount and duration. The motor-updrs (UPDRS3) score correlated significantly with the following measures of apraxia:  Meaningless Gesture Imitation, Single Object Use, Gesture Recognition.The motor-updrs (UPDRS3) correlated with deficits in Dexterity, Response Inhibition and Cognition measured using MOCA. Of note none of the patients had dementia (MOCA score was above 24 in all patients)Taken together these findings suggest that patients with Idiopathic PD have deficits in praxis that span both ideational and ideomotor domains, incorporating deficits in executive function and body schema. Parkinson’s Disease Assessment1. UPDRS (especially parts 2 (ADLS) and 3 (Motor))2. Time since levodopaSingle Object UseGesture recognition and production9HP Dexterity• The UPDRS total and UPDRS 2 sub- cores did not correlate with Praxis, Dexterity, Cognition or Motor inhibition (P>0.1)• None of the measures correlated with time since levodopa, Age, or years of educationCorrelations between UPDRS and Praxis, Dexterity, Cognition, Motor Inhibition: Mean (+/-SD)Age (years) 67 (4.8)Disease duration (years) 7 (3.6)Education (years) 14.5 (4)MOCA 26.3 (2.7)UPDRS (Total) 80.2 (24.8)Levodopa equivalent daily dose (mg)720.5 (195.3)Average Time of Assessment since Medications (min)123.7 (40.4)Meaningless Gesture Imitation (Normalised out of /100)81.7 (14.7)Gesture Production (Normalised out of /100)88.7 (9.3)Gesture Recognition (Normalised out of /100)94.7 (8.6)Single Object Use (Normalised out of /100)94.4 (10.7)MOCAAnalyses1. Correlation analyses were carried out betweenNeuropsychology, dexterity and MOCA and UPDRS as well asTime since levodopa, corrected for multiple comparisons2. A hierarchical cluster analysis was performed in which eachvariable was entered as an individual cluster comparing theirsimilarity or distance (squared Euclidian distance) – adendrogram was computed to represent relationships ofsimilarity among variablesHierarchical Cluster Analysis On this dendrogram, similar variables are joined at the left (X values closer to 0), whereas less similar variables are joined at the right. A cut-off at less than 0.6 has delineated 2 possible groups of variable relationships.Cognitive, spatial and praxis measures at the top (Purple box) seem to relate to Motor PD (UPDRS 3) severity. Conversely UPDRS2, and overall PD severity are more distantly related to Dexterity and to Praxis measure of Gesture Production (Blue box).Z-score of Euclidian distance between variables (the closer to 1, the larger the distance)Praxis and MOCA:There was a trend for correlation between Gesture Recognition and MOCA (r=0.441, p=0.059). There was no correlation between other Praxis tasks (single object use, gesture production), or measures of dexterity with MOCA ReferencesAcknowledgementsThis work was support by personal grants to Dr E Rounis from the British Medical Association (Helen Lawson grant), University of Oxford Fell Fund, and Oxford University Charitable Funds.We would like to thank that patient participants for taking part in the study and the ‘DENDRON’ network who helped identify and recruit patients in this study.The Study was approved by the South Central - Berkshire Research Ethics Committee (14/SC/0074).

Praxis deficits in patients with Parkinson's disease: a neuropsychological study

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