Altered body composition, sarcopenia, frailty, and their clinico-biological correlates, in Parkinson's disease

Frailty and Parkinson's disease: the role of diabetes mellitus

Parkinson's disease (PD) is a chronic neurodegenerative disease associated with a progressive loss of dopaminergic neurons, clinically characterized by motor and non-motor signs. Frailty is a clinical condition of increased vulnerability and negative health outcomes due to the loss of multiple physiological reserves. Chronic hyperglycemia and insulin resistance, which characterize diabetes mellitus (DM), have been reported to alter dopaminergic activity, increase the risk of PD, and influence the development of frailty. Even though diabetes may facilitate the development of frailty in patients with PD, this relationship is not established and a revision of the current knowledge is necessary. Furthermore, the synergy between DM, PD, and frailty may drive clinical complexity, worse outcomes, and under-representation of these populations in the research. In this review, we aimed to discuss the role of diabetes in the development of frailty among patients with PD. We summarized the clinical characteristics and outcomes of patients with concomitant DM, PD, and frailty. Finally, interventions to prevent frailty in this population are discussed.

Advanced glycation end products consumption and the decline of functional capacity in patients with Parkinson's disease: Cross-sectional study

INTRODUCTION

Advanced Glycation End-Products (AGEs) are a diverse group of highly reactive molecules that play a vital role in the development of neurodegenerative disorders, such as Parkinson's Disease (PD), leading to a decline in functional and cognitive capacity. The objective of this study was to assess the intake and quantification of AGEs in individuals with PD and to correlate them with their functional and cognitive abilities.

METHODS

This was a cross-sectional study involving 20 PD patients and 20 non-PD individuals as the Control group (C). The autofluorescence reader was used to evaluate skin AGEs, while food recall was used to quantify AGEs consumed for three different days. The Montreal Cognitive Assessment, Short Physical Performance Battery, and handgrip tests were used. PD patients demonstrated greater impairment in functional capacity compared to the control group.

RESULTS

Dominant Handgrip (p = 0.02) and motor performance, in the sit and stand test (p = 0.01) and Short Physical Performance Battery (SPPB) (p = 0.01) were inferior in PD patients than the control group. Although PD patients tended to consume less AGEs than the control group, AGE intake was negatively correlated with handgrip strength in individuals with PD (r = -0.59; p < 0.05).

CONCLUSION

PD patients had lower strength and functional capacity, suggesting that the effects of AGEs might be exacerbated during chronic diseases like Parkinson's.

The prevalence of sarcopenia in Parkinson's disease and related disorders- a systematic review

BACKGROUND

The prevalence of sarcopenia (reduced skeletal muscle strength and mass), Parkinson's disease (PD) and Parkinson's related disorders (PRD) all increase with age. They also share risk factors and pathogenetic features. An increased prevalence of sarcopenia in PD and PRD than the general population was thus postulated.

METHODS

Four databases were searched using predefined literature search strategies. Studies conducted in participants with PD or PRD reporting the prevalence of sarcopenia and those providing data to compute the prevalence were included. Pre-sarcopenia, probable/possible sarcopenia and confirmed sarcopenia were defined according to the main sarcopenia working groups. Risk of bias was assessed using the AXIS tool.

RESULTS

1978 studies were identified; 97 assessed in full; 14 met inclusion criteria. The median study quality score was 15/20. The range of probable sarcopenia was 23.9 to 66.7%, and it did not change after excluding PRD participants. The prevalence of confirmed sarcopenia in participants with any parkinsonian disorder ranged from 2 to 31.4%. Including just PD participants, the range was 10.9 to 31.4%. In studies with controls, sarcopenia was more prevalent in PD and PRD. There was a positive non-significant trend between severity of motor symptoms and prevalence of sarcopenia or components of sarcopenia. High heterogeneity precluded meta-analysis, therefore there was insufficient evidence to conclude whether sarcopenia is more prevalent in PD or PRD.

CONCLUSIONS

Probable and confirmed sarcopenia are common in PD and PRD and they may be associated with disease severity. This co-occurrence supports the value of screening for sarcopenia in parkinsonian populations.

Weight and survival after deep brain stimulation for Parkinson's disease

BACKGROUND

Weight loss in Parkinson's disease (PD) is common and associated with increased mortality. The clinical significance of weight changes following deep brain stimulation (DBS) of the subthalamic nucleus (STN) and globus pallidus internus (GPi) is unclear.

OBJECTIVES

To address (1) whether PD patients exhibit progressive weight loss, (2) whether staged DBS surgery is associated with weight changes, and (3) whether survival after DBS correlates with post-DBS weight.

METHODS

This is a single-center, longitudinal, retrospective cohort study of 1625 PD patients. We examined trends in weight over time and the relationship between weight and years survival after DBS using regression and mixed model analyses.

RESULTS

There was a decline in body weight predating motor symptom onset (n = 756, 0.70 ± 0.03% decrease per year, p < 0.001). Weight decline accelerated in the decade preceding death (n = 456, 2.18 ± 0.31% decrease per year, p < 0.001). DBS patients showed a weight increase of 2.0 ± 0.33% at 1 year following the first DBS lead implant (n = 455) and 2.68 ± 1.1% at 3 years if a contralateral DBS lead was placed (n = 249). The bilateral STN DBS group gained the most weight after surgery during 6 years of follow up (vs bilateral GPi, 3.03 ± 0.45% vs 1.89 ± 0.31%, p < 0.01). An analysis of the DBS cohort with date of death available (n = 72) revealed that post-DBS weight (0-12 months after the first or 0-36 months after the second surgery) was positively associated with survival (R2 = 0.14, p < 0.001).

DISCUSSION

Though PD is associated with significant weight loss, DBS patients gained weight following surgery. Higher post-operative weight was associated with increased survival. These results should be replicated in other cohorts.

Association of serum uric acid levels with bone mineral density and the presence of osteoporosis in Chinese patients with Parkinson's disease: a cross-sectional study

INTRODUCTION

As the population ages, the incidence of osteoporosis among patients suffering from Parkinson's disease (PD) will surge continually, and the ensuing disability from falls is becoming a serious social burden. Due to its antioxidant properties, much literature has indicated the possible ability of serum uric acid (UA) to prevent ageing-related diseases caused by oxidative stress, including osteoporosis and PD. Therefore, this study was for exploring the connection of serum UA levels with bone mineral density (BMD) and the osteoporosis presence in Chinese PD patients.

MATERIALS AND METHODS

A cross-sectional design was used to statistically analyze 42 clinical parameters obtained from 135 patients with PD treated in Wuhan Tongji Hospital during 2020-2022. Multiple stepwise linear regression and multiple logistic regression analyses were constructed for identifying the association of serum UA levels with BMD as well as osteoporosis in PD patients, respectively. With receiver operative characteristic (ROC) curves, the optimal cutoff value was acquired for serum UA in the diagnosis of osteoporosis.

RESULTS

According to the regression analysis adjusted for confounders, serum UA levels in PD patients had positive correlation with BMD at each site and negative correlation with the presence of osteoporosis (P < 0.05 for all). ROC curves determined that the optimal cutoff value for UA to perform well in diagnosing osteoporosis in PD patients was 284.27 μmol/L (P < 0.001).

CONCLUSION

Relatively higher serum UA levels in the physiological range can work as a biomarker of higher BMD, and were strongly linked to lower prevalence of osteoporosis in Chinese PD patients.

Sarcopenia is associated with non-motor symptoms in Han Chinese patients with Parkinson's Disease: a cross-sectional study

BACKGROUND

Sarcopenia is commonly seen in the older adults and increases in incidence with age, also in Parkinson's disease (PD). Although research has indicated that the development of sarcopenia in patients with PD may be related to both motor symptoms and non-motor symptoms (NMS), the precise relationship between the two conditions remains unclear. Therefore, we aimed to investigate the incidence of sarcopenia in patients with PD and its association with NMS.

METHODS

The study included 123 patients with PD and 38 age- and sex-matched healthy controls (HC). All participants were evaluated for sarcopenia using the 2019 Asian Sarcopenia Diagnostic Criteria, and patients with PD underwent standard assessments of motor symptoms and NMS. Multiple logistic regression and receiver operating characteristic (ROC) curve analyses were used to examine the association between sarcopenia and NMS in patients with PD.

RESULTS

The incidence of sarcopenia was significantly higher in patients with PD than in HC (26.8% vs. 10.4%, p = 0.046). Multiple logistic regression analysis revealed that poorer sleep quality (odds ratio [OR]: 1.245; 95% confidence interval [CI]: 1.011-1.533; p = 0.040) and fatigue (OR: 1.085, 95% CI: 1.006-1.170, p = 0.034) were independently associated with sarcopenia. ROC analysis indicated that the optimal cut-off value for Pittsburgh Sleep Quality Index (PSQI) scores was 10, with 72.7% sensitivity and 74.4% specificity (area under the curve [AUC] = 0.776, 95% CI: 0.683-0.868, p < 0.001). The optimal cut-off value for Fatigue Severity Scale (FSS) scores was 39, with 87% sensitivity and 50% specificity (AUC = 0.725, 95% CI: 0.629 -0.820, p < 0.001). Joint use of FSS and PSQI scores increased the predictive value for sarcopenia(AUC = 0.804, 95% CI: 0.724-0.885, p < 0.001).

CONCLUSION

Patients with PD are more susceptible to sarcopenia than healthy older adults, and fatigue and poorer sleep are positively associated with sarcopenia. Further longitudinal studies are needed to clarify the causal relationships.

Gastrointestinal Dysfunction in Parkinson's Disease: Neuro-Gastroenterology Perspectives on a Multifaceted Problem

Patients with Parkinson's disease (PD) face a multitude of gastrointestinal (GI) symptoms, including nausea, bloating, reduced bowel movements, and difficulties with defecation. These symptoms are common and may accumulate during the course of PD but are often under-recognized and challenging to manage. Objective testing can be burdensome to patients and does not correlate well with symptoms. Effective treatment options are limited. Evidence is often based on studies in the general population, and specific evidence in PD is scarce. Upper GI dysfunction may also interfere with the pharmacological treatment of PD motor symptoms, which poses significant management challenges. Several new less invasive assessment tools and novel treatment options have emerged in recent years. The current review provides an overview and a practical approach to recognizing and diagnosing common upper and lower GI problems in PD, e.g., dyspepsia, gastroparesis, small bowel dysfunction, chronic constipation, and defecatory dysfunction. Management aspects are discussed based on the latest evidence from the PD and general populations, with insights for future research pertaining to GI dysfunction in PD.

Physical Frailty, Genetic Predisposition, and Incident Parkinson Disease

Importance

Cross-sectional evidence implicates high prevalent frailty in patients with Parkinson disease (PD), whereas the longitudinal association remains unknown.

Objectives

To examine the longitudinal association of the frailty phenotype with the development of PD and to explore the modification role of genetic risk of PD in such an association.

Design, Setting, and Participants

This prospective cohort study launched in 2006 to 2010 with a follow-up of 12 years. Data were analyzed from March 2022 to December 2022. The UK Biobank recruited over 500 000 middle-aged and older adults from 22 assessment centers across the United Kingdom. Participants who were younger than 40 years (n = 101), diagnosed with dementia or PD at baseline, and developed dementia, PD, or died within 2 years from baseline were excluded (n = 4050). Participants who had no genetic data or mismatch between genetic sex and reported gender (n = 15 350), were not of self-reported British White descent (n = 27 850), and had no data for frailty assessment (n = 100 450) or any covariates were also excluded (n = 39 706). The final analysis included 314 998 participants.

Exposures

The physical frailty was assessed by the Fried criteria's frailty phenotype through 5 domains, ie, weight loss, exhaustion, low physical activity, slow walking speed, and low grip strength. The polygenic risk score (PRS) for PD comprised 44 single-nucleotide variants.

Main Outcomes and Measures

New-onset PD was identified through the hospital admission electronic health records and death register.

Results

Among 314 998 participants (mean age, 56.1 years; 49.1% male), 1916 new-onset PD cases were documented. Compared with nonfrailty, the hazard ratio (HR) of incident PD in prefrailty and frailty was 1.26 (95% CI, 1.15-1.39) and 1.87 (95% CI, 1.53-2.28), respectively, and the absolute rate difference per 100 000 person-years was 1.6 (95% CI, 1.0-2.3) for prefrailty and 5.1 (95% CI, 2.9-7.3) for frailty. Exhaustion (HR, 1.41; 95% CI, 1.22-1.62), slow gait speed (HR, 1.32; 95% CI, 1.13-1.54), low grip strength (HR, 1.27; 95% CI, 1.13-1.43), and low physical activity (HR, 1.12; 95% CI, 1.00-1.25) were associated with incident PD. A significant interaction between frailty and PRS on PD was found and the highest hazard was observed in participants with frailty and high genetic risk.

Conclusions and Relevance

Physical prefrailty and frailty were associated with incident PD independent of sociodemographic factors, lifestyles, multiple morbidities, and genetic background. These findings may have implications for the assessment and management of frailty for PD prevention.

Prevalence of sarcopenia in Parkinson's disease: A systematic review and meta-analysis

We meta-analysed the sarcopenia prevalence among patients with Parkinson´s disease (PD) in comparison to a control group and tested the effects of age, sex, sarcopenia assessments, and PD progression in the sarcopenia prevalence. The literature search was performed using five databases in March 2022. The prevalence of sarcopenia in patients with PD was 3 times higher than in the control group (OR 3.98). Subgroup analyses showed that among individuals aged ≥ 70 years the higher prevalence of sarcopenia in PD compared to controls (OR 5.32, P=0.08) tended to be higher (P=0.08) than the group < 70 years. Regarding PD progression, the prevalence of sarcopenia was not different between individuals scoring < 2.5 and ≥ 2.5 in the Hoehn and Yahr scale. Patients with PD have a higher probability of developing sarcopenia when compared with the control group and older PD patients trended to have even higher chance of sarcopenia than their older controls.

Emerging roles of leptin in Parkinson's disease: Chronic inflammation, neuroprotection and more?

An increasing body of experimental evidence implicates a relationship between immunometabolic deterioration and the progression of Parkinson's disease (PD) with a dysregulation of central and peripheral neuroinflammatory networks mediated by circulating adipokines, in particular leptin. We screened the current literature on the role of adipokines in PD. Hence, we searched known databases (PubMed, MEDLINE/OVID) and reviewed original and review articles using the following terms: "leptin/ObR", "Parkinson's disease", "immune-metabolism", "biomarkers" and "neuroinflammation". Focusing on leptin, we summarize and discuss the existing in vivo and in vitro evidence on how adipokines may be protective against neurodegeneration, but at the same time contribute to the progression of PD. These components of the adipose brain axis represent a hitherto underestimated pathway to study systemic influences on dopaminergic degeneration. In addition, we give a comprehensive update on the potential of adjunctive therapeutics in PD targeting leptin, leptin-receptors, and associated pathways. Further experimental and clinical trials are needed to elucidate the mechanisms of action and the value of central and peripheral adipose-immune-metabolism molecular phenotyping in order to develop and validate the differential roles of different adipokines as potential therapeutic target for PD patients.

Prevalence of Malnutrition in Patients with Parkinson's Disease: A Systematic Review

OBJECTIVES

This systematic review analyzed the prevalence of malnutrition in patients with Parkinson's Disease.

STUDY DESIGN

a systematic review.

METHOD

Four databases-Cochrane, PubMed, Embase and Web of Science-were searched from October 2021 to June 2022 by two independent researchers. The inclusion criteria were as follows: patients above 18 years old with confirmed Parkinson's Disease, performed screening nutritional assessment, cohort studies, case-control studies, and cross-sectional studies. Patients without Parkinson's Disease and with other parkinsonian syndromes were excluded.

RESULTS

49 studies were included in this systematic review. Patients ranged in age from 20 to 96 years. There were 5613 subjects included. According to Mini Nutritional Assessment, 23.9% (n = 634) participants were at risk of malnutrition and 11.1% (n = 294) were malnourished. According to BMI score, most patients were either obese or overweight.

CONCLUSIONS

the prevalence of malnutrition or risk of malnutrition in the study group was significant. Therefore, more specific and detailed studies on the prevalence of malnutrition in patients with Parkinson's Disease are needed.

Factors associated with frailty syndrome in elderly people with Parkinson's disease

OBJECTIVES

to analyze the sociodemographic and clinical factors associated with frailty in the elderly with Parkinson's disease in the context of a Specialized Health Care Service for the Elderly.

METHODS

documentary, analytical, correlational, cross-sectional study carried out with 230 elderly people with Parkinson's. The medical records of the patients were evaluated with a focus on two instruments: Clinical-Functional Vulnerability Index - 20; and the Multidimensional Assessment Care Plan.

RESULTS

predominance of elderly people between 80 and 89 years old; women; with low education; classified as fragile. There was a correlation between frailty and the variables: sex; age; age group; schooling; motor manifestations; non-motor manifestations; Hoehn and Yahr staging and time to diagnosis.

CONCLUSIONS

high simultaneity of frailty conditions and Parkinson's disease was observed. It is believed that the results will be able to help the structuring of protocols for nursing performance in a systematic way in the promotion of self-care of these individuals.

Handgrip Strength and Anthropometry in Parkinson’s Disease at Diagnosis

Objectives

To investigate how age, malnutrition, and the level of plasma cortisol and phosphate in patients with Parkinson's disease (PD) at time of diagnosis are associated with body composition and handgrip strength in males and females compared to controls. Materials & Methods. This cross-sectional study includes baseline data from a cohort of newly diagnosed patients with Parkinson's disease (N = 75; M/F = 41/34) in the New Parkinsonism in Umeå study (NYPUM). Body Impedance (BIS), handgrip strength (HGS) assessments, and evaluation of risk for malnutrition (Mini Nutritional Assessment (MNA) score) and cognitive performance (Mini-Mental State Examination (MMSE)) were performed at time of PD diagnosis.

Results

Low fat-free mass index (FFMI), MNA score, and a high Unified Parkinson's Disease Rating Scale (UPDRS-total and UPDRS-III) were associated with high daytime levels of P-cortisol in total PD population but not in controls. Partial correlations reveal that high fat mass percent (FM (%)) and low FFMI were associated with older age in males with PD but not females with PD. Risk of malnutrition was associated with P-cortisol in males but not in females with PD (r = −0.511, P=0.001, and n = 41 and r = −0.055, P=0.759, and n = 34, respectively). Multiple linear regressions show that an interaction between P-cortisol and P-phosphate, older age, and high UPDRS-III score were associated with HGS in total patient population and males but not females.

Conclusions

Age- and disease-associated risk factors that decrease muscle mass and HGS and increase FM (%) in patients with PD differ between males and females by an association with levels of cortisol and phosphate.

The microbiome-gut-brain axis in Parkinson disease - from basic research to the clinic

Evidence for a close bidirectional link between the brain and the gut has led to a paradigm shift in neurology, especially in the case of Parkinson disease (PD), in which gastrointestinal dysfunction is a prominent feature. Over the past decade, numerous high-quality preclinical and clinical publications have shed light on the highly complex relationship between the gut and the brain in PD, providing potential for the development of new biomarkers and therapeutics. With the advent of high-throughput sequencing, the role of the gut microbiome has been specifically highlighted. Here, we provide a critical review of the literature on the microbiome-gut-brain axis in PD and present perspectives that will be useful for clinical practice. We begin with an overview of the gut-brain axis in PD, including the potential roles and interrelationships of the vagus nerve, α-synuclein in the enteric nervous system, altered intestinal permeability and inflammation, and gut microbes and their metabolic activities. The sections that follow synthesize the proposed roles of gut-related factors in the development and progression of, in responses to PD treatment, and as therapeutic targets. Finally, we summarize current knowledge gaps and challenges and delineate future directions for the field.

Similarities, differences and overlaps between frailty and Parkinson's disease

Parkinson's disease is a neurodegenerative disorder clinically characterized by bradykinesia, rest tremor, rigidity, and postural and gait disturbances, which are frequently observed in older people. It also shows non-motor symptoms, such as depression, anxiety, cognitive impairment and dementia. The number of patients is gradually increasing worldwide. Aging is a risk factor for the onset of Parkinson's disease, and various physiological effects of aging influence its progression. Frailty is a geriatric syndrome in which the reversible and vulnerable status between robustness and disability is affected by various physiological stressors with aging. Frailty consists of physical, psychological and social aspects. Furthermore, sarcopenia, a syndrome characterized by the loss of muscle mass, strength and function, is also significantly associated with frailty. To maintain the quality of life of older people, frailty, including sarcopenia, should be quickly and appropriately managed. Polypharmacy is an important factor causing the progression of frailty in geriatric syndrome. Although Parkinson's disease and frailty have similar symptoms, and are considered to affect each other, the clinical features and mechanisms of both largely remain unclear. Nevertheless, little literature on the relationship between frailty and Parkinson's disease is currently available. This narrative review aims to clarify the relationships between Parkinson's disease and frailty, not only on the physical, but also on the mental, cognitive, and social aspects and issues regarding polypharmacy in Parkinson's disease explored by previous studies. Geriatr Gerontol Int 2022; 22: 259-270.

The Interactions between Adipose Tissue Secretions and Parkinson's disease; The Role of Leptin

Leptin is a hormone that regulates appetite by acting on receptors in the hypothalamus, where it modifies food intake to maintain equilibrium with the body energy resources. Leptin and its receptors are widely distributed in the central nervous system, suggesting that they may give neuronal survival signals. The potential of leptin to decrease/increase neuronal damage and neuronal plasticity in Parkinson's diseases (PD) is the subject of this review, which outlines our current knowledge of how leptin acts in the brain. Although leptin-mediated neuroprotective signaling results in neuronal death prevention, it can affect neuroinflammatory cascades and also neuronal plasticity which contribute to PD pathology. Other neuroprotective molecules, such as insulin and erythropoietin, share leptin-related signaling cascades, and therefore constitute a component of the neurotrophic effects mediated by endogenous hormones. With the evidence that leptin dysregulation causes increased neuronal vulnerability to damage in PD, using leptin as a target for therapeutic modification is an appealing and realistic option.

Food consumption, anthropometry and body composition of patients diagnosed with Parkinson’s disease

ABSTRACT Objective The aim of the present study was to evaluate the consumption of risk and protective foods for chronic noncommunicable diseases and to investigate associations with anthropometric parameters and body composition in individuals with Parkinson’s disease. Methods A case-series study was conducted with 79 adult and elderly patients of both genders in outpatient care. Food intake was evaluated using a food frequency questionnaire for the identification of foods with greater daily consumption, stratified by gender. The consumption frequency of each food was converted into scores of two food groups characteristics: risk and protection. The conceptual model took into account sociodemographic, behavioral and anthropometric variables as well as body composition. Results A total of 72.1% of the participants in the sample had excess weight based on the body mass index and 43.5% had excess body fat. The consumption of protective foods was greater among individuals with a higher body mass index and with a greater rate of body fat. Conclusion The data indicate a situation of reverse causality and reveal the complexity of the relationship among food intake, body fat and chronic noncommunicable diseases.

Fatores associados à síndrome de fragilidade em idosos com doença de Parkinson

RESUMO Objetivos: analisar os fatores sociodemográficos e clínicos associados à fragilidade em idosos com doença de Parkinson no contexto de um Serviço de Atenção Especializada em Saúde do Idoso. Métodos: estudo documental, analítico, correlacional, de corte transversal, realizado com 230 idosos com Parkinson. Foram avaliados os prontuários dos pacientes com enfoque em dois instrumentos: Índice de Vulnerabilidade Clínico-Funcional - 20; e o Plano de Cuidados da avaliação multidimensional. Resultados: predomínio de idosos entre 80 e 89 anos; sexo feminino; com baixa escolaridade; classificados como frágeis. Houve correlação entre a fragilidade e as variáveis: sexo; idade; faixa etária; escolaridade; manifestações motoras; manifestações não motoras; estadiamento de Hoehn e Yahr e tempo de diagnóstico. Conclusões: constatou-se alta simultaneidade das condições de fragilidade e doença de Parkinson. Acredita-se que os resultados poderão auxiliar a estruturação de protocolos para atuação da enfermagem de forma sistematizada na promoção do autocuidado desses indivíduos.

The role of frailty in Parkinson's disease: a cross-sectional study

BACKGROUND

Frailty is an age-related state of increased risk for health-related adverse outcomes that reflects multisystem physiological changes and likely influences the clinical expression and disease progression of neurodegenerative disorders. The aim of the present study was to assess the potential relationship between frailty, as assessed by a frailty index (FI), and motor symptom severity, motor subtypes, and non-motor domains in Parkinson's disease (PD).

METHODS

We consecutively enrolled 150 PD patients. We administered an FI specifically designed for PD that included 50 age-related multidimensional biological deficits. Patients underwent a clinical assessment that evaluated motor and non-motor manifestations of PD. Using the FI score, we classified PD patients as relatively fit (FI ≤ 0.10), less fit (0.10 < FI ≤ 0.21), or frail (FI > 0.21). A linear regression model was designed to explore possible associations between frailty level and PD motor and non-motor manifestations.

RESULTS

Frail patients showed greater motor symptom severity and motor complications than fitter patients. A trend towards a higher prevalence of the postural instability/gait disorder subtype was also observed in frail versus relatively fit and less fit patients. The global burden of non-motor symptoms was higher in frail patients. Increased frailty was associated with more severe motor and non-motor symptoms, as well as with more pronounced cognitive deficits. These associations remained significant even when "traditional" predictors of PD severity (age, disease duration, and levodopa equivalent daily dose) were considered.

CONCLUSIONS

The present findings indicate that the FI is associated with both motor and non-motor features of PD.

Temporalis Muscle Thickness as an Indicator of Sarcopenia Is Associated With Long-term Motor Outcomes in Parkinson's Disease

BACKGROUND

To investigate the relationship between temporalis muscle thickness (TMT) at baseline as a surrogate marker for sarcopenia and long-term motor outcomes in patients with Parkinson's disease (PD).

METHODS

We enrolled 249 patients with drug-naïve early-stage PD (119 males and 130 females, follow-up > 3 years). Baseline TMT of each patient was measured on the axial plane of T1-weighted images. The association between baseline TMT and long-term motor outcomes in PD was assessed using Cox regression models for levodopa-induced dyskinesia, wearing-off, and freezing of gait and a linear mixed model for the longitudinal increases in levodopa-equivalent dose per body weight over time. Statistical analyses were performed separately for sex if an interaction effect between TMT and sex was assumed.

RESULTS

TMT differed substantially between the sexes, and male PD patients had higher TMT (6.69 ± 1.39 mm) than female PD patients (5.64 ± 1.34 mm, p < .001). Cox regression models demonstrated that baseline TMT was not associated with the risk of developing levodopa-induced dyskinesia, wearing-off, or freezing of gait during the follow-up period. The linear mixed model was applied separately for sex and demonstrated that higher TMT at baseline was associated with slower increases in levodopa-equivalent dose per body weight in male PD patients, but not in female PD patients.

CONCLUSIONS

This study demonstrated that baseline TMT could be an indicator of the longitudinal requirement for dopaminergic medications in male patients with PD, suggesting that sarcopenia may have a detrimental effect on disease progression in PD in a sex-specific manner.

Parkinsonism and cerebrovascular disease

The relationship between cerebrovascular disease and parkinsonism is commonly seen in everyday clinical practice but remains ill-defined and under-recognised with little guidance for the practising neurologist. We attempt to define this association and to illustrate key clinical, radiological and pathological features of the syndrome of Vascular Parkinsonism (VaP). VaP is a major cause of morbidity in the elderly associated with falls, hip fractures and cognitive impairment. Although acute parkinsonism is reported in the context of an acute cerebrovascular event, the vast majority of VaP presents as an insidious syndrome usually in the context of vascular risk factors and radiological evidence of small vessel disease. There may be an anatomic impact on basal ganglia neuronal networks, however the effect of small vessel disease (SVD) on these pathways is not clear. There are now established reporting standards for radiological features of SVD on MRI. White matter hyperintensities and lacunes have been thought to be the representative radiological features of SVD but other features such as the perivascular space are gaining more importance, especially in context of the glymphatic system. It is important to consider VaP in the differential diagnosis of Parkinson disease (PD) and in these situations, neuroimaging may offer diagnostic benefit especially in those patients with atypical presentations or refractoriness to levodopa. Proactive management of vascular risk factors, monitoring of bone density and an exercise program may offer easily attainable therapeutic targets in PD and VaP. Levodopa therapy should be considered in patients with VaP, however the dose and effect may be different from use in PD. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna.

Quantitative Evaluation of Gastrocnemius Medialis Stiffness During Passive Stretching Using Shear Wave Elastography in Patients with Parkinson's Disease: A Prospective Preliminary Study

Objective

To prospectively investigate the feasibility of shear wave elastography (SWE) as a new quantitative and objective method for evaluating the stiffness of the gastrocnemius medialis (GM) muscle during passive stretching in patients with Parkinson's disease (PD).

Materials and Methods

SWE of the GM muscle was performed in 28 patients with PD [13 female and 15 male; mean age ± standard deviation (SD): 63.0 ± 8.5 years] and 12 healthy controls (5 female and 7 male; mean age ± SD: 59.3 ± 6.4 years) during passive ankle rotation. A Young's modulus-ankle angle curve was constructed. The GM slack angle and baseline Young's modulus (E₀) were compared between the markedly symptomatic and mildly symptomatic sides of patients with PD, and healthy controls. Additionally, the correlation between the GM slack angle and the severity of rigidity, and the observer reproducibility of SWE in determining the GM slack angle were evaluated.

Results

The GM slack angle was smaller on both the markedly and mildly symptomatic sides in patients with PD than in healthy controls (mean ± SD of −29.13° ± 3.79° and −25.65° ± 3.39°, respectively, vs. −21.22° ± 3.52°; p < 0.001 and p = 0.006, respectively). Additionally, in patients with PD, the GM slack angle on the markedly symptomatic side was smaller than that on the mildly symptomatic side (p = 0.003). The E₀ value was lower on both the markedly and mildly symptomatic sides in patients with PD than in healthy controls (mean ± SD of 10.11 ± 2.85 kPa and 10.08 ± 1.88 kPa, respectively, vs. 12.23 ± 1.02 kPa; p = 0.012 and p < 0.001, respectively). However, no significant difference was found between the markedly and mildly symptomatic sides in patients with PD (p = 0.634). A negative linear relationship was observed between the GM slack angle and lower limb rigidity score on the markedly symptomatic side in patients with PD (r = −0.719; p < 0.001). The intraclass correlation coefficients for observer reproducibility of SWE ranged from 0.880 to 0.951.

Conclusion

The slack angle determined by SWE may be a useful quantitative and reproducible method for evaluating muscle stiffness in patients with PD.

The Impact of Dietary Intake and Physical Activity on Body Composition in Parkinson's Disease

BACKGROUND

Skeletal muscle loss has been associated with declining physical performance and a negative prognostic effect on falls, disability, and mortality risk in Parkinson's disease.

OBJECTIVES

We aimed to analyze the clinical correlates associated with skeletal muscle wasting in Parkinson's disease.

METHODS

This was a cross-sectional, case-control, observational study. We collected information on dietary intake with a 24-hour recall questionnaire, body composition with bioelectrical impedance, motor severity with the Unified Parkinson's disease Rating Scale, and physical activity with the Global Physical Activity Questionnaire. We used multivariate linear regression analysis to analyze the sociodemographic and clinical correlates associated with skeletal muscle loss after adjusting for confounding variables.

RESULTS

Forty-three patients with Parkinson's disease and 21 matched family members were included. Patients and family members had similar body composition, anthropometrics, and nutritional parameters. Advanced patients had similar nutrient intakes compared to patients with mild-to-moderate Parkinson's disease. In the multivariate linear regression analysis, female patients with low physical activity and low energy intake were more likely to have skeletal muscle loss.

CONCLUSIONS

Skeletal muscle wasting is a complex multifactorial problem. Dietary strategies and physical exercise should be recommended, especially to females with Parkinson's disease, to prevent significant skeletal muscle wasting.

Claims-Based Frailty and Outcomes: Applying an Aging Measure to Older Adults with Parkinson's Disease

BACKGROUND

Frailty is a geriatric syndrome with negative health impacts not captured by comorbidity and disability alone. The prevalence of frailty in Parkinson's disease (PD) has been described, but data on frailty-associated outcomes are limited.

OBJECTIVE

To describe the level of frailty and investigate the association between frailty and outcomes in a Medicare sample of persons diagnosed with PD.

METHODS

We used the claims-based frailty index to assess frailty in a cohort of Medicare beneficiaries with PD in 2013. Frailty was categorized as non-frail/pre-frail, mildly frail, moderately frail, and severely frail. Adjusted logistic regression models examined the relationship between frailty and mortality, hospitalization, emergency department visits, and fall-related injuries through 2014.

RESULTS

Of 62,786 beneficiaries with PD in 2013, 55.3% were frail. Frail individuals were more likely to be female, older, Black, metropolitan dwelling, without neurologist care, nursing facility residents, or multimorbid. The average daily levodopa equivalent dose initially increased, then decreased from the pre-frail to the severely frail groups. Compared to non-frail/pre-frail persons, severely frail persons had higher adjusted odds of 1-year mortality (AOR 2.74, 95% CI 1.98, 3.78), hospitalization (AOR 2.34, 95% CI 1.74, 3.14), emergency department visits (AOR 2.97, 95% CI 2.14, 4.13), and fall-related injury (AOR 1.43, 95% CI 0.90, 2.26).

CONCLUSIONS

Frailty is common and differentially distributed among older adults with PD. Frailty in PD is associated with adverse health outcomes and death. Observational study analyses may benefit from adjustment for frailty; claims-based frailty surveillance may identify vulnerable PD patients in health system, registry, or administrative data. © 2021 International Parkinson and Movement Disorder Society.

Prevalence of malnutrition/malnutrition risk and nutrition-related risk factors among patients with Parkinson's disease: systematic review and meta-analysis

INTRODUCTION

The clinical symptoms and nutritional status of patients with Parkinson's disease (PwP) are interrelated, and the clinical outcomes in malnourished patients are often poor. Only a few studies have reviewed the prevalence of malnutrition and nutrition-related risk factors in PwP.

OBJECTIVE

To explore the prevalence of malnutrition/ malnutrition risk among PwP, and estimate nutrition-related risk factors.

METHODS

PubMed, EMBASE, and Cochrane Library were systematically searched. Literatures published between 1 January 1995 and 1 November 2020, subjects were patients with idiopathic PD underwent Mini Nutritional Assessment (MNA) were included.

RESULT

Sixteen articles, including 1650 PwP from 13 countries/regions, were included in the meta-analysis. The prevalence of malnutrition and malnutrition risk were 8.8% (Confidence interval [CI] 95%, 5.3%-12.2%) and 35.3% (CI 95%, 29.0%-41.7%), and the prevalence of nutritional disorders was 42.3% (CI 95%, 33.7%-51%). The prevalence of malnutrition in developing countries was higher than that in the developed countries. Meta-analysis reveals there were significant differences in the course of the disease (0.88 years; 95% CI, 0.26-1.50), levodopa equivalent daily dose (LEDD; 60.77 mg/day; 95% CI, 2.7-118.8), Hoehn and Yahr (H&Y) staging (0.323; CI 95%, 0.164-0.482), and unified Parkinson's disease rating scale (UPDRS) scores (total: 13.66, CI 95%: 10.57-16.75 and part III: 5.52, CI 95%: 3.79-7.25) between normal and nutritional disorder groups.

CONCLUSIONS

Malnutrition/malnutrition risk prevalence in PwP are high. The duration of the disease, LEDD, H&Y staging, and UPDRS score (part III and total) may be nutrition-related risk factors in PwP.

Osteoporosis in Parkinson's Disease: Relevance of Distal Radius Dual-Energy X-Ray Absorptiometry (DXA) and Sarcopenia

Osteoporotic fractures are common in Parkinson's disease (PD). Standard dual-energy X-ray absorptiometry (DXA) measuring bone mineral density (BMD) at the femoral neck and lumbar spine (central sites) has suboptimal sensitivity in predicting fracture risk in the general population. An association between sarcopenia and osteoporosis in PD has not been studied. We compared BMD and osteoporosis prevalence in PD patients vs controls; determined the osteoporosis detection rates using central alone vs central plus distal radius DXA; and analyzed factors (in particular, sarcopenia) associated with osteoporosis. One hundred and fifty-six subjects (102 patients with PD, 54 spousal/sibling controls) underwent femoral neck-lumbar spine-distal radius DXA. Seventy-three patients and 46 controls were assessed for sarcopenia using whole-body DXA and handgrip strength. Patients underwent clinical and serum biochemical evaluations. PD patients had significantly lower body mass index compared to controls. After adjustment for possible confounders, distal radius BMD and T-scores were significantly lower in PD patients compared to controls, but not at the femoral neck/lumbar spine. With distal radius DXA, an additional 11.0% of patients were diagnosed with osteoporosis (32.0% to 43.0%), vs 3.7% in controls (33.3% to 37.0%) additionally diagnosed; this increase was largely driven by the markedly higher detection rate in female PD patients. Female gender (adjusted odds ratio [OR_adjusted] = 11.3, 95% confidence interval [CI]: 2.6-48.6) and sarcopenia (OR_adjusted = 8.4, 95% CI: 1.1-64.9) were independent predictors for osteoporosis in PD. Distal radius DXA increased osteoporosis detection, especially in female PD patients, suggesting that diagnostic protocols for osteoporosis in PD could be optimized. A close association between osteoporosis and sarcopenia was documented for the first time in PD, which has important implications for clinical management and future research.

Changes in Body Composition Before and After Parkinson's Disease Diagnosis

BACKGROUND

Weight loss is common in Parkinson's disease (PD). However, little is known about when it starts, how PD changes as it progresses, and whether there is a differential loss of lean or fat mass. The objective of this study was to examine how body composition changes before and after PD diagnosis.

METHODS

In the Health, Aging, and Body Composition study (n = 3075; age range, 70-79 years), body composition was assessed using dual-energy x-ray absorptiometry on an annual or biennial basis from year 1 to year 10. For each PD case each year, we calculated the difference between their actual body composition measures and expected values had they not developed PD. Using linear mixed models with crossed random effects, we further examined the trend of change in body composition measures before and after PD diagnosis.

RESULTS

A total of 80 PD cases were identified in this cohort. Compared with their expected values, PD cases began to lose total and fat mass about 6-7 years before diagnosis, although the differences were not statistically significant until 3-5 years after diagnosis. The loss was substantial and persistent, with statistically significant trends of loss for total body mass (P = 0.008), fat mass (P = 0.001), and percentage fat (P < 0.001). In comparison, lean mass was stable throughout the follow-up (P = 0.16). Overall, 96% of the body mass loss in PD cases was from the loss of fat mass.

CONCLUSIONS

In this longitudinal analysis with objective measures of body composition, we found persistent weight loss in PD cases, predominantly in fat mass, starting a few years before diagnosis. © 2021 International Parkinson and Movement Disorder Society.

Skeletal muscle loss and body composition in progressive supranuclear palsy: A retrospective cross-sectional study

INTRODUCTION

Skeletal muscle mass loss has been associated with decreased physical performance; however, the body composition characteristics in progressive supranuclear palsy (PSP) are not well understood. We investigated body composition parameters, focusing on skeletal muscle mass, in patients with PSP and compared them with those of healthy older adults.

METHODS

This retrospective cross-sectional study included 39 patients with PSP and 30 healthy older adults (control group). Using a multi-frequency bioelectrical impedance analysis, we measured the skeletal mass index (SMI), basal metabolism, extracellular water/total body water ratio (ECW/TBW), and body fat percentage and examined the relationship between SMI and age, body mass index (BMI) and other body composition parameters.

RESULTS

The PSP group had a higher rate of low muscle mass (56.4%) than the control group (10.0%), although the ages and BMIs were similar. The leg SMI was lower for the PSP group, while the ECW/TBW was higher for the PSP group. The basal metabolism was lower for the PSP group than for the controls but only in the women. The basal metabolism and BMI showed a significant correlation with SMI in the PSP group. There was a significant correlation between SMI and age, ECW/TBW, and body fat percentage in the PSP group but only in the women.

CONCLUSION

This study is the first to show that a high proportion of patients with PSP have low muscle mass. We showed differences in terms of sex in muscle mass loss in women with PSP, which was associated with inactivity and aging.

Frailty in Parkinson's disease: A systematic review and meta-analysis

INTRODUCTION

Frailty and Parkinson's disease (PD) are common conditions that increase with age. Independently, frailty and PD lead to increased morbidity and mortality for patients. Few studies report on frailty in patients with PD. We performed a systematic review and meta-analysis of the prevalence, associations and outcomes of frailty in persons with PD.

METHODS

We searched four electronic databases and grey literature from inception to May 19, 2020, for articles which reported the prevalence, associations and outcomes of frailty in persons with PD.

RESULTS

One-thousand and sixty-three citations were identified, of which 127 articles were reviewed. Thirty studies were included. Twenty-eight studies were observational and the settings varied including 25 community and 5 inpatient studies.The most common frailty screening measures were the frailty phenotype and clinical frailty scale. The prevalence of frailty in PD using the FP was 0.38 (0.24-0.55) with I2 = 92.6% (p < 0.01). Frailty was associated with recurrent falls, cognitive impairment, dementia, orthostatic hypotension, fatigue, hallucinations, nursing home placement, dependency in activities of daily living and in-patient mortality. PD disease duration, motor impairment, non-tremor dominant PD (postural instability/gait difficulty dominant phenotype) and total daily levodopa dose were associated with frailty.

CONCLUSION

Frailty is common in PD. There is no agreed upon tool for identifying frailty, however, the importance of its identification is apparent given the high prevalence and the association between frailty and adverse outcomes in persons with PD. Future studies are required to guide clinicians in how best to identify and manage frail patients with PD.

Association of small intestinal bacterial overgrowth with Parkinson's disease: a systematic review and meta-analysis

Objective

Parkinson’s disease (PD) is the second most prevalent neurodegenerative disease after Alzheimer's disease (AD) worldwide. The prevalence of small intestinal bacterial overgrowth (SIBO) in PD patients is high. We conducted this comprehensive systematic review and meta-analysis to determine the association between SIBO and PD.

Methods

A comprehensive literature search of the PubMed, Cochrane Library and EMBASE databases was performed to identify studies correlating SIBO with PD. Studies were screened, and relevant data were extracted and analysed. We calculated the pooled prevalence of SIBO in all individuals with PD and compared the prevalence of SIBO between the two groups to calculate an odds ratio (OR) and 95% confidence interval (CI). Egger’s test was performed to assess publication bias.

Results

Eleven studies with 973 participants met the inclusion criteria. The pooled prevalence of SIBO in patients with PD was 46% (95% CI 36–56). A random-effects model was applied given the heterogeneity (I² = 83%) detected among the studies. Egger’s test indicated no publication bias (p = 0.0657). Subgroup analyses showed that the prevalence of SIBO was greater in studies including patients diagnosed using the lactulose hydrogen breath test (LBT) (51%, 95% CI 37–65) than in those including patients diagnosed using the glucose hydrogen breath test (GBT) (35%, 95% CI 20–50), and the prevalence of SIBO in PD was highest (55%, 95% CI 38–72) in patients diagnosed by the LBT and GBT. The prevalence of SIBO was 52% (95% CI 40–64) among patients from Western countries and 33% (95% CI 22–43) among patients from Eastern countries. The pooled OR of SIBO in PD patients compared with healthy controls was 5.22 (95% CI 3.33–8.19, p < 0.00001). We did not identify an obvious predictor of SIBO in PD patients.

Conclusion

In conclusion, our meta-analysis found a strong association between SIBO and PD with approximately half of PD patients testing positive for SIBO. These relationships significantly differed based on diagnostic test and geographic area.

Frailty and Prodromal Parkinson's Disease: Results From the HELIAD Study

BACKGROUND

To investigate the association between frailty, Parkinson's disease (PD), and the probability of prodromal Parkinson's disease (prodromal PD) in Greek community-dwelling older individuals.

METHODS

Parkinson's disease diagnosis was reached through standard clinical research procedures. Probability of prodromal PD was calculated according to the International Parkinson and Movement Disorder Society's research criteria for PD-free participants. Frailty was evaluated according to definitions of the phenotypic and multidomain approach. Logistic and linear regression models were performed to investigate associations between frailty (predictor) and the probability of prodromal PD, either continuous or dichotomous (≥30% probability score), or PD (outcome).

RESULTS

Data from 1765 participants aged 65 and older were included in the present analysis. Parkinson's disease and prodromal PD prevalence were 1.9% and 3.0%, respectively. Compared to nonfrail participants, those who were frail, as identified with either the Fried frailty phenotype or Frailty Index had approximately 4 (odds ratio [OR] 4.09, 95% confidence interval [CI] 1.54-10.89) and 12 times (OR 12.16, 95% CI 5.46-27.09) higher odds of having a PD diagnosis, respectively. Moreover, compared to the nonfrail, frail participants as identified with either the Fried frailty phenotype or Frailty Index had 2.8 (OR 2.83, 95% CI 1.09-7.37) and 8.3 times (OR 8.39, 95% CI 4.56-15.42) higher odds of having possible/probable prodromal PD, respectively.

CONCLUSIONS

Frailty status was associated with prodromal PD and PD, suggesting common characteristics or underlying mechanisms of these conditions. Although prospective studies are warranted, acknowledging the possible association of frailty, PD, and prodromal PD may improve their clinical management.

The Association Between Frailty and Parkinson's Disease in the ReSPOnD Trial

Background

Frailty and Parkinson’s disease (PD) are both highly prevalent in older people, but few studies have studied frailty in people with Parkinson’s. Identifying frailty in this population is vital, to target new interventions to those who would most benefit.

Methods

Data were collected as part of the double-blind randomised controlled rivastigmine to stabilise gait ReSPonD trial in 130 people with Hoehn and Yahr 2–3, idiopathic PD who had fallen in the year prior to enrolment. Individuals were assessed at baseline and followed up at eight months, including determination of frailty status.

Results

120 patients attended for follow-up. At follow-up, the mean (SD) age was 70.2 years (8.0), MDS-UPDRS total score 91.5 (29.1), and MDS-UPDRS motor score (Part III) 42.7 (14.8). Median disease duration was 9.2 years (IQR 4.6 to 13.1), Geriatric Depression Score 4 (IQR 2 to 6). Using the Fried frailty criteria, 31 (26%) were frail and 70 (58%) pre-frail. In univariable analysis, being female, higher depression score, and MDS-UPDRS score were associated with greater frailty. Using ordinal regression, in the multivariable model, being female (odds ratio [OR] 3.10, 95%CI 1.53 to 6.26, p=.002), higher total MDS-UPDRS score (OR 2.02, 95%CI 1.42 to 2.87, p<.0001) and higher depression (OR 1.47, 95%CI 1.05 to 2.06, p=.03) were associated with higher number of frailty markers.

Conclusion

There was a high prevalence (84%) of pre-frail and frail individuals in patients participating in this RCT. Future research should determine the optimum tool to assess frailty in this at-risk population, and delineate the association between Parkinson’s, frailty, and health outcomes.

Sarcopenia in Patients With Parkinson's Disease: A Systematic Review and Meta-Analysis

Background: Parkinson's disease (PD) and sarcopenia are two common diseases in aging people. To date, the prevalence of sarcopenia in PD patients and the relationship between clinical features and sarcopenia in PD patients are not clear. The aim of the study was to (1) assess the prevalence of sarcopenia in PD patients and (2) reveal the clinical features between PD patients with and without sarcopenia. Method: A systematic review was carried out through screening PubMed, EMBASE, and Cochrane database in May 2020. All study designs (case-control, cohort, and cross-sectional studies) were eligible for meta-analysis. Data of patients' characteristics, sarcopenia criteria, sarcopenia prevalence, and sarcopenia measures were retrieved. The primary outcome was estimated prevalence of sarcopenia by a pooled prevalence (%) and its 95% confidence interval (CI), using a random-effects model. The secondary outcome was the differences in clinical features between PD patients with and without sarcopenia by meta-analysis. Included articles were assessed for risk of bias. Potential sources of variation were investigated by using subgroup analyses and meta-regression. Result: Ten studies were included in the review. Among them, nine were cross-sectional studies, and one was a prospective cohort study. Age of participants with PD in the studies ranged from 51.1 to 80.7 years. The estimated prevalence of sarcopenia ranged from 6 to 55.5%. The random-effects pooled prevalence was 29% (95% CIs: 0.18-0.40). When only studies at low risk of bias were considered, pooled prevalence decreased to 17% (95% CIs: 0.02-0.33), with still high heterogeneity. The incidence of falls in PD patients with sarcopenia was higher than that in PD patients without sarcopenia. There was no difference in sex ratio between PD patients with and without sarcopenia. Conclusion: Sarcopenia seems to be common in patients with PD. Early assessment of sarcopenia should be implemented in PD to avoid fall and disability.

Operationalization of a frailty index in patients with multiple sclerosis: A cross-sectional investigation

BACKGROUND

Frailty is an age-related status of increased vulnerability to stressors caused by the accumulation of multiple health deficits. This construct may allow to capture the clinical complexity of patients with multiple sclerosis (MS).

OBJECTIVE

To investigate the relationship between frailty and the clinical manifestations of MS.

METHODS

Patients with MS were consecutively enrolled at five tertiary dedicated services. Disability and fatigue were assessed. The phenotypes of MS were also identified. Frailty was measured using a frailty index (FI), computed by cumulatively considering 42 age-related multidimensional health deficits.

RESULTS

Overall, 745 MS patients (mean age = 48.2 years, standard deviation = 11.7 years; women 68%) were considered. The median FI value was 0.12 (interquartile range = 0.05-0.19) and the 99th percentile was 0.40. FI scores were associated with MS disease duration, disability, fatigue, as well as with the number of previous disease-modifying treatments and current symptomatic therapies. A logistic regression analysis model showed that FI score was independently associated with the secondary progressive phenotype.

CONCLUSION

Frailty is significantly associated with major characteristics of MS. The findings of the present cross-sectional investigation should be explored in future longitudinal studies.

Gut Microbial Ecosystem in Parkinson Disease: New Clinicobiological Insights from Multi-Omics

OBJECTIVE

Gut microbiome alterations in Parkinson disease (PD) have been reported repeatedly, but their functional relevance remains unclear. Fecal metabolomics, which provide a functional readout of microbial activity, have scarcely been investigated. We investigated fecal microbiome and metabolome alterations in PD, and their clinical relevance.

METHODS

Two hundred subjects (104 patients, 96 controls) underwent extensive clinical phenotyping. Stool samples were analyzed using 16S rRNA gene sequencing. Fecal metabolomics were performed using two platforms, nuclear magnetic resonance (NMR) spectroscopy and liquid chromatography-mass spectrometry.

RESULTS

Fecal microbiome and metabolome composition in PD was significantly different from controls, with the largest effect size seen in NMR-based metabolome. Microbiome and NMR-based metabolome compositional differences remained significant after comprehensive confounder analyses. Differentially abundant fecal metabolite features and predicted functional changes in PD versus controls included bioactive molecules with putative neuroprotective effects (eg, short chain fatty acids [SCFAs], ubiquinones, and salicylate) and other compounds increasingly implicated in neurodegeneration (eg, ceramides, sphingosine, and trimethylamine N-oxide). In the PD group, cognitive impairment, low body mass index (BMI), frailty, constipation, and low physical activity were associated with fecal metabolome compositional differences. Notably, low SCFAs in PD were significantly associated with poorer cognition and low BMI. Lower butyrate levels correlated with worse postural instability-gait disorder scores.

INTERPRETATION

Gut microbial function is altered in PD, characterized by differentially abundant metabolic features that provide important biological insights into gut-brain pathophysiology. Their clinical relevance further supports a role for microbial metabolites as potential targets for the development of new biomarkers and therapies in PD. ANN NEUROL 2021;89:546-559.

Gastrointestinal dysfunction in the synucleinopathies

Interest in gastrointestinal dysfunction in Parkinson's disease has blossomed over the past 30 years and has generated a wealth of investigation into this non-motor aspect of the disorder, research that has encompassed its pathophysiology, its clinical features, and its impact on quality of life. The question of gastrointestinal dysfunction in the other synucleinopathies has not received nearly as much attention, but information and knowledge are growing. In this review, the current knowledge, controversies, and gaps in our understanding of the pathophysiology of gastrointestinal dysfunction in Parkinson's disease and the other synucleinopathies will be addressed, and extended focus will be directed toward the clinical problems involving saliva management, swallowing, gastric emptying, small intestinal function, and bowel function that are so problematic in these disorders.

Leptin levels in patients with Parkinson's disease: A systematic review and meta-analysis

BACKGROUND AND AIMS

The exact mechanism of Parkinson's disease (PD) is not fully understood yet, but it is suggested that inflammation is one of its contributing factors. Among several inflammatory factors, adipokines, especially leptin may have a great role in this mechanism; since it is not only causing inflammation, but it can also play other roles in the body that may contribute to the symptoms described for PD. Regarding the contradictions in the association of serum leptin levels with Parkinson's disease, a systematic review and meta-analysis was performed to have a more accurate estimation of this relationship.

METHODS

Published literature was obtained by searching PubMed, Embase, Cochrane Library, Scopus, Ovid, ProQuest and Google Scholar. Random-effect model analysis was used to calculate pooled standard mean difference (SMD) with 95% confidence interval (CI). Heterogeneity was tested with the heterogeneity statistic Q and quantified using I². Newcastle-Ottawa scale was used to assess the study quality.

RESULTS

Six studies including a total number of 198 PD patients and 182 controls were finally included in the meta-analysis. Serum leptin levels in PD patients were non-significantly lower than those in control group (SMD = -0.40 ng/ml, 95% CI -2.33-1.53). Subgroup analyses revealed that serum leptin levels of PD patients and controls in either females or males didn't show any significant difference.

CONCLUSIONS

This meta-analysis revealed that leptin level doesn't show any significant difference between PD patients and healthy controls, even when taking the participants' gender into consideration.

Emergency Room Visit Prevention for Older Patients with Parkinsonism in a Geriatric Clinic

BACKGROUND

Older persons with parkinsonism (PWP) are at high risk for hospitalization and adverse outcomes. Few effective strategies exist to prevent Emergency Department (ED) visits and hospitalization. The interdisciplinary Geriatrics Clinic for Parkinson's ("our clinic") was founded to address the complexity of parkinsonism in older patients, supported by a pharmacist-led telephone intervention (TI) service. Our primary objective was to study whether TI could avert ED visits in older PWP.

METHODS

Using a prospective, observational cohort, we collected data from all calls in 2016, including who initiated and reasons for the calls, patient demographics, number of comorbidities and medications, diagnoses, duration of disease, and intervention provided. Calls with intention to visit ED were classified as "crisis calls". Outcome of whether patients visited ED was collected within 1 week, and user satisfaction by anonymous survey within 3 weeks.

RESULTS

We received 337 calls concerning 114 patients, of which 82 (24%) were "crisis calls". Eighty-one percent of calls were initiated by caregivers. Ninety-three percent of "crisis calls" resolved without ED visit after TI. The main reasons for "crisis calls" were non-motor symptoms (NMS) (39%), adverse drug effects (ADE) (29%), and motor symptoms (18%). Ninety-seven percent of callers were satisfied with the TI.

CONCLUSION

Pharmacist-led TI in a Geriatrics Clinic for Parkinson's was effective in preventing ED visits in a population of older PWP, with high user satisfaction. Most calls were initiated by caregivers. Main reasons for crisis calls were NMS and ADE. These factors should be considered in care planning for older PWP.

Determinant factors of sarcopenia in individuals with Parkinson's disease

OBJECTIVE

Evaluate the occurrence of sarcopenia and determinant factors in individuals with Parkinson's disease (PD) in a city in northeastern Brazil.

METHODS

Case series with 77 men and women (adults and older adults) with PD. The risk of sarcopenia was determined using the SARC-F and SARC-CalF screening tools. The diagnosis of sarcopenia was based on the new consensus published by the European Working Group on Sarcopenia in Older People (EWGSOP2). Sarcopenic obesity was diagnosed based on the criteria proposed by Stenholm. Disease stage and severity were determined using the Hoehn and Yahr scale and the Unified Parkinson Disease Rating Scale, respectively.

RESULTS

The prevalence of sarcopenia was 19.5% and was associated with age, poor performance on activities of daily living and poor nutritional status. No significant association was found between the SARC-F score and the diagnosis of sarcopenia. The main factors that determined the variation in the parameters for the diagnosis of sarcopenia in the present sample were age, disease severity, body weight, and SARCF score.

CONCLUSION

Despite the low prevalence in the present study, sarcopenia progresses with the worsening of the nutritional status and functional capacity of individuals with PD. Further studies are needed on the factors involved in the genesis of sarcopenia. The SARC-F questionnaire is related to parameters for the diagnosis and severity of sarcopenia as well as the severity of PD.

Parkinson's disease and the non-motor symptoms: hyposmia, weight loss, osteosarcopenia

Non-motor symptoms (NMSs) are common in Parkinson's disease (PD) and can precede, sometimes for several years. NMSs include, other than gastrointestinal symptoms like constipation and dysphagia, also hyposmia, weight loss and osteosarcopenia. These three NMSs seem to be inter-related and affect patients' health and quality of life. Unfortunately, patients with these symptoms usually are not initially seen by a neurologist, and by the time they are consulted, nearly ~ 80% of the dopaminergic neurons in the substantia nigra have died. To date, no guidelines exist for screening, assessment and management of NMSs in general. A better understanding of these specific NMSs, likely in the context of others, will make it possible to approach and optimise the treatment of the motor symptoms thereby enhancing the welfare of PD patients. Identifying the NMSs could be very helpful, and among them, hyposmia, weight loss and osteosarcopenia may play an important role in solving the limitations in the diagnosis of PD. A strict collaboration between general practitioners, clinicians, geriatricians and neurologists can be one approach towards the diagnosis of pre-PD. Waiting until the motor symptoms develop and the patient is finally visited by the neurologist could be too late, considering the catastrophic prognosis of the disease.

Clinical Phenotype of LRRK2 R1441C in 2 Chinese Sisters

Pathogenic and risk variants in the LRRK2 gene are among the main genetic contributors to Parkinson's disease (PD) worldwide, and LRRK2-targeted therapies for patients with PARK-LRRK2are now entering clinical trials. However, in contrast to the LRRK2 G2019S mutation commonly found in Caucasians, North-African Arabs, and Ashkenazi Jews, relatively little is known about other causative LRRK2 mutations, and data on genotype-phenotype correlations are largely lacking. This report is from an ongoing multicentre study in which next-generation sequencing-based PD gene panel testing has so far been conducted on 499 PD patients of various ethnicities from Malaysia. We describe 2 sisters of Chinese ancestry with PD who carry the R1441C mutation in LRRK2 (which in Asians has been reported in only 2 Chinese patients previously), and highlight interesting clinical observations made over a decade of close follow-up. We further explored the feasibility of using a brief, expert-administered rating scale (the Clinical Impression of Severity Index; CISI-PD) to capture data on global disease severity in a large (n = 820) unselected cohort of PD patients, including severely disabled individuals typically excluded from research studies. All patients in this study were managed and evaluated by the same PD neurologist, and these data were used to make broad comparisons between the monogenic PD cases versus the overall "real world" PD cohort. This report contributes to the scarce literature on R1441C PARK-LRRK2, offering insights into natural history and epidemiological aspects, and provides support for the application of a simple and reliable clinical tool that can improve the inclusion of under-represented patient groups in PD research.

Progressive and accelerated weight and body fat loss in Parkinson's disease: A three-year prospective longitudinal study

INTRODUCTION

Although weight loss is common in Parkinson's disease (PD), longitudinal studies assessing weight and body composition changes are limited.

METHODS

In this three-year longitudinal study, 125 subjects (77 PD patients and 48 spousal/sibling controls) underwent clinical, biochemical and body composition assessments using dual-energy X-ray absorptiometry.

RESULTS

Patients were older than controls (65.6 ± 8.9 vs. 62.6 ± 7.1, P = 0.049), with no significant differences in gender, comorbidities, dietary intake and physical activity. Clinically significant weight loss (≥5% from baseline weight) was recorded in 41.6% of patients, with a doubling of cases (6.5 to 13.0%) classified as underweight at study end. Over three years, patients demonstrated greater reductions in BMI (mean -1.2 kg/m², 95%CI-2.0 to -0.4), whole-body fat percentage (-2.5% points, 95%CI-3.9 to -1.0), fat mass index (FMI) (-0.9 kg/m², 95%CI-1.4 to -0.4), visceral fat mass (-0.1 kg, 95%CI-0.2 to 0.0), and subcutaneous fat mass (-1.9 kg, 95%CI-3.4 to -0.5) than in controls, with significant group-by-time interactions after adjusting for age and gender. Notably, 31.2% and 53.3% of patients had FMI<3rd (severe fat deficit) and <10th centiles, respectively. Muscle mass indices decreased over time in both groups, without significant group-by-time interactions. Multiple linear regression models showed that loss of body weight and fat mass in patients were associated with age, dyskinesia, psychosis and constipation.

CONCLUSIONS

We found progressive loss of weight in PD patients, with greater loss of both visceral and subcutaneous fat, but not muscle, compared to controls. Several associated factors (motor and non-motor disease features) were identified for these changes, providing insights on possible mechanisms and therapeutic targets.

The feasibility of muscle mitochondrial respiratory chain phenotyping across the cognitive spectrum in Parkinson's disease

INTRODUCTION

There has been little work on the relationship between sarcopenia, a progressive skeletal muscle disorder, and age-related neurodegenerative diseases such as Parkinson's disease (PD).

OBJECTIVES

We aimed to determine: 1) the feasibility of characterizing skeletal muscle across a range of cognitive function in PD; 2) if muscle mitochondrial respiratory chain (MRC) function and content are preserved in older adults with PD.

METHODS

Sarcopenia was defined using handgrip strength, chair rise and bioimpedance analysis. MRC function was assessed using phosphorous magnetic resonance spectroscopy (MRS) by estimating τ_1/2 PCr (s) (phosphocreatine half-time recovery) in the calf muscles following a bout of aerobic exercise. Biopsy of the vastus lateralis muscle was performed, and MRC content assessed by fluorescent immunohistochemistry for porin and components of MRC Complexes I and IV.

RESULTS

Nine participants (78% male; mean age 79.9; PD duration 3.3 years) were recruited. Four had cognitive impairment. Six participants had probable sarcopenia. Eight participants completed MRS and had mean (SD) τ_1/2 PCr of 37.8 (7.6) seconds, suggesting preserved mitochondrial function. Muscle biopsies were obtained in all and the procedure was well tolerated. Porin Z-score, a proxy for mitochondrial mass, was lower than expected compared to controls (0-89% of fibres with low porin). There was a small amount of Complex I (0.16-4.59%) and Complex IV (0-3.79%) deficiency.

CONCLUSIONS

Detailed phenotyping, muscle biopsy and imaging was feasible and acceptable across a spectrum of cognitive function in PD. Sarcopenia was relatively common and may be associated with lower mitochondrial mass and low levels of MRC deficiency.

Frailty in ageing persons with multiple sclerosis

Background:

Recent progress in multiple sclerosis (MS) management has contributed to a greater life expectancy in persons with MS. Ageing with MS comes with unique challenges and bears the potential to greatly affect quality of life and socioeconomic burden.

Objectives:

To compare frailty in ageing persons with multiple sclerosis (pwMS) and controls; to correlate frailty with MS clinical characteristics.

Methods:

PwMS and controls over 50 years old were recruited in a cross-sectional study. Two validated frailty measures were assessed: the frailty index and the Fried’s phenotype. Several multiple linear regressions accounting for demographic and clinical characteristics were performed.

Results:

Eighty pwMS (57 females, mean age 58.5 ± 6 years old) and 37 controls (24 females, mean age 61 ± 6.5 years old) were recruited. Multivariable analysis identified significantly higher frailty index in pwMS (0.21 ± 0.12 vs 0.11 ± 0.08, p < 0.0001). Similarly, according to Fried’s phenotype, a significantly higher percentage of pwMS were frail compared to controls (28% vs 8%). In pwMS, frailty index was independently associated with expanded disability status scale (EDSS), comorbidities, education level and disease duration.

Conclusion:

Our results suggest that frailty can be routinely assessed in pwMS. Increased frailty in MS patients suggests that, along with MS therapeutics, a tailored multidisciplinary approach of ageing pwMS is needed.

Clinical implications of gastric complications on levodopa treatment in Parkinson's disease

Disorders of the gastrointestinal (GI) tract are common and distressing nonmotor symptoms of Parkinson's disease (PD) that can adversely affect levodopa absorption and lead to OFF periods, also known as motor fluctuations. Gastroparesis, which is primarily defined as delayed gastric emptying (DGE), and Helicobacter pylori infection, which is present with increased frequency in PD, are among the most common and important GI disorders reported in PD that may impair oral levodopa absorption and increase OFF time. Symptoms of gastroparesis include nausea, vomiting, postprandial bloating, fullness, early satiety, abdominal pain, and weight loss. DGE has been reported in a substantial fraction of individuals with PD. Symptoms of H. pylori infection include gastritis and peptic ulcers. Studies have found that DGE and H. pylori infection are correlated with delayed peak levodopa plasma levels and increased incidence of motor fluctuations. Therapeutic strategies devised to minimize the potential that gastric complications will impair oral levodopa absorption and efficacy in PD patients include treatments that circumvent the GI tract, such as apomorphine injection, levodopa intestinal gel delivery, levodopa inhalation powder, and deep brain stimulation. Other strategies aim at improving gastric emptying in PD patients, primarily including prokinetic agents.

Loss of high-temperature requirement protein A2 protease activity induces mitonuclear imbalance via differential regulation of mitochondrial biogenesis in sarcopenia

Cellular homeostasis requires tight coordination between nucleus and mitochondria, organelles that each possesses their own genomes. Disrupted mitonuclear communication has been found to be implicated in many aging processes. However, little is known about mitonuclear signaling regulator in sarcopenia which is a major contributor to the risk of poor health-related quality of life, disability, and premature death in older people. High-temperature requirement protein A2 (HtrA2/Omi) is a mitochondrial protease and plays an important role in mitochondrial proteostasis. HtrA2^mnd2(-/-) mice harboring protease-deficient HtrA2/Omi Ser276Cys missense mutants exhibit premature aging phenotype. Additionally, HtrA2/Omi has been established as a signaling regulator in nervous system and tumors. We therefore asked whether HtrA2/Omi participates in mitonuclear signaling regulation in muscle degeneration. Using motor functional, histological, and molecular biological methods, we characterized the phenotype of HtrA2^mnd2(-/-) muscle. Furthermore, we isolated the gastrocnemius muscle of HtrA2^mnd2(-/-) mice and determined expression of genes in mitochondrial unfolded protein response (UPR^mt ), mitohormesis, electron transport chain (ETC), and mitochondrial biogenesis. Here, we showed that HtrA2/Omi protease deficiency induced denervation-independent skeletal muscle degeneration with sarcopenia phenotypes. Despite mitochondrial hypofunction, upregulation of UPR^mt and mitohormesis-related genes and elevated total reactive oxygen species (ROS) production were not observed in HtrA2^mnd2(-/-) mice, contrary to previous assumptions that loss of protease activity of HtrA2/Omi would lead to mitochondrial dysfunction as a result of proteostasis disturbance and ROS burst. Instead, we showed that HtrA2/Omi protease deficiency results in different changes between the expression of nuclear DNA- and mitochondrial DNA-encoded ETC subunits, which is in consistent with their transcription factors, nuclear respiratory factors 1 and 2, and coactivator peroxisome proliferator-activated receptor γ coactivator 1α. These results reveal that loss of HtrA2/Omi protease activity induces mitonuclear imbalance via differential regulation of mitochondrial biogenesis in sarcopenia. The novel mechanistic insights may be of importance in developing new therapeutic strategies for sarcopenia.

Altered Body Composition and Increased Resting Metabolic Rate Associated with the Postural Instability/Gait Difficulty Parkinson's Disease Subtype

Background

Weight loss in Parkinson's disease (PD) patients is a common but poorly understood manifestation. Several studies have reported that weight changes could be related to motor symptoms, drug side effects, dysphagia, depression, and/or dementia. Weight loss in PD is not a benign phenomenon and it has several clinical and prognostic implications with increased morbidity and mortality. Thus, it is crucial to determine nutritional changes in PD patients in order to prevent malnutrition and improve their quality of life.

Objective

To compare body composition and resting metabolic rates between PD patients and controls.

Methods

A total of 64 PD patients and 52 controls were studied. The Hoehn-Yahr scale was used to determine the disease stage, clinical and epidemiological data were recorded from verbal questionnaire, Inbody S10® was used to collect corporal parameters, and FitMate system was used to assess the resting metabolic rate.

Results

No significant differences were found between both experimental groups in age, gender, height, cholesterol levels, and the presence of hypertension, diabetes, and hypo/hyperthyroidism. However, the PD group showed lower body fat mass, whole-body fat percentage, and greater resting metabolic rate compared to controls (p < 0.05), with no significant differences in musculoskeletal mass. Parkinson's disease postural instability/gait difficulty (PD-PIGD) subtype showed lower body fat parameters, increased fat-free mass, and higher resting metabolic rates.

Conclusions

These results suggest that PD patients present an increased resting metabolic rate associated with the postural instability/gait difficulty PD subtype, allowing a selective decrease of body fat mass and not musculoskeletal mass. Of note, several disease-related factors may contribute to this weight loss in PD patients, being a complex and multifactorial consequence. Our findings could likely be one of the many contributing factors. However, present findings may further add to our understanding of the phenomenon of weight loss in patients with PD.