Fall frequency, predicting falls and participating in falls research: Similarities among people with Parkinson's disease with and without cognitive impairment

A framework to standardize gait study protocols in Parkinson's disease

BackgroundResearch over the past twenty years has shown that gait outcomes have a high sensitivity for diagnosing Parkinson's disease (PD), for detecting the effects of interventions, and for monitoring disease progression, even in early disease. However, the lack of standardization in protocols and reported gait measures is impeding data aggregation across study sites and contributes to heterogeneity in the results, thus limiting the adoption of gait outcomes in clinical trials.ObjectiveTo provide recommendations for a minimum set of gait measures to be adopted in projects evaluating people with PD to enhance standardization across the field.MethodsThe Gait Advisors Leading Outcomes for Parkinson's (GALOP) committee is an advisory committee for the MJFF. Based on a five-step approach, GALOP generated recommendations for standardizing protocols that assess quantitative gait measures, following expert consensus on best practices.ResultsBuilt on the literature and consensus amongst experts, we recommend a minimum set of meta-data to accompany gait protocols and a minimum gait assessment protocol to be performed at a comfortable speed. Suggestions on challenging testing are provided.ConclusionsTo support and empower the scientific community, we have generated recommendations to collect and share gait data gathered from people with PD using an open data repository. Standardizing gait protocols and outcomes in PD has the potential of accelerating research and clinical trials, harmonizing protocols across study sites, fostering collaborations, and in the long run, improving patient care and quality of life.

Perceptions of people with Parkinson's and their caregivers of falling and falls-related healthcare services- a qualitative study

INTRODUCTION

Falls are common in Parkinson's disease, and a recognised research priority. Falls lead to physical and psychological morbidity in people with Parkinson's disease and their caregivers, however, those with cognitive impairment/ dementia and caregivers have often been excluded from previous studies. This qualitative study explored how people with Parkinson's disease and their family caregivers understood and experienced falling and healthcare services relating to falls prevention and management.

METHODS

A varied and purposive sample of 20 people with Parkinson's disease (40% confirmed or suspected cognitive impairment/ dementia) and 18 caregivers took part in semi-structured interviews. Eight people with Parkinson's disease and their caregivers were interviewed as a dyad, 22 participants were interviewed alone. Interviews were analysed through inductive thematic analysis.

RESULTS

Four themes were developed: (i) struggling with thoughts and feelings about falling, (ii) recognising and managing risks surrounding falling, (iii) navigating health and care provision for falling, and (iv) changing as a couple due to falling. Different aspects of falls provoked a range of negative emotions and a variety of coping strategies were adopted. Falls and trying to avoid falls burdened a couple in a number of ways; beyond physical health they also affected functioning, physiological wellbeing, and relationships. Dyads analysed falls to understand their aetiology and described working together to manage them. This often happened in the absence of adequate support and advice with little involvement of healthcare professionals. When cognitive impairment/ dementia was present this brought additional challenges to falls management, with caregivers taking on a greater and more frustrating role.

CONCLUSION

Dyads required relevant falls-related information and the difficulties associated with cognitive decline should be recognised by researchers and healthcare professionals. Dyads required support in attributing reasons for falls, and increased awareness of healthcare professionals' different roles to improve patient- professional communication and facilitate patient-centred care.

The prevention of falls in patients with Parkinson's disease with in-home monitoring using a wearable system: a pilot study protocol

BACKGROUND

Parkinson's disease (PD) is a chronic, progressive neurodegenerative condition that gradually worsens motor function and leads to postural instability and, eventually, falls. Several factors may influence the frequency of future falls, such as slowness, freezing of gait, loss of balance, and mobility problems, cognitive impairments, and the number of previous falls. The TED bracelet is an advanced technological wearable device able to predict falls.

AIMS

This principal aim is to investigate the feasibility of a full-scale research project that uses the TED bracelet to identify whether individuals with PD are at risk of falling.

METHODS

This study will involve a pilot prospective observational study design; the subjects will include 26 patients suffering from mild PD and 26 others with no PD and no gait problems. Data will be collected from the TED bracelet and then compared to a paper-based fall diary. The enrolled participants will have a scheduled outpatient evaluation to collect both clinical and instrumental data as well as biological samples.

DISCUSSION

This pilot study could then be implemented in a larger form to further evaluate the effectiveness of the TED device. Finally, it will help further develop gait monitoring systems for people with Parkinson's disease and other neurodegenerative diseases that can affect physical function and mobility, such as dementia and Alzheimer's.

CONCLUSIONS

Preventing falls and their complications could lead to major advancements in the quality of home care for patients with PD, which would significantly impact the quality of life of both these patients and their caregivers.

The emerging postural instability phenotype in idiopathic Parkinson disease

Identification of individuals at high risk for rapid progression of motor and cognitive signs in Parkinson disease (PD) is clinically significant. Postural instability and gait dysfunction (PIGD) are associated with greater motor and cognitive deterioration. We examined the relationship between baseline clinical factors and the development of postural instability using 5-year longitudinal de-novo idiopathic data (n = 301) from the Parkinson’s Progressive Markers Initiative (PPMI). Logistic regression analysis revealed baseline features associated with future postural instability, and we designated this cohort the emerging postural instability (ePI) phenotype. We evaluated the resulting ePI phenotype rating scale validity in two held-out populations which showed a significantly higher risk of postural instability. Emerging PI phenotype was identified before onset of postural instability in 289 of 301 paired comparisons, with a median progression time of 972 days. Baseline cognitive performance was similar but declined more rapidly in ePI phenotype. We provide an ePI phenotype rating scale (ePIRS) for evaluation of individual risk at baseline for progression to postural instability.

Cognitive correlates of dual tasking costs on the timed up and go test in Parkinson disease

Introduction

Dual tasking impairments are an increasingly recognized contributor to falls in Parkinson disease (PD) and may be a promising therapeutic target for PD fall prevention trials. Depending on the context, ambulatory dual tasking difficulties may be caused by different types of neurocognitive impairments.

Methods

We performed a cross-sectional analysis of 21 participants with PD. All participants underwent detailed neuropsychological testing that was quantified using normative z-scores. All participants completed the 3-meter timed up and go test (TUG), with and without a dual tasking assignment. Biomechanistic properties of the TUG were quantified using APDM wearable OPAL sensors. We explored correlations between dual tasking cost (DTC) in 1) total TUG duration, 2) Sit-to-stand duration, 3) Stand-to-sit duration, and 4) turn velocity.

Results

Impaired total DTC in the TUG correlated inversely with global cognitive performance measured using the Montreal Cognitive Assessment (MoCA) (r = -0.4649, p = 0.0337). Sit-to-stand DTC impairments correlated inversely with processing speed on the WAIS-IV Coding (r = -0.5762, p = 0.0063), semantic fluency (r = -0.5100, p = 0.0182) and learning and memory on the Hopkins Verbal Learning Test-Revised total recall (r = -0.5502, p = 0.0098). Impaired stand-to-sit DTC function corelated inversely with visuospatial cognitive function on the Benton Judgement of Line Orientation (JOLO) test (r = -0.5181, p = 0.0161).

Conclusions

The link between dual tasking and fall risk in PD may be caused by cognitive features other than executive dysfunction and may vary based on the ambulatory task in question. These findings shed light on the cognitive contributions to falls in PD.

Mild and marked executive dysfunction and falls in people with Parkinson's disease

BACKGROUND

Executive dysfunction and risk of falling are hallmarks of Parkinson's disease (PD). However, it is unclear how executive dysfunction predisposes people with PD to falling.

OBJECTIVES

To: (i) identify sensorimotor, balance, and cardiovascular risk factors for falls that discriminate between those with normal executive function and those with mild and marked executive dysfunction in people with PD and (ii) determine whether mild and marked executive dysfunction are significant risk factors for falls when adjusting for PD duration and severity and freezing of gait (FOG).

METHODS

Using the Frontal Assessment Battery, 243 participants were classified into normal executive function (n = 87), mild executive dysfunction (n = 100), and marked executive dysfunction (n = 56) groups. Participants were asked if they had episodes of FOG in the last month and were assessed with the Movement Disorders Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS), the Hoehn and Yahr Scale, the physiological profile assessment, and tests of orthostatic hypotension, coordinated stability, and gait and were then followed-up prospectively for falls for 32-52 weeks.

RESULTS

Several PD-specific (elevated Hoehn and Yahr stage, higher MDS-UPDRS scale scores, a history of FOG, Postural Instability and Gait Difficulty subtype, and longer PD duration), sensorimotor (poor vision, knee extension weakness, slow simple reaction time), and balance (greater postural sway and poor controlled leaning balance) factors discriminated among the normal executive function and mild and marked executive dysfunction groups. Fall rates (mean ± SD) differed significantly among the groups (normal executive function: 1.0 ± 1.7; mild executive dysfunction: 2.8 ± 5.2; marked executive dysfunction: 4.7 ± 7.3) with the presence of both mild and marked executive dysfunction identified as significant risk factors for falls when adjusting for three measures of PD severity (Hoehn and Yahr scale scores, disease duration, and FOG).

CONCLUSIONS

Several PD-specific, sensorimotor, and balance factors differed significantly among the normal, mild, and marked executive dysfunction groups and both mild and marked executive dysfunction were identified as independent risk factors for falls in people with PD.

Turning Detection During Gait: Algorithm Validation and Influence of Sensor Location and Turning Characteristics in the Classification of Parkinson's Disease

Parkinson's disease (PD) is a common neurodegenerative disorder resulting in a range of mobility deficits affecting gait, balance and turning. In this paper, we present: (i) the development and validation of an algorithm to detect turns during gait; (ii) a method to extract turn characteristics; and (iii) the classification of PD using turn characteristics. Thirty-seven people with PD and 56 controls performed 180-degree turns during an intermittent walking task. Inertial measurement units were attached to the head, neck, lower back and ankles. A turning detection algorithm was developed and validated by two raters using video data. Spatiotemporal and signal-based characteristics were extracted and used for PD classification. There was excellent absolute agreement between the rater and the algorithm for identifying turn start and end (ICC ≥ 0.99). Classification modeling (partial least square discriminant analysis (PLS-DA)) gave the best accuracy of 97.85% when trained on upper body and ankle data. Balanced sensitivity (97%) and specificity (96.43%) were achieved using turning characteristics from the neck, lower back and ankles. Turning characteristics, in particular angular velocity, duration, number of steps, jerk and root mean square distinguished mild-moderate PD from controls accurately and warrant future examination as a marker of mobility impairment and fall risk in PD.

Falls in Synucleinopathies

Parkinson's disease (PD) and other synucleinopathies, namely dementia with Lewy bodies (DLB) and multiple system atrophy (MSA), are common degenerative neurological disorders that share synuclein pathology. Although certain cardinal features of parkinsonism, including bradykinesia and rigidity, respond well to levodopa, axial features, such as gait and balance impairment, are less reliably responsive to dopaminergic therapy and surgical interventions. Consequently, falls are common in PD and other synucleinopathies and are a major contributor toward injury and loss of independence. This underscores the need for appropriate fall risk assessment and implementation of preventative measures in all patients with parkinsonism. The aim of this review is therefore to explore modifiable and non-modifiable risk factors for falls in synucleinopathies. We next review and evaluate the evidence for pharmacological, nonpharmacological, and surgical approaches for fall prevention, and emphasize individualized and multifaceted approaches.

Falls Self-Management Interventions for People with Parkinson's Disease: A Systematic Review

BACKGROUND

Falls are common in Parkinson's disease (PD). Increased involvement of people with Parkinson's (PwP) in their care has been associated with enhanced satisfaction. Self-management programmes in other long-term conditions (LTCs) have led to improvements in physical and psychological outcomes. These have been more effective when targeted toward a specific behavior.

OBJECTIVE

This paper aimed to identify and review falls self-management interventions for PwP.

METHODS

A systematic review was conducted. Electronic databases were searched in June 2018. Primary research studies (any design) reporting the delivery of falls self-management interventions to PwP were included. Data was extracted from each article and synthesised narratively.

RESULTS

Six articles were identified, relating to five different self-management interventions. All described a self-management intervention delivered alongside physiotherapy. Intervention delivery was through either group discussion (n = 3) or falls booklets (n = 3). Interventions were often incompletely described; the most common components were information about the condition, training/ rehearsal for psychological strategies and lifestyle advice and support. Arising from the design of articles included the effects of self-management and physiotherapy could not be separated. Three articles measured falls, only one led to a reduction. Four articles measured quality of life, only one led to improvement. No articles assessed skill acquisition or adherence to the self-management intervention.

CONCLUSIONS

Few falls self-management interventions for PwP have been evaluated and reported. The components of an effective intervention remain unclear. Given the benefits of self-management interventions in other LTCs, it is important that falls self-management interventions are developed and evaluated to support PwP.

Falls in Parkinson's disease: A complex and evolving picture

Falls are a major determinant of poor quality of life, immobilization, and reduced life expectancy in people affected by Parkinson's disease (PD) and in older adults more generally. Although many questions remain, recent research has advanced the understanding of this complex problem. The goal of this review is to condense new knowledge of falls in PD from prodromal to advanced disease, taking into account risk factors, assessment, and classification as well as treatment. The fundamental steps of clinical and research-based approaches to falls are described, namely, the identification of fall risk factors, clinical and instrumental methods to evaluate and classify fall risk, and the latest evidence to reduce or delay falls in PD. We summarize recent developments, the direction in which the field should be heading, and what can be recommended at this stage. We also provide a practical algorithm for clinicians.© 2017 International Parkinson and Movement Disorder Society.

Natural history of falls in an incident cohort of Parkinson's disease: early evolution, risk and protective features

The natural history of falls in early Parkinson’s disease (PD) is poorly understood despite the profound effect of falls on outcome. The primary aim of this study was to describe the natural history of falls, and characterise fallers over 54 months in 99 newly diagnosed people with PD. Seventy-nine (79.7%) participants fell over 54 months and 20 (20.3%) remained falls-naïve. Twenty six (26.2%) reported retrospective falls at baseline. Gait outcomes, disease severity and self-efficacy significantly discriminated across groups. Subjective cognitive complaints emerged as the only significant cognitive predictor. Without exception, outcomes were better for non-fallers compared with fallers at any time point. Between group differences for 54 month fallers and non-fallers were influenced by the inclusion of retrospective fallers and showed a broader range of discriminant characteristics, notably stance time variability and balance self-efficacy. Single fallers (n = 7) were significantly younger than recurrent fallers (n = 58) by almost 15 years (P = 0.013). Baseline performance in early PD discriminates fallers over 54 months, thereby identifying those at risk of falls. Clinical profiles for established and emergent fallers are to some extent distinct. These results reiterate the need for timely interventions to improve postural control and gait.

Influence of cognitive impairment on fall risk among elderly nursing home residents

BACKGROUND

Information relating the severity of cognitive decline to the fall risk in institutionalized older adults is still scarce. This study aims to identify potential fall risk factors (medications, behavior, motor function, and neuropsychological disturbances) depending on the severity of cognitive impairment in nursing home residents.

METHODS

A total of 1,167 nursing home residents (mean age 81.44 ± 8.26 years; 66.4% women) participated in the study. According to the MEC, (the Spanish version of the Mini-Mental State Examination) three levels of cognitive impairment were established: mild (20-24) "MCI", moderate (14-19) "MOCI", and severe (≤14) "SCI". Scores above 24 points indicated the absence cognitive impairment (NCI). Information regarding fall history and fall risk during the previous year was collected using standardized questionnaires and tests.

RESULTS

Sixty falls (34%) were registered among NCI participants and 417 (43%) among people with cognitive impairment (MCI: 35%; MOCI: 40%; SCI: 50%). A different fall risk model was observed for MCI, MOCI, SCI, and NCI patients. The results imply that the higher the level of cognitive impairment, the greater the number of falls (F1,481 = 113.852; Sig = 0.015), although the level of significance was not maintained when MOCI and SCI participants were compared. Depression, neuropsychiatric disturbances, autonomy constraints in daily life activity performance, and low functional mobility were factors closely associated with fall risk.

CONCLUSION

This study provides evidence indicating that fall risk factors do not hold a direct correlation with the level of cognitive impairment among elderly nursing home care residents.

The impact of cognitive performance on quality of life in individuals with Parkinson's disease

Background

Evidence points to the occurrence of cognitive impairment in all stages of PD, constituting a frequent and debilitating symptom, due to high impact on quality of life and mortality of patients.

Objective

To correlate cognitive performance with quality of life in PD.

Methods

The sample was drawn from a Movement Disorders Clinic of a reference hospital in Porto Alegre. Inclusion criteria were: PD diagnosis, according to the United Kingdom Parkinson's Disease Society Brain Bank criteria for idiopathic PD (Hughes et al. 1992) and patient consent to participate. Patients with other neurological pathologies and those submitted to deep brain stimulation were excluded. The evaluation consisted of a cognitive testing battery (composed of eight tests for assessing cognitive performance), and a questionnaire on quality of life (PDQ-39) and depression (BDI).

Results

The sample comprised 85 individuals with PD, with a mean age of 62.9 years (±10.7), mean disease duration of 10.4 years (±5.7), and mean educational level of four years (±4.3). There was a significant relationship between total score on the PDQ and all cognitive tests, showing that poor cognitive performance was correlated with poor quality of life. Moreover, a significant correlation was observed between cognitive tests and depression, H&Y, education level, and age.

Conclusion

It may be concluded that the individuals with PD in this sample showed a correlation between poorer quality of life and worse cognitive performance. Poor performance was also correlated with more advanced stage, older age, low level of education and depression.

Predictive model for falling in Parkinson disease patients

Background/aims

Falls are a common complication of advancing Parkinson's disease (PD). Although numerous risk factors are known, reliable predictors of future falls are still lacking. The aim of this study was to develop a multivariate model to predict falling in PD patients.

Methods

Prospective cohort with forty-nine PD patients. The area under the receiver-operating characteristic curve (AUC) was calculated to evaluate predictive performance of the purposed multivariate model.

Results

The median of PD duration and UPDRS-III score in the cohort was 6 years and 24 points, respectively. Falls occurred in 18 PD patients (30%). Predictive factors for falling identified by univariate analysis were age, PD duration, physical activity, and scores of UPDRS motor, FOG, ACE, IFS, PFAQ and GDS (p-value < 0.001), as well as fear of falling score (p-value = 0.04). The final multivariate model (PD duration, FOG, ACE, and physical activity) showed an AUC = 0.9282 (correctly classified = 89.83%; sensitivity = 92.68%; specificity = 83.33%).

Conclusions

This study showed that our multivariate model have a high performance to predict falling in a sample of PD patients.

•

In PD patients the fall rates doubles the reported rates in community welling older people without neurological disease, ranging from 35% to 90%.

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Falls have a negative psychosocial impact creating a spiral of increased fear of falling and reduced physical activity, and increased likelihood of nursing home admission.

•

A multivariate model (PD duration, freezing of gait, Addenbrook's Cognitive Examination, and physical activity) to predict falling in our sample of PD patients showed a high performance.

Global cognitive function and processing speed are associated with gait and balance dysfunction in Parkinson's disease

Background

Our primary objective was to determine the relationship between global cognitive function and specific domains of gait and balance in a cohort of Parkinson’s disease (PD) subjects. In a secondary analysis, we determined whether specific cognitive domains correlated with gait and balance performance.

Methods

Fourteen PD subjects (mean age 61.1 ± 7.8 years) were recruited from the Rush University Medical Center Movement Disorders clinic. Subjects underwent clinical assessment using the motor subsection of the Unified Parkinson’s Disease Rating Scale (UPDRS) followed by quantitative gait and balance assessments using the APDM Mobility Lab™ system (Mobility Lab, APDM Inc., Portland, OR). Subjects completed global cognitive testing using the Mattis Dementia Rating Scale (MDRS) as well as domain specific cognitive measures. Spearman’s rho was used to assess correlations between cognitive measures and gait and balance function, with False Discovery Rate (FDR) correction for multiple comparisons.

Results

Global cognitive function had the strongest correlation with stride velocity (r = 0.816, p = 0.001), turn duration (r = −0.806, p = 0.001), number of steps to turn (r = −0.830, p = 0.001), and mean velocity of postural sway in the medio-lateral direction (r = −0.726, p = 0.005). A significant correlation was found between processing speed and two turning measures (turn duration, r = −0.884, p = 0.001; number of steps to turn, r = −0.954, p < 0.001), but no other associations were found between specific cognitive domains and gait domains.

Conclusions

This pilot study provides preliminary data regarding the association between global cognitive function and pace-related measures of gait, turning, and postural sway. Furthermore, reduced processing speed was found to be associated with difficulty in performing turns.

Cognitive Impairment in Fall-Related Studies in Parkinson's Disease

Background: There is increasing evidence to suggest a tight relationship between cognitive impairment and falls in Parkinson’s disease (PD). Here, we draw attention to a potentially significant flaw in the existent falls-related research, namely the apparent exclusion of patients with cognitive impairment or dementia.

Objective: Our objective was to review all published, on-going or scheduled fall-related intervention studies, in order to investigate the extent to which cognitively impaired individuals with PD were included in these studies.

Methods: We analyzed published controlled trials regarding falls and PD in commonly used databases, as well as relevant ongoing clinical trials registered within the World Health Organization database, clinicaltrials.gov and the European Clinical Trials Database.

Results: Fourteen of the fifteen published studies included had explicit cognitive exclusion criteria as part of their study protocol. Most of the 54 on-going PD fall-related studies excluded patients with cognitive impairment.

Conclusions: This suggests that individuals with cognitive impairment or dementia are excluded from fall-related research studies. We strongly recommend that future work in this area should include a representative sample of patients with PD, including subjects with cognitive decline.

Postural instability and falls are more frequent in Parkinson’s disease patients with worse trunk mobility

ABSTRACT Postural instability and axial rigidity are frequent symptoms of the Parkinson’s disease (PD). Objective Correlate the occurrence of falls and the activity of rolling over in bed with performance on the Trunk Mobility Scale (TMS) in patients with PD, and determine whether this instrument score can predict the risk of falls. Method This is a cross-sectional study. Assessed patients reported the frequency of falls in the previous year and whether they had difficulties rolling over in bed. Then, the following scales were applied: TMS, Hoehn and Yahr, Unified Parkinson’s Disease Rating Scale-III and Schwab and England Activities of Daily Living. Results Eighty-five patients were analyzed. Patients with a history of falling showed worse performance in the TMS (p < 0.01). There is a significant correlation between TMS and the activity of rolling over in bed (p < 0.01). Conclusion PD fallers present worse scores in TMS, and there is a significant correlation between difficulty rolling over in bed and TMS score.

Comparison of the Fullerton Advanced Balance Scale, Mini-BESTest, and Berg Balance Scale to Predict Falls in Parkinson Disease

BACKGROUND

The correct identification of patients with Parkinson disease (PD) at risk for falling is important to initiate appropriate treatment early.

OBJECTIVE

This study compared the Fullerton Advanced Balance (FAB) scale with the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS) to identify individuals with PD at risk for falls and to analyze which of the items of the scales best predict future falls.

DESIGN

This was a prospective study to assess predictive criterion-related validity.

SETTING

The study was conducted at a university hospital in an urban community.

PATIENTS

Eighty-five patients with idiopathic PD (Hoehn and Yahr stages: 1-4) participated in the study.

MEASUREMENTS

Measures were number of falls (assessed prospectively over 6 months), FAB scale, Mini-BESTest, BBS, and Unified Parkinson's Disease Rating Scale.

RESULTS

The FAB scale, Mini-BESTest, and BBS showed similar accuracy to predict future falls, with values for area under the curve (AUC) of the receiver operating characteristic (ROC) curve of 0.68, 0.65, and 0.69, respectively. A model combining the items "tandem stance," "rise to toes," "one-leg stance," "compensatory stepping backward," "turning," and "placing alternate foot on stool" had an AUC of 0.84 of the ROC curve.

LIMITATIONS

There was a dropout rate of 19/85 participants.

CONCLUSIONS

The FAB scale, Mini-BESTest, and BBS provide moderate capacity to predict "fallers" (people with one or more falls) from "nonfallers." Only some items of the 3 scales contribute to the detection of future falls. Clinicians should particularly focus on the item "tandem stance" along with the items "one-leg stance," "rise to toes," "compensatory stepping backward," "turning 360°," and "placing foot on stool" when analyzing postural control deficits related to fall risk. Future research should analyze whether balance training including the aforementioned items is effective in reducing fall risk.

Fall risk is associated with amplified functional connectivity of the central executive network in patients with Parkinson's disease

Falls are debilitating problems that markedly impact the health-related quality of life of many patients with Parkinson's disease (PD). Numerous studies point to the role of executive function and attention in falls; however, the brain mechanisms underlying these relationships are less clear. Here, we aim to evaluate the brain mechanisms underlying the role of executive function in falls. Patients with PD who were fallers (n = 27) or non-fallers (n = 53) and 27 healthy older adults were examined in a cross-sectional study. Gray matter volumes of the caudate head and posterior putamen were evaluated, as these striatal regions play a role in the executive and the sensorimotor cortico-striatal networks, respectively. The functional connectivity of the central executive network and of the sensorimotor network was measured using intrinsic brain connectivity during resting state functional magnetic resonance imaging. Compared to non-fallers and healthy controls, fallers had lower gray matter volume in the caudate head, but not in the posterior putamen, and increased connectivity between posterior partial regions of the central executive network, with no difference within the sensorimotor network. Mediation analysis demonstrated that the relationships between caudate head gray matter volume and fall history and risk were mediated by increased connectivity within the central executive network, apparently via attentional changes. The above findings provide additional converging evidence for the involvement of executive-related brain changes in falls in PD and support the important role of attention and executive function in fall risk.