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 Predictors of falls/fractures in LBD, etc. 
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Post Predictors of falls/fractures in LBD, etc.
This '06 journal article on falls and fractures has some info on LBD.

Recently someone on one of the MSA-related Yahoo!Groups asked if I could help find some data on his risk of falls and fractures. I forwarded him the abstract below from a couple of years ago. This person obtained the full article and was kind enough to send me a copy.

This was a British study of 782 patients with a clinical (during life) diagnosis of parkinsonism and pathologically confirmed diagnoses -- 127 with PSP, 91 with MSA, 46 with DLB, 8 with CBD, 474 with PD, 27 with vascular parkinsonism, and 9 with AD. The clinical records of the 782 patients were examined. Analysis was done to determine the predictors, if any, of falls and fractures.

In general, one reason that falls occur frequently in PD and the four atypical parkinsonism disorders is that bradykinesia (slowed movement) is involved. As the researchers say: "Bradykinesia prolongs reaction times following a postural challenge." One reason that fractures of the arm are not as common in people with PD and the atypical parkinsonism disorders is, again, because of bradykinesia. "Protective responses, including outstretching of the arm," are less likely to occur.

Besides bradykinesia, there are other factors that contribute to falls in the atypical parkinsonism disorders:
CBD: gait unsteadiness and cognitive impairment contribute to falls
DLB: gait unsteadiness and cognitive impairment contribute to falls
MSA: orthostatic hypotension and cerebellar or parkinsonian gait disorder are "important precipitants"

Here are some results of the analysis:

Cases experiencing falls from disease onset to death:
CBD: 100%
PSP: 97.5%
MSA: 77.6%
PD: 73.3%
DLB: 58%

Median time to first fall (after disease onset):
PSP: 17 months, with 12 months for Richardson's Syndrome and 47 months for PSP-Parkinsonism
CBD: 30 months
MSA: 42 months
DLB: 54 months
PD: 108 months

Falls occur within how many years of disease onset (median) in a majority of patients?
PSP: three years
MSA: four years
DLB: five years
PD: nine years

"The incidence of fractures was higher in PSP than in PD, but lower in MSA, CBD, ...DLB... partially reflecting the differences in disease duration. ... More than one quarter of patients with PSP (28.6%) fractured at least one bone and the frequency of fractures was significantly higher than in the other diseases."

In conclusion, the authors state: "The disease burden associated with disturbances of posture, resulting in falls and fractures, appears to be highest in PSP."

The authors recommend three things -- "early assessment for osteoporosis, treatment of decreased bone mineral density, and physiotherapy intervention to limit falling related morbidity" in those with the Richardson's Syndrome (RS) type of PSP and "those with other bradykinetic rigid syndromes with symmetrical disease onset, postural instability, autonomic dysfunction, and cognitive disturbance, and in particular women..." [I think the "other bradykinetic rigid syndromes with symmetrical disease onset, postural instability, autonomic dysfunction, and cognitive disturbance" include MSA and DLB. CBD typically has asymmetric onset.]

I've copied rather extensive excerpts below. I'd suggest searching for the term "DLB."

Robin


Here are excerpts:

"The diagnoses of Parkinson’s disease (PD) and progressive
supranuclear palsy (PSP) are contingent on the presence
of postural instability and falls. In these and other brady-
kinetic rigid syndromes, falls occur frequently and are
associated with a poorer quality of life. The risk of bone
fracture increases with a history of falls, impairment of
mobility, low body mass index, and low bone mineral den-
sity. In patients with disturbances of gait due to parkinson-
ism, fractures are more common than in those with gait
disturbances due to other neurological conditions such as
peripheral neuropathies."

"A number of factors contribute to falls in other bradykine-
tic rigid syndromes. Gait unsteadiness and cognitive im-
pairment contribute to falls in corticobasal degeneration
(CBD), dementia with Lewy bodies (DLB) and in those
with pathological changes diagnostic of Alzheimer’s
disease (AD) who present with parkinsonism. In MSA, on
the other hand, orthostatic hypotension and cerebellar or
parkinsonian gait disorder are important precipitants."

"We have retrospectively analysed data from a large
number of pathologically diagnosed PD, PSP, MSA, CBD,
DLB, VP, and AD patients and have investigated the rela-
tion between pathological diagnosis and the bones frac-
tured. We have also quantified the temporal evolution of
falls in each disease group and analysed the relation
between time from disease onset to first fall (latency) and
disease."

Subjects
"A retrospective analysis was performed using the clinical
files of 782 patients with a lifetime diagnosis of a brady-
kinetic rigid syndrome or parkinsonism with a pathologi-
cally confirmed diagnosis (PD, n=474; PSP, n=127;
MSA, n=91; DLB, n=46; VP, n=27; AD, n=9; CBD, n=8)
archived at the Queen Square Brain Bank for Neurological
Disorders. Patients were recruited from around the United
Kingdom and died between 1988 and 2003. ... The PSP
group were further divided according to the number of
clinical features reported associated with each clinical
phenotype: RS (supranuclear gaze palsy, abnormality of
saccadic eye movements, cognitive changes in first two
years), PSP-P (tremor and non-axial dystonia in the first
two years, asymmetric onset, and response to levo-
dopa)."

Results
"Among the 782 cases the incidence of falls from disease
onset to death was 77.5%. It was highest in CBD (100%)
and PSP (97.5%) and lowest in MSA (77.6%) and PD
(73.3%). Falls occurred earlier in those with PSP (median
17 months; range 0–244 months) than all other diseases."

"In PD univariable analysis showed an association between
the occurrence of falls and the late clinical features of cog-
nitive dysfunction, speech disturbance, dysphagia, auto-
nomic dysfunction, and hallucinations and a negative
association between the falls and early and late tremor."

"There were no significant associations between falls and
clinical features in VP, DLB, CBD, and AD; this may be
due to the small sample sizes for these diseases."

"In PD female gender, older age, symmetrical onset, and
autonomic dysfunction were all independent predictors of
earlier falls."

"There were 166 fractures recorded in 134 (17.1%)
patients. Eighty patients (16.9%) with PD sustained a
total of 96 fractures, 36 (28.6%) patients with PSP sus-
tained 52 fractures, and 10 (11%) patients with MSA
sustained a fracture." [So only 8 patients with other
diagnoses sustained fractures.]

"Hip fractures comprised 46.9% of all fractures in PD and
one third of fractures occurred in the upper limb."

"The clinical features that were significantly associated
with fractures in PD were early falls (9.3% with fractures
v 3.2% no fractures), late falls (100% v 66.7%), and late
postural instability (88.4% v 71%); in PD fractures were
also more frequent in women (28.6% v 11.3%)."

Discussion
"Falls occur within the first three years of disease onset
in a majority of patients with PSP, within four years in
MSA, five for those with DLB, and a median of nine
years for those with PD."

"In this study, the incidence of falls and fractures was
high (77.6% and 17.1%)."

"Studies have estimated an incidence of falls as high as
69% in PD and 32% in elderly patients."

"Patients with other bradykinetic rigid syndromes, inclu-
ding PSP, CBD, and MSA, fall more frequently and earlier
in the disease than in PD, and it has been suggested that
these patients have a higher incidence of fractures. We
have found that more than three quarters of patients with
PSP (97%), MSA (77%), and CBD (100%) fell during their
disease, though only...58% of patients with DLB fell."

"The incidence of fractures was higher in PSP than in PD,
but lower in MSA, CBD, VP, DLB, and AD, partially
reflecting the differences in disease duration."

Fractures
"Nordell et al reported that in a community dwelling popula-
tion of 65–74 year olds fractures of the upper extremities,
and in particular the distal radius, were most common and
fractures of the proximal femur or hip were half as common
as radial fractures."

"In all bradykinetic rigid syndromes diagnosed in our study
this proportion is reversed, reflecting a common disturbance
of postural reflexes. Bradykinesia prolongs reaction times
following a postural challenge and thereby limiting the pro-
tective responses, including outstretching of the arm, thus
limiting fractures of the distal upper limb."

Conclusion
"The disease burden associated with disturbances of posture,
resulting in falls and fractures, appears to be highest in PSP."

"Furthermore, the presence of early supranuclear gaze palsy,
cognitive change, and a lack of response to levodopa predicts
early falls and bone fractures."

"Patients with RS, and those with other bradykinetic rigid
syndromes with symmetrical disease onset, postural insta-
bility, autonomic dysfunction, and cognitive disturbance, and
in particular women, may benefit from early assessment for
osteoporosis, treatment of decreased bone mineral density,
and physiotherapy intervention to limit falling related mor-
bidity."

_____________________

Here's the abstract:

Predictors of falls and fractures in bradykinetic rigid syndromes: a retrospective study

Williams, DR, et al
Reta Lila Weston Institute of Neurological Studies, University College, London

Journal of Neurology, Neurosurgery, and Psychiatry
April 2006, 77(4):468-73

BACKGROUND: Falls and fractures contribute to morbidity and mortality in bradykinetic rigid syndromes.

METHODS: The authors performed a retrospective case notes review at the Queen Square Brain Bank for Neurological Disorders and systematically explored the relation between clinical features and falls and fractures in 782 pathologically diagnosed cases (474 with Parkinson's disease (PD); 127 progressive supranuclear palsy (PSP); 91 multiple system atrophy (MSA); 46 dementia with Lewy bodies (DLB); 27 vascular parkinsonism; nine Alzheimer's disease; eight corticobasal degeneration).

RESULTS: Falls were recorded in 606 (77.5%) and fractures in 134 (17.1%). In PD, female gender, symmetrical onset, postural instability, and autonomic instability all independently predicted time to first fall. In PD, PSP, and MSA latency to first fall was shortest in those with older age of onset of disease. Median latency from disease onset to first fall was shortest in Richardson's syndrome (12 months), MSA (42), and PSP-parkinsonism (47), and longest in PD (108). In all patients fractures of the hip were more than twice as common as wrist and forearm fractures. Fractures of the skull, ribs, and vertebrae occurred more frequently in PSP than in other diseases.

CONCLUSION: Measures to prevent the morbidity associated with falls and fractures in bradykinetic rigid syndromes may be best directed at patients with the risk factors identified in this study.

PMID: 16543524


Wed Aug 13, 2008 12:45 am
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