Trends in death certification for multiple sclerosis, motor neuron disease, Parkinson’s disease and epilepsy in English populations 1979–2006

Factors associated with the place of death of persons with advanced dementia: A systematic review of international literature with meta-analysis

BACKGROUND

Many individuals with advanced dementia die in hospital, despite preferring home death. Existing evidence of factors affecting their place of death is inconsistent. To inform policies/practices for meeting needs/preferences, systematically establishing the evidence is pertinent, particularly given the exponential rise in advanced dementia prevalence.

AIM

To identify factors influencing where people with advanced dementia die.

DESIGN AND DATA SOURCES

This systematic review with meta-analysis was registered on PROSPERO (CRD42022366722). Medline, CINAHL, PsycINFO, SocINDEX and a grey literature database, Overton, were searched on 21/12/2022, supplemented by hand-searching/citation tracking. Papers reporting quantitative data on factors associated with place of death in advanced dementia were included and appraised using QualSyst. Data were analysed using random effects with the certainty of evidence determined using the GRADE criteria.

RESULTS

Thirty-three papers involving >5 million individuals (mean age = 89.2 years) were included. Long-term care setting deaths were relatively common but hospice deaths were rarer. Marriage's association with home death underscores social networks' importance, while younger age's and male gender's associations with hospital death demonstrate patients' and families' interdependency. Pneumonia/COPD's opposing effects on hospital deaths with cancer/functional impairment highlight the challenges of advanced dementia care. Unlike hospital/nursing home bed availability's lack of effect, capitated funding (fixed-amount-per-patient-per-period) decreased hospital death likelihood.

CONCLUSION

This comprehensive review of place of death determinants highlight the profound challenges of advanced dementia end-of-life care. Given that bed capacity did not affect place of death, a capitation-based, integrated palliative care model would appear more likely to meet patients' needs in a resource-constrained environment.

21st century accelerating neurological deaths in UK and major Western countries: - Demographic and/or multiple-interactive-environmental causes?

OBJECTIVE

We examine whether the rise in neurological death rates over the 21st century are solely explained by the Gompertzian hypothesis.

STUDY DESIGN

We examine two data-sets. First, Office of National Statistics (ONS, 2022) for nineteen mortality categories in England/Wales, including Alzheimer's, Dementias and Parkinson's Disease. Secondly, WHO (2020) Combined Neurological Mortality (CNM), from WHO Global mortality categories, Nervous Disease Deaths, and Alzheimer's & Other Dementias.

METHODS

Based on ONS data we investigate trends in Age-Standardised Mortality Rates (ASMR) of CNM 2000-2022. Based on WHO data we examine rates of Early Deaths (55-74) and ASMR, for CNM between 2000 and 2015 in the ten Major 'Western' economies: Australia, Canada, France, Germany, Italy, Japan, Netherlands, Spain, UK, and the USA.

RESULTS

In England & Wales death rates have increased 348% for Alzheimer's, 235% for Dementias, and 105% for Parkinson's Disease in contrast with falls in most other cause mortality. Early Adults Deaths CNM rates increased in eight countries, an average of 19%. Neurological ASMR rose in every country, averaging 43%, the highest was the UK 95%.

CONCLUSION

We reject the Gompertzian hypothesis as an all-encompassing explanation for these marked increases in ASMR. Increases in early adult neurological deaths suggests this cannot be solely explained by an aging population. Furthermore, increases in mortality could be related to an increased prevalence of neurological conditions in this age group. Action is urgently needed to investigate factors - whether environmental, lifestyle or health systems - that could explain these findings.

Update: Descriptive epidemiology of Parkinson disease

We review the descriptive epidemiology of Parkinson disease (PD). PD is a prevalent neurologic disorder in high Socio-Demographic Index (SDI) nations with rising prevalence in low and middle SDI nations. PD became a prevalent disorder in high SDI nations during the 20th century. Population growth, population aging, and increased disease duration are major drivers of rising PD prevalence. Exposure to industrial toxicants may also be a contributor to rising PD prevalence. PD is an age-related disorder with incidence likely peaking in the 8th decade of life and prevalence in the 9th decade of life. PD is notable for significant sex difference in PD risk with greater risk in men. There may be ancestral differences in PD prevalence and risk. PD is associated with moderately increased mortality though this may be underestimated. Despite significant research, there is considerable uncertainty about basic features of PD epidemiology.

Comparison of 2 Methods for Estimating Multiple Sclerosis-Related Mortality

BACKGROUND AND OBJECTIVES

Determining whether multiple sclerosis (MS) causes death is challenging. Our objective was to contrast 2 frameworks to estimate probabilities of death attributed to MS (PMS) and other causes (Pother): the cause-specific framework (CSF), which requires the causes of death, and the excess mortality framework (EMF), which does not.

METHODS

We used data from the Observatoire Français de la Sclérose en Plaques (OFSEP, n = 37,524) and from a comparative subset where causes of death were available (4,004 women with relapsing-onset MS [R-MS]). In CSF, the probabilities were estimated using the Aalen-Johansen method. In EMF, they were estimated from the excess mortality hazard, which is the additional mortality among patients with MS as compared with the expected mortality in the matched general population. PMS values were estimated at 30 years of follow-up, (1) with both frameworks in the comparative subset, by age group at onset, and (2) with EMF only in the OFSEP population, by initial phenotype, sex, and age at onset.

RESULTS

In the comparative subset, the estimated 30-year PMS values were greater using EMF than CSF: 10.9% (95% CI 8.3-13.6) vs 8.7% (6.4-11.8) among the youngest and 20.4% (11.3-29.5) vs 16.2% (8.7-30.2) for the oldest groups, respectively. In the CSF, probabilities of death from unknown causes ranged from 1.5% (0.7-3.0) to 6.4% (2.5-16.4), and even after their reallocation, PMS values remained lower with CSF than with EMF. The estimated probabilities of being alive were close using the 2 frameworks, and the estimated POther (EMF vs CSF) was 2.6% (2.5-2.6) vs 2.1% (1.2-3.9) and 18.1% (16.9-19.3) vs 26.4% (16.5-42.2), respectively, for the youngest and oldest groups. In the OFSEP population, the estimated 30-year PMS values ranged from 7.5% (6.4-8.7) to 24.0% (19.1-28.9) in patients with R-MS and from 25.4% (21.1-29.7) to 36.8% (28.3-45.3) in primary progressive patients, depending on sex and age.

DISCUSSION

EMF has the great advantage of not requiring death certificates, their quality being less than optimal. Conceptually, it also seems more relevant because it avoids having to state, for each individual, whether death was directly or indirectly caused by MS or whether it would have occurred anyway, which is especially difficult in such chronic diseases.

Analysis of Multiple Causes of Death: A Review of Methods and Practices

BACKGROUND

Research and reporting of mortality indicators typically focus on a single underlying cause of death selected from multiple causes recorded on a death certificate. The need to incorporate the multiple causes in mortality statistics-reflecting increasing multimorbidity and complex causation patterns-is recognized internationally. This review aims to identify and appraise relevant analytical methods and practices related to multiple causes.

METHODS

We searched Medline, PubMed, Scopus, and Web of Science from their incept ion to December 2020 without language restrictions, supplemented by consultation with international experts. Eligible articles analyzed multiple causes of death from death certificates. The process identified 4,080 items of which we reviewed 434 full-text articles.

RESULTS

Most articles we reviewed (76%, n = 332) were published since 2001. The majority of articles examined mortality by "any- mention" of the cause of death (87%, n = 377) and assessed pairwise combinations of causes (57%, n = 245). Since 2001, applications of methods emerged to group deaths based on common cause patterns using, for example, cluster analysis (2%, n = 9), and application of multiple-cause weights to re-evaluate mortality burden (1%, n = 5). We describe multiple-cause methods applied to specific research objectives for approaches emerging recently.

CONCLUSION

This review confirms rapidly increasing international interest in the analysis of multiple causes of death and provides the most comprehensive overview, to our knowledge, of methods and practices to date. Available multiple-cause methods are diverse but suit a range of research objectives. With greater availability of data and technology, these could be further developed and applied across a range of settings.

Mortality of Parkinson's disease in Italy from 1980 to 2015

OBJECTIVE

To evaluate mortality for Parkinson's disease (PD) in Italy during a long time period (1980-2015) and to discuss the role of possible general and specific influencing factors.

METHODS

Based on mortality data provided by the Italian National Institute of Statistics, sex- and age-specific crude mortality rates were computed, for the whole country and for its main geographical sub-areas. Rates were standardized using both direct (annual mortality rates AMRs) and indirect (standardized mortality rates SMRs) methods. SMRs were used to evaluate geographical differences, whereas AMRs and joinpoint linear regression analysis to study mortality trends.

RESULTS

Considering the entire period, highest mortality rates were observed in males (AMR/100,000: 9.0 in males, 5.25 in females), in North-West and Central Italy (SMR > 100). Overall PD mortality decreased from mid-eighties onwards and then rapidly reversed the trend in the period 1998-2002, rising up to a maximum in 2015, with some differences according to sex and geographical areas.

CONCLUSIONS

Several factors may have contributed to the rapid inversion of decreasing trend in mortality observed in the last part of XX century. Possible explanations of this rising trend are related to the increasing burden of PD (especially in males and in certain Italian regions), caused by different factors as population aging, physiological prevalence rise due to incidence exceeding mortality, and growing exposure to environmental or occupational risk factors. In addition, the accuracy of death certificate compilation could account for geographical differences and for the temporal trend. The role of levodopa and recently introduced dopaminergic drugs is also discussed.

Educational inequalities in epilepsy mortality in the Baltic countries and Finland in 2000-2015

Little is known about socioeconomic differences in epilepsy mortality. This study examined educational inequalities in epilepsy mortality in the general population in the Baltic countries and Finland in 2000-2015. Education-specific mortality estimates for individuals aged 30-74 in Estonia, Latvia and Lithuania were obtained from census-linked mortality datasets while data for Finland came from the register-based population and death data file of Statistics Finland. Trends and educational inequalities in epilepsy mortality were assessed using age-standardised mortality rates (ASMRs) per 100,000 person years and age-adjusted mortality rate ratios (RRs) calculated using Poisson regression. ASMRs were higher in men than women in all countries. ASMRs reduced in 2000-2015 among all men and women except for Finnish women. Among men, an inverse educational gradient in epilepsy mortality in 2000-2007 widened in 2008-2015 with ASMRs falling among high and mid educated men in all countries but increasing among low educated men in three countries. An inverse educational gradient in female mortality remained in all countries throughout 2000-2015. Although epilepsy mortality fell in the Baltic countries and Finland (men only) in 2000-2015, this masked a clear inverse educational gradient in mortality that became steeper across the period.

Increasing epilepsy-related mortality: A multiple causes of death study in Northern Italy

PURPOSE

to assess the burden of epilepsy as the underlying or contributory cause of death, to investigate time trends in mortality with epilepsy, and to examine the main associated comorbidities.

METHODS

All deaths from January 1, 2008 to December 31, 2019 with any mention of epilepsy were retrieved from the mortality register of the Veneto Region (Italy). The average annual percent change (AAPC) in age-standardized mortality rates was estimated by log-linear models. The association between mention of epilepsy and of selected disease categories in death certificates was assessed by conditional logistic regression.

RESULTS

Any mention of epilepsy was reported in 5,907 death certificates; of these, epilepsy was selected as the underlying cause in 1,020 decedents. Deaths with epilepsy represented 0.8% of total mortality in 2008-2011, increasing to 1.3% in 2016-2019. The AAPC was 4.7% for males (95% CI 3.0-6.4, p<0.001) and 6.2% for females (95% CI 4.5-7.9, p<0.001). A strong association was found between mention of epilepsy and meningitis/encephalitis, congenital anomalies/cerebral palsy and other paralytic syndromes, central nervous system tumours, cerebrovascular diseases, and dementia/Alzheimer.

CONCLUSIONS

The present analysis from Southern Europe confirms recent reports limited to the UK and the US on increasing epilepsy-related mortality rates. aging of the population and the growing prevalence of neurological disorders are among long-term causes of this unfavorable trend; further studies on mortality data and other health archives are warranted.

Trends in Mortality From Parkinson Disease in the United States, 1999-2019

BACKGROUND AND OBJECTIVES

The mortality from Parkinson disease (PD) and its long-term trends in the United States in recent decades remains unknown. This study aimed to describe the trends in PD mortality in the United States from 1999 to 2019.

METHODS

We used data from the National Vital Statistics System, a nationwide, population-based death registry, to determine national trends in PD mortality, overall and by age, sex, race/ethnicity, urban-rural classification, and geographic location. Analyses focused on the data from 479,059 deaths due to PD from 1999 to 2019. Joinpoint regression was performed to examine temporal trends in age-adjusted death rates.

RESULTS

The age-adjusted mortality from PD increased from 5.4 (95% confidence interval [CI] 5.3-5.5) per 100,000 population in 1999 to 8.8 (95% CI, 8.7-8.9) per 100,000 population in 2019, with an average annual percent change of 2.4% (95% CI, 1.8%-3.0%). From 1999 to 2019, PD mortality increased significantly across all age groups, both sexes, various racial/ethnic groups, and different urban-rural classifications. The US states and District of Columbia with reported death rates all experienced an increase in PD mortality. Significant differences by sex and race/ethnicity were noted. Age-adjusted PD mortality rates were twice as high in men as in women and were greater in White individuals than those from other racial/ethnic groups.

DISCUSSION

From 1999 to 2019, the mortality from PD in the United States has increased significantly. The increase was regardless of age, sex, race/ethnicity, urban-rural classification, and geographic location. A comprehensive evaluation of long-term trends in PD mortality is important for health care priority setting.

21st Century Early Adult (55-74) Deaths from Brain-Disease-Deaths Compared to All Other Cause Mortality in the Major Western Countries - Exposing a Hidden Epidemic

OBJECTIVES

To examine early adult deaths (EAD) - people aged 55-74 due to brain disease deaths (BDD) compared to all other causes (AOC) in the 21st century in 21 major Western countries (MWC).

METHOD

EAD are below MWCc average life expectancy. All mortality drawn from the latest WHO data. The three global BDD categories consist of mental and behaviour disorder, nervous diseases and Alzheimer and other dementias. Mortality rates per million are analysed for people 55-74 years and total age-standardised death rates (ASDR). BDD rates between 2000-2015 compared against AOC of deaths for EAD and ASDR. Confidence Intervals determine any significant difference AOC and BDD over the period 2000-15, plus an examination of EAD in six separate global mortality categories.

RESULTS

EAD: The separate BDD categories for EAD significantly positively correlated, validating their combination as BDD. Every country's AOC 55-74 rates fell substantially, but fourteen country's BDD rose substantially (>20%) and all MWC countries BDD rose significantly more than AOC. ASDR: All nations total AOC fell substantially, whereas seventeen BDD rates rose substantially and every country's BDD significantly increased compared to AOC deaths. Six other EAD mortalities, circulatory, cancer, respiratory, compared to BDD produced Odds Ratios ranging from 1:1.54 to 1:2.36 such were the marked differences over the period.

DISCUSSION

Positive news is that AOC are down across all investigated countries in the 21st century. However, the extent of the EAD rises in just 16 years indicates that these BDD conditions are starting earlier suggesting multiple interactive environmental factors impacting upon brain related diseases.

Mortality from Parkinson's disease and other causes among a workforce manufacturing paraquat: an updated retrospective cohort study

BACKGROUND

Epidemiological studies of the association between Parkinson's disease (PD) and paraquat (PQ) exposure have given inconsistent findings. The aim of the study was to update information on the risk of PD and mortality from major causes of death among a UK workforce who manufactured PQ by extending the follow-up by seven and a half years.

METHODS

This retrospective cohort study included all employees who had ever worked on any of the four plants at Widnes, UK where PQ was manufactured between 1961 and 1995. The 926 male and 42 female workers were followed through 31 December 2017. Mortalities for males were compared with national and local rates, including rates for PD as a mentioned cause of death.

RESULTS

A total of 394 male and 21 female workers had died by end of follow-up. Four death certificates of male workers mentioned PD, including two deaths that were due to PD. At least 6 death certificates of male employees would have been expected to have mentioned PD (SMR = 0.67; 95% CI 0.18-1.72). Reduced mortalities compared with local rates were found for major causes of death.

CONCLUSIONS

The study provided no evidence of an increased risk of PD, or increased mortalities from other causes among PQ production workers whose exposure to PQ on a daily basis was at least comparable to that of a PQ sprayer or mixer/loader.

Mortality trend for multiple sclerosis in Italy during the period 1980-2015

BACKGROUND

The epidemiology of Multiple Sclerosis (MS) is relevant for health-services planning. Most of MS prevalence and incidence studies in Italy referred to specific geographical areas and periods, whereas mortality data are routinely collected at the national level. The aim was to assess MS mortality trend and geographical differences in Italy from 1980 to 2015.

METHODS

Mortality data were provided by the Italian Institute of Statistics. Due to a low number of annual deaths, mortality data were analysed for both the entire period under study and for sub-periods. Temporal trends were first evaluated using age-adjusted mortality rates (AMRs) comparing each sub-period with the initial one. Then, the annual percent change in mortality was estimated through the joinpoint regression model. Spatial differences between 5 main geographical areas were evaluated using standardized mortality ratios (SMRs).

RESULTS

During the study period, 4,959 deaths for males and 7,434 for females were observed. The higher overall AMR was observed for females (F:0.71 vs. M: 0.56 per 100,000 persons per year). Analysing mortality by gender and geographical area, SMRs 〈 100 were observed in South Italy for both sexes, and in Central Italy for males only, whereas SMRs 〉 100 for Islands for both sexes, and in North-East and North-West for females only. The analysis of the mortality trend through AMRs calculated for sub-periods revealed no difference between the first and the last period for males, whereas a significant increase in mortality was observed for females. The joinpoint regression analysis showed a significant decrease in mortality up to 1995 for males (APC -3.23%) and up to 1999 for females, (APC -1.01%), followed by a significant increase for both sexes, but more marked for females (APC +1.9% M, +2.34% F).

CONCLUSION

The increasing trend of mortality for MS, especially for females, may reflect the increase in the prevalence of MS and the improvement in the quality of diagnosis or coding of the cause of death.

Multiple cause of death analysis in multiple sclerosis: A population-based study

OBJECTIVE

To gain a better understanding of the complex patterns of causes that contribute to death due to multiple sclerosis (MS) by assessing the relationship between MS and other causes of death listed on death certificates.

METHODS

Multiple cause of death data for all adult deaths (aged ≥18 years) in British Columbia, Canada, between 1986 and 2013 were accessed. All causes, as listed on the death certificate, whether underlying or contributing, were considered "any mention" causes. The associations between mention of MS on the death certificate and mention of other causes of death were examined by logistic regression, adjusted for age, sex, and calendar year (Bonferroni-corrected α level = 0.002). Findings were also sex-stratified.

RESULTS

Among 771,288 deaths, MS was mentioned on 2,153 certificates. If MS was mentioned (versus not mentioned), there was a greater chance that specific conditions contributed to the death: respiratory infection (adjusted odds ratio [aOR], 3.03 [95% confidence interval (CI), 2.73-3.36]), aspiration pneumonia (aOR, 7.15 [95% CI, 6.23-8.22]), urinary tract infection (UTI) (aOR, 10.2 [95% CI, 8.7-12.0]), other infection including sepsis (aOR, 1.34 [95% CI, 1.15-1.56]), and skin disease (aOR, 5.06 [95% CI, 3.96-6.46]). Sex differences existed for urinary tract infection (men: aOR, 14.9 [95% CI, 11.5-19.3]; women: aOR, 8.00 [95% CI, 6.53-9.81]) and chronic respiratory disease (men = aOR, 1.36 [95% CI, 1.14-1.63]; women = aOR, 0.97 [95% CI, 0.84-1.13]).

CONCLUSIONS

Deaths attributed to MS were commonly caused by infection (especially respiratory and urinary tract-related); conditions associated with advanced disability and immobility, such as aspiration pneumonia; and chronic respiratory disease in men. All are potentially modifiable; interventions that reduce the frequency or severity of these complications could improve survival in MS.

Analysis of the reasons and costs of hospitalization for epilepsy patients in East China

PURPOSE

This study aimed to assess the cause and cause-specific risks of hospitalization for epilepsy patients in East China. Further analysis was performed for inpatient hospitalization days, hospital mortality and costs.

METHOD

This study was performed on epilepsy patients admitted to our hospital including 21 community health centers in East China from January 2011 to April 2017. Case records including patient data, length of hospitalization, reasons for admission, hospital mortality, and the costs incurred for hospitalization of epilepsy patients were reviewed.

RESULTS

The three principal reasons for admission were: 1) cerebral vascular disease (CVD), 2) newly diagnosed epilepsy with unknown etiology; and 3) frequent seizures including status epilepticus. The median length of hospitalization was 13 days. The three major reasons regarding inpatient days were: 1) Parkinson's Disease (PD), 2) dementia, 3) trauma. The average hospital mortality was 14.81‰ (17/1148) with 1) lung infection (mainly pneumonia), 2) depression (deaths occurred by suicide) and 3) frequent seizures including status epilepticus being the three top reasons. The three major financial cost incurred for in-patients with epilepsy were: 1) PD, 2) arteriovenous malformation and 3) trauma.

CONCLUSIONS

The most common hospitalized reasons for epilepsy patients were CVD, PD and dementia, which all were common diseases in the elderly. Consequently, the hospitalization days of these patients were longer and their financial burden was heavier. Epilepsy patients with comorbid depression should be closely monitored to prevent suicide from the onset of epilepsy.

Are rises in Electro-Magnetic Field in the human environment, interacting with multiple environmental pollutions, the tripping point for increases in neurological deaths in the Western World?

Whilst humans evolved in the earth's Electro-Magnetic-Field (EMF) and sun-light, both being essential to life but too much sun and we burn. What happens if background EMF rise to critical levels, coinciding with increasing environmental pollutants? Two of the authors can look back over 50 clinical years and appreciate the profound changes in human morbidity across a range of disparate conditions - autoimmune diseases, asthma, earlier cancer incidence and reduced male sperm counts. In particular have been increased autism, dyslexia, Attention Deficit Hyperactivity Disorder and neurological diseases, such as Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Parkinson's Disease, Early Onset Dementia, Multiple System Atrophy and Progressive Supranuclear Palsy. What might have caused these changes-whilst genetic factors are taken as given, multiple environmental pollutants are associated with neurological disease although the mechanisms are unclear. The pace of increased neurological deaths far exceeds any Gompertzian explanation - that because people are living longer they are more likely to develop more age-related problems such as neurological disease. Using WHO global mortality categories of Neurological Disease Deaths (NDD) and Alzheimer's and Dementia deaths (Alz), updated June 2018, together they constitute Total Neurological Mortality (TNM), to calculate mortality rates per million for people aged 55-74 and for the over-75's in twenty-one Western countries. Recent increases in American people aged over-75's rose 49% from 1989 to 2015 but US neurological deaths increased five-fold. In 1989 based on Age-Standardised-Deaths-Rates America USA was 17th at 324 pm but rising to 539 pm became second highest. Different environmental/occupational factors have been found to be associated with neuro-degenerative diseases, including background EMF. We briefly explore how levels of EMF interact upon the human body, which can be described as a natural antennae and provide new evidence that builds upon earlier research to propose the following hypothesis. Based upon recent and new evidence we hypothesise that a major contribution for the relative sudden upsurge in neurological morbidity in the Western world (1989-2015), is because of increased background EMF that has become the tipping point-impacting upon any genetic predisposition, increasing multiple-interactive pollutants, such as rises in petro-chemicals, hormone disrupting chemicals, industrial, agricultural and domestic chemicals. The unprecedented neurological death rates, all within just twenty-five years, demand a re-examination of long-term EMF safety related to the increasing background EMF on human health. We do not wish to 'stop the modern world', only make it safer.

Time Trends of the Incidence, Prevalence, and Mortality of Parkinsonism

Objectives:We assessed trends in the incidence, prevalence, and post-diagnosis mortality of parkinsonism in Ontario, Canada over 18 years. We also explored the influence of a range of risk factors for brain health on the trend of incident parkinsonism.Methods:We established an open cohort by linking population-based health administrative databases from 1996 to 2014 in Ontario. The study population comprised residents aged 20–100 years with an incident diagnosis of parkinsonism ascertained using a validated algorithm. We calculated age- and sex-standardized incidence, prevalence, and mortality of parkinsonism, stratified by young onset (20–39 years) and mid/late onset (≥40 years). We assessed trends in incidence using Poisson regression, mortality using negative binomial regression, and prevalence of parkinsonism and pre-existing conditions (e.g., head injury) using the Cochran–Armitage trend test. To better understand trends in the incidence of mid/late-onset parkinsonism, we adjusted for various pre-existing conditions in the Poisson regression model.Results:From 1996 to 2014, we identified 73,129 incident cases of parkinsonism (source population of ∼10.5 million), of whom 56% were male, mean age at diagnosis was 72.6 years, and 99% had mid/late-onset parkinsonism. Over 18 years, the age- and sex-standardized incidence decreased by 13.0% for mid/late-onset parkinsonism but remained unchanged for young-onset parkinsonism. The age- and sex-standardized prevalence increased by 22.8%, while post-diagnosis mortality decreased by 5.5%. Adjustment for pre-existing conditions did not appreciably explain the declining incidence of mid/late-onset parkinsonism.Conclusion:Young-onset and mid/late-onset parkinsonism exhibited differing trends in incidence over 18 years in Ontario. Further research to identify other factors that may appreciably explain trends in incident parkinsonism is warranted.

Controlled population-based comparative study of USA and international adult [55-74] neurological deaths 1989-2014

Objectives

A population‐based controlled study to determine whether adult (55‐74 years) neurological disease deaths are continuing to rise and are there significant differences between America and the twenty developed countries 1989‐91 and 2012‐14.

Method

Total Neurological Deaths (TND) rates contrasted against control Cancer and Circulatory Disease Deaths (CDD) extrapolated from WHO data. Confidence intervals compare USA and the other countries over the period. The Over‐75's TND and population increases are examined as a context for the 55‐74 outcomes.

Results

Male neurological deaths rose >10% in eleven countries, the other countries average rose 20% the USA 43% over the period. Female neurological deaths rose >10% in ten counties, averaging 14%, the USA up 68%. USA male and female neurological deaths increased significantly more than twelve and seventeen countries, respectively. USA over‐75s population increased by 49%, other countries 56%. Other countries TND up 187% the USA rose fourfold. Male and female cancer and CDD fell in every country averaging 26% and 21%, respectively, and 64% and 67% for CDD. Male neurological rates rose significantly more than Cancer and CCD in every country; Female neurological deaths rose significantly more than cancer in 17 countries and every country for CDD. There was no significant correlation between increases in neurological deaths and decreases in control mortalities.

Conclusions

There are substantial increases in neurological deaths in most countries, significantly so in America. Rises in the 55‐74 and over‐75's rates are not primarily due to demographic changes and are a matter of concern warranting further investigation.

Predictors of Mortality in Veterans with Multiple Sclerosis in an Outpatient Clinic Setting

BACKGROUND

Examining factors that increase risk of death in veterans with multiple sclerosis (MS) may help reduce MS-related mortality. We sought to determine predictors of mortality in veterans with MS attending an outpatient clinic.

METHODS

Review of electronic medical records of 226 veterans with MS regularly followed up from January 1, 2000, through December 31, 2014.

RESULTS

Mortality at the end of the 15-year study period was 14%. Patients with MS died prematurely, with a standardized mortality rate of 1.35 relative to the general (Oklahoma) population. The main causes of death documented were MS disease itself (57% of cases), infection (43%), and cancer and respiratory failure (18% each). Cox regression analysis using the whole cohort showed that progressive MS type; older age at entry into the study; presence of sensory, cerebellar, or motor (weakness and/or ataxia) concerns on presentation; more disability on presentation; higher body-mass index; being diabetic; never received disease-modifying therapy; and presence of pressure ulcers or neurogenic bladder were significant predictors of higher mortality.

CONCLUSIONS

Initial presentation by MS type (progressive MS), higher level of disability, and associated motor, sensory, and cerebellar concerns are significant predictors of MS-related mortality. The main causes of death were MS disease itself, infection, respiratory disease, and cancer. More attention should be given to preventive strategies that delay mortality, such as yearly immunization and aggressively treating MS-related complications and diabetes mellitus.

Time Trends in the Incidence of Parkinson Disease

IMPORTANCE

Changes over time in the incidence of parkinsonism and Parkinson disease (PD) remain uncertain.

OBJECTIVE

To investigate secular trends (period effects) and birth cohort trends in the incidence of parkinsonism and PD over 30 years in a geographically defined American population.

DESIGN, SETTING, AND PARTICIPANTS

We used the medical records-linkage system of the Rochester Epidemiology Project to identify incidence cases of PD and other types of parkinsonism in Olmsted County, Minnesota, from 1976 to 2005. All cases were classified by a movement disorder specialist using defined criteria through the review of the complete medical records within the system. The analyses for this study were conducted between May 2015 and January 2016.

MAIN OUTCOMES AND MEASURES

Incidence rates of parkinsonism and PD over 30 years. We tested for secular trends (period effects) using negative binomial regression models and for birth cohort effects using age-period-cohort models.

RESULTS

Of 906 patients with parkinsonism, 501 were men, and the median age at onset was 74 years (interquartile range, 66-81 years). Of the 464 patients with PD, 275 were men, and the median age at onset was 73 years (interquartile range, 64-80 years). The overall incidence rates increased significantly over 30 years in men for both parkinsonism (relative risk [RR], 1.17 per decade; 95% CI, 1.03-1.33) and PD (RR, 1.24 per decade; 95% CI, 1.08-1.43). These trends were driven primarily by the older age groups. In particular, for men 70 years or older, incidence rates increased for both parkinsonism (RR, 1.24 per decade; 95% CI, 1.07-1.44) and PD (RR, 1.35 per decade; 95% CI, 1.10-1.65). The secular trends were not significant for women overall or in age strata. We observed an increased risk for both men and women born in the 1920 cohort (1915-1924). However, this birth cohort effect was significant only for PD and only in men.

CONCLUSIONS AND REVELANCE

Our study suggests that the incidence of parkinsonism and PD may have increased between 1976 and 2005, particularly in men 70 years and older. These trends may be associated with the dramatic changes in smoking behavior that took place in the second half of the 20th century or with other lifestyle or environmental changes. However, the trends could be spurious and need to be confirmed in other populations.

Progressive Dwindling in Multiple Sclerosis: An Opportunity to Improve Care

Introduction

In the general ageing population, 40% of deaths occur following a prolonged trajectory of “progressive dwindling,” characterised by chronic accumulation of disability and frailty, and associated with increased dependency and reduced reserves. Those who progressively dwindle are poorly catered for by current healthcare systems and would benefit from a coordinated approach to their medical and social care, known as formative care. People with multiple sclerosis (pwMS) may be more likely to progressively dwindle, and may be appropriate targets for formative care pathways.

Objectives

To determine the proportion of pwMS who follow a progressive dwindling trajectory prior to death. To relate trajectory to place of death, and examine what factors predict the progressively dwindling trajectory.

Methods

A retrospective observational study of 582 deceased pwMS enrolled in the UK MS Tissue Bank, including death certificates and extensive clinical summaries.

Results

73.7% of pwMS had a “progressively dwindling” trajectory of dying. This was predicted by those who reach MS disease milestones earlier. 72.5% of pwMS died an MS-related death, which was predicted by an aggressive disease course from onset. Those who progressively dwindled were equally likely to die in hospital as those with other trajectories to death.

Conclusions

The progressively dwindling trajectory of dying is very common in pwMS, and can be predicted by earlier disease milestones. Pathways could target pwMS in these years prior to death, to improve care.

Neurological deaths of American adults (55-74) and the over 75's by sex compared with 20 Western countries 1989-2010: Cause for concern

Background:

Have USA total neurological deaths (TNDs) of adults (55–74) and the over 75's risen more than in twenty Western Countries?

Methods:

World Health Organization TND data are compared with control mortalities cancer mortality rates (CMRs) and circulatory disease deaths (CDDs) between 1989–1991 and 2008–2010 and odds ratios (ORs) and confidence intervals calculated.

Results:

Neurological Deaths – Twenty country (TC) average 55–74 male rates per million (pm) rose 2% to 503 pm, USA increased by 82% to 627 pm. TC average females rose 1% to 390 pm, USA rising 48% to 560 pm. TC average over 75's male and female increased 117% and 143%; USA rising 368% and 663%, significantly more than 16 countries. Cancer mortality – Average 55–74 male and female fell 20% and 12%, USA down 36% and 18%. TC average over 75's male and female fell 13% and 15%, the USA 29% and 2%. Circulatory deaths – TC average 55–74 rates fell 60% and 46% the USA down 54% and 53%. Over 75's average down 46% and 39%, USA falling 40% and 33%. ORs for rose substantially in every country. TC average 75's ORs for CMR: TND male and females were 1:2.83 and 1:3.04 but the USA 1:5.18 and 1:6.50. The ORs for CDD: TND male and females TC average was 1:3.42 and 1:3.62 but the USA 1:6.13 and 1:9.89.

Conclusions:

Every country's neurological deaths rose relative to the controls, especially in the USA, which is a cause for concern and suggests possible environmental influences.

The rise of mortality from mental and neurological diseases in Europe, 1979-2009: observational study

Background

We studied recent trends in mortality from seven mental and neurological conditions and their determinants in 41 European countries.

Methods

Age-standardized mortality rates were analysed using standard methods of descriptive epidemiology, and were related to cultural, economic and health care indicators using regression analysis.

Results

Rising mortality from mental and neurological conditions is seen in most European countries, and is mainly due to rising mortality from dementias. Mortality from psychoactive substance use and Parkinson’s disease has also risen in several countries. Mortality from dementias has risen particularly strongly in Finland, Iceland, Malta, Netherlands, Spain, Sweden and the United Kingdom, and is positively associated with self-expression values, average income, health care expenditure and life expectancy, but only the first has an independent effect.

Conclusions

Although trends in mortality from dementias have probably been affected by changes in cause-of-death classification, the high level of mortality from these conditions in a number of vanguard countries suggests that it is now among the most frequent causes of death in high-income countries. Recognition of dementias as a cause of death, and/or refraining from life-saving treatment for patients with dementia, appear to be strongly dependent on cultural values.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-840) contains supplementary material, which is available to authorized users.

Co-morbidities of persons dying of Parkinson's disease

Introduction

Disease interactions can alter functional decline near the end of life (EOL). Parkinson's disease (PD) is characterized by frequent occurrences of co-morbidities but data challenges have limited studies investigating co-morbidities across a broad range of diseases. The goal of this study was to describe disease associations with PD.

Methods

We conducted an analysis of death certificate data from 1998 to 2005 in Nova Scotia. All death causes were utilized to select individuals dying of PD and compare with the general population and an age–sex-matched sample without PD. We calculated the mean number of death causes and frequency of disease co-occurrence. To account for the chance occurrence of co-morbidities and measure the strength of association, observed to expected ratios were calculated.

Results

PD decedents had a higher mean number of death causes (3.37) than the general population (2.77) and age–sex-matched sample (2.88). Cancer was the most common cause in the population and matched sample but fifth for those with PD. Cancer was one of nine diseases that occurred less often than what would be expected by chance while four were not correlated with PD. Dementia and pneumonia occurred with PD 2.53 ([CI] 2.21–2.85) and 1.83 (CI 1.58–2.08) times more often than expected. The strength of association for both is reduced but remains statistically significant when controlling for age and sex.

Discussion

Those with PD have a higher number of co-morbidities even after controlling for age and sex. Individuals dying with PD are more likely to have dementia and pneumonia, which has implications for the provision of care at EOL.

Place of death, and its relation with underlying cause of death, in Parkinson's disease, motor neurone disease, and multiple sclerosis: a population-based study

BACKGROUND

Little is known about place of death in chronic neurological diseases. Mortality statistics are ideal for examining trends in place of death, but analyses are limited by coding rule changes.

AIM

To examine the relationship between place of death and underlying cause of death in Parkinson's disease, multiple sclerosis and motor neurone disease and the impact of coding rule changes on analysis of place of death.

DESIGN

Population-based study. Proportion ratios for death in hospice, home, care home and hospital were calculated according to underlying cause of death, using multivariable Poisson regression.

PARTICIPANTS

Deaths in England (1993-2010) with any mention of Parkinson's disease, multiple sclerosis or motor neurone disease as a cause of death, identified from national mortality data.

RESULTS

In this study, 125,242 patients with Parkinson's disease, 23,501 with multiple sclerosis, and 27,030 with motor neurone disease were included. Home deaths ranged from 9.7% (Parkinson's disease) to 27.1% (motor neurone disease), hospice deaths ranged from 0.6% (Parkinson's disease) to 11.2% (motor neurone disease) and hospital deaths ranged from 43.4% (Parkinson's disease) to 55.8% (multiple sclerosis). In Parkinson's disease and multiple sclerosis, cancer as underlying cause of death increased likelihood of hospice death (proportion ratio (PR): 18.8, 95% confidence interval (CI) = 16.1-22.0; 8.88, 95% CI = 7.49-10.5) and home death (PR: 1.91, 95% CI = 1.80-2.04; 1.71, 95% CI = 1.56-1.88). Dementia as underlying cause of death increased likelihood of care home death in Parkinson's disease (PR: 1.25, 95% CI = 1.19-1.32), multiple sclerosis (PR: 1.73, 95% CI = 1.22-2.45) and motor neurone disease (PR: 2.36, 95% CI = 1.31-4.27).

CONCLUSIONS

Underlying cause of death has a marked effect on place of death. The effects of coding rule changes are an essential consideration for all research using underlying cause of death to study place of death.

Young-onset amyotrophic lateral sclerosis: historical and other observations

There is a wide range of age at initial symptom onset in amyotrophic lateral sclerosis despite a mean age of 65 years in population-based studies. 'Young-onset' amyotrophic lateral sclerosis typically refers to patients younger than ∼45 years and accounts for about 10% of cases in contemporary series. A review of published cases of amyotrophic lateral sclerosis from 1850 to 1950 revealed a far higher proportion of cases with young onset (>50%), with a steady decline to the contemporary figure. It is possible that this is not solely explained by increases in life expectancy. While there is still a rich variation in phenotypes among cases of young-onset amyotrophic lateral sclerosis, bulbar onset was found to be significantly under-represented in analysis of a large patient database, with implications for age-related vulnerabilities pertaining to focality of symptom onset. The timing of initiating pathological processes in relation to the emergence of symptoms is discussed, including the potential role of very early development and the interaction of epigenetic and environmental factors.

Birth cohort effects in neurological diseases: amyotrophic lateral sclerosis, Parkinson's disease and multiple sclerosis

BACKGROUND

Generational differences in disease rates are the main subject of age-period-cohort (APC) analysis, which is mostly applied in cancer and suicide research. This study applied APC analysis to selected neurological diseases: amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD) and multiple sclerosis (MS).

METHODS

The analyses were based on Swiss mortality data. Age-stratified data has been available for MS, PD and ALS since 1901, 1921, and 1942, respectively. APC analysis was performed within the framework of logit models. Main effect models were extended by implementing nested effects, i.e. age effects nested in subperiods, in order to account for the fact that age profiles may change for reasons other than generational influences.

RESULTS

In preliminary analyses, APC analysis yielded noteworthy birth cohort effects in all three diseases. After implementing nested effects, the birth cohort effects disappeared in ALS, and smoothed out in PD, where they were greater for the generations born before the 1920s. In MS, the birth cohort effects remained stable, and exhibited a peak in cohorts born in the 1910s and 1920s.

CONCLUSIONS

APC analysis yielded some evidence for birth cohort effects, i.e. predisposing risk factors that may change in historical terms, in MS and PD, but probably not in ALS.

How can the national burden of Parkinson's disease comorbidity and mortality be estimated for the Japanese population?

Background

Good medical care results in long survival for patients with Parkinson’s disease (PD). However, little is known about the burden of PD comorbidity and mortality in Japan. This is the first study to examine comorbid diseases of PD decedents and extrapolate PD death rates from multiple-cause coding mortality data for the total population of Japan.

Methods

Data for 4589 certified deaths due to PD as the underlying cause of death (ICD-10 code: G20) were obtained from the 2008 Japanese vital statistics. Of those, comorbidities listed in the death certificates of 477 randomly selected decedents were analyzed. All diseases or conditions mentioned on death certificates were counted and ranked in descending order of frequency. The death rates (per 100 000 population) from PD were calculated using Japanese National Vital Statistics. The estimated rate of deaths with PD was extrapolated using US death data from a multiple-cause coding system, as no such system is available in Japan, with adjustment for the difference in disease structure between countries.

Results

Average age at death was 80.9 years. The top 5 comorbid diseases ranked as contributory causes of death were cerebrovascular diseases (4.0%), dementia (3.8%), diabetes mellitus (3.6%), malignant neoplasm (2.5%), and heart diseases (2.3%). Overall, the death rates from and with PD were 3.6 and 5.8, respectively.

Conclusions

Analysis restricted to data from the underlying-cause coding system underestimated the national burden of PD comorbidity and mortality. Use of death certificates and multiple-cause mortality data complement the existing system.

Mortality from Parkinson's disease and other causes among a workforce manufacturing paraquat: a retrospective cohort study

Objective To assess the risk of Parkinson's disease (PD) and update information on mortality from major causes of death among a UK workforce who manufactured paraquat (PQ) between 1961 and 1995. There have been no previous studies of the incidence of PD among PQ production workers, although much epidemiological literature exists concerning the relationship between pesticides and PD, and interest has focused on PQ and its users. Methods The cohort included all employees who had ever worked on any of the four plants at Widnes where PQ was manufactured between 1961 and 1995, and 926 male and 42 female workers were followed through 30 June 2009. Mortalities for males were compared with national and local rates, including rates for PD as a mentioned cause of death. Results Overall, 307 workers had died by 30 June 2009. One male death was due to PD, and no other death certificate mentioned PD. At least 3.3 death certificates of male employees would have been expected to have mentioned PD (standardised mortality ratio=31; 95% CI 1 to 171). Personal monitoring results were indicative that the exposure of a PQ production worker on a daily basis was at least comparable with that of a PQ sprayer or mixer/loader. Reduced mortalities compared with local rates were found for major causes of death. Conclusions The study provided no evidence of an increased risk of PD, or increased mortalities from other causes.