Recurrent falls in Parkinson's disease after one year of follow-up: A nested case-control study

Physiotherapy and Exercise in Parkinson's Disease

Physiotherapy is an important treatment strategy in Parkinson's disease. Guidelines recommend early and regular physiotherapy referrals, which may improve a variety of symptoms, including falls. There are multiple types of physiotherapy with different goals and benefits. Exercise as well can improve symptoms and may alter disease trajectory. Studies are limited by heterogenous interventions and outcome measures, and further research is needed in generating high-quality research and expanding physical therapy access.

Machine Learning Predicts Risk of Falls in Parkison's Disease Patients in a Multicenter Observational Study

BACKGROUND

Postural instability and gait difficulties are key symptoms of Parkinson's disease (PD), elevating the risk of falls substantially. Falls afflict 35% to 90% of PD patients, representing a major challenge in managing the condition. Accurate prediction of fall risk and identification of contributing factors are essential for timely interventions.

OBJECTIVES

Our objective was to develop and validate a machine learning (ML) algorithm across multiple centers in Italy to accurately forecast fall risk and identify related factors using routinely collected clinical data.

METHODS

Patient data from two Italian centers (N = 251) were divided into a training cohort (N = 164) for ML model development and a validation cohort (N = 87). External validation was conducted on a subset of PPMI study patients (N = 65). We compared the performance of logistic regression (LR) and Support Vector Classifier (SVC) models trained on clinical data. The Shapley Additive exPlanations (SHAP) method was employed to examine the predictive power of individual variables.

RESULTS

In the training set, SVC outperformed LR slightly (AUC: LR = 0.779 ± 0.054, SVC = 0.792 ± 0.056). However, LR demonstrated better prediction accuracy in both internal (AUC: LR = 0.753, SVC = 0.733) and external validation cohorts (AUC: LR = 0.714, SVC = 0.676). SHAP analysis on the LR model revealed associations between fall risk and both motor and non-motor variables.

CONCLUSIONS

ML-based models effectively estimate fall risk across different clinical centers, enabling tailored interventions to enhance PD patients' quality of life. Challenges persist in predicting falls in US-based patients due to demographic and healthcare system differences.

The impact of psychiatric comorbidity on Parkinson's disease outcomes: a systematic review and meta-analysis

Background

The burden of psychiatric symptoms in Parkinson's disease includes depression, anxiety, apathy, psychosis, and impulse control disorders. However, the relationship between psychiatric comorbidities and subsequent prognosis and neurological outcomes is not yet well understood. In this systematic review and meta-analysis, in individuals with Parkinson's disease, we aimed to characterise the association between specific psychiatric comorbidities and subsequent prognosis and neurological outcomes: cognitive impairment, death, disability, disease progression, falls or fractures and care home admission.

Methods

We searched MEDLINE, Embase, PsycINFO and AMED up to 13th November 2023 for longitudinal observational studies which measured disease outcomes in people with Parkinson's disease, with and without specific psychiatric comorbidities, and a minimum of two authors extracted summary data. Studies of individuals with other parkinsonian conditions and those with outcome measures that had high overlap with psychiatric symptoms were excluded to ensure face validity. For each exposure-outcome pair, a random-effects meta-analysis was conducted based on standardised mean difference, using adjusted effect sizes-where available-in preference to unadjusted effect sizes. Study quality was assessed using the Newcastle-Ottawa Scale. Between-study heterogeneity was assessed using the I2 statistic and publication bias was assessed using funnel plots. PROSPERO Study registration number: CRD42022373072.

Findings

There were 55 eligible studies for inclusion in meta-analysis (n = 165,828). Data on participants' sex was available for 164,514, of whom 99,182 (60.3%) were male and 65,460 (39.7%) female. Study quality was mostly high (84%). Significant positive associations were found between psychosis and cognitive impairment (standardised mean difference [SMD] 0.44, [95% confidence interval [CI] 0.23-0.66], I2 30.9), psychosis and disease progression (SMD 0.46, [95% CI 0.12-0.80], I2 70.3%), depression and cognitive impairment (SMD 0.37 [95% CI 0.10-0.65], I2 27.1%), depression and disease progression (SMD 0.46 [95% CI 0.18-0.74], I2 52.2), depression and disability (SMD 0.42 [95% CI 0.25-0.60], I2 7.9%), and apathy and cognitive impairment (SMD 0.60 [95% CI 0.02-1.19], I2 27.9%). Between-study heterogeneity was moderately high.

Interpretation

Psychosis, depression, and apathy in Parkinson's disease are all associated with at least one adverse outcome, including cognitive impairment, disease progression and disability. Whether this relationship is causal is not clear, but the mechanisms underlying these associations require exploration. Clinicians should consider these psychiatric comorbidities to be markers of a poorer prognosis in people with Parkinson's disease. Future studies should investigate the underlying mechanisms and which treatments for these comorbidities may affect Parkinson's disease outcomes.

Funding

Wellcome Trust, UK National Institute for Health Research (NIHR), National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) at South London and Maudsley NHS Foundation Trust and King's College London, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) at University College London Hospitals NHS Foundation Trust, National Brain Appeal.

Prevention of Falls in Parkinson's Disease: Guidelines and Gaps

Background

People living with Parkinson's disease (PD) have a high risk for falls.

Objective

To examine gaps in falls prevention targeting people with PD as part of the Task Force on Global Guidelines for Falls in Older Adults.

Methods

A Delphi consensus process was used to identify specific recommendations for falls in PD. The current narrative review was conducted as educational background with a view to identifying gaps in fall prevention.

Results

A recent Cochrane review recommended exercises and structured physical activities for PD; however, the types of exercises and activities to recommend and PD subgroups likely to benefit require further consideration. Freezing of gait, reduced gait speed, and a prior history of falls are risk factors for falls in PD and should be incorporated in assessments to identify fall risk and target interventions. Multimodal and multi-domain fall prevention interventions may be beneficial. With advanced or complex PD, balance and strength training should be administered under supervision. Medications, particularly cholinesterase inhibitors, show promise for falls prevention. Identifying how to engage people with PD, their families, and health professionals in falls education and implementation remains a challenge. Barriers to the prevention of falls occur at individual, environmental, policy, and health system levels.

Conclusion

Effective mitigation of fall risk requires specific targeting and strategies to reduce this debilitating and common problem in PD. While exercise is recommended, the types and modalities of exercise and how to combine them as interventions for different PD subgroups (cognitive impairment, freezing, advanced disease) need further study.

Predictors of Falls with Injuries in People with Parkinson's Disease

Background

Falls are frequent in Parkinson's disease (PD), but there is lack of information about predictors of injurious falls.

Objectives

To determine predictors of falls with injuries in people with PD; to compare circumstances and consequences of falls in single and recurrent fallers.

Methods

Participants (n = 225) were assessed by disease-specific, self-report, and balance measures, and followed-up for 12 months with a diary to record falls, their circumstances, and injuries. Univariate and multivariate analyses were performed. Circumstances and consequences of falls presented by single and recurrent fallers were compared.

Results

A total of 805 falls were analyzed, 107 (13%) were falls with injuries. Multivariate logistic regression model revealed that greater PD duration and higher balance confidence were protective factors; better balance during gait, outdoor falls, and falls related to extrinsic factors were risk factors for falls with injuries, when compared to falls with no injuries. Multivariate multinomial regression model revealed that, when compared to zero fall, past falls and daily levodopa equivalent dose were predictors of falls with injuries; these predictors together with disability were predictors of falls with no injuries. Single falls (n = 27; 3%) were more common outdoors because of extrinsic factors, whereas recurrent falls (n = 778; 97%) were more common indoors because of intrinsic factors. Single falls led to more injuries than recurrent falls (P < 0.05).

Conclusions

Different predictors of falls with injuries were obtained when different outcomes were compared. It should be noted that falls with injuries might be influenced by fall-related activities and environmental factors. Single and recurrent falls differed on circumstances and consequences.

Systematic review for the prevention and management of falls and fear of falling in patients with Parkinson's disease

OBJECTIVE

To synthesize recent empirical evidence for the prevention and management of falls and fear of falling in patients with Parkinson's disease (PD).

DATA SOURCE

Database from PubMed, Cochrane Library, and EMBASE.

STUDY DESIGN

Systematic review.

DATA COLLECTION

We searched the PubMed, Cochrane Library, and EMBASE databases for studies published from inception to February 27, 2021. Inclusion criteria were nonreview articles on prevention and management measures related to falls and fall prevention in Parkinson's disease patients.

PRINCIPAL FINDINGS

We selected 45 articles and conducted in-depth research and discussion. According to the causes of falls in PD patients, they were divided into five directions, namely physical status, pre-existing conditions, environment, medical care, and cognition. In the cognitive domain, we focused on the fear of falling. On the above basis, we constructed a fall prevention model, which is a tertiary prevention health care network, based on The Johns Hopkins Fall Risk Assessment Tool to provide ideas for the prevention and management of falling and fear of falling in PD patients in clinical practice CONCLUSIONS: Falls and fear of falls in patients with Parkinson's disease can be reduced by effective clinical prevention and management. Future studies are needed to explore the efficacy of treatment and prevention of falls and fear of falls.

Clinical Usefulness of Retropulsion Tests in Persons with Mild to Moderate Parkinson's Disease

People with Parkinson's disease (PwPD) have an increased risk for falls and near falls. They have particular difficulties with maintaining balance against an external perturbation, and several retropulsion tests exist. The Unified PD Rating Scale item 30 (UPDRS30) is the most common, involving an expected shoulder pull. Others recommend using an unexpected shoulder pull, e.g., the Nutt Retropulsion Test (NRT). We aimed to evaluate the clinical usefulness of these tests for detecting future fallers. By using two different golden standards related to self-reported prospective falls and near falls over 6 months following two different time points with 3.5 years between, we estimated sensitivity/specificity, Youden index, predictive values, and likelihood ratios for each test. The different time points yielded a different prevalence of falls and near falls, as well as different predictive values. When comparing the performance of the NRT and UPDRS30 for detecting future fallers, we found that the NRT consistently performed better than UPDRS30. However, neither test exhibited optimal performance in terms of predictive values and associated likelihood ratios. Our findings speak against using either of these tests as a single assessment for this purpose and support previous recommendations of using a multifactorial approach when targeting balance problems in PwPD.

Development of a Parkinson's disease specific falls questionnaire

BACKGROUND

Falls are a major health burden for older adults with Parkinson's disease (PD), but there is currently no reliable questionnaire to capture the circumstances and consequences of falls in older adults with PD. This study aimed to develop a PD-specific falls questionnaire and to evaluate its test-retest reliability in older adults with PD.

METHODS

A novel PD-specific falls questionnaire (PDF-Q) was developed in two modes (online and paper-based version) and used to assess falls and near-falls events over the past 12-months. Questions were agreed upon by an expert group, with the domains based on previous falls-related questionnaires. The questions included the number and circumstances (activities, location and direction) of falls and near-falls, and consequences (injuries and medical treatment) of falls. The PDF-Q was distributed to 46 older adults with PD (online n = 30, paper n = 16), who completed the questionnaire twice, 4 weeks apart. Kappa (κ) statistics were used to establish test-retest reliability of the questionnaire items.

RESULTS

Pooled results from both questionnaires for all participants were used to assess the overall test-retest reliability of the questionnaire. Questions assessing the number of falls (κ = 0.41) and the number of near-falls (κ = 0.51) in the previous 12-months demonstrated weak agreement, while questions on the location of falls (κ = 0.89) and near-falls (κ = 1.0) demonstrated strong to almost perfect agreement. Questions on the number of indoor (κ = 0.86) and outdoor (κ = 0.75) falls demonstrated moderate to strong agreement, though questions related to the number of indoor (κ = 0.47) and outdoor (κ = 0.56) near-falls demonstrated weak agreement. Moderate to strong agreement scores were observed for the most recent fall and near-fall in terms of the direction (indoor fall κ = 0.80; outdoor fall κ = 0.81; near-fall κ = 0.54), activity (indoor fall κ = 0.70; outdoor fall κ = 0.82; near-fall κ = 0.65) and cause (indoor fall κ = 0.75; outdoor fall κ = 0.62; near-fall κ = 0.56).

CONCLUSIONS

The new PDF-Q developed in this study was found to be reliable for capturing the circumstances and consequences of recent falls and near-falls in older adults with PD.

Golf as a Physical Activity to Potentially Reduce the Risk of Falls in Older Adults with Parkinson's Disease

Advanced age is associated with an increased risk for falls in aging adults. Older adults are also more likely to be diagnosed with Parkinson’s disease (PD), with advanced age as the most significant risk factor. PD is a neurodegenerative disorder with four Cardinal motor symptoms: rigidity, bradykinesia, postural instability, and tremor. Thus, people (person)-with-Parkinson’s disease (PwP) have an even greater risk of falling than non-disorder age-matched peers. Exercise is an activity requiring physical effort, typically carried out to sustain or improve overall health and fitness, and it lowers the risk of falls in the general population. The sport of golf provides a low-impact all-around workout promoting a range of motion, activation of muscles in the upper and lower body, flexibility, and balance. Swinging a golf club offers a unique combination of high amplitude axial rotation, strengthening postural musculature, coordination, and stabilization, demonstrating the potential to impact PD symptoms positively. Golf may be a novel exercise treatment regimen for PD to use in conjunction with traditional medical therapy. We completed a literature review to determine the relationship between the game of golf, PD, and the risk of falls. We concluded that regularly playing golf can lower the risk for falls in community ambulating older adults with PD and demonstrates the potential to improve quality of life for PwP.

Merging Yoga and Occupational Therapy for Parkinson's Disease: A Feasibility and Pilot Program

The purpose of this study was to assess feasibility and changes in outcome measures following the Merging Yoga and Occupational Therapy for Parkinson's Disease (MY-OT for PD) program: a 14-session program which combined community-based yoga for PD, and fall-risk focused group occupational therapy sessions. Seventeen participants completed an 8-week control period consisting of their normal participation, and an 8-week intervention period (14 MY-OT for PD sessions). There were fewer self-reported falls in the intervention (6) vs. control periods (10). One fall risk factor management scale (the Fall Prevention and Management Questionnaire, p=.02), and balance (p<.01) showed significant improvement between the control and intervention. The MY-OT for PD program is an encouraging occupational therapist-led program, which may improve balance and reduce self-reported falls.

Parkinson's disease prevalence, age distribution and staging in Colombia

Parkinson’s disease (PD) has the second highest prevalence among neurodege - nerative diseases. In Colombia, PD population dynamics are currently unknown. Health records offer a unique resource to study frequency and multi-morbidity of chronic diseases. The aim of this research is to estimate prevalence and staging using administrative data (AD) provided by Health Maintenance Organizations (HMOs). A cross-sectional study was conducted using 2015 AD from two Colombian HMOs (4.312.928 beneficiaries, 9.01% of the affiliated Colombian population). PD prevalence and severity was estimated by age and sex. Prevalence was adjusted to WHO demographics. Age-adjusted PD prevalence was 205.89 per 100.000 inhabitants. Prevalence increment of 62.13% was found between those aged ≥40 years and those aged ≥50 years. Similarly, each extra decade (50-80+) represented an increment of 83.65%, 80.95%, and 35.10%. Between 40 and 89 years, males exhibited a significantly higher PD prevalence compared to females. Advanced PD was more frequent as age increased from 3.77% in the group between 40 to 49 years to 25.86% in those older than 89 years. More common related comorbidities were arterial hypertension, diabetes, and psychiatric disorders; the first two increased their frequency with age, and the last one maintained its prevalence across all age groups. AD sets are useful to estimate the prevalence and staging of PD. Prevalence of PD in Colombia is higher in men and increases with age, as well as disease severity.

Fractures in the prodromal period of Parkinson disease

OBJECTIVE

To examine the association between fractures and Parkinson disease (PD) during the 5-year prodromal phase as compared to controls.

METHODS

We performed a population-based case-control study of Medicare beneficiaries in the United States from 2004 to 2009. We identified 89,632 incident PD cases and 117,760 comparable controls 66-90 years of age in 2009. PD case status was the outcome, and noncranial fracture the independent variable. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for association between fracture and PD in yearly time intervals prior to PD diagnosis/control reference date, after adjusting for covariates.

RESULTS

There were 39,606 total fractures (25.4% cases, 14.3% controls) over the 5 years prior to the PD diagnosis/control reference date. PD was positively associated with fractures even after adjusting for age, sex, race/ethnicity, Charlson comorbidity index, alcohol use, tobacco use, and osteoporosis. The association between PD and fracture was evident at yearly time windows prior to PD diagnosis/control reference date. The association between PD and each type of fracture strengthened as the PD diagnosis/control reference date approached (all time interaction p values ≤0.02). Among beneficiaries with a mechanism of injury, the majority were attributed to falls (74.6% cases, 72.8% controls).

CONCLUSION

Fractures occur more commonly during the prodromal period of PD compared to controls, especially as diagnosis date approached, suggesting that patients with PD may experience unrecognized motor and nonmotor symptoms.

Home-based monitoring of falls using wearable sensors in Parkinson's disease

INTRODUCTION

Falling is among the most serious clinical problems in Parkinson's disease (PD). We used body-worn sensors (falls detector worn as a necklace) to quantify the hazard ratio of falls in PD patients in real life.

METHODS

We matched all 2063 elderly individuals with self-reported PD to 2063 elderly individuals without PD based on age, gender, comorbidity, and living conditions. We analyzed fall events collected at home via a wearable sensor. Fall events were collected either automatically using the wearable falls detector or were registered by a button push on the same device. We extracted fall events from a 2.5-year window, with an average follow-up of 1.1 years. All falls included were confirmed immediately by a subsequent telephone call. The outcomes evaluated were (1) incidence rate of any fall, (2) incidence rate of a new fall after enrollment (ie, hazard ratio), and (3) 1-year cumulative incidence of falling.

RESULTS

The incidence rate of any fall was higher among self-reported PD patients than controls (2.1 vs. 0.7 falls/person, respectively; P < .0001). The incidence rate of a new fall after enrollment (ie, hazard ratio) was 1.8 times higher for self-reported PD patients than controls (95% confidence interval, 1.6-2.0).

CONCLUSION

Having PD nearly doubles the incidence of falling in real life. These findings highlight PD as a prime "falling disease." The results also point to the feasibility of using body-worn sensors to monitor falls in daily life. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Correlation of the Korean Version of Falls Efficacy Scale-International With Quantitative Balance and Gait Parameters Through Exercise Program in Elderly Men

Objective

To determine correlation of the Korean version of Falls Efficacy Scale-International (KFES-I) with other gait and balance parameters through exercise program in older men.

Methods

Between July 2015 and April 2018, 50 men of 103 participants in an exercise program for preventing falls who aged over 60 years, completed the evaluation before and after the program, had fear of falling (FOF), and could walk independently as an outpatient were enrolled retrospectively. The program comprised lower extremities and core muscle strengthening exercises following stretching exercises twice a week for 8 weeks. FOF using the KFES-I, Berg Balance Scale (BBS), Modified Barthel Index (MBI), stair up and gait categories in MBI (MBI-gait), and Timed Up and Go test (TUG) were evaluated. Quantitative gait and balance parameters were measured by gait analysis, posturography, and isokinetic dynamometer. They were compared before and after the program. Moreover, correlations of KFES-I with other parameters were examined.

Results

Fifty participants were enrolled. After the program, significant improvements were noted in right stride length (p=0.013) in gait analysis, MBI (p=0.012), BBS (p<0.000), TUG test (p<0.000), and KFES-I (p<0.000) scores. KFES-I was significantly correlated with MBI (r=-0.35, p=0.013), and MBI-gait (r=-0.341, p=0.015).

Conclusion

Risk of falls could be significantly improved through exercise. KFES-I had significant correlations with MBI-gait parameters. Participants showed increases in gait and balancing ability on quantitative measurements through exercises. Therefore, regular stretching, strengthening, and balancing exercises may help prevent falls in older people.

What predicts falls in Parkinson disease?: Observations from the Parkinson's Foundation registry

BACKGROUND

We undertook this study to identify patients with Parkinson disease (PD) with no or rare falls who may progress to frequent falling by their next annual follow-up visit.

METHODS

We analyzed data in the National Parkinson Foundation Quality Improvement Initiative database to identify factors predicting which patients with PD with no or rare falls at the baseline visit will report at least monthly falls at the annual follow-up visit. Multivariable models were constructed using logistic regression. Variables were introduced in 4 blocks: in the 1st block, variables present at or before the baseline visit were entered; in the 2nd, baseline visit assessments; in the 3rd, interventions implemented during baseline visit; and, in the 4th block, changes in comorbidities, living situation, and treatment between visits.

RESULTS

Of 3,795 eligible participants, 3,276 (86.3%) reported no or rare falls at baseline visit, and of them, 382 (11.7%) reported at least monthly falls at follow-up visit. Predictors included female sex, <90% diagnostic certainty, motor fluctuations, levodopa treatment, antidepressant treatment, prior deep brain stimulation (DBS), worse quality of life, Hoehn & Yahr stage 2 or 3, worse semantic fluency, and, between visits, addition of amantadine, referral to occupational therapy, social services, or DBS, new diagnoses of cancer or osteoarthritis, and increased emergency visits.

CONCLUSIONS

This large-scale analysis identified several predictors of progression to falling in PD. Such identifiers may help target patient subgroups for falls prevention intervention. Some factors are modifiable, offering opportunities for developing such interventions.

A prospective study of falls in relation to freezing of gait and response fluctuations in Parkinson's disease

INTRODUCTION

Falls are a disabling feature of Parkinson's disease (PD). In this prospective study we investigated: (1) in which motor state patients with PD fallmost often; and (2) whether freezing of gait (FOG) and dyskinesias contribute to falls.

METHODS

Patients with PD who had fallen at least once in the previous year and had wearing-off were recruited. During six months, patients complete a standardized fall report. We analyzed data regarding fall circumstances and motor state at the time of each first 10 falls.

RESULTS

We included 36 patients with PD (34 freezers), with mean ± SD age of 67.5 ± 6.3 years and disease duration of 12.4 ± 4.1 years. 50% had Hoehn & Yahr (HY) 2 at ON-state and 56% had a HY 4 at OFF. All 36 patients fell at least once during the follow-up period (total number of falls: 252; mean ± SD: 19.03 ± 33.9). Falls at ON were 50% of the total falls, followed by Transition (30%) and OFF (20%). Overall, 69% of falls were related to FOG, 28% were unrelated to FOG and 3% were related to dyskinesia. There was a significant relationship between motor state and circumstances (χ2(2) = 31.496,p < 0.001), showing that FOG-related falls happened mostly at OFF-state.

CONCLUSION

This study showed that patients with PD fall mostly at ON. Additionally, FOG is an important contributor to falls in patients with PD. This information may assist clinicians in optimizing medication to prevent further falls.

Dynamics of change in self-reported disability among persons with Parkinson's disease after 2 years of follow-up

Symptoms of Parkinson's disease (PD) progress over time causing significant disability. Yet, change in disability over shorter time periods has not been entirely understood. The purpose of this study was to assess the Self-Assessment Disability Scale (SADS) in persons with Parkinson's disease (PD) after 2 years of follow-up and compare it with the score observed at baseline. Additionally, we aimed at evaluating association of motor and non-motor PD features at baseline with a higher disability after 2 years of follow-up. A total of 120 consecutive persons with PD, who denied falling in the past 6 months, were initially recruited. After 2 years of follow-up, 88 (73.3%) persons with PD were evaluated for SADS. The total disability (SADS) score did not change after follow-up (p = 0.529). We observed increase in difficulty at "Getting out of bed" (p = 0.006), "Getting up out of armchair" (p = 0.013), "Walking about house/flat" (p = 0.003), "Walking outside" (p = 0.010), and "Traveling by public transport" (p = 0.014). After adjusting for several potential confounding factors, falls in the past year (β = 8.32, 95% confidence interval (CI) 1.04-15.59) and higher Unified Parkinson's Disease Rating Scale part 3 at baseline (β = 0.26, 95%CI 0.01-0.51) remained associated with higher PD-related disability. This finding suggests that accumulation of overall PD-related disability tends to occur over a longer time span. Further studies are needed to gradually assess long-term evolution of disability in PD.