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Quality of Life, Cognitive Impairment, Treatment, and Physical Exercise in Patients with Parkinson’s Disease: A Review

Vernon Furtado da Silva1, Kaliny M Simões2, Ivete de A. Freire1, Ramón N Cárdenas1, Luiz G O Gonçalvez1, Célio J Borges1 Angeliete G Militão1, e João R Valentim-Silva1

1Physical Education Department of Federal University of Rondônia (UNIR), Rondônia, Brazil, 2Universitary Center of João Pessoa, Paraíba, Brazil (UNIPÊ), Paraiba, Brazil

ABSTRACT

da-Silva-Vernon F, Simões KM, Freire IA, Cárdenas RN, Gonçalvez LGO, Borges CJ, Militão AG, e Valentim-Silva JR. Quality of Life, Cognitive Impairment, Treatment, and Physical Exercise in Patients with Parkinson’s Disease: A Review. JEPonline 2017;20(5):98-113. The purpose of this study was to review the quality of life (QOL), cognitive impairments, treatment, and physical exercise in patients with Parkinson's disease (PD). The information was taken from publications indexed in Medline, SciELO, and Lilacs from 2005 through 2017. After inclusion and exclusion criteria were applied, 59 of 145 articles remained. Motor, cognitive, and physical alterations were identified in most of the studies, with an evaluation of the influence they exerted on the PD patients’ QOL. Depression, anxiety, fatigue, and mobility were some of the changes evaluated. The PDQ-39 questionnaire was most commonly used in the studies. The review found strong evidence that supports physical exercise improves the PD patients’ QOL, cognitive impairments, and physical function.

Keywords: Cognition, Parkinson's Disease, Physical Exercise, Quality of Life

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative disorder that was first described by the English doctor, James Parkinson, in 1817. It is a chronic, progressive disease that results in the degeneration of the central nervous system, which causes a decrease in the neurotransmitter dopamine. As a consequence, PD affects motor functions with changes such as resting tremor and postural instability, muscular rigidity, bradykinesia, and akinesia (20). Due to these progressive impairments, the disease has a direct influence on a person’s quality of life (QOL). It not only interferes in the accomplishment of activities of daily living (ADLs), it also makes social coexistence more difficult.

Since the onset of PD is initially characterized by motor alterations, it is believed that the physical dimensions would be the most aggravating effects. However, with the advancement of the disease, new aggravations arise that significantly alter the QOL of the patient (25). It is a disease with symptoms that generally affect adults age 60 or older (21). Also, a factor that increases the challenge of living with the disease is the common changes that associate with aging itself. Aging interfere with QOL, thus making the patient even more fragile.

The aging process is known to trigger a series of physiological dysfunctions that reduce physical and mental capacities. In addition to the presence of one or more additional diseases or disorders, there is a recognizable compromise in QOL. For many years PD was described as a motor disorder, and the non-motor symptoms and/or disorders were not often addressed (25). The cognitive changes represent a prevalence of 93% as a cause of functional disability in patients with PD. Hence, they can be as incapacitating as the motor alterations (40,53). In particular, there are problems with focused attention and planning, slowing of thought, language and memory difficulties, and personality changes that may predict later onset of dementia (7). The executive functions that are changed are related to the ability to plan, make decisions in the face of new circumstances, and initiate and monitor goal-directed behavior (53).

It is important that the patients’ psychological well-being and QOL are attended to as well (34). While many studies (14-26) on patients with chronic incurable diseases have focused on therapeutic effects, the use of drugs, and the physical commitment to support therapeutic interventions, the goal of treatment should be focused on improving QOL, which is the case in PD (15). In this context, it is worth considering the types of treatments that are used in PD to improve the QOL of the disease carrier. For example, knowing the factors that are related to the perception of QOL is necessary and fundamental for the elaboration of an intervention strategy that aims to improve the QOL in patients with PD (52), in addition to the importance of knowing the cognitive alterations that interfere in the QOL, and the treatments used to benefit the carrier.

In view of the above, the primary purpose of this study was to present a review of the last 10 yrs of literature on QOL, cognitive alterations, and treatments in PD patients. It is anticipated that the review will help facilitate an understanding of the dimensions that encompass the disease, thus contributing to the analysis of the healthcare strategies used to improve the QOL of PD patients.

METHODS

This study is a review of the literature, which sought to investigate empirical studies related to QOL, cognitive changes, and treatments in PD patients. The following databases were used: (a) Latin American and Caribbean Literature in Health Sciences (LILACS); (b) National Library of Medicine (MEDLINE); and (c) ScientificElectronic Library Online - (SciELO). To select the articles, descriptors were used by combining them with the boolean operator AND: "Quality of life AND Parkinson’s", "Cognition AND Parkinson’s", Cognitive alterations AND Parkinson's, Treatment AND Parkinson’s, “Physical Exercise AND Quality of Life in Parkinson’s Disease”, and Physical Exercise AND Cognition in Parkinson’s Disease.

Regarding the search for the articles in the data sources, health terminologies were used from the Descriptors in Health Sciences (DeCS). We assigned a standard for indexing the scientific journal articles to search for subjects of scientific literature in the information sources. The articles included complete papers published in national and international scientific journals between 2005 and 2017 in Portuguese and English, which included in the title and/or previously mentioned descriptors. Articles on drug treatments were excluded.

The data were collected during April and May of 2017. Initially, 145 articles were found. After reading the titles of articles, 49 were excluded. After reading the abstracts, 21 were excluded and after reading the articles, 16 articles were excluded. These steps resulted in the inclusion of 59 studies that were analyzed in this study.

Figure 1. Organization Chart of the Search Process, Exclusion and Inclusion of the Studies that Composed the Present Investigation.

Quality of Life (QOL) and Cognitive Changes in PD Patients

Cognitive changes are common in PD patients. They interfere with the individual's ability to perform routine activities, thereby compromising QOL. To understand the influence of these changes on QOL, Ikuta et al. (23) carried out a study with 58 subjects that were divided into two groups: the Parkinson's Group (PG) and the Control Group (CG). The subjects were submitted to cognitive evaluation tests to analyze the presence of cognitive deficits in patients with PD. When compared to the CG, the PG patients presented greater cognitive impairment. Ikuta et al. (23) also reported that the longer the disease progressed, the greater the motor impairment.

In order to describe the relationship between subjective sleep quality and cognitive functions, Santos et al. (42) looked at 24 elderly PD subjects that used at least one antiparkinsonian drug (either levodopa, pramipexole, amantadine or biperiden). It is worth noting that 91.7% reported having some musculoskeletal pain, 29.0% reported depression, 29.2% reported mild anxiety, and 75% of the subjects reported poor sleep quality and associated disorders; all interfered with their QOL. Clearly, the decrease in executive functions caused by PD limited the subjects’ ability to perform activities of daily living (ADLs) that in turn interfered with the subject's QOL.

Bertoldi and colleagues (3) studied 9 elderly men and women subjects with PD. The purpose of the study was to evaluate the effects of muscle strengthening on balance, mobility, and QOL. Their study also determined the correlation between muscle strengthening and QOL, using the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, the Parkinson's Disease Questionnaire (PDQ-39), and the maximal load test (1 RM). Their results indicate that there was a significant increase in muscle strength, which was effective in improving the PD subjects’ balance and QOL. The findings also showed that the better the subjects’ balance, the better the QOL. This demonstrates the effectiveness and the importance of the muscle strengthening program in this population of subjects.

Peternella and Marcon (34), using the same PDQ-39 questionnaire with 40 elderly subjects with PD, aimed at assessing QOL with the subjects’ disease progression and severity. It was observed that among the signs and symptoms, bradykinesia was the most frequently reported by 37 parkinsonians, which was followed by tremor and postural instability (35) and rigidity (29), slow ADLs and gait (7), fatigue and muscular weakness (4), and stiffness and lack of balance (2). The male subjects reported the worse quality of life, but there was no statistical difference between the sexes. The evolution time and severity of the disease was higher in males compared to females. Statistical differences were observed in ADLs, with social support reaching the men more than the women while emotional well-being and body discomfort were more common in the women. In agreement, Filippin et al. (16) and Silva et al. (51) reported that emotional and motor aspects negatively influence the QOL of subjects with PD as well as limiting their social interaction. The overall effect is that it subjects’ ADLs are directly influenced, thus incapacitating subjects with PD from fulfilling their basic needs.

Interestingly, Silva et al. (50), aimed at investigating the factors related to the decrease in the perception of QOL of individuals with PD in a sample of 25 subjects classified between Stages 1 and 5 on the Hoehn and Yahr Degree of Disability Scale, with QOL evaluated according to PDQ-39. They found that the worst perceptions about QOL are related to "mobility" with an average impairment of 55%, and to "daily life" with an impairment of 52.78%. There was also a high correlation between the total score on PDQ-39 and "activities of daily living", "emotional well-being", and "mobility". Their results verify that motor impairments associated with the signs and symptoms of PD have a negative influence on the perception of the individuals’ QOL.

In order to evaluate the effects of aquatic physical therapy (APT) on the QOL of patients with PD in the mild to moderate stages, Silva et al. (49) used the PDQ-39 before and after the APT sessions to measure perception of the QOL. Thirteen subjects underwent 16 sessions of APT in a heated therapeutic pool (2 times·wk-1 for 1 hr each session). After APT, it was observed that the QOL was more affected in the later stages of the disease, and that prior to APT, the QOL was worse in the more advanced stage of the disease. However, despite the improvement in the QOL scores after APT, the most advanced stage continued to present the worse perception of QOL.

Lopes et al. (28) evaluated the impact caused by voice alteration in the QOL of 56 female subjects with idiopathic PD and Adductor Spasmodic Dysphonia (ASD). Twenty-eight subjects were in the Control Group, 14 subjects were in the ASD Group, and 14 subjects were in the Idiopathic PD Group. Using the Voice-Related QOL (VRQOL) questionnaire, their findings indicated that the greatest negative impact on Voice-Related QOL was found in the subjects with ASD, followed by the subjects in the Idiopathic PD Group and, finally, the subjects in the Control Group.

Given the progressive, chronic, idiopathic, and highly disabling etiology of PD in regards to QOL, Christofoletti and colleagues (7) conducted a study with the purpose of analyzing the health-related QOL of PD subjects compared with healthy controls. Their sample consisted of 40 subjects of both sexes between the ages of 61 and 83. The Brazilian SF-36 questionnaire was applied to all subjects. Those in the Parkinson’s Group presented significantly lower scores than those in the Control Group, both physically and mentally. The decrease in QOL was explained by the co-occurrence of neurodegenerative phenomena and the psychological suffering generated by the disease as well as the stigma it produces.

As to the perception of QOL of individuals with PD from a Movement Disorders Outpatient Clinic, Lana et al. (27) initiated a study of individuals >40 yrs of age with PD between Stages 1 and 3 of the Modified Hoehn and Yahr Scale. Their findings indicate that the median of the total PDQ-39 score was 25%, with the worse perception of QOL in "Activities of Daily Living (ADL)" (41.67%) and "Mobility" (34.32%). There was a high association between the total score and "Mobility" (r=0.82), and a moderate association between "ADL" (r=0.68), "Communication" (r=0.53), and the total score. The findings show that the motor limitations related to mobility, ADLs, and communication are significantly related to the perception of the QOL of individuals with PD.

Sanches and Cardoso (41) evaluated the occurrence of fatigue in PD, and its relationship to QOL. Twelve subjects of both sexes with PD participated in the study. None of the subjects had cognitive problems that may influence the results of the study. Fatigue was measured using the Fatigue Severity Scale (FSS), and for QOL analysis the researchers applied the PDQ-39 questionnaire. The results indicated that 50% of subjects were defined as having fatigue. A significant correlation was observed between fatigue and mobility, and a significant correlation was also found between fatigue and emotional well-being.

In view of these findings, the cognitive, motor, and physical changes caused by PD compromised the QOL of the subjects. As a result, PD limits the accomplishment of routine activities along with the diminished responses linked to the aging phase, given that PD is a more common pathology in old age when senescence itself limits the individual.

Treatment for Patients with PD

The purpose of studies in search of new treatments for PD is to minimize the symptoms and to improve the QOL of individuals with PD. Christofoletti et al. (6), for example, aimed to verify the efficacy of a cognitive-motor intervention on the depressive symptoms of patients with idiopathic PD. They divided 26 patients with PD into an Experimental Group (EG) and a Control Group (CG). The subjects were evaluated using the Geriatric Depression Scale. Then, the subjects in the EG were submitted to a 6-month sequence of physiotherapeutic exercises with cognitive-motor stimulation. The results indicated a decrease in depressive symptoms in the EG, but the decrease was not significant (level of 6%). Also, there was no significant difference when compared to the CG.

Christofoletti et al. (8) set out to verify the efficacy of a specific physiotherapeutic training program on static and dynamic balance in 23 patients with PD who were divided into the Control Group (CG) and the Experimental Group (EG). The subjects in the EG were submitted to a sequence of physiotherapeutic exercises of motor and cognitive stimulation, during 3 weekly visits over a course of 6 months. The treatment resulted in a significant (P ................
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