Brian Wood

Incidence and prediction of falls in Parkinson's disease: a prospective multidisciplinary study

Objectives: To accurately establish the incidence of falls in Parkinsons disease (PD) and to investigate predictive risk factors for fallers from baseline data. Methods: 109 subjects with idiopathic PD diagnosed according to the brain bank criteria underwent a multidisciplinary baseline assessment comprising demographic and historical data, disease specific rating scales, physiotherapy assessment, tests of visual, cardiovascular and autonomic function, and bone densitometry. Patients were then prospectively followed up for one year using weekly prepaid postcards along with telephone follow up. Results: Falls occurred in 68.3% of the subjects. Previous falls, disease duration, dementia, and loss of arm swing were independent predictors of falling. There were also significant associations between disease severity, balance impairment, depression, and falling. Conclusions: Falls are a common problem in PD and some of the major risk factors are potentially modifiable. There is a need for future studies to look at interventions to prevent falls in PD.

A meta-analysis of six prospective studies of falling in Parkinson's disease

Recurrent falls are a disabling feature of Parkinsons disease (PD). We have estimated the incidence of falling over a prospective 3 month follow‐up from a large sample size, identified predictors for falling for PD patients repeated this analysis for patients without prior falls, and examined the risk of falling with increasing disease severity. We pooled six prospective studies of falling in PD (n = 473), and examined the predictive power of variables that were common to most studies. The 3‐month fall rate was 46% (95% confidence interval: 38–54%). Interestingly, even among subjects without prior falls, this fall rate was 21% (12–35%). The best predictor of falling was two or more falls in the previous year (sensitivity 68%; specificity 81%). The risk of falling rose as UPDRS increased, to about a 60% chance of falling for UPDRS values 25 to 35, but remained at this level thereafter with a tendency to taper off towards later disease stages. These results confirm the high frequency of falling in PD, as almost 50% of patients fell during a short period of only 3 months. The strongest predictor of falling was prior falls in the preceding year, but even subjects without any prior falls had a considerable risk of sustaining future falls. Disease severity was not a good predictor of falls, possibly due to the complex U‐shaped relation with falls. Early identification of the very first fall therefore remains difficult, and new prediction methods must be developed.

Urinary dysfunction in Parkinson's disease: A review

Urinary dysfunction, primarily in the form of detrusor overactivity, is highly prevalent amongst individuals with idiopathic Parkinsons disease (IPD). There has been increasing realisation of the importance of this and other non-motor features of the condition. The presentation of, pathophysiology behind and management options for bladder dysfunction in IPD are discussed.

Osteoporosis in Parkinson's disease

There are few studies of osteoporosis in Parkinsons disease (PD). We assessed the prevalence of osteoporosis in a PD clinic cohort. All subjects with a confirmed diagnosis of PD attending a clinic were invited to participate. All consenting subjects had bone density measured by dual energy X‐ray absorptiometry scanning. Further data, including demography, disease duration, and disease severity, were collected. One hundred five subjects participated; median age was 75 (54–92) years. Fifty‐one (49%) patients were men. Of the men: median T score, −1.3 (range, −4.7 to 3.8); median Z score, 0.0 (−3.2 to 4.7); diagnostic categories: osteoporosis, 20%; osteopenia, 41%; normal, 39%. Of the women: median T score −2.7 (−4.7 to 1.4); median Z score, −0.25 (−2.6 to 4.2); diagnostic categories: osteoporosis, 63%; osteopenia, 28%; and normal, 9%. Whole sample: osteoporosis, 42%; osteopenia, 34%; and normal, 24%. There were associations between age, depression, disease duration, and osteoporosis but not with disease severity. Female gender was an independent predictor of osteoporosis. The prevalence of osteoporosis/osteopenia is considerable in PD patients but does not exceed that of other people of similar age. Osteoporosis/osteopenia was present in almost all women of this age group with PD.

The prevalence of Parkinson's disease in a rural area of North-East England.

AIMS AND OBJECTIVES We have previously reported the age-adjusted prevalence of idiopathic Parkinsons disease (PD) in North Tyneside, an urban area of North-East England, as 139 cases (95% CI 116 to 162) per 100,000. The aim of this study was to report the prevalence of idiopathic PD in a rural area of North-East England. METHODS The same case-finding methodology as that employed in North Tyneside was used to identify cases of PD in an area of North Northumberland with a population of 59,613 at the 2001 UK census. All GPs in the study area were asked to provide details of patients registered with their service that may have PD or were on PD medication. Furthermore, all patients registered with the local PD service or under the care of a consultant neurologist or other relevant secondary care specialist were considered for inclusion. Inclusion in the study required fulfillment of the UK Brain Bank criteria. RESULTS One-hundred-and-six cases were identified (50 women and 56 men), giving crude and age-adjusted prevalence estimates of 178 cases (95% CI 144 to 212) and 142 cases (95% CI 118 to 165) per 100,000 respectively. The age-adjusted prevalence rate within our rural study area was remarkably similar to that seen in other urban UK studies. Only 71 cases (67.0%) were identified through GP records. CONCLUSIONS The prevalence of PD rural and urban areas of North-East England is remarkably similar.

Physical assessment as a predictor of mortality in people with Parkinson's disease: a study over 7 years

The primary aim of this study was to ascertain whether a battery of physical function measures in a Parkinsons disease (PD) patient cohort predicted mortality status at 7‐year follow‐up. Secondary aims were establishing which specific tests were the most useful, and whether PD phenotype was a predictor. A retrospective correlation design was used in this study. A cohort of 109 PD patients underwent baseline physiotherapy assessment of gait, balance, posture, muscle strength, and ability to change postural set. We compared mortality status at 7‐year follow‐up and baseline physical assessment tests. Tinetti gait and balance scores, UPDRS score, 10‐m walk test (time, velocity, and number of strides), posture in standing, lying to sitting, sitting to standing, getting up from floor assessments, and time to ascend and descend four steps were found to be statistically significant physical predictors of mortality at 7‐year follow‐up. In addition, age, sex, and mini‐mental state examination were significant nonphysical predictors of mortality. Using Cox regression, a survival model was constructed with age, sex, and Tinetti gait score as independent predictors of mortality. The results of this study suggest that there is a link between reduced physical function and an increased mortality risk in PD populations.

Palliative care in people with idiopathic Parkinson's disease who die in hospital

Background The UK National Institute for Health and Clinical Excellence guidelines state that palliative care options for people with Parkinsons disease (PD) should be discussed. Aims To investigate whether palliative care guidelines are adhered to for people with PD who die in hospital. Setting/participants The medical notes of all people with a diagnosis of idiopathic PD who were living in two adjacent areas of northeast England and who died over a 3-year period were examined. Demographic data and specific information regarding events around the time of death were recorded. Results For the 236 patients identified, the average age at death was 82.8 years. Of these patients, 110 (46.6%) died in hospital, 56 (23.7%) at home, 59 (25.0%) in a care home and for 11 patients (4.7%) the place of death was not recorded. For those who died in hospital, only three patients, and seven relatives of patients, had had a recorded discussion with a clinician regarding their preferred place of death and only 15 (13.6%) were referred to a specialist palliative care team. Forty-six patients (41.8%) were placed on the Liverpool Care Pathway. Conclusions For those dying in hospital, there are few previously documented end-of-life care discussions with patients or their relatives. The use of end-of-life pathways and access to specialist palliative care is variable. Following the Neuberger report, the Liverpool Care Pathway is to be replaced with individual end-of-life care plans. It is important to engage patients, and their relatives, in decision making regarding preferences at the end of life.

The pragmatic use of apomorphine at the end of life.

Parkinson’s Disease (PD) is an irreversible degenerative neurological disorder with no known cure. Apomorphine is a potent short-acting D1/D2 dopamine agonist administered sub-cutaneously that is used in the treatment of PD. Optimising PD medication is an important aspect of end of life care. There are no previously reported cases of apomorphine providing symptom relief in terminal care of PD patients. This case highlights its potential benefits for symptom control at the end of life.

Experience of care home residents with Parkinson's disease: Reason for admission and service use

The care needs of people with Parkinsons disease (PD) are poorly understood. We aimed to investigate the factors that precipitate entry to institutional care, and on‐going care needs once in care, within a representative cohort of community‐dwelling people with PD.

Medication use in people with late stage Parkinson's disease and parkinsonism living at home and in institutional care in north-east England: A balance of symptoms and side-effects?

BACKGROUND People with Parkinsons disease (PD) and parkinsonism living in care homes (residential or nursing care) in the UK represent around 10-15% of all people with PD and 3-5% of all care home residents. There are few previous data on medication use in those living in care homes with PD. In this study we aimed to compare medication use in a representative cohort of people with PD living in care homes in north-east England with those living in their own homes. METHOD All people with late stage (Hoehn and Yahr III-V) idiopathic PD, PD dementia, or atypical parkinsonian syndromes under the care of the Northumbria Healthcare NHS Foundation Trust PD service on 1st January 2015 were identified. Demographic, disease characteristics and medication use data were collected from an audit of medical notes of all those identified. RESULTS We identified 377 people who met the inclusion criteria, 91 (24.1%) of whom were living in a care home. Disease stage, age and age at disease onset were all significantly higher and levodopa equivalent dose significantly lower in those living in care homes, although disease duration and levodopa dose were not. Greater age, lower levodopa equivalent dose and higher disease stage were independently associated with being in a care home. CONCLUSIONS Although people in care homes had more advanced disease, they were on a significantly lower levodopa equivalent dose. This is likely to be due to the requirement to balance symptom management with drug side-effects.