Dysphagia predicts poor outcome in late-stage Parkinson's disease

Abstract

Background: Few data exist on the rate of clinical progression for Parkinson's disease (PD) patients who have entered a late stage of the disease. Objective: Study the clinical progression of a late-stage PD (LSPD) population over one year follow-up. Methods: 50 LSPD patients (Schwab and England ADL Scale <50 or Hoehn Yahr Stage >3 in MED ON) underwent an extensive clinical assessment at baseline and after one year and an acute levodopa test at baseline. Results: Mean age of LSPD patients (female 46%) was 77.5 ± 5.9 years and mean disease duration was 15.5± 6.5 years. At baseline, 76% had levodopainduced motor complications (MC), usually non-troublesome, 68% were demented, 54% had psychosis and 68% depression. Caregiver distress was high. L-dopa responsiveness was mild (18% ± 12 of improvement on MDS-UPDRS-III). After one-year, 20% of the patients were dead, institutionalized or HY 5. MDS-UPDRS-motor mean score worsened 7.2±10.3 points although there was heterogeneity between patients, and there was a global worsening of non-motor symptoms, mostly in cognition/mood, urinary and gastrointestinal domains. Nevertheless, MC improved despite similar levodopa equivalent dose. Functional independence and quality of life worsened. Dysphagia severity at baseline predicted a poor outcome (death, institutionalization or HY 5) (Hazard ratio 2.3, 95% CI 1.12-4.4; p = 0.01), whereas magnitude of Ldopa response of LSPD patients did not. Conclusions: LSPD patients still present a significant, although heterogeneous, motor and non-motor progression over 1 year. Dysphagia severity predicts the occurrence of additional disease severity milestones and its management must be prioritized.

Should We Consider Deep Brain Stimulation Discontinuation in Late‐Stage Parkinson's Disease?

“…The clinical picture of our DBS-treated patients is similar to previously reported cohorts of LSPD patients, 6,21,25,26 confirming the presence of a common ground of disability milestones, which are invariably present in the latest PD stage, independent of previous treatment approaches. As expected, the percentage of troublesome levodopa-related motor complications or troublesome dyskinesia is low and even lower (25% and 11%, respectively) compared with those reported in another cohort of orally treated LSPD patients.…”

“…As expected, the percentage of troublesome levodopa-related motor complications or troublesome dyskinesia is low and even lower (25% and 11%, respectively) compared with those reported in another cohort of orally treated LSPD patients. 5,21 Concomitantly, the most frequent NMS are roughly comparable, 19 being cognition, mood, and urinary disturbances and daytime sleepiness are those reported in at least three-quarters of patients.…”

“…The number of PD patients submitted to STN-DBS has exponentially increased during the last decades, 19,20 which in turn is likely to bring a growing prevalence of DBStreated LSPD patients, raising new challenging questions on how this device-aided treatment should be managed in the latest disease stage. LSPD patients have been defined as an "orphan population," 21 as these patients are usually not included in clinical trials because of the great disability they carry and their difficulties in reaching the hospital. In this regard, our study has targeted a subgroup of an orphan PD cohort, previously submitted to an invasive treatment for advanced PD.…”

“…Indeed, our patients still present an acute significant motor response to stimulation (17% for MDS-UPDRS part III), comparable to that reported for levodopa in a later stage, with a similar pattern of response for appendicular signs (tremor > > rigidity > > bradykinesia) and a milder or absent effect on axial signs. 18,21 The similarities with levodopa are evident not only in the magnitude of the effect but also regarding the timing of this effect. As with levodopa, STN-DBS presents an acute motor effect that is rapidly evident with the stimulation challenge test on parkinsonian motor symptoms, 28 as well on some NMS, such as anxiety, sialorrhea, and drowsiness.…”

Non-pharmacological Treatment Challenges in Early Parkinson's Disease for Axial and Cognitive Symptoms: A Mini Review

“…The most common cause of death in PD patients is aspiration pneumonia, resulting from preexisting dysphagia (58,59), and therefore, its management should be prioritized. Dysphagia is not just a symptom of late stage PD.…”