Palmomental reflex is an important clinical marker of REM sleep behavior disorder in patients with Parkinson’s disease

Ravi Yadav; Rohan Mahale; Pramod K Pal

doi:10.4103/AOMD.AOMD_7_18

ORIGINAL ARTICLES

Year : 2018 | Volume : 1 | Issue : 1 | Page : 44-48

Palmomental reflex is an important clinical marker of REM sleep behavior disorder in patients with Parkinson’s disease

Ravi Yadav, Rohan Mahale, Pramod K Pal
Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Web Publication

24-Dec-2018

Correspondence Address:
Dr. Ravi Yadav
Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru 560029, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AOMD.AOMD_7_18

Abstract

OBJECTIVES: To find important clinical features in differentiating patients with Parkinson’s disease (PD) with and without rapid eye movement sleep behavior disorder (RBD).
METHODS: This study was a prospective, questionnaire-based study performed at the National Institute of Mental health and Neurosciences, Bangalore, after prior institutional ethical approval. Patients with PD were clinically examined and the presence of RBD was diagnosed using the minimal criteria for the diagnosis of RBD (International Classification of Sleep Disorders-1). RBD screening questionnaire based on the minimal criteria was used. The bed-partners were interviewed with Mayo sleep questionnaire. Other scales included Unified Parkinson’s Disease Rating Scale-part III (UPDRS-III), Hoehn and Yahr Stage, Mini-Mental Status Examination (MMSE), Pittsburgh sleep quality index, Parkinson’s Disease Sleep Scale, Epworth Sleep Scale (ESS), Hamilton anxiety rating scale (HAM-A), and Hamilton depression rating scale (HAM-D).
RESULTS: A total of 126 patients with PD without RBD (mean age: 61.1±9.8 years) and 30 with RBD (mean age 54.1±11.1 years) were enrolled. The patients with RBD had higher gait score (P < 0.05), higher HAM-A (P = 0.02), and higher ESS score (P < 0.001) as compared to patients without RBD. Patients with RBD had a mean MMSE score of 26.87±2.31 (range: 23–30), and in patients, without RBD it was 27.98±2.33 (range: 23–30;. P = 0.005). There was no difference in features as olfactory dysfunction, rigidity score, blink rate, tremors, stooped stance, and postural instability in the two groups. However, palmomental reflex was present in 63.3% of patients with RBD and only 34.9% with non-RBD (P = 0.007).
CONCLUSIONS: Patients with PD with RBD have a significant presence of palmomental reflex that can be a useful clinical marker.

Keywords: Palmomental reflex, Parkinson’s disease, primitive reflex, REM sleep behavior disorders

How to cite this article:
Yadav R, Mahale R, Pal PK. Palmomental reflex is an important clinical marker of REM sleep behavior disorder in patients with Parkinson’s disease. Ann Mov Disord 2018;1:44-8

How to cite this URL:
Yadav R, Mahale R, Pal PK. Palmomental reflex is an important clinical marker of REM sleep behavior disorder in patients with Parkinson’s disease. Ann Mov Disord [serial online] 2018 [cited 2023 Mar 28];1:44-8. Available from: https://www.aomd.in/text.asp?2018/1/1/44/248389

Introduction

Rapid eye movement (REM) sleep behavior disorder is an important preclinical marker of Parkinson’s disease (PD) as well as a major non-motor disorder in patients with PD.^{[1],[2],[3],[4]} The identification of this disorder is important for treatment and reducing the caregiver and patient distress. Questionnaire identified REM sleep behavior disorder (RBD) and confirmed by the presence of classic polysomnographic features.^[5] RBD is characterized by loss of normal skeletal muscle atonia during REM sleep with prominent motor activity and dreaming.^[6] The history of dream enactment and violent behavior during sleep is an important component of diagnosis.^[6] There is a need of symptoms and signs useful to the clinicians for identifying cases of RBD among cases with PD.^[7]

This study was performed to find important clinical characteristics in differentiating patients with PD with and without REM sleep behavior disorder (RBD).

Methods

This was a prospective case–control study and was approved by the institute ethics committee. All participants gave written informed consent before undergoing clinical evaluation. All patients were recruited from the outpatient as well as inpatient department of National Institute of Mental Health and Neuroscience, a tertiary care institute situated in Bengaluru, India. Patients with PD were diagnosed as per the Queen-square diagnostic criteria. The clinical history was obtained, and detailed neurological examination was performed. The patients were evaluated using the Unified Parkinson’s Disease Rating Scale III (UPDRS-III).^[8] RBD was diagnosed based on the minimal criteria of International Classification of Sleep Disorders. All patients were screened for RBD using RBD screening questionnaire, and if bed partner or spouse was available, question one of Mayo sleep questionnaire were applied.^[5],[9] Other scales used were Pittsburg Sleep Quality Index, Epworth Sleepiness Scale, Hamilton Anxiety Scale, Hamilton Depression Scale, and Parkinson’s Disease Sleep Scale.^{[10],[11],[12],[13],[14]}

Results

A total 126 patients with PD without RBD (mean age: 61.1±9.8 years) and 30 with RBD (mean age 54.1±11.1 years) were enrolled. Males constituted 21/30 (70%) in PD-RBD and 98/126 (77.8%) in parkinson's disease-non REM sleep behavior disorder group (PD-NRBD). The gender difference between the two groups was not statistically significant (P = 0.35). The mean age at onset of a motor symptom of PD (years) was 54.8±10.7 years (range: 32–77) in PD-RBD and 48.6±12.3 years (range: 22–74) in PD-NRBD group. There was the significant statistical difference between the groups (P = 0.017). The majority of the patients in both the groups were the akinetic-rigid predominant type of PD (56.7% in PD-RBD and 52.4% in PD-NRBD). The predominant tremor type of PD was 43.3% in PD-RBD and 47.6% in the PD-NRBD group. This classification was based on the predominant symptom of the patient and calculation of tremor/bradykinesia ratio of UPDRS-motor score [Table 1].

Table 1: Demographic characteristics of patients with and without REM sleep behavior disorder

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The mean duration of PD (years) at the time of presentation was 6.3±4.8 (range: 1–19) in the PD-RBD and 5.6±4.6 (range: 1–22) in the PD-NRBD group. There was no significant statistical difference between the groups (P = 0.40). The mean duration of treatment (months) was 53.8±51.0 (range: 6–192) in PD-RBD and 43.5±42.9 (range: 3–216) in PD-NRBD. The difference was not statistically significant (P = 0.78). Glabellar tap was present in 96.7% in the PD-RBD group and 87.3% in the PD-NRBD group. There was no statistically significant difference between the two groups (P = 0.19).

Palmomental reflex was present in 63.3% in the PD-RBD group and 34.9% in the PD-NRBD group. There was a significant statistical difference between the two groups (P = 0.007). None of the patients in both the groups had other release signs [Table 2].

Table 2: Important clinical features of patients with and without REM sleep behavior disorder

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Patients with RBD had a mean Mini-Mental Status Examination (MMSE) score of 26.87±2.31 (range: 23–30), and in patients, without RBD it was 27.98±2.33 (range: 23–30). This was significant (P = 0.005). The association between the palmomental reflex and outcome variable (RBD) was significantly different in the different levels of the education. The tests of conditional independence, as the Mantel–Haenszel was applied and the P-values were 0.008 (below 0.05). This analysis was performed using the level of education as a covariate [Table 3] and [Supplementary Table 1]. There was a significant difference between the patients with and without palmomental reflex among patients with RBD in terms of gait stability (P = 0.01), thus showing the patients with palmomental reflex positivity and RBD were more likely to have gait abnormalities. There was no difference in features as olfactory dysfunction, rigidity score, blink rate, tremors, stooped stance, and postural instability in the two groups.

Table 3: The distribution of patients of Parkinson’s disease and palmomental reflex according to the education within patients with REM sleep behavior disorder

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Supplementary Table 1: The distribution of patients with Palmomental reflex according to the cutoffs for dementia (MMSE < 24)

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Discussion

The novel clinical finding of the significant presence of palmomental reflex in RBD positive patients further supports that the PD with RBD group has relatively higher frontal dysfunction.^{[15],[16],[17],[18]} The primitive reflexes are a group of innate motor responses seen in infancy that evolved to support the survival of the infant. Snout, palmomental, grasp, and glabellar reflexes are present from birth and are lost with the maturation of frontal lobes. Although these reflexes are considered to be frontal release reflexes, palmomental reflex has more robust literature evidence of association with neurological dysfunction. A study by Marti-Vilalta and Graus^[19] showed that the reflex was present in 11% of the healthy adults but 72% in adults with neurological diseases. Similar observations have been reported by other authors.^[19],[20]

The reappearance of these reflexes occurs in neurodegenerative disorders such as Alzheimer’s disease (AD), frontotemporal dementia (FTD), vascular dementia (VaD), and other subcortical dementia. Palmomental reflex is seen predominantly in the disorders with subcortical dysfunction. Links et al.^[21] did a retrospective study on 204 subjects to detect the importance of palmomental reflex in discriminating various types of cognitive disorders. A higher proportion of subjects with diffuse Lewy body dementia ^{More Details} and AD with vascular overlap were found to have palmomental reflex than patients with FTD. Primitive reflexes were not positively predictive of FTD or VaD. The palmomental reflex was the most common primitive reflex in this study. There was no significant difference between early- and late-stage groups in the presence of primitive reflexes or parkinsonian signs. This study showed that the primitive reflexes were not clinically discriminative of frontally based dementias such as FTD and VaD.

Patients with PD having baseline mild cognitive impairment and RBD have more risk of developing dementia in subsequent visits than those without RBD. The presence of RBD is predictive of progressive cognitive dysfunction in these patients. There are many studies showing an evidence of the common background of cognitive deficits in RBD and synucleinopathies. The cholinergic dysfunction is common to both RBD and synucleinopathy.^[21] Patients with idiopathic RBD were found to have impaired cortical activation in both wakefulness and REM and EEG slowing in these patients points toward central nervous system dysfunction corresponding to the subclinical cognitive deficits.^[22] Patients with RBD usually present with deficits in attention, executive functions, episodic verbal memory, nonverbal learning, and decision-making.^{[23],[24],[25],[26],[27]} PD patients with RBD have a distinct PD subtype with specific autonomic, motor, and cognitive profiles. One study on five cluster model has classified five groups: (1) motor and non-motor disease; (2) poor posture and cognition; (3) severe tremor; (4) poor psychological well-being, RBD, and sleep; and (5) severe motor and non-motor disease with poor psychological well-being.^[23] The best cluster groups among PD was based on orthostatic hypertension, mild cognitive impairment, RBD, depression, anxiety, and UPDRS part two and three scores. Three subtypes were defined: motor/slow progression, diffuse/malignant, and intermediate.^[26] It thus indirectly related to the advanced stage of patients with PD and cognitive dysfunction.

The limitations of the study is small group of patients of PD with RBD. The results need to be evaluated in a larger cohort of PD with RBD patients. Also, the presence of palmomental reflex may be affected by many other causes like small vessel disease, so it may not have very high specificity. Also this study is a questionnaire-based study and there is a chance of recall bias. But nonetheless, this sign may be used to further clinically define the PD phenotype with RBD.

To conclude, in this study, we showed that palmomental reflex could be used to identify patients who are more likely associated with RBD. This could be a reflection of the impaired cognitive dysfunction in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

We acknowledge the patient for her support and cooperation.

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