The main presentations of MSA, which include autonomic dysfunction and cerebellar symptoms in addition to parkinsonism, were reflected in our preliminary Hr-QoL interviews. Patients with MSA reported difficulties with bladder and autonomic dysfunction among their most common and severe problems, which were not reported as commonly by patients with PSP, or those with PD (32). Lack of coordination, which was also more commonly reported in MSA patients than in PSP patients, is likely to reflect not only parkinsonism but also cerebellar dysfunction, which also results in "difficulty walking" and "balance problems." The reported items "transferring from lying down to sitting" or "difficulty standing up without support" may reflect orthostatic hypotension in addition to bradyki-nesia. Other issues more often rated as important by patients with MSA such as "worrying about the family," "worrying about the future," or "change of role within the family" may reflect the younger age group affected by MSA. Although these issues can also be important to patients with PSP, other items were rated as more important by patients with PSP.
Problems commonly reported in PSP but rare in Parkinson's disease or MSA include early postural impairment and falls, visual impairment owing to supranuclear gaze palsy, eyelid apraxia or photophobia, clinically relevant cognitive impairment, personality change, swallowing difficulties, and speech disturbances (33). In addition, patients with PSP may develop neuropsychiatry complications, including apathy, inhibition, and depression (29,30). From the patients' point of view, these issues are also particular problems, although apathy and personality change were less problematic from the patients than from the carers' point of view (34).
In patients with MSA as well as PSP, difficulties beyond those of physical and mental symptoms of the disease were rated as important. Patients in both groups not only reported difficulties in daily activities but patients with MSA reported being anxious and worried about the future, had experienced loss of self-esteem and confidence, felt ignored or that nobody could understand their difficulties. Patients with PSP reported difficulties in showing their emotions, frustration and isolation, difficulties in communication, and worrying about others' reactions. Without doubt, the impact on the emotional and social aspects of Hr-QoL goes beyond that of physical impairment and disability in both disorders.
For other atypical parkinsonism such as corticobasal degeneration there are currently no data available on Hr-QoL. However, it is likely that, as in the other atypical parkinsonian disorders, there is considerable overlap of Hr-QoL issues, but that some features specific to this syndrome are also particularly relevant to their Hr-QoL, e.g., loss of hand function owing to alien limb, and impairment of activities of daily living because of apraxia. Other features important to PSP or MSA, such as bladder dysfunction or visual disturbances, are likely to have less impact in this patient group.
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