Association of dietary selenium intake and all-cause mortality of Parkinson's disease and its interaction with blood cadmium level: a retrospective cohort study

BACKGROUND

Parkinson's disease (PD) is a slowly progressive neurodegenerating disease that may eventually lead to disabling condition and pose a threat to the health of aging populations. This study aimed to explore the association of two potential risk factors, selenium and cadmium, with the prognosis of Parkinson's disease as well as their interaction effect.

METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 to 2015-2016 and National Death Index (NDI). Participants were classified as Parkinson's patients by self-reported anti-Parkinson medications usage. Cox regression models and restricted cubic spline models were applied to evaluate the association between PD mortality and selenium intake level as well as blood cadmium level. Subgroup analysis was also conducted to explore the interaction between them.

RESULTS

A total of 184 individuals were included. In full adjusted cox regression model (adjusted for age, gender, race, hypertension, pesticide exposure, smoking status and caffeine intake), compared with participants with low selenium intake, those with normal selenium intake level were significantly associated with less risk of death (95%CI: 0.18-0.76, P = 0.005) while no significant association was found between low selenium intake group and high selenium group (95%CI: 0.16-1.20, P = 0.112). Restricted cubic spline model indicated a nonlinear relationship between selenium intake and PD mortality (P for nonlinearity = 0.050). The association between PD mortality and blood cadmium level was not significant (95%CI: 0.19-5.57, P = 0.112). However, the interaction term of selenium intake and blood cadmium showed significance in the cox model (P for interaction = 0.048). Subgroup analysis showed that the significant protective effect of selenium intake existed in populations with high blood cadmium but not in populations with low blood cadmium.

CONCLUSION

Moderate increase of selenium intake had a protective effect on PD mortality especially in high blood cadmium populations.

Factors associated with longer survival among older medicare patients after diagnosis of supratentorial primary brain malignancies: a retrospective cohort study

OBJECTIVES

Despite recent advances, the prognosis for primary malignant brain tumors (PMBTs) remains poor. Some commonly prescribed medications may exhibit anti-tumor properties in various cancers, and neurodegenerative diseases may activate pathways that counteract gliomagenesis. Our study is focused on determining if there is a correlation between the use of metformin, beta-blockers, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs), or the presence of Parkinson's disease (PD), and the survival rates following a diagnosis of a PMBT.

METHODS

This analysis of the 100% Texas Medicare Database identified patients aged 66+ years diagnosed with a supratentorial PMBT from 2014-2017. Cox proportional hazards regression was employed to analyze survival following diagnosis and associations of survival with surgical intervention, radiation, PD diagnosis, and prescription of metformin, beta-blockers, ACEIs, or ARBs.

RESULTS

There were 1,943 patients who met study criteria, and the median age was 74 years. When medication utilization was stratified by none, pre-diagnosis only, post-diagnosis only, or both pre- and post-diagnosis (continuous), continuous utilization of metformin, beta-blockers, ACEIs, or ARBs was associated with prolonged survival compared to no utilization (hazard ratio [HR]:0.45, 95% CI:0.33-0.62; HR:0.71. 95% CI:0.59-0.86; HR:0.59, 95% CI:0.48-0.72; and HR:0.45, 95% CI:0.35-0.58 respectively). PD was also associated with longer survival (HR:0.59-0.63 across the four models).

DISCUSSION

Our study suggests that metformin, beta-blockers, ACEIs, ARBs, and comorbid PD are associated with a survival benefit among geriatric Medicare patients with supratentorial PMBTs.

Case-Fatality Rate in Parkinson's Disease: A Nationwide Registry Study

BACKGROUND

Patients with Parkinson's disease (PD) may have an increased risk of mortality, but robust estimates are lacking.

OBJECTIVE

To compare mortality rates nationally between patients with PD and controls.

METHODS

The case-fatality rates of Finnish PD patients diagnosed in 2004-2018 (n = 23,688; 57% male, mean age at diagnosis = 71 years) and randomly selected sex- and age-matched control subjects (n = 94,752) were compared using data from national registries. The median follow-up duration was 5.8 years (max 17 years).

RESULTS

The case-fatality rate in patients with PD was higher than that in matched controls (HR 2.29; 95% CI 2.24-2.33; P < 0.0001). Excess fatality among PD patients was already present at 1 year from diagnosis and then plateaued at 29% at 12 years after diagnosis. The long-term relative hazard of death in PD patients vs. matched controls did not differ based on sex. Patients with early-onset PD (age at diagnosis <50 years old) had the highest relative hazard of death (HR 3.36) compared to matched control subjects, and the relative hazard decreased with higher age at diagnosis. The seven-year excess risk of death decreased during the study period, especially in men. In patients with PD, male sex, increasing age, and increasing comorbidity burden were associated with an increased risk of death.

CONCLUSIONS

An increased risk of death among PD patients was evident from early on. The increase in risk was greatest among young-onset patients. The excess risk in early PD declined during the study period, particularly in men. The reasons for this are unknown.

Factors Associated with Preferred Place of Care and Death in Patients with Parkinson's Disease: A Cross-Sectional Study

Background

A significant proportion of people with Parkinson's disease (PwPD) die in hospital settings. Although one could presume that most PwPD would favor being cared for and die at home, there is currently no evidence to support this assumption.

Objective

We aimed at exploring PwPD's preferences for place of end-of-life care and place of death, along with associated factors.

Methods

A cross-sectional study was conducted to investigate PwPD's end-of life wishes regarding their preferred place of care and preferred place of death. Using different approaches within a generalized linear model framework, we additionally explored factors possibly associated with preferences for home care and home death.

Results

Although most PwPD wished to be cared for and die at home, about one-third reported feeling indifferent about their place of death. Preferred home care was associated with the preference for home death. Furthermore, a preference for dying at home was more likely among PwPD's with informal care support and spiritual/religious affiliation, but less likely if they preferred institutional care towards the end of life.

Conclusions

The variation in responses regarding the preferred place of care and place of death highlights the need to distinguish between the concepts when discussing end-of-life care. However, it is worth noting that the majority of PwPD preferred care and death at home. The factors identified in relation to preferred place of care and death provide an initial understanding of PwPD decision-making, but call for further research to confirm our findings, explore causality and identify additional influencing factors.

A Dementia mortality rates dataset in Italy (2012-2019)

Dementia is on the rise in the world population and has been defined by the World Health Organization as a global public health priority. In Italy, according to demographic projections, in 2051 there will be 280 elderly people for every 100 young people, with an increase in all age-related chronic diseases, including dementia. Currently the total number of patients with dementia is estimated to be over 1 million (mainly with Alzheimer's disease (AD) and Parkinson's disease (PD)). In-depth studies of the etiology and physiology of dementia are complicated due to the complexity of these diseases and their long duration. In this work we present a dataset on mortality rates (in the form of Standardized Mortality Ratios, SMR) for AD e PD in Italy at provincial level over a period of 8 years (2012-2019). Access to long-term, spatially detailed and ready-to-use data could favor both health monitoring and the research of new treatments and new drugs as well as innovative methodologies for early diagnosis of dementia.

Multi-omic landscaping of human midbrains identifies disease-relevant molecular targets and pathways in advanced-stage Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is the second most common neurodegenerative disorder whose prevalence is rapidly increasing worldwide. The molecular mechanisms underpinning the pathophysiology of sporadic PD remain incompletely understood. Therefore, causative therapies are still elusive. To obtain a more integrative view of disease-mediated alterations, we investigated the molecular landscape of PD in human post-mortem midbrains, a region that is highly affected during the disease process.

METHODS

Tissue from 19 PD patients and 12 controls were obtained from the Parkinson's UK Brain Bank and subjected to multi-omic analyses: small and total RNA sequencing was performed on an Illumina's HiSeq4000, while proteomics experiments were performed in a hybrid triple quadrupole-time of flight mass spectrometer (TripleTOF5600+) following quantitative sequential window acquisition of all theoretical mass spectra. Differential expression analyses were performed with customized frameworks based on DESeq2 (for RNA sequencing) and with Perseus v.1.5.6.0 (for proteomics). Custom pipelines in R were used for integrative studies.

RESULTS

Our analyses revealed multiple deregulated molecular targets linked to known disease mechanisms in PD as well as to novel processes. We have identified and experimentally validated (quantitative real-time polymerase chain reaction/western blotting) several PD-deregulated molecular candidates, including miR-539-3p, miR-376a-5p, miR-218-5p and miR-369-3p, the valid miRNA-mRNA interacting pairs miR-218-5p/RAB6C and miR-369-3p/GTF2H3, as well as multiple proteins, such as CHI3L1, HSPA1B, FNIP2 and TH. Vertical integration of multi-omic analyses allowed validating disease-mediated alterations across different molecular layers. Next to the identification of individual molecular targets in all explored omics layers, functional annotation of differentially expressed molecules showed an enrichment of pathways related to neuroinflammation, mitochondrial dysfunction and defects in synaptic function.

CONCLUSIONS

This comprehensive assessment of PD-affected and control human midbrains revealed multiple molecular targets and networks that are relevant to the disease mechanism of advanced PD. The integrative analyses of multiple omics layers underscore the importance of neuroinflammation, immune response activation, mitochondrial and synaptic dysfunction as putative therapeutic targets for advanced PD.

Activating transcription factor-4 promotes neuronal death induced by Parkinson's disease neurotoxins and α-synuclein aggregates

Parkinson's disease (PD) is a neurodegenerative disease characterized by the loss of dopaminergic neurons in the substantia nigra resulting in severe and progressive motor impairments. However, the mechanisms underlying this neuronal loss remain largely unknown. Oxidative stress and ER stress have been implicated in PD and these factors are known to activate the integrated stress response (ISR). Activating transcription factor 4 (ATF4), a key mediator of the ISR, and has been reported to induce the expression of genes involved in cellular homeostasis. However, during prolonged activation ATF4 can also induce the expression of pro-death target genes. Therefore, in the present study, we investigated the role of ATF4 in neuronal cell death in models of PD. We demonstrate that PD neurotoxins (MPP+ and 6-OHDA) and α-synuclein aggregation induced by pre-formed human alpha-synuclein fibrils (PFFs) cause sustained upregulation of ATF4 expression in mouse cortical and mesencephalic dopaminergic neurons. Furthermore, we demonstrate that PD neurotoxins induce the expression of the pro-apoptotic factors Chop, Trb3, and Puma in dopaminergic neurons in an ATF4-dependent manner. Importantly, we have determined that PD neurotoxin and α-synuclein PFF induced neuronal death is attenuated in ATF4-deficient dopaminergic neurons. Furthermore, ectopic expression of ATF4 but not transcriptionally defective ATF4ΔRK restores sensitivity of ATF4-deficient neurons to PD neurotoxins. Finally, we demonstrate that the eIF2α kinase inhibitor C16 suppresses MPP+ and 6-OHDA induced ATF4 activation and protects against PD neurotoxin induced dopaminergic neuronal death. Taken together these results indicate that ATF4 promotes dopaminergic cell death induced by PD neurotoxins and pathogenic α-synuclein aggregates and highlight the ISR factor ATF4 as a potential therapeutic target in PD.

Parkinson disease clinical subtypes: key features & clinical milestones

OBJECTIVES

Based on multi-domain classification of Parkinson disease (PD) subtypes, we sought to determine the key features that best differentiate subtypes and the utility of PD subtypes to predict clinical milestones.

METHODS

Prospective cohort of 162 PD participants with ongoing, longitudinal follow-up. Latent class analysis (LCA) delineated subtypes based on score patterns across baseline motor, cognitive, and psychiatric measures. Discriminant analyses identified key features that distinguish subtypes at baseline. Cox regression models tested PD subtype differences in longitudinal conversion to clinical milestones, including deep brain stimulation (DBS), dementia, and mortality.

RESULTS

LCA identified distinct subtypes: "motor only" (N = 63) characterized by primary motor deficits; "psychiatric & motor" (N = 17) characterized by prominent psychiatric symptoms and moderate motor deficits; "cognitive & motor" (N = 82) characterized by impaired cognition and moderate motor deficits. Depression, executive function, and apathy best discriminated subtypes. Since enrollment, 22 had DBS, 48 developed dementia, and 46 have died. Although there were no subtype differences in rate of DBS, dementia occurred at a higher rate in the "cognitive & motor" subtype. Surprisingly, mortality risk was similarly elevated for both "cognitive & motor" and "psychiatric & motor" subtypes compared to the "motor only" subtype (relative risk = 3.15, 2.60).

INTERPRETATION

Psychiatric and cognitive features, rather than motor deficits, distinguish clinical PD subtypes and predict greater risk of subsequent dementia and mortality. These results emphasize the value of multi-domain assessments to better characterize clinical variability in PD. Further, differences in dementia and mortality rates demonstrate the prognostic utility of PD subtypes.

Occupational pesticide exposure and the risk of death in patients with Parkinson's disease: an observational study in southern Brazil

BACKGROUND

Multiple studies have suggested that various pesticides are associated with a higher risk of developing Parkinson's disease (PD) and may influence the progression of the disease. However, the evidence regarding the impact of pesticide exposure on mortality among patients with PD is equivocal. This study examines whether pesticide exposure influences the risk of mortality among patients with PD in Southern Brazil.

METHODS

A total of 150 patients with idiopathic PD were enrolled from 2008 to 2013 and followed until 2019. In addition to undergoing a detailed neurologic evaluation, patients completed surveys regarding socioeconomic status and environmental exposures.

RESULTS

Twenty patients (13.3%) reported a history of occupational pesticide exposure with a median duration of exposure of 10 years (mean = 13.1, SD = 11.2). Patients with a history of occupational pesticide exposure had higher UPDRS-III scores, though there were no significant differences in regards to age, sex, disease duration, Charlson Comorbidity Index, and age at symptom onset. Patients with occupational pesticide exposure were more than twice as likely to die than their unexposed PD counterparts (HR = 2.32, 95% CI [1.15, 4.66], p = 0.018). Occupational pesticide exposure was also a significant predictor of death in a cox-proportional hazards model which included smoking and caffeine intake history (HR = 2.23, 95% CI [1.09, 4.59], p = 0.03)) and another which included several measures of socioeconomic status (HR = 3.91, 95% CI [1.32, 11.58], p = 0.01).

CONCLUSION

In this prospective cohort study, we found an increased all-cause mortality risk in PD patients with occupational exposure to pesticides. More studies are needed to further analyze this topic with longer follow-up periods, more detailed exposure information, and more specific causes of mortality.

[123I]FP-CIT SPECT in Clinically Uncertain Parkinsonism Predicts Survival: A Data-Driven Analysis

BACKGROUND

Dopamine transporter SPECT is an established method to investigate nigrostriatal integrity in case of clinically uncertain parkinsonism.

OBJECTIVE

The present study explores whether a data-driven analysis of [123I]FP-CIT SPECT is able to stratify patients according to mortality after SPECT.

METHODS

Patients from our clinical registry were included if they had received [123I]FP-CIT SPECT between 10/2008 and 06/2016 for diagnosis of parkinsonism and if their vital status could be determined in 07/2017. Specific binding ratios (SBR) of the whole striatum, its asymmetry (asymmetry index, AI; absolute value), and the rostrocaudal gradient of striatal binding (C/pP: caudate SBR divided by posterior putamen SBR) were used as input for hierarchical clustering of patients. We tested differences in survival between these groups (adjusted for age) with a Cox proportional hazards model.

RESULTS

Data from 518 patients were analyzed. Median follow-up duration was 3.3 years [95% C.I. 3.1 to 3.7]. Three subgroups identified by hierarchical clustering were characterized by relatively low striatal SBR, high AI, and low C/pP (group 1), low striatal SBR, high AI, and high C/pP (group 2), and high striatal SBR, low AI, and low C/pP (group 3). Mortality was significantly higher in group 1 compared to each of the other two groups (p = 0.029 and p = 0.003, respectively).

CONCLUSION

Data-driven analysis of [123I]FP-CIT SPECT identified a subgroup of patients with significantly increased mortality during follow-up. This suggests that [123I]-FP-CIT SPECT might not only serve as a diagnostic tool to verify nigrostriatal degeneration but also provide valuable prognostic information.

Mortality and cause of death in South Korean patients with Parkinson's disease: a longitudinal follow-up study using a national sample cohort

OBJECTIVE

The incidence rate of Parkinson's disease (PD) is growing rapidly owing to the ageing population. We investigated the mortality rates and causes of death in South Korean patients with PD.

DESIGN

We investigated a national cohort using the nationwide insurance database.

SETTING

Korean Health Insurance Review and Assessment Service-National Sample Cohort database.

PARTICIPANTS

We included 3510 participants ≥60 years of age who were diagnosed with PD between 2002 and 2013, as well as 14 040 matched controls.

INTERVENTIONS

None PRIMARY AND SECONDARY OUTCOME MEASURES: A stratified Cox proportional hazards model was used to evaluate patients with PD who were matched 1:4 with non-PD control subjects adjusted for age, sex, income and region of residence. The causes of death were grouped into 12 classifications.

RESULTS

The adjusted HR for mortality in the PD group was 2.09 (95% CI 1.94 to 2.24, p<0.001). Subgroup analysis according to age (<70 years, 70-79 years, and ≥80 years) and sex revealed that patients with PD showed higher adjusted HRs for mortality across all subgroups. Mortalities caused by metabolic, mental, neurologic, circulatory, respiratory, and genitourinary diseases, as well as trauma, were more common in the PD group than in the control group, with the highest OR observed in patients with neurologic disease.

CONCLUSIONS

We demonstrated that PD in South Korean patients ≥60 years of age was associated with increased mortality in both sexes regardless of age.

Matched Cohort Analysis of Total Hip Arthroplasty in Patients With and Without Parkinson's Disease: Complications, Mortality, Length of Stay, and Hospital Charges

BACKGROUND

Increased complication rate has been reported in Parkinson's disease (PD) patients following total hip arthroplasty (THA). However, this has not previously been studied on a national scale. The purpose of this study was to determine whether PD patients had increased cost, complication, mortality, and length of stay following THA using a national database.

METHODS

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was evaluated for the years 2000-2014. PD patients were matched 1:3 with non-PD control patients for age, gender, Charlson Comorbidity Index, and year of admission using a propensity score matching procedure. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort.

RESULTS

794,689 THAs were performed from 2000-2014. 4003 patients (0.50%) had comorbid Parkinson's disease. Before matching, arthroplasty patients with PD were significantly older (P < .001), more frequently male (P < .001), and had greater Charlson Comorbidity Index (P < .001). In the matched cohort, PD was associated with increased length of stay (3.1 vs 2.7 days, P < .001), total hospital charges ($49,061 vs $45,571, P < .001), and in-hospital complication rate (14.6% vs 11.7%, P < .001). There was no difference in-hospital mortality (0.50% vs 0.47%, P = .781).

CONCLUSIONS

Matched cohort analysis demonstrated increases in complication rate, length, and cost of hospitalization for THA in patients with PD. However, in-hospital mortality rate in PD patients was not increased. Of note, the elevation in per-episode cost ($3490) may be of concern when considering PD patients for surgery within the evolving "bundled payment" model of care.

LEVEL OF EVIDENCE

Prognostic- Level III.

Dysphagia predicts poor outcome in late-stage Parkinson's disease

BACKGROUND

Few data exist on the rate of clinical progression for Parkinson's disease (PD) patients who have entered a late stage of the disease.

OBJECTIVE

Study the clinical progression of a late-stage PD (LSPD) population over one year follow-up.

METHODS

50 LSPD patients (Schwab and England ADL Scale <50 or Hoehn Yahr Stage >3 in MED ON) underwent an extensive clinical assessment at baseline and after one year and an acute levodopa test at baseline.

RESULTS

Mean age of LSPD patients (female 46%) was 77.5 ± 5.9 years and mean disease duration was 15.5 ± 6.5 years. At baseline, 76% had levodopa-induced motor complications (MC), usually non-troublesome, 68% were demented, 54% had psychosis and 68% depression. Caregiver distress was high. l-dopa responsiveness was mild (18% ± 12 of improvement on MDS-UPDRS-III). After one-year, 20% of the patients were dead, institutionalized or HY 5. MDS-UPDRS-motor mean score worsened 7.2 ± 10.3 points although there was heterogeneity between patients, and there was a global worsening of non-motor symptoms, mostly in cognition/mood, urinary and gastrointestinal domains. Nevertheless, MC improved despite similar levodopa equivalent dose. Functional independence and quality of life worsened. Dysphagia severity at baseline predicted a poor outcome (death, institutionalization or HY 5) (Hazard ratio 2.3, 95% CI 1.12-4.4; p = 0.01), whereas magnitude of l-dopa response of LSPD patients did not.

CONCLUSIONS

LSPD patients still present a significant, although heterogeneous, motor and non-motor progression over 1 year. Dysphagia severity predicts the occurrence of additional disease severity milestones and its management must be prioritized.

Hazardous effects of chemical pesticides on human health-Cancer and other associated disorders

Poisoning from pesticides is a global public health problem and accounts for nearly 300,000 deaths worldwide every year. Exposure to pesticides is inevitable; there are different modes through which humans get exposed to pesticides. The mode of exposure is an important factor as it also signifies the concentration of pesticides exposure. Pesticides are used extensively in agricultural and domestic settings. These chemicals are believed to cause many disorders in humans and wildlife. Research from past few decades has tried to answer the associated mechanism of action of pesticides in conjunction with their harmful effects. This perspective considers the past and present research in the field of pesticides and associated disorders. We have reviewed the most common diseases including cancer which are associated with pesticides. Pesticides have shown to be involved in the pathogenesis of Parkinson's and Alzheimer's diseases as well as various disorders of the respiratory and reproductive tracts. Oxidative stress caused by pesticides is an important mechanism through which many of the pesticides exert their harmful effects. Oxidative stress is known to cause DNA damage which in turn may cause malignancies and other disorders. Many pesticides have shown to modulate the gene expression at the level of non-coding RNAs, histone deacetylases, DNA methylation patterns suggesting their role in epigenetics.

Relative survival in patients with dementia with Lewy bodies and Parkinson's disease dementia

INTRODUCTION

The understanding of survival in dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) is limited, as well as the impact of these diagnoses in an ageing co-morbid population.

METHODS

A retrospective study of 177 patients who received a DLB or PDD diagnosis between 1997-2014 at the Memory Clinic in Malmö, Sweden. Relative survival was evaluated by adjusting all-cause survival for expected survival, estimated from population life-tables, matched by sex, age and calendar year. Predictors of relative survival were investigated using multivariate regression modelling.

RESULTS

At follow-up, 143 (81%) patients were deceased with a median survival of 4.1 years (IQR 2.6-6.0). After 10-years follow-up, the standardized mortality ratio was 3.44 (95% CI 2.92-4.04). Relative survival was worse with younger age at diagnosis (excess hazard ratio [eHR] 0.91, 95% CI 0.88-0.94 per year of age), female sex (eHR 1.45, 95% CI 1.01-2.09) and lower mini-mental state examination (eHR 0.93, 95% CI 0.90-0.96). Subgroup analysis (n = 141) showed higher mortality in DLB patients who were positive for APOE ɛ4 (eHR 2.00, 95% CI 1.35-2.97).

CONCLUSION

The mortality is over three-times higher in patients diagnosed with dementia with Lewy bodies and Parkinson's disease dementia during a ten-year follow-up, compared to persons in the general population. Excess mortality is found primarily in younger patients, females and carriers of APOE ε4. Further research is needed regarding survival and possible interventions, including disease-modifying treatments, to improve care for this patient group.

Typical features of Parkinson disease and diagnostic challenges with microdeletion 22q11.2

OBJECTIVE

To delineate the natural history, diagnosis, and treatment response of Parkinson disease (PD) in individuals with 22q11.2 deletion syndrome (22q11.2DS), and to determine if these patients differ from those with idiopathic PD.

METHODS

In this international observational study, we characterized the clinical and neuroimaging features of 45 individuals with 22q11.2DS and PD (mean follow-up 7.5 ± 4.1 years).

RESULTS

22q11.2DS PD had a typical male excess (32 male, 71.1%), presentation and progression of hallmark motor symptoms, reduced striatal dopamine transporter binding with molecular imaging, and initial positive response to levodopa (93.3%). Mean age at motor symptom onset was relatively young (39.5 ± 8.5 years); 71.4% of cases had early-onset PD (<45 years). Despite having a similar age at onset, the diagnosis of PD was delayed in patients with a history of antipsychotic treatment compared with antipsychotic-naive patients (median 5 vs 1 year, p = 0.001). Preexisting psychotic disorders (24.5%) and mood or anxiety disorders (31.1%) were common, as were early dystonia (19.4%) and a history of seizures (33.3%).

CONCLUSIONS

Major clinical characteristics and response to standard treatments appear comparable in 22q11.2DS-associated PD to those in idiopathic PD, although the average age at onset is earlier. Importantly, treatment of preexisting psychotic illness may delay diagnosis of PD in 22q11.DS patients. An index of suspicion and vigilance for complex comorbidity may assist in identifying patients to prioritize for genetic testing.

Mortality and quality of death certification in a cohort of patients with Parkinson's disease and matched controls in North Wales, UK at 18 years: a community-based cohort study

OBJECTIVE

This investigation reports the cause and the quality of death certification in a community cohort of patients with Parkinson's disease (PD) and controls at 18 years.

SETTING

Denbighshire North Wales, UK.

PARTICIPANTS

The community-based cohorts consisted of 166 patients with PD and 102 matched controls.

PRIMARY OUTCOMES

All-cause mortality was ascertained at 18 years by review of hospitals' primary care records and examination of death certificates obtained from the UK General Register Office. Mortality HRs were estimated using Cox proportional regression, controlling for covariates including age at study entry, age at death, gender, motor function, mood, health-related quality of life (HRQoL) and cognitive function.

RESULTS

After 18 years, 158 (95%) of patients in the PD cohort and 34 (33%) in the control cohort had died. Compared with the general UK population, the PD cohort had a higher risk of mortality (standard mortality rate, 1.82, 95% CI 1.55 to 2.13). As the primary or underlying cause of death, PD was not reported in 75/158 (47%) of the death certificates. In addition, although 144/158 (91%) of the PD cohort had a diagnosis of dementia, this was reported in less than 10% of death certificates. The main cause of death reported in the PD cohort was pneumonia (53%), followed by cardiac-related deaths (21%). Compared with controls, patients with PD had a greater risk of pneumonia (2.03, 95% CI 1.34 to 3.6), poorer HRQoL and more likely to reside in institutional care at death (P<0.01).

CONCLUSION

This investigation found that PD was associated with an excess risk of mortality compared with the general population. However, PD as a primary or underlying cause of death recorded on certificates was found to be suboptimal. This suggests that the quality of mortality statistics drawn from death certificates alone is not a valid or reliable source of data.

Association of soil selenium, strontium, and magnesium concentrations with Parkinson's disease mortality rates in the USA

Among the 41 soil elements analyzed from 4856 sites across the contiguous 48 states, average Parkinson's disease (PD) mortality rates between 1999 and 2014 have the most significant positive correlation with the average soil strontium (Sr) concentrations (correlation r = 0.47, significance level p = 0.00), and average PD mortality rates have the most significant inverse correlation with the average soil selenium (Se) concentrations (r = -0.44, p = 0.00). Multivariate regression models indicate that soil Sr and Se concentrations can explain 35.4% of spatial disparities of the state average PD mortality rates between 1999 and 2014 (R ² = 0.354). When the five outlier states were removed from the model, concentrations of soil Sr and Se can explain 62.4% (R ² = 0.624) of the spatial disparities of PD mortality rates of the 43 remaining states. The results also indicate that high soil magnesium (Mg) concentrations suppressed the growth rate of the PD mortality rates between 1999 and 2014 in the 48 states (r = -0.42, p = 0.000). While both Se and Sr have been reported to affect the nervous system, this study is the first study that reported the statistically significant association between the PD mortality rates and soil concentrations of Se, Sr, and Mg in the 48 states. Given that soil elemental concentration in a region is broad indicator of the trace element intake from food, water, and air by people, implications of the results are that high soil Se and Mg concentrations helped reduce the PD mortality rates and benefited the PD patients in the 48 states.

Development and validation of prognostic survival models in newly diagnosed Parkinson's disease

OBJECTIVE

The objective of this study was to develop valid prognostic models to predict mortality, dependency, and "death or dependency" for use in newly diagnosed Parkinson's disease (PD).

METHODS

The models were developed in the Parkinsonism Incidence in North-East Scotland study (UK, 198 patients) and validated in the ParkWest study (Norway, 192 patients), cohorts that attempted to identify and follow-up all new PD cases in the study area. Dependency was defined using the Schwab & England scale. We selected variables measured at time of diagnosis to include in the models. Internal validation and external validation were performed by calculating C-statistics (discrimination) and plotting observed versus predicted risk in quantiles of predicted risk (calibration).

RESULTS

Older age, male sex, increased severity of axial features, and Charlson comorbidity index were independent prognostic factors in the mortality model. Increasing age, higher smoking history, increased severity of axial features, and lower MMSE score were independent predictors in the models of dependency and "death or dependency." Each model had very good internal calibration and very good or good discrimination (internal and external C-statistics for the models were 0.73-0.75 and 0.68-0.78, respectively). Although each model clearly separated patients into groups according to risk, they tended to overestimate risk in ParkWest. The models were recalibrated to the baseline risk in the ParkWest study and then calibrated well in this cohort.

CONCLUSIONS

We have developed prognostic models for predicting medium-term risk of important clinical outcomes in newly diagnosed PD. These models have validity for use for stratification of randomization, confounder adjustment, and case-mix correction, but they are inadequate for individualized prognostication. © 2017. The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Risk Factors for Hip Fracture in Older Men: The Osteoporotic Fractures in Men Study (MrOS)

Almost 30% of hip fractures occur in men; the mortality, morbidity, and loss of independence after hip fractures are greater in men than in women. To comprehensively evaluate risk factors for hip fracture in older men, we performed a prospective study of 5994 men, primarily white, age 65+ years recruited at six US clinical centers. During a mean of 8.6 years of 97% complete follow-up, 178 men experienced incident hip fractures. Information on risk factors including femoral neck bone mineral density (FNBMD) was obtained at the baseline visit. Cox proportional hazards models were used to calculate the hazard ratio (HR) with 95% confidence intervals; Fine and Gray models adjusted for competing mortality risk. Older age (≥75 years), low FNBMD, currently smoking, greater height and height loss since age 25 years, history of fracture, use of tricyclic antidepressants, history of myocardial infarction or angina, hyperthyroidism or Parkinson's disease, lower protein intake, and lower executive function were all associated with an increased hip fracture risk. Further adjustment for competing mortality attenuated HR for smoking, hyperthyroidism, and Parkinson's disease. The incidence rate of hip fracture per 1000 person-years (PY) was greatest in men with FNBMD T-scores <-2.5 (white women reference database) who also had 4+ risk factors, 33.4. Men age ≥80 years with 3+ major comorbidities experienced hip fracture at rates of 14.52 versus 0.88 per 1000 PY in men age <70 years with zero comorbidities. Older men with low FNBMD, multiple risk factors, and multimorbidity have a high risk of hip fracture. Many of these assessments can easily be incorporated into routine clinical practice and may lead to improved risk stratification. © 2016 American Society for Bone and Mineral Research.

Long-term mortality patterns in a residential cohort exposed to inorganic selenium in drinking water

Selenium (Se) is a metalloid of considerable nutritional and toxicological importance in humans. To date, limited epidemiologic evidence exists about the health effects of exposure to this trace element in drinking water. We investigated the relationship between Se levels in water and mortality in the municipality of Reggio Emilia, Italy, where high levels of Se were previously observed in drinking water. From 1974 to 1985, 2065 residents consumed drinking water with Se levels close to the European standard of 10μg/l, in its inorganic hexavalent form (selenate). Follow-up was conducted for the years 1986-2012 in Reggio Emilia and a lesser exposed comparison group of around 100,000 municipal residents, with comparable socio-demographic characteristics. Overall mortality from all causes, cardiovascular disease and cancer showed little evidence of differences. However, excess rate ratios were seen for some site specific cancers such as neoplasms of buccal cavity and pharynx, urinary tract, lymphohematopoietic tissue, melanoma, and two neurodegenerative diseases, Parkinson's disease and amyotrophic lateral sclerosis. Excess mortality in the exposed cohort for specific outcomes was concentrated in the first period of follow-up (1986-1997), and waned starting 10 years after the high exposure ended. We also found lower mortality from breast cancer in females during the first period of follow-up. When we extended the analysis to include residents who had been consuming the high-selenium drinking water for a shorter period, mortality rate ratios were also increased, but to a lesser extent. Overall, we found that the mortality patterns related to long-term exposure to inorganic hexavalent selenium through drinking water were elevated for several site-specific cancers and neurodegenerative disease.

Premotor Symptoms as Predictors of Outcome in Parkinsons Disease: A Case-Control Study

Background

To evaluate the association between the premotor symptoms and the prognosis of PD.

Methods

A total of 1213 patients who were diagnosed of PD from January 2001 to December 2008 were selected from the Taiwan’s National Health Insurance Research Database. Patients were traced back to determine the presence of premotor symptoms, including rapid eye movement sleep behavior disorder (RBD), depression, and constipation. Cox’s regression analysis was used to detect the risks between the occurrence of premotor symptoms and the outcome (including death, psychosis, accidental injury, dementia and aspiration pneumonia). In addition, the association between premotor symptoms and levodopa equivalent dosage (LED) was examined.

Results

Higher occurrence of death, dementia and aspiration pneumonia were identified in PD patients with premotor symptoms than without premotor symptoms (HR 1·69, 95% CI 1·34–2·14, p <0·001 for death; HR 1·63, 95% CI 1·20–2·22, p = 0·002 for dementia; HR 2·45, 95% CI 1·42–4·21, p = 0·001 for aspiration pneumonia). In a comorbidities-stratified analysis, PD patients with premotor symptoms showed significantly high risks of mortality and morbidity (dementia and aspiration pneumonia), especially in the absence of comorbidities. Independent predictors of mortality in PD were found to be higher age, male sex, constipation, RBD, RBD with constipation and depression, and diabetes. Furthermore, no significant differences of LED and subsequent accidental injury were noted between PD patient with or without premotor symptoms.

Conclusion

Premotor symptoms seem to be not merely risk factors, but also prognostic factors of PD.

Socioeconomic status in relation to Parkinson's disease risk and mortality: A population-based prospective study

Little is known about the role of socioeconomic status in relation to Parkinson's disease (PD) risk, and no study has investigated whether the impact of socioeconomic status on all-cause mortality differs between individuals with and without PD.In this population-based prospective study, over 4.6 million Swedish inhabitants who participated in the Swedish census in 1980 were followed from 1981 to 2010. The incidence rate of PD and incidence rate ratio were estimated for the association between socioeconomic status and PD risk. Age-standardized mortality rate and hazard ratio (HR) were estimated for the association between socioeconomic status and all-cause mortality for individuals with and without PD.During follow-up, 66,332 incident PD cases at a mean age of 76.0 years were recorded. Compared to individuals with the highest socioeconomic status (high nonmanual workers), all other socioeconomic groups (manual or nonmanual and self-employed workers) had a lower PD risk. All-cause mortality rates were higher in individuals with lower socioeconomic status compared with high nonmanual workers, but relative risks for all-cause mortality were lower in PD patients than in non-PD individuals (e.g., for low manual workers, HR: 1.12, 95% confidence interval [CI]: 1.09-1.15 for PD patients; HR: 1.36, 95% CI: 1.35-1.36 for non-PD individuals).Individuals with lower socioeconomic status had a lower PD incidence compared to the highest socioeconomic group. Lower socioeconomic status was associated with higher all-cause mortality among individuals with and without PD, but such impact was weaker among PD patients.

Co-morbidity burden in Parkinson's disease: Comparison with controls and its influence on prognosis

Background

Many aspects of co-morbidity burden in Parkinson’s disease (PD) are unclear, but it may be an important predictor of prognosis or confounder of associations in epidemiological studies.

Objectives

To determine how best to assess co-morbidity burden in PD, to compare with matched controls, and investigate its association with prognostic outcomes.

Methods

Data from an incident, community-based cohort with prospective follow-up (the PINE study) were used (198 patients with PD and 151 controls). The reliability of three co-morbidity scales (the Charlson co-morbidity index (CCI), the Cumulative Illness Rating scale and a simple disease count) were evaluated. The association with mortality and development of dependency was assessed with Cox regression. The co-morbidity burden in PD and controls was compared at baseline and over 5 years of follow-up using linear mixed modelling.

Results

The CCI was more reliable and was an independent predictor of mortality with a time-dependent effect (hazard ratio = 1.27 [1.08–1.49] in first four years of follow-up; no significant association after four years). Associations between the other scales and mortality and between each scale and development of dependency were non-significant once adjusted for confounders. Co-morbidity burden was similar between cases and controls at baseline and there was no evidence of differential accrual of co-morbidity between patients and controls (p = 0.94).

Conclusions

The CCI is probably the better scale for measuring co-morbidity burden in PD. There were no differences between PD and controls. Co-morbidity burden at diagnosis was associated with mortality in the early part of the disease course, but not later.

•

The Charlson Index was a reliable and valid way to measure co-morbidity burden in PD.

•

There was no difference in co-morbidity burden between PD and matched controls.

•

Higher co-morbidity at diagnosis was associated with higher early mortality.

[Hospital Mortality in Parkinson's Disease: Retrospective Analysis in a Portuguese Tertiary Centre]

INTRODUCTION

Parkinson's disease is associated with high hospital mortality. Male gender, late age at onset, higher disability and the coexistence of cognitive impairment or depression have been suggested to be risk factors of death. Pneumonia and cardiovascular diseases are the leading causes of death.

OBJECTIVE

To characterize the mortality (causes of hospital admission and death) of Parkinson's disease patients in a tertiary hospital, as well as demographic and clinical characteristics.

MATERIAL AND METHODS

Identification of hospital admissions of Parkinson's disease patients that resulted in inpatient death between 2008 and 2014. Retrospective review of medical files and inclusion of patients with disease clinically confirmed by a neurologist. Assessment of causes of death and demographic and clinical characteristics of patients.

RESULTS

1525 hospital admissions of Parkinson's disease patients were identified, of which 150 resulted in death. Of these, 52 patients met the inclusion criteria. Mean age at onset of Parkinson's disease symptoms was 66.8 years (± 8.7) and mean duration of disease was 12.5 years (± 7.9). Sixty-five percent of patients were in stages 4-5 of the Hoehn and Yahr scale. Thirty-three patients (63%) had dementia and eleven (21%) had depression. Infections were the leading cause of death (respiratory in 63% of cases).

DISCUSSION

Similarly to literature, pneumonia was the leading cause of hospital death and most patients presented advanced disease stage and dementia. Contrarily to other studies, life expectancy was not reduced and cardiovascular diseases and trauma were not causes of death in our population.

CONCLUSIONS

This is the first Portuguese mortality study in Parkinson's disease. Pneumonia is the leading cause of death. Advanced disease stage and dementia were common features in these patients.

Effect of heat waves on morbidity and mortality due to Parkinson's disease in Madrid: A time-series analysis

BACKGROUND

Parkinson's disease (PD) is one of the factors which are associated with a higher risk of mortality during heat waves. The use of certain neuroleptic medications to control some of this disease's complications would appear to be related to an increase in heat-related mortality.

OBJECTIVE

To analyse the relationship and quantify the short-term effect of high temperatures during heat wave episodes in Madrid on daily mortality and PD-related hospital admissions.

METHODS

We used an ecological time-series study and fit Poisson regression models. We analysed the daily number of deaths due to PD and the number of daily PD-related emergency hospital admissions in the city of Madrid, using maximum daily temperature (°C) as the main environmental variable and chemical air pollution as covariates. We controlled for trend, seasonalities, and the autoregressive nature of the series.

RESULTS

There was a maximum daily temperature of 30°C at which PD-related admissions were at a minimum. Similarly, a temperature of 34°C coincides with an increase in the number of admissions. For PD-related admissions, the Relative Risk (RR) for every increase of 1°C above the threshold temperature was 1.13 IC95%:(1.03-1.23) at lags 1 and 5; and for daily PD-related mortality, the RR was 1.14 IC95%:(1.01-1.28) at lag 3.

CONCLUSION

Our results indicate that suffering from PD is a risk factor that contributes to the excess morbidity and mortality associated with high temperatures, and is relevant from the standpoint of public health prevention plans.

Valuing Treatments for Parkinson Disease Incorporating Process Utility: Performance of Best-Worst Scaling, Time Trade-Off, and Visual Analogue Scales

OBJECTIVE

The objective of this study was to compare treatment profiles including both health outcomes and process characteristics in Parkinson disease using best-worst scaling (BWS), time trade-off (TTO), and visual analogue scales (VAS).

METHODS

From the model comprising of seven attributes with three levels, six unique profiles were selected representing process-related factors and health outcomes in Parkinson disease. A Web-based survey (N = 613) was conducted in a general population to estimate process-related utilities using profile-based BWS (case 2), multiprofile-based BWS (case 3), TTO, and VAS. The rank order of the six profiles was compared, convergent validity among methods was assessed, and individual analysis focused on the differentiation between pairs of profiles with methods used.

RESULTS

The aggregated health-state utilities for the six treatment profiles were highly comparable for all methods and no rank reversals were identified. On the individual level, the convergent validity between all methods was strong; however, respondents differentiated less in the utility of closely related treatment profiles with a VAS or TTO than with BWS. For TTO and VAS, this resulted in nonsignificant differences in mean utilities for closely related treatment profiles.

CONCLUSIONS

This study suggests that all methods are equally able to measure process-related utility when the aim is to estimate the overall value of treatments. On an individual level, such as in shared decision making, BWS allows for better prioritization of treatment alternatives, especially if they are closely related. The decision-making problem and the need for explicit trade-off between attributes should determine the choice for a method.

Baseline C-Reactive Protein Levels and Life Prognosis in Parkinson Disease

Background

C-reactive protein (CRP) is a biomarker of inflammation, and high levels of CRP correlate with vascular death. Chronic inflammation is considered to be involved in neurodegeneration, although there is no evidence linking it with the process of neurodegenerative diseases.

Objective

To determine the role of baseline CRP levels in the prognosis of patients with Parkinson disease (PD).

Methods

A cohort of 313 patients with a mean age of 69.1 and mean PD duration of 7.9 years was retrospectively followed for a mean observation time of 1,753 days. CRP was measured when patients were not diagnosed with any infections, and levels were repetitively measured to investigate a tendency of “regression to mean.” The primary outcome measure was a survival time from study enrollment to death.

Results

During the observation period 56 patients died. Baseline CRP was log-linearly associated with a risk of death in PD. Mean survival time was 3,149 (95% confidence interval; 3,009-3,289) days in patients with CRP ≤ 0.8mg/L (lower two thirds) and 2,620 (2,343-2,897) days in those with CRP > 0.8 mg/L (top third, p < 0.001, log-rank test). The adjusted hazard ratio (HR) per two-fold higher CRP concentration for all deaths was 1.29 (1.10-1.52), and after excluding PD-unrelated deaths, such as cancer or stroke, HR was 1.23 (1.01-1.49) (adjusted for age, sex, PD duration, modified Hohen-Yahr stages, MMSE scores, and serum albumin).

Conclusions

Baseline CRP concentrations were associated with the risk of death and predicted life prognosis of patients with PD. The associations were independent from PD duration, PD severity, cognitive function, ages, and nutritional conditions, suggesting the possibility that subclinical chronic inflammation is associated with a neurodegenerative process in PD.

Place of death of people living with Parkinson's disease: a population-level study in 11 countries

BACKGROUND

Most people prefer to receive end-of-life care in familiar surroundings rather than in hospital. This study examines variation in place of death for people dying from Parkinson's disease (PD) across 11 European and non-European countries.

METHODS

Using death certificate data of 2008 for Belgium, France, Italy, Hungary, Czech Republic, New Zealand, USA, Canada, Mexico, South Korea and Spain for all deaths with PD as an underlying cause (ICD-10 code: G20) cross-national differences in place of death were examined. Associations between place of death and patient socio-demographic and regional characteristics were evaluated using multivariable binary logistic regression analyses.

RESULTS

The proportion of deaths in hospital ranged from 17% in the USA to 75% in South Korea. Hospital was the most prevalent place of death in France (40%), Hungary (60%) and South Korea; nursing home in New Zealand (71%), Belgium (52%), USA (50%), Canada (48%) and Czech Republic (44%); home in Mexico (73%), Italy (51%) and Spain (46%). The chances of dying in hospital were consistently higher for men (Belgium, France, Italy, USA, Canada), those younger than 80 years (Belgium, France, Italy, USA, Mexico), and those living in areas with a higher provision of hospital beds (Italy, USA).

CONCLUSIONS

In several countries a substantial proportion of deaths from PD occurs in hospitals, although this may not be the most optimal place of terminal care and death. The wide variation between countries in the proportion of deaths from PD occurring in hospital indicates a potential for many countries to reduce these proportions.

Mortality study of civilian employees exposed to contaminated drinking water at USMC Base Camp Lejeune: a retrospective cohort study

BACKGROUND

Two drinking water systems at U.S. Marine Corps Base Camp Lejeune, North Carolina were contaminated with solvents during 1950s-1985.

METHODS

We conducted a retrospective cohort mortality study of 4,647 civilian, full-time workers employed at Camp Lejeune during 1973-1985 and potentially exposed to contaminated drinking water. We selected a comparison cohort of 4,690 Camp Pendleton workers employed during 1973-1985 and unexposed to contaminated drinking water. Mortality follow-up period was 1979-2008. Cause-specific standardized mortality ratios utilized U.S. age-, sex-, race-, and calendar period-specific mortality rates as reference. We used survival analysis to compare mortality rates between Camp Lejeune and Camp Pendleton workers and assess the effects of estimated cumulative contaminant exposures within the Camp Lejeune cohort. Ground water contaminant fate/transport and distribution system models provided monthly estimated contaminant levels in drinking water serving workplaces at Camp Lejeune. The confidence interval (CI) indicated precision of effect estimates.

RESULTS

Compared to Camp Pendleton, Camp Lejeune workers had mortality hazard ratios (HRs) >1.50 for kidney cancer (HR = 1.92, 95% CI: 0.58, 6.34), leukemias (HR = 1.59, 95% CI: 0.66, 3.84), multiple myeloma (HR = 1.84, 95% CI: 0.45, 7.58), rectal cancer (HR = 1.65, 95% CI: 0.36, 7.44), oral cavity cancers (HR = 1.93, 95% CI: 0.34, 10.81), and Parkinson's disease (HR = 3.13, 95% CI: 0.76, 12.81). Within the Camp Lejeune cohort, monotonic exposure-response relationships were observed for leukemia and vinyl chloride and PCE, with mortality HRs at the high exposure category of 1.72 (95% CI: 0.33, 8.83) and 1.82 (95% CI: 0.36, 9.32), respectively. Cumulative exposures were above the median for most deaths from cancers of the kidney, esophagus, rectum, prostate, and Parkinson's disease, but small numbers precluded evaluation of exposure-response relationships.

CONCLUSION

The study found elevated HRs in the Camp Lejeune cohort for several causes of death including cancers of the kidney, rectum, oral cavity, leukemias, multiple myeloma, and Parkinson's disease. Only 14% of the Camp Lejeune cohort died by end of follow-up, producing small numbers of cause-specific deaths and wide CIs. Additional follow-up would be necessary to comprehensively assess drinking water exposure effects at the base.

Treatment effect of memantine on survival in dementia with Lewy bodies and Parkinson's disease with dementia: a prospective study

OBJECTIVE

To investigate the effect on survival of treatment with memantine in patients with dementia with Lewy bodies (DLB) and Parkinson's disease with dementia (PDD).

METHODS

75 patients with DLB and PDD were included in a prospective double-blinded randomised placebo-controlled trial (RCT) of memantine, of whom long-term follow-up was available for 42. Treatment response was recorded 24 weeks from baseline and measured by Clinical Global Impression of Change (CGIC). The participants were grouped as responders (CGIC 1-3) or non-responders (CGIC 4-7). The 24-week RCT was followed by open-label treatment and survival was recorded at 36 months.

RESULTS

After 36-month follow-up, patients in the memantine group had a longer length of survival compared with patients in the placebo group (log rank x²=4.02, p=0.045). Within the active treatment group, survival analysis 36 months from baseline showed that the memantine responders, based on CGIC, had higher rates of survival compared with the non-responders (log rank x²=6.595, p=0.010). Similar results were not seen in the placebo group.

CONCLUSIONS

Early treatment with memantine and a positive clinical response to memantine predicted longer survival in patients with DLB and PDD. This suggests a possible disease-modifying effect and also has implications for health economic analysis. However, owing to the small study sample, our results should merely be considered as generating a hypothesis which needs to be evaluated in larger studies.

TRIAL REGISTRATION NUMBER

ISRCTN89624516.

Subthalamic deep brain stimulation: clinical and neuropsychological outcomes in mild cognitive impaired parkinsonian patients

This observational study reports the long-term follow-up of 184 Parkinson's disease (PD) patients treated with subthalamic deep brain stimulation (STN-DBS), retrospectively analyzing the outcomes of subjects with pre-surgical mild cognitive impairment (MCI) compared to those of patients with normal cognition. Patients were divided into PD-MCI or normal cognition groups at baseline, and then compared after 1, 3, 5 and >5 years of follow-up. Subjects assessed by outpatient clinical follow-up evaluation, not performing a complete clinical and neuropsychological follow-up assessment, were separately considered and rated according to their functional autonomy in daily living activities. The MCI prevalence at baseline was 23 %, increasing to 34 % at 1 year and over 40 % after 3 years. Dementia progressively affected more than 30 % of subjects after a median time of 6 years in the PD-MCI group and 11 years in the normal cognition group (p: 0.028). The mortality risk was slightly higher in PD-MCI patients. Outpatient clinical evaluations showed a progressive increase of subjects completely dependent in the activities of daily living, which ranged from the 11 % at 3 years to 23 % at 5 years and 31 % at >5 years. MCI can be frequently observed in PD patients, possibly influencing the outcome of surgical therapy. Our findings confirm the sustained long-lasting efficacy of STN-DBS on motor functions in both PD-MCI and normal cognition subjects. PD-MCI patients showed a more precocious cognitive impairment, as expected by natural history studies, but no case of dementia was observed early after surgery.

Objective assessment of fall risk in Parkinson's disease using a body-fixed sensor worn for 3 days

BACKGROUND

Patients with Parkinson's disease (PD) suffer from a high fall risk. Previous approaches for evaluating fall risk are based on self-report or testing at a given time point and may, therefore, be insufficient to optimally capture fall risk. We tested, for the first time, whether metrics derived from 3 day continuous recordings are associated with fall risk in PD.

METHODS AND MATERIALS

107 patients (Hoehn & Yahr Stage: 2.6±0.7) wore a small, body-fixed sensor (3D accelerometer) on lower back for 3 days. Walking quantity (e.g., steps per 3-days) and quality (e.g., frequency-derived measures of gait variability) were determined. Subjects were classified as fallers or non-fallers based on fall history. Subjects were also followed for one year to evaluate predictors of the transition from non-faller to faller.

RESULTS

The 3 day acceleration derived measures were significantly different in fallers and non-fallers and were significantly correlated with previously validated measures of fall risk. Walking quantity was similar in the two groups. In contrast, the fallers walked with higher step-to-step variability, e.g., anterior-posterior width of the dominant frequency was larger (p = 0.012) in the fallers (0.78 ± 0.17 Hz) compared to the non-fallers (0.71 ± 0.07 Hz). Among subjects who reported no falls in the year prior to testing, sensor-derived measures predicted the time to first fall (p = 0.0034), whereas many traditional measures did not. Cox regression analysis showed that anterior-posterior width was significantly (p = 0.0039) associated with time to fall during the follow-up period, even after adjusting for traditional measures.

CONCLUSIONS/SIGNIFICANCE

These findings indicate that a body-fixed sensor worn continuously can evaluate fall risk in PD. This sensor-based approach was able to identify transition from non-faller to faller, whereas many traditional metrics were not successful. This approach may facilitate earlier detection of fall risk and may in the future, help reduce high costs associated with falls.

Faster cognitive decline in elders without dementia and decreased risk of cancer mortality: NEDICES Study

OBJECTIVE

To assess whether faster cognitive decline in elders without dementia is associated with decreased risk of cancer mortality.

METHODS

In this population-based, prospective study of 2,627 people without dementia aged 65 years and older (Neurological Disorders in Central Spain), a 37-item version of the Mini-Mental State Examination (37-MMSE) was administered at 2 visits (baseline and follow-up, approximately 3 years later). We divided change in 37-MMSE into tertiles (lower tertile ≥ 2 point improvement in score, higher tertile ≥ 2 point decline in score). Community-dwelling elders were followed for a median of 12.9 years, after which the death certificates of those who died were examined.

RESULTS

A total of 1,003 (38.2%) died, including 339 (33.8%) deaths among participants who were in the higher tertile of 37-MMSE change and 664 (66.2%) deaths among those in the remaining tertiles. Cancer was reported significantly less often in those in the higher tertile of MMSE change (20.6%) than in those in the remaining tertiles (28.6%): in an unadjusted Cox model, hazard ratio for cancer mortality in participants within the higher tertile = 0.75 (p = 0.04) compared with the participants within the remaining tertiles. In a Cox model that adjusted for a variety of demographic factors and comorbidities, hazard ratio for cancer mortality in participants within the higher tertile = 0.70 (p = 0.01).

CONCLUSION

In this population-based, prospective study of community-dwelling elders without dementia, faster cognitive decline was associated with a decreased risk of cancer mortality. Further studies are required to elucidate this inverse association in elders without dementia.

Disease progress and response to treatment as predictors of survival, disability, cognitive impairment and depression in Parkinson's disease

AIM

To describe the time to clinical events (death, disability, cognitive impairment and depression) in Parkinson's disease using the time course of disease status and treatment as explanatory variables.

METHODS

Disease status based on the Unified Parkinson's Disease Rating Scale (UPDRS) and the time to clinical outcome events were obtained from 800 patients who initially had early Parkinson's disease. Parametric hazard models were used to describe the time to the events of interest.

RESULTS

Time course of disease status (severity) was an important predictor of clinical outcome events. There was an increased hazard ratio for death 1.4 (95% CI 1.31, 149), disability 2.75 (95% CI 2.30, 3.28), cognitive impairment 4.35 (95% CI 1.94, 9.74), and depressive state 1.43 (95% CI 1.26, 1.63) with each 10 unit increase of UPDRS. Age at study entry increased the hazard with hazard ratios of 49.1 (95% CI 8.7, 278) for death, 4.76 (95% CI 1.10, 20.6) for disability and 90.0 (95% CI 63.3-128) for cognitive impairment at age 60 years. Selegiline treatment had independent effects as a predictor of death at 8 year follow-up with a hazard ratio of 2.54 (95% CI 1.51, 4.25) but had beneficial effects on disability with a hazard ratio of 0.363 (95% CI 0.132, 0.533) and depression with a hazard ratio of 0.372 (95% CI 0.12, 0.552).

CONCLUSIONS

Our findings show that the time course of disease status based on UPDRS is a much better predictor of future clinical events than any baseline disease characteristic. Continued selegiline treatment appears to increase the hazard of death.

Mortality and prognosis in patients with neurogenic orthostatic hypotension

The prognosis of neurogenic orthostatic hypotension (NOH) has been poorly studied. The aim of this study was to evaluate retrospectively comorbidities and causes of death in patients with NOH. Clinical information and causes of death were obtained for 104 patients (45 with multiple system atrophy, 9 with pure autonomic failure, 43 with Parkinson's disease, and 7 with other types of autonomic neuropathy) referred to the Autonomic Unit from 1996 to 2009. Cardiovascular diseases (hypertension, cardiac comorbidities, atrial fibrillation and heart failure) were present in 53 (51%) NOH patients. At the end of follow-up, 44 patients were deceased. Type of NOH was the main factor associated with mortality. The main causes of death were infectious/respiratory (54%) and cardiac (16%). In NOH patients, cardiovascular diseases are frequent, although mortality is mainly due to infectious and respiratory causes. Detection of cardiovascular diseases may be useful in the choice of anti-hypotensive treatments.

The impact of Parkinson's disease as a comorbid diagnosis

Clinicians, departments and trusts are compared using Hospital Standardised Mortality Ratios. The benchmarking process makes corrections for patients' past medical histories, using a tool called the Charlson Index of Co-morbidity. Patients with any of 17 conditions receive an adjustment to their expected mortality and length of stay. Although the weighting of these conditions has been altered to take account of advances in medical practice, there have been no conditions added to the list since Charlson's original paper of 1986. The Charlson Index of Co-morbidity does not make a correction for Parkinson's disease. We describe evidence of the impact of Parkinson's disease as a co-morbid condition and recommend that, in future, benchmarking processes should take account of this important and common diagnosis.

Recurrent falls and mortality in Parkinson's disease: a prospective two-year follow-up study

OBJECTIVES

To evaluate the risk factors for recurrent falling and mortality in Parkinson's disease (PD) in a prospective study design.

MATERIALS AND METHODS

One hundred and twenty-five PD patients were included in the study. Baseline medical data were collected, and patients were clinically tested for mobility and balance. Falls were prospectively recorded for 2 years. Mortality was documented 4 years after the baseline.

RESULTS

Seventy-nine patients reported altogether 3125 falls during the follow-up, and 59 patients were classified as recurrent fallers. Altogether 126 fall injuries including six fractures were reported. Eighteen patients had died by the time of the hospital chart review. History of falling (OR 3.02, 95% CI 1.23-7.44) and the Unified Parkinson's Disease Rating Scale activities of daily living score (OR 1.13, 95% CI 1.04-1.22) were independent risk factors for recurrent falling in PD, whereas slow walking speed (OR 16.28, 95% CI 1.85-142.97) was an independent risk factor for mortality in PD.

CONCLUSIONS

History of falling and disease severity indicate increased risk of recurrent falls in PD, while patients with slow walking speed may have an increased risk of mortality. Recurrent falling was not associated with increased risk of mortality in PD in this study.

Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease

BACKGROUND

Deep-brain stimulation is the surgical procedure of choice for patients with advanced Parkinson's disease. The globus pallidus interna and the subthalamic nucleus are accepted targets for this procedure. We compared 24-month outcomes for patients who had undergone bilateral stimulation of the globus pallidus interna (pallidal stimulation) or subthalamic nucleus (subthalamic stimulation).

METHODS

At seven Veterans Affairs and six university hospitals, we randomly assigned 299 patients with idiopathic Parkinson's disease to undergo either pallidal stimulation (152 patients) or subthalamic stimulation (147 patients). The primary outcome was the change in motor function, as blindly assessed on the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III), while patients were receiving stimulation but not receiving antiparkinsonian medication. Secondary outcomes included self-reported function, quality of life, neurocognitive function, and adverse events.

RESULTS

Mean changes in the primary outcome did not differ significantly between the two study groups (P=0.50). There was also no significant difference in self-reported function. Patients undergoing subthalamic stimulation required a lower dose of dopaminergic agents than did those undergoing pallidal stimulation (P=0.02). One component of processing speed (visuomotor) declined more after subthalamic stimulation than after pallidal stimulation (P=0.03). The level of depression worsened after subthalamic stimulation and improved after pallidal stimulation (P=0.02). Serious adverse events occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation, with no significant between-group differences at 24 months.

CONCLUSIONS

Patients with Parkinson's disease had similar improvement in motor function after either pallidal or subthalamic stimulation. Nonmotor factors may reasonably be included in the selection of surgical target for deep-brain stimulation. (ClinicalTrials.gov numbers, NCT00056563 and NCT01076452.)