Co-morbidities of persons dying of Parkinson's disease

Gut-Brain Axis Deregulation and Its Possible Contribution to Neurodegenerative Disorders

The gut-brain axis is an essential communication pathway between the central nervous system (CNS) and the gastrointestinal tract. The human microbiota is composed of a diverse and abundant microbial community that compasses more than 100 trillion microorganisms that participate in relevant physiological functions such as host nutrient metabolism, structural integrity, maintenance of the gut mucosal barrier, and immunomodulation. Recent evidence in animal models has been instrumental in demonstrating the possible role of the microbiota in neurodevelopment, neuroinflammation, and behavior. Furthermore, clinical studies suggested that adverse changes in the microbiota can be considered a susceptibility factor for neurological disorders (NDs), such as Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD), and amyotrophic lateral sclerosis (ALS). In this review, we will discuss evidence describing the role of gut microbes in health and disease as a relevant risk factor in the pathogenesis of neurodegenerative disorders, including AD, PD, HD, and ALS.

Prevalence of different types of wound infection in subjects with Parkinson's disease and total joint arthroplasty: A meta-Analysis

A meta-analysis study to assess the influence of Parkinson's disease (PD) on different types of wound infection (WI) in total joint arthroplasty (TJA) patients. A comprehensive literature examination till January 2023 was implemented and 1976 linked studies were appraised. The picked studies contained 76 661 subjects with TJA in the picked studies' baseline, 19 188 of them were PD, and 57 473 were non-PD. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of PD on different types of WI in TJA patients by the dichotomous and continuous styles and a fixed or random model. PD had a significantly higher postoperative surgical site WI (OR, 1.76; 95% CI, 1.15-2.67, P = .009), superficial WI (OR, 3.36; 95% CI, 1.41-7.99, P = .006), and periprosthetic WI (OR, 4.89; 95% CI, 2.13-11.22, P < .001) compared to the non-PD in TJA patients' post-surgery wounds. PD had a significantly higher postoperative surgical site WI, superficial WI, and periprosthetic WI compared to the non-PD in TJA patients' post-surgery wounds. Though precautions should be taken when commerce with the consequences since some of the picked studies for this meta-analysis was with low sample sizes.

Sociodemographic and Geographic Disparities in End-of-Life Health Care Intensity Among Medicare Beneficiaries With Parkinson Disease

Background and Objective

Current studies of end-of-life care in Parkinson disease (PD) do not focus on diverse patient samples or provide national views of end-of-life resource utilization. We determined sociodemographic and geographic differences in end-of-life inpatient care intensity among persons with PD in the United States (US).

Methods

This retrospective cohort study included Medicare Part A and Part B beneficiaries 65 years and older with a qualifying PD diagnosis who died between January 1, 2017, and December 31, 2017. Medicare Advantage beneficiaries and those with atypical or secondary parkinsonism were excluded. Primary outcomes included rates of hospitalization, intensive care unit (ICU) admission, in-hospital death, and hospice discharge in the last 6 months of life. Descriptive analyses and multivariable logistic regression models compared differences in end-of-life resource utilization and treatment intensity. Adjusted models included demographic and geographic variables, Charlson Comorbidity Index score, and Social Deprivation Index score. The national distribution of primary outcomes was mapped and compared by hospital referral region using Moran I.

Results

Of 400,791 Medicare beneficiaries with PD in 2017, 53,279 (13.3%) died. Of decedents, 33,107 (62.1%) were hospitalized in the last 6 months of life. In covariate-adjusted regression models using White male decedents as the reference category, odds of hospitalization was greater for Asian (AOR 1.38; CI 1.11-1.71) and Black (AOR 1.23; CI 1.08-1.39) male decedents and lower for White female decedents (AOR 0.80; CI 0.76-0.83). ICU admissions were less likely in female decedents and more likely in Asian, Black, and Hispanic decedents. Odds of in-hospital death was greater among Asian (AOR 2.49, CI 2.10-2.96), Black (AOR 1.11, CI 1.00-1.24), Hispanic (AOR 1.59; CI 1.33-1.91), and Native American (AOR 1.49; CI 1.05-2.10) decedents. Asian and Hispanic male decedents were less likely to be discharged to hospice. In geographical analyses, rural-dwelling decedents had lower odds of ICU admission (AOR 0.77; CI 0.73-0.81) and hospice discharge (AOR 0.69; CI 0.65-0.73) than urban-dwelling decedents. Nonrandom clusters of primary outcomes were observed across the US, with highest rates of hospitalization in the South and Midwest (Moran I = 0.134; p < 0.001).

Discussion

Most persons with PD in the US are hospitalized in the last 6 months of life, and treatment intensity varies by sex, race, ethnicity, and geographic location. These group differences emphasize the importance of exploring end-of-life care preferences, service availability, and care quality among diverse populations with PD and may inform new approaches to advance care planning.

Risk of myocardial infarction in Parkinson's disease: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Previous studies investigating cardiovascular disorders in patients with Parkinson's disease (PD) showed heterogeneous results regarding whether there is a higher or lower risk of myocardial infarction (MI) in these patients compared to the general population. Because of the inconsistency in findings, herein the aim was to perform a systematic review and meta-analysis to investigate the risk of MI in patients with PD.

METHODS

A comprehensive literature search was performed using four databases, PubMed, Web of Science, Scopus and Embase, in June 2022. Peer-reviewed observational studies comprising case-controls, cohort, cross-sectional and longitudinal studies that reported MI in the PD population were included.

RESULTS

After the screening, 20 studies with a total of 80,441 patients with PD and 802,857 controls were included in our qualitative and quantitative synthesis. The pooled estimated odds ratio for MI in PD patients compared to controls was 0.80 (95% confidence interval [CI] 0.56-1.05) which indicates that there is no association. The pooled prevalence of MI was 5% (95% CI 3%-7%) with a range of 1%-20% amongst patients with PD. The men (6%, 95% CI 1%-13%) and women (6%, 95% CI 1%-14%, Q = 29.27, I2 = 98.50%, p < 0.001) had similar MI prevalence.

CONCLUSION

This comprehensive systematic review and meta-analysis provide compelling evidence that PD is associated with a reduced risk of MI. Whilst the exact mechanism underlying this association remains to be fully elucidated, it is clear that certain risk factors for cardiac events appear to be less present in PD patients, which may serve as a protective factor. However, given the reports of increased risk for cerebrovascular events in PD patients, it is possible that the major risk factors for MI and cardiovascular accidents in this population differ. These findings have important implications for clinical management and further research in this area is warranted.

Facilitators and barriers to the delivery of palliative care to patients with Parkinson's disease: a qualitative study of the perceptions and experiences of stakeholders using the socio-ecological model

OBJECTIVE

Palliative care (PC) can improve the quality of life of Parkinson's disease (PD) patients and their carers. However, the impact of PC services on patients with PD remains unclear. This research was conducted to identify the barriers and facilitators influencing PC services for patients with PD based on the Social Ecological Model (SEM) framework.

METHODS

This research was conducted through semi-structured interviews, employing SEM to organize themes and identify potential solutions across multiple levels.

RESULTS

A total of 29 interviewees (5 PD clinicians, 7 PD registered nurses, 8 patients, 5 caregivers, and 4 policy makers) completed the interviews. Facilitators and barriers were identified according to the levels of the SEM. Several facilitators were identified, i.e., (1) individual level: the critical needs among PD patients and their relatives and the desire for PC knowledge among health professionals; (2) interpersonal level: social support; (3) organizational level: the investments towards systematization of PC; and nurses are the bridge between patients and doctors; (4) community level: the convenience of community services; and hospital-community-family-based services; (5) culture and policy level: existing policy.

CONCLUSION

The social-ecological model proposed in this study helps illuminate the complex and multilevel factors that may influence PC delivery to PD patients.

The effect of Parkinson's disease on total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

The purpose of this systematic review was to determine the effect of Parkinson's disease (PD) on clinical outcomes and complications after total knee arthroplasty (TKA). Our systematic review was conducted to answer the following questions: (1) does TKA negatively affect clinical outcomes in patients with PD? and (2) does TKA cause more complications in patients with PD?

METHODS

A rigorous and systematic approach was used, and each selected study was evaluated for methodological quality. Data on study design, total number of cases enrolled, follow-up duration, PD severity, clinical outcome, and complications after TKA were analyzed.

RESULTS

Fourteen studies were included. Nine studies reported clinical scores. TKA significantly increased knee and functional scores in the PD group. However, compared with knee and functional scores in the non-PD group, the increase in scores in the PD group was not statistically significant, but tended to be less than that in the non-PD group. Eleven studies reported complications. In six studies, there was no difference in the complication rate between the PD and non-PD group or did not include a control group. In five studies, the PD group had higher medical complication rates and similar or higher surgical complication rates than the non-PD group.

CONCLUSIONS

Patients with PD who underwent TKA showed satisfactory functional improvement and pain reduction. However, these outcomes were not as good as those in the non-PD group. The PD group had a higher probability of occurrence of medical complications than the non-PD group. Further, the PD group had a similar or higher surgical complication rate than the non-PD group.

Analysis of Parkinson's Disease Outpatient Counselling for Advance Directive Creation: A Cross-Sectional Questionnaire-Based Survey of German General Practitioners and Neurologists

A major proportion of people with Parkinson’s disease (PwP) in Germany has written an advance directive (AD). Unfortunately, these ADs are unclear for PD-specific endpoints. We previously established consensus-based recommendations for disease-specific content of an AD in PwP. However, the implementation of those recommendations and the consulting of AD creation and modification in PwP remains to be evaluated. This study aimed to investigate the practical use of PD-specific recommendations for ADs in outpatient settings. A total of 87 physicians (45 general practitioners (GPs) and 42 neurologists, 10% response rate) answered a self-constructed semiquantitative questionnaire. The participants were asked to evaluate the suggested PD-specific recommendations for ADs and the supply of palliative care in the outpatient setting. Overall, the vast majority of treating physicians agreed on the usefulness of the newly constructed PD-specific recommendations. Consultations to discuss information about PD-specific ADs were scarce with short durations. Only 24% of participating physicians implemented the PD-specific recommendations in their daily practice. GPs and neurologists agreed on the benefit of disease-specific recommendations for ADs. In future, a more general integration of these recommendations in routine care might improve specific AD creation of PwP and advanced care planning.

Parkinson’s disease, treatment choice and survival over time

•

Dopamine agonists were the preferred initiating treatment choice.

•

Dopamine agonist-users had lower risk for death compared to MAO-B-users.

•

Few patients had specialist health care contacts during the study period.

Objectives

Methods

Results

Conclusions

Rotigotine patch prescription in inpatients with Parkinson's disease: evaluating prescription accuracy, delirium and end-of-life use

BACKGROUND

Rotigotine patch, a trans-dermal dopamine agonist, is used acutely to replace oral dopaminergic medications for inpatients with Parkinson's disease where enteral routes are no longer available, and is also an option in end-of-life care where patients can no longer swallow. Concerns regarding acute use of Rotigotine include difficulty achieving dopaminergic equivalence, promotion of delirium/hallucinations and promotion of terminal agitation.

OBJECTIVE

our objectives were to establish: (i) accuracy of Rotigotine prescribing, (ii) rates of delirium/hallucinations and (iii) rates of terminal agitation.

METHOD

we retrospectively evaluated the use of Rotigotine in an inpatient population at a UK teaching hospital. Prescriptions between January 2018 and July 2019 were identified and inpatient records were analysed. OPTIMAL Calculator 2 was used as a gold standard for assessing conversion of oral dopaminergic medication to Rotigotine.

RESULTS

a total of 84 inpatients were included. 25 (30%) patients were prescribed the recommended dose of Rotigotine; 31 (37%) higher and 28 (33%) lower than recommended. A total of 15 of 41 (37%) patients with dementia and 22 of 49 (45%) patients with delirium before initiation of Rotigotine inappropriately received the higher dose; 20 (24%) patients developed new/worsening delirium and 8 (10%) patients developed new/worsening hallucinations; and 59 (70%) patients were dead at time of evaluation, of these 40 (68%) died in hospital, 10 (25%) of whom experienced terminal agitation.

CONCLUSIONS

acute conversion of oral dopaminergic medication to trans-dermal Rotigotine patch remains problematic despite the availability of validated tools. Inappropriate dosing may precipitate or worsen delirium/hallucinations. Use at end-of-life requires further evaluation.

Prognostic predictors relevant to end-of-life palliative care in Parkinson's disease and related disorders: a systematic review

Parkinson's disease and related disorders (PDRD) are the second most common neurodegenerative disease and a leading cause of death. However, patients with PDRD receive less end-of-life palliative care (hospice) than other illnesses, including other neurologic illnesses. Identification of predictors of PDRD mortality may aid in increasing appropriate and timely referrals. To systematically review the literature for causes of death and predictors of mortality in PDRD to provide guidance regarding hospice/end-of-life palliative care referrals. We searched MEDLINE, PubMed, EMBASE and CINAHL databases (1970-2020) of original quantitative research using patient-level, provider-level or caregiver-level data from medical records, administrative data or survey responses associated with mortality, prognosis or cause of death in PDRD. Findings were reviewed by an International Working Group on PD and Palliative Care supported by the Parkinson's Foundation. Of 1183 research articles, 42 studies met our inclusion criteria. We found four main domains of factors associated with mortality in PDRD: (1) demographic and clinical markers (age, sex, body mass index and comorbid illnesses), (2) motor dysfunction and global disability, (3) falls and infections and (4) non-motor symptoms. We provide suggestions for consideration of timing of hospice/end-of-life palliative care referrals. Several clinical features of advancing disease may be useful in triggering end-of-life palliative/hospice referral. Prognostic studies focused on identifying when people with PDRD are nearing their final months of life are limited. There is further need for research in this area as well as policies that support need-based palliative care for the duration of PDRD.

The Effect of Deep Brain Stimulation on Swallowing Function in Parkinson's Disease: A Narrative Review

Unlike appendicular motor symptoms, such as bradykinesia and rigidity, in Parkinson's disease (PD), which have already been reported to respond well to deep brain stimulation (DBS), there is limited literature on the effects of DBS on swallowing function in patients with PD. The field lacks consensus as there are conflicting reports among existing studies regarding whether swallowing function improves or declines following DBS implantation. This narrative review aims to summarize and analyze the studies published on the effect of DBS on swallowing function in patients with PD. We collated studies published up to February 2020 using a comprehensive electronic database search of PubMed, SCOPUS, EMBASE, and the Cochrane Library. Two reviewers independently assessed the studies using strict inclusion and exclusion criteria. The primary literature search yielded 529 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text, we finally included and reviewed 14 publications. Nine of these studies reported positive effects of DBS on swallowing function and four studies showed no significant positive results. The remaining study showed decreased swallowing function after unilateral subthalamic nucleus-DBS surgery. In conclusion, we found that DBS has the potential to improve swallowing function in patients with PD. However, high-quality evidence is lacking. To clearly elucidate the effect of DBS on swallowing function in patients with PD, high-quality randomized controlled trials should be conducted in the future.

Effectiveness of pharmacologic treatment for dysphagia in Parkinson's disease: a narrative review

BACKGROUND

The effectiveness of pharmacological treatment on dysphagia in Parkinson's disease (PD) is debatable. We reviewed the literature for analyzing the effect of pharmacological treatment on the improvement of dysphagia in PD patients.

METHODS

We searched the PubMed database for papers published before June 21, 2020, that evaluated the effect of pharmacologic treatments for improving dysphagia in patients with PD. The following inclusion criteria were applied for the selection of articles: 1) studies performed on patients with dysphagia due to PD, 2) studies where pharmacologic treatment was applied for improvement of dysphagia, and 3) those where follow-up evaluation was performed after the treatment.

RESULTS

The primary literature search yielded 415 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text articles, we finally included nine studies in this review. In five previous studies, the positive effects of dopaminergic drugs on dysphagia were reported, whereas two showed no significant positive results. The remaining two studies showed equivocal results.

CONCLUSION

We found that dopaminergic drugs have some potential to improve dysphagia in patients with PD. However, studies with high-quality evidence are lacking. For the clear elucidation of the effect of dopaminergic drugs on dysphagia in patients with PD, randomized controlled trials with large cohorts and detailed analyses should be conducted in the future.

Postoperative outcomes after total hip arthroplasty in patients with Parkinson disease: A protocol of case control study

BACKGROUND

Parkinson disease (PD) is a progressive neuromuscular disease associated with bradykinesia, tremor, and postural instability. We aimed to compare outcomes and complications of total hip arthroplasty (THA) between patients with PD and those without.

METHODS

A single institution retrospective cohort from 2000 to 2018 was reviewed. PD patients were matched 1:2 with non-PD control patients for age, gender, American Society of Anesthesiologists score, and body mass index using a propensity score matching procedure. The primary outcome measures were postoperative complications and revision between PD and cohort groups. Secondary outcome measures were Harris Hip Score, hip range of motion, patient satisfaction, and surgery time. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort.

RESULTS

Using prospectively collated data, we identified 35 PD patients after primary THA. A control cohort of 70 primary THA patients was matched.

CONCLUSION

Our hypothesis was that PD would have adverse impact on complication rates, range of movement, or improvement in functional outcome after subsequent THA.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5446).

Multimorbidity and Frailty: Tackling Complexity in Parkinson's Disease

Parkinson's disease (PD) is a condition that predominantly affects older people. It is imperative that clinical management considers the other significant illnesses that people with PD accumulate as they age in conjunction with their resilience to cope with physiological change. Multimorbidity and frailty act synergistically to heighten the risk of adverse outcomes for older people with PD. These states are associated with increased likelihood of hospitalization, polypharmacy, adverse drug effects including the anticholinergic burden of medications, drug-disease and drug-drug interactions. Management should be integrated, holistic and individualised to meticulously balance the risks of interventions considering the vulnerability of the individual to recover from disturbance to their environmental, physical and cognitive equilibrium.

Parkinson Matters

Recent epidemiological observations have drawn attention to the rapid rise in the burden caused by Parkinson's disease over the past years, emphasizing that Parkinson's disease is a matter of serious concern for our future generations. A recent report by Public Health England corroborates this message, by providing new insight on trends in deaths associated with neurological diseases in England between 2001 to 2014. The report indicates that mortality associated with Parkinson's disease and related disorders increased substantially between 2001 and 2014. This trend is partially explained by increased longevity in the population. However, it is possible that changes in exposure to risk factors, recent improvements in multidisciplinary care (leading to prolonged survival), and improved diagnostic awareness or improved registration also influenced the observed trend. Furthermore, patients with Parkinson's disease and related disorders were found to die at an advanced age, and the majority die in a care home or hospital, despite a preponderant preference for many patients and their families to spend their last days at home. To combat these concerning observations, future efforts should be focused on providing resources for vulnerable elderly Parkinson patients, avoiding unplanned hospital admissions and out-of-home deaths as much as possible. Possible solutions include a community-based network of specifically trained allied health therapists, personal case managers for Parkinson patients, dedicated Parkinson nursing homes, and improved centralised support services from university clinics to regional community hospitals aimed at facilitating optimal wide-scale care delivery.

Effect of Parkinson's disease on primary total joint arthroplasty outcomes: A meta-analysis of matched control studies

BACKGROUND

Currently, no meta-analysis exists elucidate the outcomes of total joint arthroplasty (TJA) in patients with Parkinson's disease (PD). The aim of this study was to investigate the outcomes of TJA in patients with PD with respect to complication and revision in comparison to a TJA cohort without PD.

METHODS

MEDLINE, Scopus, EMBASE, and Cochrane Library databases were searched with English language restrictions. The primary outcome measures were complications and revision, whereas the secondary outcomes included length of stay (LOS) and total charge.

RESULTS

Seven studies with a total of 124163 patients were included. The most important finding from our study was that PD patients had a 42% higher risk for any medical complication (P = 0.004) and a 65% higher risk for any surgical complication (P = 0.01) compared to the matched cohort. Specifically, PD was associated with increased superficial wound infection (P = 0.006), dislocation (P = 0.01), deep vein thrombosis (DVT) (P = 0.02), LOS (P = 0.0005), and total hospital charges (P < 0.00001). However, PD did not increase the risks for periprosthetic infection (P = 0.32) and revision (P = 0.17).

CONCLUSIONS

Patients with PD are at increased risk for medical complication and surgery complications, particularly superficial wound infection, dislocation, and DVT as compared to patients without PD. PD patients also exhibit increased LOS and total hospital charges. However, PD did not increase the risks for periprosthetic infection and revision.

Advance Directives of German People with Parkinson's Disease Are Unspecific in regard to Typical Complications

Parkinson's disease (PD) is a progressive neurodegenerative movement disorder with an increased morbidity and mortality. People with PD (PwP) may suffer from decreased quality of life due to various motor and nonmotor symptoms. To a huge proportion, PwP have written an advance directive (AD); however, the content of these forms in regard to PD-specific complications is unclear. The aim of this study was to qualitatively and quantitatively analyze ADs of PwP in Germany. ADs of PwP were analyzed in a German sample of members of the German PD patient association. Participants completed a questionnaire about their AD and sent a copy of their AD to the study center for detailed analyses. ADs were qualitatively and quantitatively analyzed for general and PD-specific aspects and usefulness concerning treatment decisions. 82 PwP were included in the study, and in 76, an AD could be analyzed. Family members, notaries, lawyers, and general physicians mainly counseled writing of the ADs. 4 PwP consulted a neurologist to establish a specific AD for PD. In the analysis, ADs displayed a good specificity for general aspects, but they were unspecific to PD in the vast majority of cases. PwP should be encouraged to create an AD early in their disease and adapt it in the course of the disease. PD-specific aspects for an AD could be details in relation to dopaminergic therapies at the end of life, management of non-oral advanced therapies, neuropsychiatric symptoms, dementia, and swallowing disturbances.

Palliative care for persons with Parkinson's disease: a qualitative study on the experiences of health care professionals

Background

Parkinson’s disease (PD) is a chronic and neurodegenerative disease associated with a wide variety of symptoms. The risk of complications increases with progression of the disease. These complications have a tremendous impact on the quality of life of people with PD. The aim of this study was to examine health care professionals’ experiences of potential barriers and facilitators in providing palliative care for people with PD in the Netherlands.

Methods

This was a qualitative descriptive study. The data were collected from 10 individual in-depth interviews and three focus groups (n = 29) with health care professionals. Health care professionals were selected based on a positive answer to the question: “In the past 2 years, did you treat or support a person with PD who subsequently died?” The data were analyzed by thematic text analysis.

Results

Health care professionals supported the development of a palliative care system for PD but needed to better understand the essence of palliative care. In daily practice, they struggled to identify persons’ needs due to interfering PD-specific symptoms such as cognitive decline and communication deficits. Timely addressing the personal preferences for providing palliative care was identified as an important facilitator. Health care professionals acknowledged being aware of their lack of knowledge and of their little competence in managing complex PD. Findings indicate a perceived lack of care continuity, fragmentation of services, time pressure and information discontinuity.

Conclusions

Health care professionals experienced several facilitators and barriers to the provision of palliative care to people with PD. There is a need to improve the knowledge on complex PD and the continuity of information, as well as optimize coordination and deliver care based on a persons’ preferences. Additional training can help to become more knowledgeable and confident.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0441-6) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Prognostic- Level III.

Dementia and Parkinson's Disease: Similar and Divergent Challenges in Providing Palliative Care

Dementia and Parkinson's disease are incurable neurological conditions. Patients often experience specific, complex, and varying needs along their disease trajectory. Current management typically employs a multidisciplinary team approach. Recognition is growing that this team approach should also address palliative care issues to optimize quality of life for patient and family caregivers, but it remains unclear how palliative care is best delivered. To inspire future service development and research, we compare the trajectories and conceptualization of palliative care between dementia and Parkinson's disease. Both Parkinson's disease and dementia are characterized by a protracted course, with progressive but fairly insidious development of disability. However, patients with Parkinson's disease may experience relatively stable periods initially but with time, a wide range of debilitating symptoms develops, many of which do not respond well to treatment. Eventually, dementia develops in most Parkinson patients, while motor disability develops in many dementia patients. In both diseases, symptoms such as pain, apathy, sleeping problems, falls, and a high caregiver burden are prevalent. Advance care planning has benefits in terms of being prepared before the disease progresses into a stage with communication problems or severe cognitive impairment. However, for both conditions, the protracted disease trajectories complicate conceptualization of palliative care through different stages of the disease, with pertinent questions such as when to offer what interventions pro-actively. Given the similarities and differences, we should develop palliative approaches that are partially generic and partially disease-specific. These should be integrated seamlessly with disease-specific care. Substantial research is already being performed on dementia palliative care. This may also inform the further development of palliative care for Parkinson's disease, including an evaluation of palliative interventions and services.

End of life planning in parkinsonian diseases

INTRODUCTION

The utilization of advance directives in individuals with Parkinson's disease (PD) and atypical parkinsonian disorders (APD) and their caregivers requires further investigation. This study determined the utilization rates of four forms of advance directives: living will, durable power of attorney, durable power of attorney for healthcare, and medical orders in these individuals. We hypothesized that having a neurodegenerative parkinsonian disorder or exposure to these disorders would increase the likelihood of having advance directives.

METHODS

50 PD participants, 49 APD participants, 50 caregivers and 50 non-caregiver controls were surveyed regarding advance directives.

RESULTS

The median number of advance directives was 1 in controls, 2 in caregivers and PD participants and 3 in APD participants. Patients with PD were 4.08 times more likely to have durable power of attorney (p < 0.001) and 2.08 times more likely to have durable power of attorney for healthcare (p = 0.011) than controls. Patients with APD were 1.66 times more likely to have a living will (p = 0.006), 4.81 times more likely to have a durable power of attorney (p < 0.001) and 2.47 times more likely to have a durable power of attorney for healthcare (p = 0.003) than controls. Caregivers were1.58 times more likely to have a living will (p = 0.012) and 2.21 times more likely to have a durable power of attorney for healthcare than controls.

CONCLUSION

Having or being exposed to parkinsonian disorders significantly increases the likelihood of utilizing advance directives. Additionally, exposure to a parkinsonian disorder as a caregiver increases advance directive use.

Matched Cohort Analysis of Elective Lumbar Spinal Fusion in Patients With and Without Parkinson's Disease: In-hospital Complications, Length of Stay, and Hospital Charges

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

Parkinson's disease (PD) is a neurodegenerative condition associated with significant morbidity and mortality. PD patients often develop spinal conditions and are known to have high complication rates following surgery. This study evaluated the outcomes of lumbar fusion surgery in patients with PD using a large, public, national database.

METHODS

The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) was used to identify elective lumbar spinal fusion patients with and without PD for the years 2000 to 2012. PD patients were matched with non-PD controls for comorbidity and age using propensity score matching. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort.

RESULTS

A total of 231 351 elective lumbar fusion patients were examined, of which 1332 had PD. Before matching, elective lumbar fusion patients with PD were significantly older (P < .001) and more likely male (P < .001) compared with non-PD patients. In the matched cohort, PD was associated with increased length of stay (6.91 vs 5.78 days) (P < .001) and total hospital charges ($129 212.40 vs $110 324.40) (P < .001). There was no significant difference in overall in-hospital complication rate between PD patients and matched non-PD patients (22.3% vs 21.4%) (P = .524).

CONCLUSIONS

Analysis demonstrated significant increases in length and cost of hospitalization for elective lumbar spinal fusion in patients with PD. However, inpatient complication rates in PD patients were not significantly increased. As a growing number of PD patients undergo elective spine surgery, further studies are needed to optimize operative planning. Further study is needed to assess the long-term outcomes of lumbar spinal fusion in PD.

Sex Differences in Cardiovascular Risk Factors for Dementia

Dementia, characterized by a progressive cognitive decline and a cumulative inability to behave independently, is highly associated with other diseases. Various cardiovascular disorders, such as coronary artery disease and atrial fibrillation, are well-known risk factors for dementia. Currently, increasing evidence suggests that sex factors may play an important role in the pathogenesis of diseases, including cardiovascular disease and dementia. Recent studies show that nearly two-thirds of patients diagnosed with Alzheimer’s disease are women; however, the incidence difference between men and women remains vague. Therefore, studies are needed to investigate sex-specific differences, which can help understand the pathophysiology of dementia and identify potential therapeutic targets for both sexes. In the present review, we summarize sex differences in the prevalence and incidence of dementia by subtypes. This review also describes sex differences in the risk factors of dementia and examines the impact of risk factors on the incidence of dementia in both sexes.

Influence of Parkinsonism on outcomes of elderly pneumonia patients

INTRODUCTION

Pneumonia is one of the most frequent reasons for hospitalization in patients with Parkinson's disease. The present study aimed to evaluate the impact of Parkinsonism on the clinical courses of elderly patients hospitalized for pneumonia.

METHODS

We conducted a retrospective cohort study of patients aged ≥60 years who were hospitalized for pneumonia, using data from a national inpatient database in Japan. We performed one-to-four matching for age and sex between patients with and without Parkinsonism. Multivariable regression analyses were carried out for in-hospital mortality, length of stay, and discharge to home.

RESULTS

Patients with Parkinsonism had significantly lower in-hospital mortality than those without Parkinsonism (odds ratio, 0.81; 95% confidence interval, 0.74-0.89). Length of stay was 8.1% longer in patients with Parkinsonism. Patients with Parkinsonism were less likely to be discharged to home (odds ratio, 0.62; 95% confidence interval, 0.58-0.67).

CONCLUSION

Parkinsonism was not an independent predictor of in-hospital mortality, but was related to prolonged length of stay and discharge other than to home in patients with pneumonia.

Impaired Quality of Life and Need for Palliative Care in a German Cohort of Advanced Parkinson's Disease Patients

Background

Parkinson’s disease (PD) is the second most frequent neurodegenerative disease of the elderly. Patients suffer from various motor and non-motor symptoms leading to reduced health-related quality of life (HRQOL) and an increased mortality. Their loss of autonomy due to dementia, psychosis, depression, motor impairments, falls, and swallowing deficits defines a phase when palliative care interventions might help to sustain or even improve quality of life.

Objective

The aim of this study was to investigate the current status of palliative care implementation and quality of life in a local cohort of advanced PD patients in order to frame and improve future care.

Methods

76 geriatric patients with advanced idiopathic PD meeting the inclusion criteria for palliative care interventions were clinically evaluated by neurological examination using Movement Disorders Society Unified Parkinson’s Disease Rating Scale, Barthel Index, Montreal Cognitive Assessment Test, and a structured interview concerning palliative care implementation.

Results

HRQOL is severely reduced in our cohort of geriatric advanced PD patients. We found motor deficits, impairment of activities of daily living, depression, and cognitive decline as most relevant factors determining decreased HRQOL. Only 2.6% of our patients reported present implementation of palliative care. By contrast, 72% of the patients indicated an unmet need for palliative care.

Conclusion

Quality of life is dramatically affected in advanced PD patients. However, we found palliative care to be implemented extremely rare in their treatment concept. Therefore, geriatric patients suffering from advanced PD should be enrolled for palliative care to provide adequate and holistic treatment which may improve or sustain their quality of life.

From Genomics to Omics Landscapes of Parkinson's Disease: Revealing the Molecular Mechanisms

Molecular mechanisms of Parkinson's disease (PD) have already been investigated in various different omics landscapes. We reviewed the literature about different omics approaches between November 2005 and November 2017 to depict the main pathological pathways for PD development. In total, 107 articles exploring different layers of omics data associated with PD were retrieved. The studies were grouped into 13 omics layers: genomics-DNA level, transcriptomics, epigenomics, proteomics, ncRNomics, interactomics, metabolomics, glycomics, lipidomics, phenomics, environmental omics, pharmacogenomics, and integromics. We discussed characteristics of studies from different landscapes, such as main findings, number of participants, sample type, methodology, and outcome. We also performed curation and preliminary synthesis of multiple omics data, and identified overlapping results, which could lead toward selection of biomarkers for further validation of PD risk loci. Biomarkers could support the development of targeted prognostic/diagnostic panels as a tool for early diagnosis and prediction of progression rate and prognosis. This review presents an example of a comprehensive approach to revealing the underlying processes and risk factors of a complex disease. It urges scientists to structure the already known data and integrate it into a meaningful context.

The Outcomes of Total Hip Replacement in Patients with Parkinson's Disease: Comparison of the Elective and Hip Fracture Groups

INTRODUCTION

The aim of the study was to compare the clinical outcomes following elective and traumatic total hip arthroplasty in Parkinson's disease patients.

MATERIALS AND METHODS

Ten patients with osteoarthritis comprise the elective group (mean age at operation 74 years; mean follow-up 82 months). Thirteen patients with femoral fracture comprise the hip fracture group (mean age 76 years; mean follow-up 54 months). All patients were followed up at 6 and 36 months postoperatively and at the time of the latest follow-up.

RESULTS

Despite the significant improvement in Merle d'Aubigné-Postel and pain scores, disability related to Parkinson's disease increased during the follow-up. Whereas more than 1/3 of hip fracture patients and all elective patients walked independently at 36 months after total hip arthroplasty, 43% of living patients from both groups were able to walk independently at the time of the latest follow-up. The medical complications were seen mainly in patients with hip fracture.

CONCLUSIONS

Excellent pain relief with preserved walking ability without support of another person and acceptable complication profile was observed in Parkinson's disease patients at 36 months after elective total hip arthroplasty. This procedure may be indicated in Parkinson's disease patients after careful and individualized planning.

Increase in Parkinson's disease-related mortality among males in Northern Italy

BACKGROUND

According to standard mortality statistics based on the underlying cause of death (UCOD), mortality from Parkinson's disease (PD) is increasing in most European countries. However, mortality trends are better investigated taking into account all the diseases reported in the death certificate (multiple causes of death approach, MCOD).

METHODS

All deaths of residents in the Veneto Region (Northern Italy) aged≥45 years with any mention of PD were extracted from 2008 to 2015. The Annual Percent Change (APC) in age-standardized mortality rates was computed both for PD as the UCOD, and by MCOD. The association with common chronic comorbidities and acute complications was investigated by log-binomial regression. The frequency of the mention of PD in death certificates was investigated through linkage with an archive of patients with a previous clinical diagnosis of the disease.

RESULTS

PD was reported in 2.1% of all deaths, rising from 1.9% in 2008 to 2.4% in 2015. Among males, age-standardized rates increased over time both in analyses based on the UCOD (APC +4.1%; Confidence Interval +1.5%,+6.7%), and on MCOD (APC +2.2%; +0.2,+4.2%). Among females time trends were not significant. Mention of PD was associated with that of dementia/Alzheimer and acute infectious diseases. Among known PD patients, the disease was reported only in 60.2% of death certificates.

CONCLUSIONS

Mortality associated to PD is steeply increasing among males in Northern Italy; further investigations on time trends for PD, both through all available electronic health archives and clinical studies, should be set as a priority for epidemiological research.

Medicines administration for residents with dysphagia in care homes: A small scale observational study to improve practice

BACKGROUND

In the UK, 69.5% of residents in care homes are exposed to one or more medication errors and 50% have some form of dysphagia. Hospital research identified that nurses frequently crush tablets to facilitate swallowing but this has not been explored in care homes. This project aimed to observe the administration of medicines to patients with dysphagia (PWD) and without in care homes.

METHOD

A convenient sample of general practitioners in North Yorkshire invited care homes with nursing, to participate in the study. A pharmacist specialised in dysphagia observed nurses during drug rounds and compared these practices with national guidelines. Deviations were classified as types of medication administration errors (MAEs).

RESULTS

Overall, 738 administrations were observed from 166 patients of which 38 patients (22.9%) had dysphagia. MAE rates were 57.3% and 30.8% for PWD and those without respectively (p<0.001). PWD were more likely to experience inappropriate prescribing (IP). Signs of aspiration were more frequently observed in PWD when IP occurred (p<0.001).

CONCLUSION

Observation of medication administration practices by independent pharmacists may enable the identification of potentially dangerous practices and be used as a method of staff support. Unidentified signs of aspiration suggest that nurses require training in dysphagia and need to communicate its presence to the resident's GP. Further research should explore the design of an effective training for nurses.

Occurrence, management and outcomes of hip fractures in patients with Parkinson's disease

INTRODUCTION

Hip fractures can be debilitating, especially in patients with pre-existing Parkinson's disease; they have reportedly worse outcomes than non-Parkinson's disease patients.

SOURCES OF DATA

A computerized literature search on PubMed, Medline, Embase, and CINAHL, supplemented by a manual search of related publications.

AREAS OF AGREEMENT

Parkinson's disease patients were found to have significantly lower bone mineral density; higher incidence of falls and hip fractures; delays to receiving their Parkinson's disease medication and surgery; higher risk of pneumonia, urinary infection, pressure sores, post-operative mortality; surgical complications and sequelae, including failed fixation, dislocation, longer hospital stay, re-operation; and increased risk of contralateral hip fracture.

AREAS OF CONTROVERSY

Regain of mobility and return to previous residential status have been variably reported.

GROWING POINTS

All Parkinson's disease patients should be screened and considered for primary prevention treatment. On admission with hip fractures, attention should be paid to avoid delays to medication, ensuring safe anaesthetic and timely surgery, and post-operative chest physiotherapy and mobilization.

RESEARCH

Research is needed in minimizing the bone-resorptive effects of anti-Parkinson's disease medication.

Life-sustaining treatment orders, location of death and co-morbid conditions in decedents with Parkinson's disease

INTRODUCTION

End-of-life care in Parkinson's Disease (PD) is poorly described. Physician Orders for Life Sustaining Treatment (POLST) forms specify how much life-sustaining treatment to provide. This study aims to better understand end-of-life care in PD using data from the Oregon POLST and Death Registries.

METHODS

Oregon death certificates from the years 2010-2011 were analyzed. Death certificates were matched with forms in the Oregon POLST Registry. Descriptive analyses were performed for both the full PD dataset as well as those with POLST forms.

RESULTS

There were 1073 (1.8%) decedents with PD listed as a cause of death and 56,961 without. Three hundred and seventy three (35%) decedents with PD had a POLST form. POLST preferences were not significantly different between those with or without PD, however location of death was; hospital (13% PD vs 24% without p < 0.01), home (32% vs 40% p < 0.01) and care facility (52% vs 29% p < 0.01). Compared to those without a POLST or those without a Comfort Measures Only (CMO) order, decedents with PD and a CMO order were less likely to die in a hospital (5.4% vs 14.7% p < 0.01) and more likely to die at home (39.1% vs 29.1% p < 0.01). In those with PD, dementia was the most common comorbid condition listed on death certificates (16%).

CONCLUSION

Decedents with PD die less frequently at home than the general population. POLST forms mitigate some of this discrepancy. While not often thought to be terminal, PD and its complications are commonly recorded causes of death.

Risk of pneumonia in new users of cholinesterase inhibitors for dementia

OBJECTIVES

To compare the risk of pneumonia in older adults receiving donepezil, galantamine, or rivastigmine for dementia.

DESIGN

Retrospective cohort study.

SETTING

Nationally representative 5% sample of Medicare databases.

PARTICIPANTS

Medicare beneficiaries aged 65 and older who newly initiated cholinesterase inhibitor therapy between 2006 and 2009.

MEASUREMENTS

Pneumonia, defined as the presence of a diagnosis code for pneumonia as the primary diagnosis on an inpatient claim or on an emergency department claim followed by dispensing of appropriate antibiotics. Cox proportional hazards models were used to estimate the risk of pneumonia. Subgroup analyses and sensitivity analyses were conducted using alternative pneumonia definitions and adjustments using high-dimensional propensity scores to test the robustness of the results.

RESULTS

The mean age of 35,570 new users of cholinesterase inhibitors (30,174 users of donepezil, 1,176 users of galantamine, 4,220 users of rivastigmine) was 82; 75% were women, and 82% were white. The cumulative incidence of pneumonia was 51.9 per 1,000 person-years. The risk of pneumonia for rivastigmine users was 24% lower than that of donepezil users (hazard ratio (HR)=0.75, 95% confidence interval (CI)=0.60-0.93). Risk in galantamine users (HR=0.87, 95% CI=0.62-1.23) was not significantly different from risk in donepezil users. Results of subgroup and sensitivity analyses were similar to the primary results.

CONCLUSION

The risk of pneumonia was lower in individuals receiving rivastigmine than in those receiving donepezil. Additional studies are needed to confirm the findings of pneumonia risk between the oral and transdermal forms of rivastigmine and in users of galantamine.

Cardiovascular medication burden in dementia disorders: a nationwide study of 19,743 dementia patients in the Swedish Dementia Registry

Introduction

Administration of several cardiovascular drugs has an effect on dementia. We aimed to investigate whether there are differences in the use of cardiovascular medication between different dementia disorders.

Methods

We obtained information about dementia patients from the Swedish Dementia Registry. Patients were diagnosed with one of these dementia disorders: Alzheimer’s disease (n = 8,139), mixed dementia (n = 5,203), vascular dementia (n = 4,982), Lewy body dementia (n = 605), frontotemporal dementia (n = 409) and Parkinson’s disease dementia (n = 405). Multivariate logistic regression analysis was performed to investigate the association between use of cardiovascular medication and dementia disorders, after adjustment for age, gender, living alone, cognitive status and total number of drugs (a proxy for overall co-morbidity).

Results

Seventy percent of all the dementia patients used cardiovascular medication. Use of cardiovascular drugs is common in patients with vascular and mixed dementia. Male gender, higher age, slightly better cognitive status and living with another person was associated with use of cardiovascular medication.

Conclusions

Cardiovascular medication is used extensively across dementia disorders and particularly in vascular and mixed dementia. Future research should investigate the tolerability and effectiveness of these drugs in the different dementia disorders.

[Epidemiology of parkinsonism in the Guadalajara Health Area]

OBJECTIVES

1) To determine the prevalence of Parkinson syndromes in the Guadalajara Health Area and its Basic Health Zones, as well as the typology of the Parkinson's disease; 2) to determine the distribution of antiparkinsonian medication use in the whole Area, and 3) to evaluate the cost per person and per year of this use according to the criteria of sex and age.

MATERIAL AND METHOD

A descriptive cross-sectional study including 1,352 subjects affected by parkinsonism in the Guadalajara Area of both sexes and all ages. The variables measured were age, sex, environment, diagnosis, typology of the Parkinson's disease using the Hoehn and Yahr index, treatment, total cost and mean cost of the treatment per person per year. Prevalences were calculated, and the appropriate descriptive statistics were used.

RESULTS

The prevalence of parkinsonism was 585/10(5) inhabitants, being higher in a rural environment (P<.05), in females (P<.01) and in subjects over 90 years (P<.01). The majority suffered from Parkinson's disease (P<.001), of whom 43.4% had symptoms equivalent to Yahr grade II (P<.001). The active ingredient most used was levodopa/carbidopa (51.3%) (P<.001) and the mean drug cost per person was 514.37€.

CONCLUSIONS

The prevalence of parkinsonism is similar to that in the rest of the country, although in our study there is a predominance of females and it is in a rural environment. Levodopa is the drug most used, and the mean therapeutic cost per person is similar to the rest of Spain.