Psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral Scale in people with Parkinson's disease.

PURPOSE: To verify the psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral (FaB-Brazil) Scale in Parkinson's disease (PD). MATERIAL AND METHODS: Participants (n = 96) were assessed by disease-specific, self-report and functional mobility measures. Internal consistency of the FaB-Brazil scale was evaluated using Cronbach's alpha and inter-rater and test-retest reliability using intraclass correlation coefficients (ICC). The standard error of measurement (SEM), minimal detectable change (MDC), ceiling and floor effects, and convergent and discriminative validity were evaluated. RESULTS: Internal consistency was moderate (α = 0.77). Excellent inter-rater (ICC = 0.90; p < 0.001) and test-retest (ICC = 0.91; p < 0.001) reliability were found. The SEM was 0.20 and MDC was 0.38. Ceiling and floor effects were not found. Convergent validity was established by the positive correlations between the FaB-Brazil scale and age, modified Hoehn and Yahr, PD duration, Movement Disorders Society-Unified Parkinson's Disease Rating Scale, Motor Aspects of Experiences of Daily Living, Timed Up & Go and 8-item Parkinson's Disease Questionnaire, and negative correlations between the FaB-Brazil scale and community mobility, Schwab & England, and Activities-specific Balance Confidence scale. Females showed greater protective behaviors than males; recurrent fallers showed greater protective behaviors than non-recurrent fallers (p < 0.05). CONCLUSIONS: The FaB-Brazil scale is reliable and valid for assessing people with PD.

Fall-related behaviors should be part of the fall risk assessment of community-dwelling people with Parkinson's disease.The Brazilian-Portuguese version of the Fall Behavioral (FaB-Brazil) Scale is reliable and valid for assessing everyday behaviors and actions related to falling in community-dwelling people with Parkinson's disease.The FaB-Brazil scale may be used to tailor individualized fall prevention programs.

Predictors of Falls with Injuries in People with Parkinson's Disease.

Background: Falls are frequent in Parkinson's disease (PD), but there is lack of information about predictors of injurious falls. Objectives: To determine predictors of falls with injuries in people with PD; to compare circumstances and consequences of falls in single and recurrent fallers. Methods: Participants (n = 225) were assessed by disease-specific, self-report, and balance measures, and followed-up for 12 months with a diary to record falls, their circumstances, and injuries. Univariate and multivariate analyses were performed. Circumstances and consequences of falls presented by single and recurrent fallers were compared. Results: A total of 805 falls were analyzed, 107 (13%) were falls with injuries. Multivariate logistic regression model revealed that greater PD duration and higher balance confidence were protective factors; better balance during gait, outdoor falls, and falls related to extrinsic factors were risk factors for falls with injuries, when compared to falls with no injuries. Multivariate multinomial regression model revealed that, when compared to zero fall, past falls and daily levodopa equivalent dose were predictors of falls with injuries; these predictors together with disability were predictors of falls with no injuries. Single falls (n = 27; 3%) were more common outdoors because of extrinsic factors, whereas recurrent falls (n = 778; 97%) were more common indoors because of intrinsic factors. Single falls led to more injuries than recurrent falls (P < 0.05). Conclusions: Different predictors of falls with injuries were obtained when different outcomes were compared. It should be noted that falls with injuries might be influenced by fall-related activities and environmental factors. Single and recurrent falls differed on circumstances and consequences.

Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral (FaB-Brazil) Scale.

PURPOSE: To develop and cross-culturally adapt a Brazilian-Portuguese version of the Falls Behavioral Scale (FaB-Brazil) and to verify its psychometric properties. MATERIAL AND METHODS: The translation and cross-cultural adaptation process of the scale followed standard guidelines. The FaB-Brazil scale was applied to 93 community-dwelling older people. Cronbach's alpha was calculated to evaluate internal consistency and the intraclass correlation coefficient (ICC) to evaluate interrater and test-retest reliability. The standard error of measurement (SEM), minimal detectable change (MDC), ceiling and floor effects, convergent and discriminative validity were evaluated. A significance level of .05 was set for statistical analyses. RESULTS: Internal consistency was moderate (α = 0.73). An excellent inter-rater (ICC = 0.93; p < 0.001) and a good test-retest (ICC = 0.79; p < 0.001) reliability were found. The SEM was 0.27 and MDC was 0.53. Neither ceiling nor floor effects were found. Convergent validity was established by the positive correlations between the FaB-Brazil scale, age, and functional mobility, and by the negative correlations between the FaB-Brazil scale and balance confidence, community mobility and EuroQol-5D (p < 0.05). No significant differences were found between males and females and between non-fallers and fallers. CONCLUSIONS: Our results offer evidence for the reliability and validity of the FaB-Brazil scale for community-dwelling older people.Implications for RehabilitationFall-related behaviors should be part of the fall risk assessment of community-dwelling older people.The Brazilian-Portuguese version of the Falls Behavioral Scale (FaB-Brazil) is reliable and valid for assessing fall-related behaviors in community-dwelling older people.The FaB-Brazil scale may be used to raise awareness about potential fall hazards and to guide fall prevention programs.

Predicting falls in people with Parkinson's disease: impact of methodological approaches on predictors identified.

BACKGROUND: Previous investigations of falls predictors in people with Parkinson's disease (PD) have used various statistical methods and categorization of falls outcomes. The impact of methodological differences on falls predictors has not been investigated. OBJECTIVES: To describe similarities and differences in predictors modelled for fall rates [negative binomial (NB), Poisson Inverse Gaussian (PIG) and quantile regression] and previously-reported predictors of time to second fall (Cox regression), i.e. past falls, motor fluctuations, disability, levodopa dose and balance impairment. To investigate whether predictors from quantile regression vary across subsets of fallers based on fall frequency. METHODS: Participants with PD (n = 229) were followed-up for 12 months. NB and PIG regression were used to determine predictors of fall rates, with the best fitting model reported. Quantile regression was used to determine predictors at higher (62nd, 70th, 80th) percentiles of the falls distribution. Univariate and multivariate analyses were performed. RESULTS: Predictors of fall rates were the same in NB and PIG multivariate models, with the PIG model fitting our data better. Past falls, disability and levodopa dose were associated with fall rates from PIG and quantile regression. Freezing of gait was associated with fall rates from PIG regression. Disease severity predicted less (70th percentile, approximately 2-4) and more (80th percentile, approximately ≥ 5) frequent falls, and anteroposterior stability also predicted less frequent falls (p < 0.05), from quantile regression. CONCLUSIONS: Not all predictors of time to second fall were predictors of fall rates. Quantile regression revealed some divergent predictors depending on the percentile of fall frequency examined.

Anxiety Independently Contributes to Severity of Freezing of Gait in People With Parkinson's Disease.

Freezing of gait is a disabling feature of Parkinson's disease, and it has been shown that nonmotor symptoms, such as anxiety and cognitive impairment, may be involved in the pathophysiology of the phenomenon. However, the association between freezing of gait severity and nonmotor symptoms is yet to be determined. Therefore, the overall aim of this study was to determine factors that contribute to severity of freezing of gait in people with Parkinson's disease. Participants (N=78) were assessed by disease-specific and self-report measures, including the Hospital Anxiety and Depression Scale (HADS), the Montreal Cognitive Assessment, and the Freezing of Gait Questionnaire (FOG-Q). Participants were classified as "freezers" if they scored ≥1 on item 3 of the FOG-Q; the sum of items 3-6 was used to determine freezing of gait severity. Freezers (N=27) showed higher scores on the HADS anxiety (p=0.002) and HADS depression (p=0.006) subscales. A multivariate linear model showed that disease severity (as measured by using the modified Hoehn and Yahr scale) accounted for 31% of the variance in FOG-Q severity scores (p<0.001). The presence of HADS anxiety ≥8 points increased the explained variance to 38% (p=0.010), and the full model (reached by adding the levodopa equivalent dose) explained 42% of the variance in freezing of gait severity (p=0.026). The findings provide additional support for the contribution of anxiety to greater freezing of gait severity, taking into account not only the frequency but the duration of the episodes, and suggest that anxiety should be routinely evaluated in people with Parkinson's disease who present with freezing of gait.

Parkinson's Disease Impulsive-Compulsive Disorders Questionnaire - Current Short (QUIP-CS) - Translation and validation of content of Portuguese Version / Parkinson's Disease Impulsive-Compulsive Disorders Questionnaire - Current Short (QUIP-CS) - Tradução e validação de conteúdo em português do Questionário para Avaliação de Distúrbios Impulsivo-Compulsivos na Doença de Parkinson

ABSTRACT Objective Parkinson's disease (PD) management is usually successfully reached with proper pharmacological treatment. However, PD patients can manifest neuropsychiatric symptoms secondary to medical therapy, including impulse control disorders (ICD), presenting as pathological gambling, hypersexuality, compulsive buying, drinking or eating disorders. We translated and validated the Portuguese version of the gold-standard questionnaire Parkinson's Disease Impulsive-Compulsive Disorders Questionnaire, or (QUIP) for identifying ICDs in PD patients. Methods Translation, back translation and submission to instrument developer was performed, that approved its new version comparing it to his original, validated version, with no loss of it's original properties. Then, the Portuguese version was administered to 30 PD patients. They also were asked to rate from 1 to 5 the level of comprehensibility of the questions. Results The average level of comprehension was 4.06 ± 0.69 DP, considering 3 or more as acceptable. No patient has answered 1 or 2. Conclusion Our results on Portuguese version of QUIP-CS show that QUIP-CS translated and corrected version was easily understood and easily self-applied.

RESUMO Objetivo O manejo da doença de Parkinson (DP) é usualmente alcançado com sucesso com o tratamento farmacológico apropriado. Entretanto, os pacientes com DP podem manifestar sintomas neuropsiquiátricos secundários à terapêutica, como a síndrome de descontrole dos impulsos (SDI), que se apresenta como o jogar patológico, a hipersexualidade, o comprar, beber ou comer compulsivos. Traduzimos e validamos a versão em português do questionário padrão-ouro para identificação de transtornos impulsivo-compulsivos na DP (QUIP-CS) para identificar nesses pacientes a presença de SDI. Métodos Foram realizadas a tradução, a retrotradução e a submissão do instrumento ao desenvolvedor deste, que aprovou a nova versão comparando esta à sua, que já está validada, sem a perda das suas propriedades originais. Após, a versão em português foi administrada a 30 pacientes com o diagnóstico de DP. Eles também foram solicitados a classificar o nível de compreensibilidade das questões, graduando-as de 1 a 5. Resultados O nível médio de compreensão foi 4,06 ± 0,69 DP, considerando-se 3 ou mais como aceitável. Nenhum paciente respondeu 1 ou 2. Conclusão Os nossos resultados para a versão em português da QUIP-CS mostraram que essa versão, traduzida e corrigida, foi facilmente compreendida e aplicada pelos próprios pacientes.

Predictors of Recurrent Falls in People with Parkinson's Disease and Proposal for a Predictive Tool.

BACKGROUND: Falls are a debilitating problem for people with Parkinson's disease (PD). OBJECTIVES: To compare clinical and functional characteristics of non-fallers, single and recurrent fallers (≥2 falls); to determine predictors of time to second fall; and to develop a predictive tool for identifying people with PD at different categories of falls risk. METHODS: Participants (n = 229) were assessed by disease-specific, self-report and balance measures and followed up for 12 months. Area under the receiver operating characteristic curves (AUC), Kaplan-Meier curves and log-rank test were performed. Selected predictors with p < 0.10 in univariate analysis were chosen to be entered into the Cox regression model. RESULTS: Eighty-four (37%) participants had ≥2 falls during the follow-up. Recurrent fallers significantly differed from single fallers. The final Cox model included history of ≥2 falls in the past year (Hazard Ratio [HR] = 3.94; 95% confidence interval [CI] 2.26-6.86), motor fluctuations (HR = 1.91; 95% CI 1.12-3.26), UPDRS activities of daily living (ADL) (HR = 1.10 per 1 point increase; 95% CI 1.06-1.14) and levodopa equivalent dose (LED) (HR = 1.09 per 100 mg increase; 95% CI 1.02-1.16). A 3-predictor tool included history of ≥2 falls in the past year, motor fluctuations and UPDRS ADL >12 points (AUC = 0.84; 95% CI 0.78-0.90). By adding LED >700 mg/day and Berg balance scale ≤49 points, a 5-predictor tool was developed (AUC = 0.86; 95% CI 0.81-0.92). CONCLUSIONS: Two predictive tools with moderate-to-high accuracy may identify people with PD at low, medium and high risk of falling recurrently within the next year. However, future studies to address external validation are required.

The Role of MAPT Haplotype H2 and Isoform 1N/4R in Parkinsonism of Older Adults.

BACKGROUND AND OBJECTIVE: Recently, we have shown that the Parkinson's disease (PD) susceptibility locus MAPT (microtubule associated protein tau) is associated with parkinsonism in older adults without a clinical diagnosis of PD. In this study, we investigated the relationship between parkinsonian signs and MAPT transcripts by assessing the effect of MAPT haplotypes on alternative splicing and expression levels of the most common isoforms in two prospective clinicopathologic studies of aging. MATERIALS AND METHODS: using regression analysis, controlling for age, sex, study and neuropathology, we evaluated 976 subjects with clinical, genotyping and brain pathology data for haplotype analysis. For transcript analysis, we obtained MAPT gene and isoform-level expression from the dorsolateral prefrontal cortex for 505 of these subjects. RESULTS: The MAPT H2 haplotype was associated with lower total MAPT expression (p = 1.2x10-14) and global parkinsonism at both study entry (p = 0.001) and proximate to death (p = 0.050). Specifically, haplotype H2 was primarily associated with bradykinesia in both assessments (p<0.001 and p = 0.008). MAPT total expression was associated with age and decreases linearly with advancing age (p<0.001). Analysing MAPT alternative splicing, the expression of 1N/4R isoform was inversely associated with global parkinsonism (p = 0.008) and bradykinesia (p = 0.008). Diminished 1N/4R isoform expression was also associated with H2 (p = 0.001). CONCLUSIONS: Overall, our results suggest that age and H2 are associated with higher parkinsonism score and decreased total MAPT RNA expression. Additionally, we found that H2 and parkinsonism are associated with altered expression levels of specific isoforms. These findings may contribute to the understanding of the association between MAPT locus and parkinsonism in elderly subjects and in some extent to age-related neurodegenerative diseases.

Comparison of Self-report and Performance-Based Balance Measures for Predicting Recurrent Falls in People With Parkinson Disease: Cohort Study.

BACKGROUND: Balance confidence and fear of falling are factors associated with recurrent falls in people with Parkinson disease (PD). However, the accuracy for predicting falls on the basis of self-report measures has not been widely investigated. OBJECTIVE: The study objectives were: (1) to compare the accuracy of the Activities-specific Balance Confidence Scale (ABC) and the Falls Efficacy Scale-International (FES-I) with that of the Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Functional Reach Test (FRT), and Timed "Up & Go" Test (TUG) for predicting recurrent falls in people with PD and (2) to explore the ability of combinations of up to 3 tests to predict recurrent falls. DESIGN: This was a prospective cohort study involving 225 people with PD. METHODS: Participants were assessed with the ABC, FES-I, BBS, FRT, TUG, and DGI. Participants who reported 2 or more falls in the 12-month follow-up period were classified as recurrent fallers. Areas under the receiver operating characteristic curves were determined, and the Akaike information criterion was used to select the best predictive model. RESULTS: Eighty-four participants (37.3%) were classified as recurrent fallers. Areas under the receiver operating characteristic curves for the ABC, FES-I, TUG, FRT, DGI, and BBS were 0.73, 0.74, 0.72, 0.74, 0.76, and 0.79, respectively. Two-test models provided additional discriminating ability compared with individual measures and had Akaike information criterion values similar to those of 3-test models, particularly the combination of the BBS with the FES-I. LIMITATIONS: The lack of an external validation sample was a limitation of this study. CONCLUSIONS: The ABC and FES-I demonstrated moderate accuracy in predicting recurrent falls and a predictive ability similar to that of performance-based balance measures, especially the FRT and the TUG. Two-test models showed performance similar to that of 3-test models, suggesting that a combination of 2 measures may improve the ability to predict recurrent falls in people with PD. Specifically, the combination of the BBS with the FES-I may be considered.

Disability is an Independent Predictor of Falls and Recurrent Falls in People with Parkinson's Disease Without a History of Falls: A One-Year Prospective Study.

BACKGROUND: Predictors of falls in people with Parkinson's disease (PD) who have not previously fallen are yet to be identified. OBJECTIVES: We aimed to identify predictors of all falls and recurrent falls in people with PD who had not fallen in the previous year and to explore the timing of falls in a 12-month follow-up period. METHODS: Participants with PD (n = 130) were assessed by disease-specific, self-report and balance measures. Falls were recorded prospectively for 12 months. Univariate and multivariate analyses were performed. Kaplan-Meier survival analysis was used to investigate time to falling. RESULTS: Forty participants (31%) had ≥1 fall during follow-up and 21 (16%) had ≥2 falls. Disability, reduced balance confidence and greater concern about falling were associated with ≥1 fall in univariate analyses. Additionally, PD duration and severity, freezing of gait and impaired balance were associated with ≥2 falls (p <  0.05). Disability (Schwab and England scale, Odds Ratio [OR] = 0.56 per 10 points increase; 95% confidence interval [CI] 0.39-0.80; p = 0.002) was associated with ≥1 fall in the final multivariate model (area under the receiver operating characteristic curve [AUC] = 0.65; 95% CI 0.55-0.76; p = 0.005). Disability (Unified Parkinson's Disease Rating Scale activities of daily living, OR = 1.20; 95% CI 1.07-1.34; p = 0.001) and levodopa equivalent dose (OR = 1.11 per 100 mg increase; 95% CI 0.95-1.30; p = 0.19) were associated with ≥2 falls in the final multivariate model (AUC = 0.72; 95% CI 0.60-0.84; p = 0.001). Recurrent fallers experienced their first fall earlier than single fallers (p <  0.05). CONCLUSIONS: Self-reported disability was the strongest single predictor of all falls and recurrent falls.

Recurrent Falls in People with Parkinson's Disease without Cognitive Impairment: Focusing on Modifiable Risk Factors.

Falls can be considered a disabling feature in Parkinson's disease. We aimed to identify risk factors for falling, testing simultaneously the ability of disease-specific and balance-related measures. We evaluated 171 patients, collecting demographic and clinical data, including standardized assessments with the Unified Parkinson's Disease Rating Scale (UPDRS), activities of daily living (ADL) and motor sections, modified Hoehn and Yahr Scale, Schwab and England, eight-item Parkinson's Disease Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale-International (FES-I), Berg Balance Scale, Dynamic Gait Index, Functional Reach, and Timed Up and Go. ROC curves were constructed to determine the cutoff scores for all measures. Variables with P < 0.1 entered a logistic regression model. The prevalence of recurrent falls was 30% (95% CI 24%-38%). In multivariate analysis, independent risk factors for recurrent falls were (P < 0.05) levodopa equivalent dose (OR = 1.283 per 100 mg increase; 95% CI = 1.092-1.507), UPDRS-ADL > 16 points (OR = 10.0; 95% CI = 3.6-28.3), FES-I > 30 points (OR = 6.0; 95% CI = 1.6-22.6), and Berg ≤ 48 points (OR = 3.9; 95% CI = 1.2-12.7).We encourage the utilization of these modifiable risk factors in the screening of fall risk.

Past smoking and current dopamine agonist use show an independent and dose-dependent association with impulse control disorders in Parkinson's disease.

BACKGROUND: Previous studies have described the association between dopamine replacement therapy in Parkinson's disease and impulse control disorders. METHODS: A case-control study was performed to establish the prevalence of four of these behaviors in Brazilian patients with Parkinson's disease on stable dopamine replacement therapy and the possible associated risk factors. We investigated 152 patients and 212 healthy controls for pathological gambling, compulsive sexual behavior and compulsive buying and eating. RESULTS: Overall, patients had more impulsive control disorders than controls (18.4% vs. 4.2%, P < 0.001). Impulse control disorders were more common in younger patients (P = 0.008) and in those taking dopamine agonist (P < 0.001) and levodopa (P = 0.02). Higher Unified Parkinson's Disease Rating Scale motor score (P = 0.03) and past smoking (P = 0.02) were also associated in the univariate analysis. Variables independently associated with impulse control disorders were history of smoking (odds ratio = 1.059 for each year of smoking, P = 0.010) and current use of pramipexole (odds ratio = 2.551 for each increase in 1 mg, P < 0.001). CONCLUSIONS: Dopaminergic stimulation and previous exposure to smoking are independently associated with impulse control disorders in a dose-dependent manner.

Treatment of Sydenham chorea with corticosteroids.

Despite treatment with valproic acid and neuroleptics, a significant proportion of patients with Sydenham chorea (SC) remain with chorea. We evaluated the effect of intravenous methyl-prednisolone followed by oral prednisone in patients with SC refractory to conventional treatment. Patients were enrolled in the study if they failed to improve with conventional treatment, despite the development of side effects. Chorea was rated on a 0 to 4 score. Five patients, 3 of them women, were included in the study. The median pretreatment rating score of the chorea was 3 (range, 3-4) and dropped to 1 (range, 0-2) after a median follow-up of 7 months (range, 3-7 months). Two patients developed Cushing syndrome. Our data suggest that intravenous methyl-prednisolone followed by oral prednisone is an effective and well-tolerated treatment of refractory SC.