Clinical Interventions in Aging

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Assessment of cognitive impairment in patients with Parkinsons disease: prevalence and risk factors
This article was published in the following Dove Press journal: Clinical Interventions in Aging 12 February 2014 Number of times this article has been viewed

Qiumei Wang 1 Zhenxin Zhang 2 Ling Li 2 Hongbo Wen 2 Qun Xu 3,4

Department of Geriatrics, Department of Neurology, 3School of Basic Medicine, Peking Union Medical College Hospital, 4Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, Peoples Republic of China
1 2

Background: Although Parkinsons disease (PD) is clinically characterized by motor symptoms, cognitive impairment is one of the most disabling non-motor symptoms. Despite it attracting increasing attention worldwide, less is known about its prevalence in the Chinese population. The objective of this study was to assess cognitive impairment and related risk factors in Chinese PD patients. Methods: We collected the demographic, diagnostic, and treatment information of 901 PD patients from 42 centers throughout the Peoples Republic of China, then administered a battery of neuropsychological tests, to assess motor, cognitive, and neuropsychiatric symptoms. Results: Overall, 193 of 901 (21.4%) PD patients met the criteria for dementia (PD-D), and 206 (22.8%) met the criteria for mild cognitive impairment (PD-MCI). Visuospatial dysfunction and attention/executive impairment predominated. Increased severity of cognitive impairment was associated with greater motor impairment. Patients with psychiatric symptoms, such as depression and hallucinations, were more likely to have dementia. Potentially, the younger-aged and more educated are shown less cognitive impairment, but age at onset, and levodopa equivalent dose, were not associated with the presence of cognitive dysfunction. Conclusion: The prevalence and prole of cognitive impairment in Chinese PD patients, as well as the risk factors, are similar as those reported for other races, but the frequency of nonamnestic cognitive domains differs. Keywords: cognitive impairment, risk factor, prevalence, Parkinsons disease

Introduction
Cognitive impairment is one of the most common and disabling non-motor symptoms in Parkinsons disease (PD), yet it is not routinely treated in clinical practice. The prevalence of PD-related cognitive impairment varies greatly across studies. Moreover, although overt dementia in PD patients (PD-D) has been extensively investigated,1 and specic diagnostic criteria have been developed,2 there is no established diagnosis criteria for subtler impairment in PD patients.3 Our understanding of cognitive impairment and dementia in the Chinese PD population is particularly limited. Two small-scale studies,4,5 and reviews of the literature on all non-motor symptoms,6 have revealed that Chinese PD patients suffer from nonmotor symptoms, but there appear to be some differences, compared with prevalence rates and risk factors for these symptoms within Western populations.6 Notably, there is no epidemiological data on cognitive impairment from a large sample of Chinese patients. Therefore, we recruited a series of PD patients, to investigate the frequency

Correspondence: Zhenxin Zhang Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, Peoples Republic of China Tel +86 10 6915 4063 Fax +86 10 6915 4063 Email [email protected]

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and proles of cognitive impairment, and to assess possible predictive risk factors, within this population.

Patients and methods Patients and study instruments

A total of 901 PD patients were recruited from 42 universityafliated hospitals throughout seven cities in The Peoples Republic of China from December 2005 to January 2008. All relevant information from patients in each hospital was recorded. Patients were then examined using a standardized interview documents on demographic, diagnostic, and treatment information, along with a three-part assessment battery. This study was approved by the institutional review boards of the relevant hospitals, and written informed consent was obtained from every patient selected. The neuropsychological examination comprised three parts. Section A consisted of patient demographics, including age, gender, education, occupation, and living situation. Section B documented diagnostic and treatment information, and data regarding the onset and symptoms of PD. Section C comprised four scales for rating symptoms. The motor and related symptoms battery contained the Hoehn and Yahr Scale (HY),7 Part I (Mentation, Behavior, and Mood), Part II (Activities of Daily Living), and Part IV (Complications) of the Unied PD Rating Scale (UPDRS).8 The cognitive battery contained the Chinese version of the Mini Mental State Exam (C-MMSE) (30 maximum) and the Montreal Cognitive Assessment (MoCA) (30maximum). Additionally, all patients were assessed using standard cognitive tests: the Fuld Object Memory Evaluation (020 points), to assess the memory domain, the Fuld Verbal Fluency test (FVFT), to evaluate verbal ability, the revised Wechsler Intelligence Scale for Children (WISC-R) Block Design (62maximum), to assess visuospatial function, the revised Wechsler Adult Intelligence Scale (WAIS-R) Digit Span (22 points), to evaluate attention, and the seventeen-item Hamilton Depression Rating Scale with 17 items (Hdrs-17) and Neuropsychiatric Inventory (NPI), to evaluate behavior and mood. Cut-offs for determination of cognitive impairment were based on individual education levels. We included only cases of PD with clinical onset before the starting date of the survey. We employed a standardized diagnostic appraisal for all patients, which followed the UK Parkinsons Disease Society Brain Bank Criteria for idiopathic PD. A principal investigator reconrmed all assessments, after regional supervisors had made diagnoses using all available information from each center. The diagnosis of probable PD with dementia (PD-D) was made using

criteria recommended by the Movement Disorder Society.2 PD patients with mild cognitive impairment (PD-MCI) were not clinically demented, but were impaired in any one of four cognitive domains: attention, executive function, visuospatial function, and free-recall memory.

Data analyses
Data are expressed as means with standard deviations (SD) for normal distributions. We used chi-square tests for nominal variables, and Fishers Exact tests for quantitative variables. Logistic regression analyses were performed to evaluate categorical predictor variables for PD-D and PD-MCI. Odds ratios (OR) and 95% condence intervals (CI) were reported. Differences were considered statistically significant at P,0.05. Analyses were performed using SAS version 8.0statistical software (SAS Institute Inc., Cary, NC, USA).

Results Patient characteristics

A total of 901 consecutive patients met the UK Parkinsons Disease Society Brain Bank Criteria for idiopathic PD; a total of 18 patients were excluded because of symptoms suggesting atypical parkinsonism (n=12), and overlapping enrollment with different centers (n=6). There were 562 (62.4%) men. The average age was 65.410.7 years (Table1). The average duration of PD in this sample was 5.54.5 years. According to the HY scale, 19.2%, 62.2%, and 18.6% were at Stages I, II, and III or higher, respectively.
Table 1 Patient characteristics
Characteristic Patients, n Men, n (%) Age (mean SD, years) Education (mean SD, years) Occupation, n (%) Laborers/service workers Administrators Professionals Financially independent, n (%) Age at PD onset (mean SD years) PD duration (mean SD years) Duration (onset to first visit) #6 years 724 years .24 years HY stage, n (%) Stage I Stage II Stage $III 901 562 (62.4) 65.4 10.7 10.7 4.6 392 (43.5) 253 (28.1) 256 (28.4) 722 (80.1) 60.0 11.1 5.5 4.5 542 (60.2) 236 (26.2) 123 (13.6) 173 (19.2) 560 (62.2) 168 (18.6)

Abbreviations: PD, Parkinsons disease; SD, standard deviation; HY, Hoehn and Yahr scale.

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Cognitive impairment assessment in PD patients

Cognitive impairment prevalence in PD

Among the 901 patients, 21.4% (n=193) met the PD-D criteria recommended by the Movement Disorder Society, and 22.8% (n=206) met the criteria for PD-MCI. Overall, 44.3% of PD patients had some degree of cognitive impairment (Table2). The cognitive assessment scores for patients with PD-D, PD-MCI, and PD with no cognitive impairment (PD-NoCI) are shown in Table3. PD-D and PD-MCI patients performed signicantly worse in nearly all the domains, compared with PD-NoCI patients. C-MMSE and MoCA global cognitive scores were signicantly lower for both PD-MCI and PD-D patients. Based on the proposed cut-off value of 26 (or less) to identify cognitive impairment using both MoCA and MMSE,10 we found that MoCA could detect 86.5% of PD-D and 84.5% of PD-MCI, whereas MMSE identied just 65.3% of PD-D and 33.6% of PD-MCI (Table4). Our results indicate that MoCA is more sensitive than MMSE for assessing cognitive impairment in Chinese PD patients.

were 70.0%, 67.4%, and 53.4%, respectively (Table4). When we merged the executive impairment and attention domains for analysis, 168 (87.0%) PD-D patients had executive and/or attention dysfunction. Overall, the attention/executive and visuospatial domains were the most commonly impaired; about one-third of PD-D patients were nonamnestic.

Predictive risk factors for PD-related cognitive impairment

Among demographic factors (Table5), having longer education and a professional career, were potentially protective factors against cognitive impairment. Males were less likely to have PD-MCI (OR =0.63, P=0.02), but gender was not a signicant predictive factor for PD-D (OR =0.97, P=0.90). Incidence of PD-MCI was much lower in patients with selfsupport nance independency (OR =0.44, P=0.002), but this was not the case with PD-D (OR =0.77, P=0.30). With regard to age, PD patients who were at least 75 years old were twenty-one times more likely to develop PD-D, and four times more likely to suffer from PD-MCI (P,0.001), than patients younger than 55 years. However, age at PD onset was not an inuential factor. Among clinical predictive risk factors (Table5), cognitive impairment was associated with higher axial UPDRS impairment score, and advanced HY stages. Based on the Movement Disorder Society criteria, PD-D occurred in 12.1% of HY Stage I patients, 17.9% of Stage II patients, and 42.9% of patients at Stage III or higher. For PD-MCI, these values were 15.6%, 22.7%, and 30.9%, respectively (Stage $III versus Stage I PD-MCI: OR =3.97; Stage $III versus Stage I PD-D: OR =4.77; P=0.001). Patients with axial impairment were two times more likely to have cognitive impairment (PD-MCI: OR =2.07; PD-D: OR =2.57; P,0.05). Levodopa dosage was not a signicantly inuential factor. In addition, 24.4% (n=220) of all PD patients suffered from depression, and 7.0% experienced hallucinations. In this series of patients, severity of depression symptoms was positively associated with dementia risk (OR=1.98, P=0.03, the data was calculated in patients with Hdes-17 scores 12

Cognitive deficit profiles in PD-MCI and PD-D

We employed a set of standard cognitive tests to investigate cognitive decit proles in PD-MCI and PD-D patients (Table4). In PD-MCI patients, the most common cognitive decits were visuospatial dysfunction (40.3%), executive dysfunction (27.7%), memory impairment (15.0%), and attention impairment (12.6%). Although we used different tests to assess attention and executive function, the basic cognitive processes of these two domains cannot be clearly divided, and often overlap. For this reason, we merged the two domains for analysis purposes, and found that 83 (40.3%) PD-MCI patients exhibited executive/attention dysfunction. Overall, most cognitive impairment in PD-MCI patients corresponded to visuospatial dysfunction and attention/executive impairment; only 15% of cognitive impairment in PD-MCI patients was amnestic (Table4). In PD-D patients, approximately 82.4% (159 patients) had visuospatial dysfunction; the frequencies of executive dysfunction, memory impairment, and attention impairment
Table 2 Cognitive impairment prevalence and PD duration
Duration (years) Age at admission (years) HY stage $3 (%) Dementia % (n=193) MCI % (n=206) 21.4 22.8 Overall n=901 02 n=305 63.9 10.7 5.9 20.7 20.7 34 n=229 65.5 10.9 15.8 15.3 20.5

56 n=136 65.4 10.1 19.8 22.1 24.3

78 n=79 65.4 11.6 37.3 19.0 27.8

910 n=64 66.5 9.6 31.0 35.9 18.7

$11 n=88 68.2 10.3 55.4 30.7 22.7

Abbreviations: PD, Parkinsons disease; HY, Hoehn and Yahr scale; MCI, mild cognitive impairment.

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Table 3 Cognitive test scores for patients with PD-D, PD-MCI, and PD-NoCI
Cognition (mean SD) MMSE (me total) MoCA (mo total) Attention (WAIS-R Digit Span Backward) Attention (WAIS-R Digit Span total) Visuospatial (Block Design) Dysexecutive (RVR total) Dysexecutive (F words) Memory impairment (FOM initial) Memory impairment (FOM total) PD-MCI (n=206) 26.2 2.5 20.0 4.1 3.5 1.0 10.8 2.2 22.8 10.9 35.0 8.6 6.0 3.0 6.1 1.5 14.8 2.6 PD-D (n=193) 21.9 5.3 14.7 5.4 2.7 1.3 9.0 2.7 11.2 10.0 25.6 10.4 4.7 2.8 4.3 2.0 11.0 4.3 PD-NoCI (n=502) 28.6 1.5 24.9 3.2 4.4 1.2 12.4 2.2 37.0 10.2 43.2 9.3 7.2 3.3 7.1 1.3 16.6 1.9 P ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.0001

Abbreviations: PD, Parkinsons disease; PD-D, dementia; PD-MCI, mild cognitive impairment; PD-NoCI, no cognitive impairment; MMSE, Mini Mental State Exam; MoCA, Montreal Cognitive Assessment; SD, standard deviation; WAIS, Revised Wechsler Adult Intelligence Scale; RVR, Rapid Verbal Retrieve; FOM, Fuld Object Memory Evaluation.

versus patients with Hdes-17 scores 7), and patients with hallucinations were more likely to have dementia (OR =3.15; P,0.001). Clearly, cognitive impairment is associated with the severity of PD motor and neuropsychiatric symptoms in this population.

Discussion
We thoroughly and systematically investigated the prevalence of cognitive impairment in Chinese PD patients, and found that 22.8% had PD-MCI, while 21.4% met the PD-D criteria of the Movement Disorder Society. Two large studies, from Germany and Norway, have reported similar frequencies of PD-MCI (30.6%11 and 25.8%,12 respectively). The prevalence of PD-D described in other large studies varies greatly; a population-based study of PD patients in the Netherlands reported 22% dementia,13 and a study of 1,449 PD outpatients in Germany found that 29% exhibited dementia.14 Asmaller German study (605 subjects), reported that 13.1% had dementia.11 The differences in PD-MCI and PD-D frequencies between studies are probably due to different study methods, varying criteria, and differences in disease severity. In addition, the studies mentioned above were cross-sectional, and only described point prevalence; cumulative prevalence is often
Table 4 Cognitive impairment profiles in PD-D and PD-MCI patients
PD-D n (%) Patients MMSE ,cut-off MoCA ,cut-off Attention impairment Visuospatial dysfunction Executive impairment Memory impairment 193 126 (65.3) 167 (86.5) 103 (53.4) 159 (82.4) 135 (70.0) 130 (67.4) PD-MCI n (%) 206 69 (33.6) 174 (84.5) 26 (12.6) 83 (40.3) 57 (27.7) 31 (15.0)

Abbreviations: PD, Parkinsons disease; PD-D, dementia; PD-MCI, mild cognitive impairment; MMSE, Mini Mental State Exam; MoCA, Montreal Cognitive Assessment.

much greater, as has been shown in a Norwegian cohort,15 and by the Sydney Multicenter Study.16,17 For example, in the former study, the point prevalence of dementia is 26%, while the 8-year cumulative prevalence of dementia is 78.2%.15 In the latter study, the point prevalence of dementia in patients at 20 years is 83%.16 Although it has been reported that Asian populations may have a lower incidence of dementia overall,18 our results indicate that the prevalence of cognitive impairment in Chinese PD patients is not signicantly different from that observed in other races and areas. With regard to cognitive impairment in PD-MCI and PD-D, the frequencies of memory impairment in our study are very close to those reported by others: 13.3%15.1%12,19 in PD-MCI patients, and 67.4% in PD-D patients.20 In similarity with an earlier study,19 we found that attention/executive impairment and visuospatial dysfunction are the predominating forms of cognitive impairment in Chinese PD-MCI and PD-D patients. Memory and executive defects had been reported to be the most common impairment proles in PD.21 Impaired attention was found to be an important aspect of cognitive impairment in PD; it is the most useful parameter to differentiate PD-D from Alzheimers disease.22 We employed the WAIS-R scale to assess attention, because it is routinely employed by the clinics involved in this study. Although WAIS-R is usually employed to measure working memory, the capacity to maintain attention is prerequisite for completing the test. Notably, the frequency of nonamnestic domain impairment was higher in our study sample than has been reported by other studies.12,19 The different results may be due to the use of different study methods, varying degrees of disease severity, and different demographic factors. However, it may also reect diverse patterns of neuronal degeneration associated with PD.23 A recently published hypothesis for PD proposes two different patterns of disease evolution: ie, frontal-striatal basal ganglia circuits, and posterior cortical

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Cognitive impairment assessment in PD patients

Table 5 Predictive risk factors for PD-related cognitive impairment

PD-D (n=193) n (%) Male Age at entry (vs ,55 years) 5564 years 6574 years $75 years Education (vs 06 years) 712 years $13 years Occupation (vs professional) Financially independent (vs not) Yes Age of PD onset (vs ,59 years) $59 years Hoehn and Yahr scale (vs stage I) Stage II Stage $III Levodopa dose (vs ,400 mg) 400599 mg $600 mg UPDRS axial impairment (vs not) Yes Depression (vs Hrsd-17 total ,9) (Yes: Hrsd-7 total $9, ,12) (Yes: Hrsd-17 total $12) Hallucinations (vs not) Yes 118 (61.1) 31 (16.1) 72 (37.3) 77 (39.9) 84 (43.5) 35 (18.1) 27 (14.0) 124 (64.3) 137 (71.0) 100 (51.8) 72 (37.3) 32 (16.6) 56 (29.0) 70 (36.3) 31 (16.1) 88 (45.6) 42 (21.8) PD-MCI (n=206) n (%) 113 (54.8) 41 (19.9) 79 (38.3) 57 (27.7) 100 (48.5) 48 (23.3) 41 (19.9) 164 (79.6) 137 (66.5) 127 (61.6) 52 (25.2) 36 (17.5) 47 (22.8) 50 (24.3) 35 (17.0) 66 (32.0) 19 (9.2) PD-NoCI (n=502) n (%) 331 (65.9) 156 (31.1) 189 (37.6) 53 (10.5) ,0.001 221 (44.0) 228 (45.4) 0.02 118 (23.5) 0.002 434 (86.4) 0.73 254 (50.6) ,0.001 333 (66.3) 44 (8.8) 0.30 102 (20.3) 78 (15.5) 0.003 38 (7.6) 0.03 79 (15.7) 107 (21.3) ,0.001 33 (6.6) 3.15 (1.626.15) 1.13 (0.602.13) 1.98 (1.183.34) 0.54 1.25 (0.612.54) 2.57 (1.384.77) 0.35 1.10 (0.661.84) 1.40 (0.892.20) 0.72 (0.391.32) 1.24 (0.712.18) 0.01 2.07 (1.173.69) 1.31 (0.702.45) 4.77 (2.0810.95) 0.45 0.77 (0.471.28) 1.12 (0.681.83) 0.88 (0.421.86) ,0.001 1.67 (0.992.82) 3.97 (1.928.18) 0.44 (0.260.74) 0.44 1.30 (0.672.53) 0.48 (0.260.87) 0.30 0.77 (0.481.26) 0.30 (0.170.54) 0.15 (0.070.31) 0.004 0.49 (0.300.79) Adjusted predictors for PD-D P-value 0.90 ,0.001 OR (95% CI) 0.97 (0.591.59) 2.51 (1.085.84) 6.25 (2.2317.50) 21.81 (6.9568.43) ,0.001 0.52 (0.320.86) 0.27 (0.150.49) Adjusted predictors for PD-MCI P-value 0.02 ,0.001 OR (95% CI) 0.63 (0.420.94) 1.00 (0.551.84) 1.57 (0.693.60) 4.26 (1.6910.70)

Abbreviations: PD, Parkinsons disease; PD-D, dementia; PD-MCI, mild cognitive impairment; PD-NoCI, no cognitive impairment; OR, odds ratio; CI, confidence interval; UPDRS, Unified PD Rating Scale; Hrsd-17, Hamilton Rating Scale for Depression; vs, versus.

syndromes. Executive and attention defects are more obvious when the frontal-striatal pathway is involved, whereas visuospatial and memory dysfunction are more representative of posterior cortical decits.24 In summary, the prole of cognitive domain impairment described here is similar to that reported in other races. Difference in the frequencies of domain impairment may be due to differences in methodology, racial composition, and disease evolution. Understanding which factors can be used to predict cognitive impairment in PD is very important. We conrmed a previously reported series of potential risk factors for PD cognitive impairment in the current study. Patients with higher axial UPDRS impairment scores, HY stages,25,26 and ages2628 are more likely to manifest cognitive impairment. Conversely, higher educational attainment,4,26 male gender,28 professional occupation, and nancial independence are, potentially, protective factors against cognitive impairment. The latter two factors may arise because receiving education is more predominant among men during economically

difcult times, while better chronic disease management increased during better economic conditions. In our study, age was an inuential factor for cognitive impairment in PD, in contrast to the ndings reported by Arnaldi etal.29 Although age at onset of motor symptom was not a signicant inuential factor, there are some studies which suggest that late-onset PD is predictive of cognitive impairment.27,30 Medications used to treat PD may affect cognition. But our study, and others,4,28 shows that the levodopa equivalent dose is not associated with the risk of cognitive impairment in PD. Hallucinations15,30,31 and depression26 have also been associated with cognitive impairment in PD patients, but these have different genetic explanations. With regard to hallucinations, one study reported that visual perception is more globally impaired in patients with PD-D than in PD-NoCI or healthy controls.32 A recent publication posited that visual hallucinations are a common feature of disorders that affect temporal lobe structures and impair ascending monoaminergic pathways.33 This provides a reasonable explanation

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Dovepress 8. Fahn S, Elton RL, UPDRS program members. Unied Parkinsons Disease Rating Scale. In: Fahn S, Marsden CD, Goldstein M, Calne DB, editors. Recent Developments in Parkinsons Disease. Vol 2. Florham Park, NJ: Macmillan Healthcare Information; 1987:153163. 9. Nasreddine ZS, Phillips NA, Bedirian V , etal. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695699. 10. Dubois B, Burn D, Goetz C, etal. Diagnostic procedures for Parkinsons disease dementia: recommendations from the movement disorder society task force. Mov Disord. 2007;22(16):23142324. 11. Balzer-Geldsetzer M, Costa AS, Kronenburger M, etal. Parkinsons disease and dementia: a longitudinal study (DEMPARK). Neuroepidemiology. 2011;37(34):168176. 12. Aarsland D, Bronnick K, Williams-Gray C, etal. Mild cognitive impair ment in Parkinson disease: a multicenter pooled analysis. Neurology. 2010;75(12):10621069. 13. de Lau LM, Schipper CM, Hofman A, Koudstaal PJ, Breteler MM. Prognosis of Parkinson disease: risk of dementia and mortality: the Rotterdam Study. Arch Neurol. 2005;62(8):12651269. 14. Riedel O, Klotsche J, Spottke A, etal. Frequency of dementia, depres sion, and other neuropsychiatric symptoms in 1,449 outpatients with Parkinsons disease. J Neurol. 2010;257(7):10731082. 15. Aarsland D, Andersen K, Larsen JP, Lolk A, Kragh-Sorensen P. Prevalence and characteristics of dementia in Parkinson disease: an 8-year prospective study. Arch Neurol. 2003;60(3):387392. 16. Hely MA, Reid WG, Adena MA, Halliday GM, Morris JG. The Sydney multicenter study of Parkinsons disease: the inevitability of dementia at 20 years. Mov Disord. 2008;23(6):837844. 17. Caviness JN, Driver-Dunckley E, Connor DJ, et al. Dening mild cognitive impairment in Parkinsons disease. Mov Disord. 2007;22(9): 12721277. 18. Sahadevan S, Saw SM, Gao W, Tan L, Chin JJ, Venketasubramanian N. Ethnic differences in Singapores dementia prevalence: the stroke, Parkinsons disease, epilepsy, and dementia in Singapore study. J Am Geriatr Soc. 2008;56(11):20612068. 19. Mamikonyan E, Moberg PJ, Siderowf A, etal. Mild cognitive impair ment is common in Parkinsons disease patients with normal MiniMental State Examination (MMSE) scores. Parkinsonism Relat Disord. 2009;15(3):226. 20. Noe E, Marder K, Bell KL, Jacobs DM, Manly JJ, Stern Y. Comparison of dementia with Lewy bodies to Alzheimers disease and Parkinsons disease with dementia. Mov Disord. 2004;19(1):6067. 21. Muslimovic D, Post B, Speelman JD, Schmand B. Cognitive prole of patients with newly diagnosed Parkinson disease. Neurology. 2005;65(8):12391245. 22. Bronnick K, Emre M, Lane R, Tekin S, Aarsland D. Prole of cognitive impairment in dementia associated with Parkinsons disease compared with Alzheimers disease. J Neurol Neurosurg Psychiatry. 2007;78(10): 10641068. 23. Jellinger K. Post mortem studies in Parkinsons disease is it possible to detect brain areas for specic symptoms? J Neural Transm Suppl. 1999;56:1. 24. Marder K. Cognitive impairment and dementia in Parkinsons disease. Mov Disord. 2010;25(S1):S110S116. 25. Poletti M, Frosini D, Pagni C, et al. Mild cognitive impairment and cognitive-motor relationships in newly diagnosed drug-naive patients with Parkinsons disease. J Neurol Neurosurg Psychiatry. 2012;83(6): 601606. 26. Riedel O, Klotsche J, Spottke A, et al. Cognitive impairment in 873 patients with idiopathic Parkinsons disease. J Neurol. 2008;255(2): 255264. 27. Hobson P, Meara J. Risk and incidence of dementia in a cohort of older subjects with Parkinsons disease in the United Kingdom. Mov Disord. 2004;19(9):10431049. 28. Uc E, McDermott M, Marder K, etal. Incidence of and risk factors for cognitive impairment in an early Parkinson disease clinical trial cohort. Neurology. 2009;73(18):14691477.

for how visual hallucination is linked to cognitive decline. Depression and symptom severity are associated with cognitive impairment in PD. However, it is thought that the rate and comorbidity of depression and dementia may both be driven by the severity of PD.26,34,35 In summary, potential risk factors for cognitive impairment in the Chinese population are similar to those reported in other races. However, there are several limitations to our study. All of our subjects were recruited consecutively from the outpatient departments of selected centers; the population may have not included some bedridden or severely disabled PD patients. With regard to the related risk factors for cognitive impairment in PD, we did not include disease comorbidity, medications other than for treatment of PD, or family history. Further studies should follow this cohort to explore cumulative prevalence and related risk factors, and focus on the progression and prognosis of cognitive impairment in PD. In conclusion, the study aimed to explore the point prevalence and cognitive impairment prole in Chinese PD patients. Notably, it was found that MoCA is a more sensitive tool than the MMSE for identifying cognitive impairment in this population.

Acknowledgment
This study was supported by Peking Union Medical College Hospital (grant no 2006332).

Disclosure
The authors declare that they have no competing interests.

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