Tinetti balance performance is associated with mortality in older adults with Parkinson’s disease: a longitudinal study

Tinetti balance performance is associated with mortality in older adults with Parkinson’s disease: a longitudinal study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tinetti balance performance is associated with mortality in older adults with Parkinson’s disease: a longitudinal study Louise Laurent, Pierre Koskas, Janina Estrada, Mélanie Sebbagh, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1665061/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jan, 2023 Read the published version in BMC Geriatrics → Version 1 posted 8 You are reading this latest preprint version Abstract Background: Parkinson’s disease (PD) is associated with a 3-fold increased risk of death and this mortality risk is closely related to advancing age. Evidence is lacking regarding the factors associated with the risks of mortality or nursing-home (NH) admission, in elderly patients with PD. We aimed at identifying the clinical characteristics associated with these outcomes, in older community dwelling patients with PD. Methods: Retrospective, observational analysis of data from patients referred to our geriatric day hospital. Motor assessment included Unified Parkinson Disease Rating Scale (UPDRS) score and UPDRS axial sub-score, Tinetti Performance Oriented Mobility Assessment (POMA) balance and gait tests, and gait speed. Levodopa equivalent dose, comorbidity, cognitive performance, functional status (basic and instrumental Activities of Daily Living) were examined. Cox proportional hazards models were performed to identify the factors associated with 5-year mortality and NH admission rate. Results: We included 98 patients (mean age 79.4±5.3) of whom 18 (18.3%) died and 19 (19.4%) were admitted into NH over the 5-year follow-up. In multivariate Cox models, poor balance on the Tinetti POMA scale (HR=0,82 95%CI (0.66-0.96), p=0.02) and older age (HR= 1,12 95%CI (1.01-1.25), p=0,04) were the only variables significantly associated with increased mortality risk. A Tinetti balance score below 11/16 was associated with a 6.7 hazard for 5-year mortality (p<0.01). No specific factor was associated with NH admissions. Conclusions: The Tinetti POMA test may be an accurate instrument for identifying the older individuals with PD at higher risk of mortality, and should be considered in clinical setting. Parkinson’s disease older adults Tinetti balance Figures Figure 1 Figure 2 Introduction Parkinson's disease (PD) is the second most common neurodegenerative disease after Alzheimer's Disease, and represents the leading cause of motor disability in older adults (1). More than half of the patients with PD are older than 75, and it affects up to 3.5% of the population aged over than 80 (1)(2). Multimorbidity and non-motor symptoms, which are common in the elderly, worsen PD symptoms (3)(4). Subjects with PD are likely to experience a shorter life span compared to healthy individuals of the same age, and this risk of dying increases with aging (5)(6)(7). Indeed, 90% of deaths in PD patients occur after the age of 70, and after at least 10 years of disease progression (8). The presence of major neurocognitive disorders and the incidence of falls increase this risk (1)(5). Impaired swallowing and dysphagia, leading to aspiration pneumonitis, also shorten the lifespan of individuals with PD (9). The American Academy of Neurology has highlighted higher age at onset of PD, associated comorbidities, presentation with rigidity and bradykinesia, and secondary decrease in dopaminergic sensitivity as predictors of faster motor progression, institutionalization, and increased mortality risk (5)(10). Other studies also showed that increased mortality in PD was independently associated with motor disability, low motor Unified Parkinson Disease Rating Scale (UPDRS) score, as well as the presence of psychotic symptoms (6)(8). Individuals with PD might also face a greater risk of nursing home admission and limitations in daily living activities compared to the general population, although evidence remains heterogeneous and controversial (11)(12). Women with PD were shown to be five times more likely institutionalized than men (13). Progression of motor symptoms, neuropsychiatric disorders (delusion and hallucinations) and older age have been associated with odds of institutionalization (12)(14)(15). Non-motor symptoms, iatrogenic conditions and polypharmacy have also been related to poor prognosis in elderly patients with PD (1)(4)(16). However, to our knowledge there is limited evidence on predictors of mortality and institutionalization, in elderly patients with PD. These factors are crucial to help develop personalized care plans for the most at-risk individuals, or to design future clinical trials to improve these outcomes. The aim of this study was to identify the clinical characteristics of community dwelling elderly PD patients associated with higher risks of mortality and institutionalization at five years. Mehods Design and setting This is a retrospective, monocentric, observational analysis of data from community- dwelling elderly patients with PD, admitted between July 2007 and March 2019, in the geriatric day hospital of Bretonneau (Assistance Publique-Hôpitaux de Paris.Nord, France). This hospital is a referral center for geriatric care in the northern Parisian district. PD diagnosis was based on clinical examination by the referring neurologist, positive response to Levodopa treatment (10) and clinical confirmation by the hospital neurologist. Inclusion and non-inclusion criteria Inclusion criteria were: - Age at PD diagnosis of 65 years and older, - Comprehensive assessment performed by our multidisciplinary team (geriatrician, neurologist and physiotherapists) Non-inclusion criteria were: - Absence of available follow-up information for at least twelve months after the first evaluation - Presence of clinical symptoms suggestive of others Parkinson syndromes, according to the American Academy of Neurology recommendations (10) - Evidence for another neurodegenerative disease (e.g. Alzheimer's disease), at the time of the first evaluation or during the follow-up - Non-agreement to the use of their medical data - Insufficient fluency in French to understand and perform the tests or legal guardianship Clinical assessment All patients underwent an initial comprehensive geriatric assessment along their first stay in the day hospital including as follows: - Main socio-demographic data - Number and severity of comorbidities, using the Cumulative Illness Rating Scale (CIRS-G scale) - Performance in Activities of Daily Living (ADL) (score 0–6) and instrumental activities of daily living (IADL) (score 0–4), - Cognitive performance according to the Mini Mental State Examination (MMSE) (score 0–30), - Weight measurement and Body Mass Index calculation, - Handgrip strength of the dominant hand, measured by hydraulic dynamometer (Sissel, Sweden) - Number of drugs taken per day and daily Levodopa equivalent dose. Motor assessment : - A physiotherapist performed the following tests for all included participants : Unified Parkinson Disease Rating Scale (UPDRS) motor score and UPDRS axial sub-score (17) Tinetti Performance Oriented Mobility Assessment (POMA) balance (/16) and gait (/12) tests (18) Timed Up and Go (TUG) and Cognitive Timed Up and Go (same test while performing a cognitive dual task: counting backwards from 100 by 2). Both tests were timed in seconds (19) Gait speed was measured on a 10-meter distance, asking the patient to walk at his/her usual pace from a still position. Main Outcomes The primary endpoint of the study was mortality, from any cause. The secondary endpoint was admission into a nursing home. Death and institutionalization events were retrospectively collected every 6 months, over a maximum follow-up period of 5 years, using data available on the professional medical database of the hospital (ORBIS® software), completed by phone interviews with the patients, their general physician, specialists or staff of rehabilitation care units or nursing homes. The date of date censoring was set for March 1 st 2020. Statistical analysis Demographic and clinical characteristics of patients at inclusion were subjected to descriptive statistics. Continuous variables were compared according to the living or deceased status of patients during follow-up and the degree of significance p was assessed by Student's and Wilcoxon's test, and by Fischer's test for sex, the only discrete variable. A result was significant when p was less than 0.05. Variables showing an association with mortality with a significance level of less than 0.2 were analyzed using the Cox proportional hazard model and hazard ratios are reported with a 95% confidence interval. Data from patients lost to follow-up were censored. All statistical analyses were performed using R software (version 1.2.5). Ethical considerations and data sharing policy The research database was approved by the National Commission for Information Technology and Civil Liberties (Commission Nationale de l’Informatique et des Libertés, record number 1858079), since 2006. Consistent with the European General Data Protection Regulation, all patients were provided written and oral information about the data management explaining how their final research could be used anonymously for clinical research. The study protocol was also approved by the Regional Ethics Committee in Geriatric Medicine (CEGID Gérond’if, Paris 2021 #12021). According to the latter statements, despite full data availability in our records, sharing the clinical data of our patients would compromise the ethical standards mentioned above. Results Study population One hundred eleven patients with an initial diagnosis of PD were referred to Bretonneau day hospital between July 2007 and March 2019. Thirteen patients were not included in our analysis: 3 patients with a more likely alternative diagnosis (two with Lewy body disease and one with multiple system atrophy suspicion), 5 patients with probable Alzheimer's disease, and 5 patients lost to follow-up before one year. The median follow-up duration was 4 years. Living or deceased status during follow-up was confirmed in 58 patients (59.2%), after complete 4-year monitoring. Point censoring occurred for twenty-nine patients (29.6%) included after March 2015, when death or nursing home admission were not observed within the study duration (less than four years). Eleven patients (11.2%) were lost to follow-up between 1 and 5 years after inclusion. Mean age was 79.4 (standard deviation=5.3), ranging from 68 to 94 years old. The mean time since diagnosis of PD was 3.8 ±3.6 years. Our sample comprised 57% of males. Few patients had severe motor impairment; rigidity, bradykinesia and postural instability were common, whereas resting tremor was absent in half of the population (Figure 1). Eighteen (18.4%) patients deceased during the follow up period, with a mean age at death of 84.5 years. Factors Associated with Mortality In univariate analyze (Table 1), slower gait speed was significantly associated with an increased risk of mortality (p=0.04). Tinetti balance score on admission was also lower in deceased participants than in those who survived (11.6 vs. 13.6, p=0.03). Table 1: Patients’ characteristics, according to the occurrence of death or institutionalization over follow-up. Characteristics . M (SD) Global population (N=98) Decease Instutionalization No N=80 Yes N=18 p No N=79 Yes N=19 p Age (years) 79.4 (5.3) 78.9 (5.2) 81.6 (5.4) 0.07 79.4 (5.4) 79.6 (5.2) 0.84 Male gender % (N) 57.1 (56) 52.5 (42) 77.8 (14) 0.07 57.0 (45) 57.9 (11) 1 Time from onset (Y) 3.8 (3.6) 3.8 (3.7) 3.7 (3.1) 0.85 3.7 (3.7) 4.2 (3.1) 0.59 UPDRS Motor score 14.6 (5.1) 14.5 (4.8) 15.2 (6.4) 0.68 14.8 (5.1) 14.1 (5.1) 0.62 UPDRS axial 7.9 (3.3) 7.8 (3.1) 8.3 (4.0) 0.54 7.9 (3.3) 7.6 (3.4) 0.68 Levodopa equivalent dose (mg) 368.5 (212.0) 368.5 (224.3) 368.8 (143.6) 1.0 364.9 (210.1) 385.9 (226.9) 0.72 Weight (kg) 65.1 (11.7) 64.8 (11.8) 66.4 (11.5) 0.66 65.4 (12.1) 63.9 (10.5) 0.62 MMSE (/30) 25.6 (3.8) 25.8 (3.5) 24.8 (5.4) 0.53 25.7 (3.8) 25.1 (4.1) 0.65 Grip strength (kg) 22.7 (8.0) 23.1 (8.2) 20.6 (6.5) 0.25 22.9 (8.4) 21.8 (5.6) 0.59 ADL (/6) 5.5 (0.8) 5.5 (0.9) 5.6 (0.7) 0.80 5.5 (0.8) 5.6 (0.8) 0.70 IADL (/4) 3.3 (1.1) 3.3 (1.0) 3.1 (1.2) 0.38 3.2 (1.1) 3.2 (1.0) 0.75 Gait speed (m/s) 0.8 (0.3) 0.8 (0.3) 0.7 (0.3) 0.03 0.8 (0.2) 0.8 (0.4) 0.81 TUG (s) 18.1 (9.2) 17.5 (9.0) 20.6 (9.8) 0.24 18.1 (9.5) 18.0 (8.2) 0.94 TUGc (s) 24.9 (15.7) 24.4 (15.2) 27.0 (18.2) 0.57 24.5 (15.7) 26.1 (16.0) 0.51 Tinetti balance score (/16) 13.3 (2.7) 13.7 (2.1) 11.6 (4.0) 0.04 13.4 (2.6) 13.2 (2.5) 0.70 Tinetti gait score (/12) 9.1 (2.7) 9.2 (2.7) 8.6 (2.6) 0.42 9.1 (2.8) 9.2 (2.1) 0.90 Number of drugs 5.1 (2.7) 5.1 (2.7) 5.3 (2.7) 0.72 5.1 (2.8) 5.4 (2.3) 0.55 CIRS-G 6.4 (2.1) 6.2 (2.0) 7.2 (2.5) 0.13 6.4 (2.2) 6.4 (1.8) 1 Abbreviations : M = mean ; SD = standard deviation ; N = number of subjects ; UPDRS = United Parkinson’s Disease Rating Scale ; MMSE = Mini Mental State Evaluation ; ADL = Activities of Daily Living ; IADL = Instrumental Activities of Daily Living ; TUG = Timed Up and Go ; TUGc = Timed Up and Go Cognitive task ; CIRS-G = Cumulative Illness Rating Scale for Geriatrics In a multivariate model (Table 2), two factors remained independently associated with mortality: age and Tinetti balance score (HR=0.82 95% CI [0,66-0,96] p=0.02). Individuals from the lowest tertile (score below 11/16) experienced 6-fold higher mortality than those from the higher tertile (score over 14/16) (HR 6.65 95% CI [1.68-26.30], p < 0.01), See Table 3 and Figure 2. However, there was no significant difference regarding the Tinetti gait test. We did not find any other risk factor significantly associated with mortality in our study. Post-hoc analyses of the items of the Tinetti POMA balance scale All the single items of the Tinetti balance test were included in a multivariate model to explore their association with mortality (data not shown). The ability to maintain balance with eyes closed was associated with a significant reduction in mortality HR = 0.26 [0.07-0.95, p = 0.04), with a sensitivity of 22.2% (CI 6.41%-47.64%) and a specificity of 93.75% (CI 86.01%-97.94%). This association was no longer significant after Bonferroni correction for multiple comparisons. Factors Associated with institutionalization A total of 19 patients (19.4%) were admitted to nursing home, within the study duration. No single factor was significantly associated with the risk of institutionalization in our study. Table 2 : Multivariate analysis of factors associated with mortality Characteristics HR (CI 95%) P Age (years) 1.12 (1.01-1.25) 0.04 Male gender 3.06 (0.95-9.84) 0.06 CIRS-G 1.04 (0.83-1.29) 0.74 Gait speed (m/s) 0.44 (0.02-8.49) 0.59 Tinetti balance score /16 0.82 (0.66-0.96) 0.02 N = 90 ; 17 events. CI = confidence interval; CIRS-G = Cumulative Illness Rate Scale for Geriatrics; HR = Hazard Ratio Table 3 : Multivariate analysis of factors associated with mortality including tertiles of Tinetti POMA balance performance Characteristics HR (CI 95%) P Age (years) 1.07 (0.98-1.17) 0.14 Male gender 2.78 (0.89-8.70) 0.08 Tinetti balance score /16 - First tertile (> 14) REF REF - Second tertile ([11 ;14[) 1.26 (0.37-4.28) 0.70 - Third tertile (<11) 6.65 (1.68-26.3) <0.01 Abbreviations : CI = confidence interval ; HR = Hazard Ratio Discussion In this retrospective, observational study of elderly patients with PD, we observed a significant association between poor performance on the Tinetti POMA balance test and increased mortality. Moreover, individuals from the lowest tertile (score of less than 11/16) experienced 6-fold higher mortality than their counterparts with the best performance (score greater than 14/16). This association was independent of age, gender or multimorbidity. No other single factor was associated with mortality risk or institutionalization during the follow-up period. To our knowledge, there are no risk-assessment tools for clinicians to identify older patients with PD at risk of poor clinical outcomes, such as mortality or nursing home admission. Although the UPDRS, or the comprehensive assessment of physical and cognitive performances play a key role in routine assessment, none of them demonstrated a predictive value for adverse outcomes in this population (20)(21). In our study, the 5-year mortality was 18.3 % and the time lapse between diagnosis of PD and death ranged from 1.5 to 13.5 years, reflecting a major clinical heterogeneity, which was already described elsewhere (7)(22). Nonetheless, the mean duration of 6.9 years in our analysis is shorter than in other published studies (12 years from the onset of the disease) (23)(24). This difference may reflect the faster adverse consequences of PD symptoms in elderly patients compared with younger ones (23)(25). The severity of motor impairment was suggested as a prognostic factor for disease progression, disability or impaired quality of life in several studies (10)(11)(26). However, the most used tool in this setting is the UPDRS motor score, which was not associated with mortality in our study of elderly subjects with PD. Axial motor impairment alters mobility and was also proposed as a prognostic factor (25). Yet, the measured axial UPDRS sub-score was not associated with mortality in our sample. Although the UPDRS motor score remains essential in the follow-up of patients with PD, our results highlighted the role of other tests in the evaluation of patients with this disease. In our analysis, a poor Tinetti balance (but not gait) performance was significantly associated with higher mortality. Another study suggested a link between reduced physical function assessed with the Tinetti test and an increased mortality risk in individuals with PD (26). However, the latter study included younger patients with PD (mean age 74 vs 79.4 in our study) and did not dissociate the two subparts of the Tinetti Performance Oriented Mobility Assessment. Thus, our results show the importance of static balance disorder in elderly patients (27). Although gait, balance and posture disorders frequently co-exist in PD, they are not systematically associated, and when they are, one disorder may be predominant. However, balance is often tested using the clinical pull test, which has a low inter-rater reliability and gives little insights regarding the patient's balance in everyday life (29)(30). On the other hand, the Tinetti balance test can be performed in less than 5 minutes, in a routine consultation. A score below 11/16 is likely to indicate a high risk of mortality and should encourage the neurologist or the geriatrician to propose reinforced individualized treatment plan, to minimize the risk of fall, including physical activity, physiotherapy and rehabilitation. We did not find any other factor associated with mortality in our population. Gait speed, although significantly lower in participants who died at 5 years in our study, was no longer significantly associated with mortality, in our multivariate model. The interaction between the Tinetti score and gait speed was non-significant (p=0.19), despite a significant correlation between the two variables (r=0.52 p <0.001). However, several studies supported an association between gait speed and survival in elderly subjects (31)(32). Our study population included individuals with slow gait speed (mean=0.8 m/s), and most of them can be considered at risk of falling. We assume that as gait speed was globally slow in elderly patients with PD, as a consequence of PD, multimorbidity and advancing age, this measure lost its predictive value of increased risk of death, which was found in the general population (33). Except older age, other non-physical characteristics: gender, cognitive performance, daily living abilities, medication (including Levodopa equivalent prescribed dose) were not associated with mortality risk in our study population. There is conflicting evidence in the literature regarding the influence of gender on disease progression(13)(34). Cognitive status as reflected by the MMSE was generally good in our patients, with a mean score above 25/30 at inclusion. Data from the literature suggest that MMSE is insignificantly altered in the early stages of PD(1)(33). The functional autonomy of the patients included in our study as reflected by the ADL and IADL scores was also globally preserved, probably explaining the absence of a significant association with mortality risk. Equally, other studies did not find any association between the initial dose of Levodopa and mortality risk (16). We did not find any factor associated with institutionalization during follow-up. Nursing home admission depends on multiple factors, beyond the mere consequences of motor or cognitive decline. Evidence regarding the causal factors of nursing home admission in PD is controversial (35)(36). In particular, home care support, either family or professional, can enable disabled patients to remain at home. Social and financial situation, which was not evaluated in our study, also plays a key role in the patients' outcomes. Conversely, social isolation or low income may result in a faster admission to a nursing home. The main strength of our study is that, to our knowledge, it is the first one carried out specifically in elderly PD patients, focusing on factors associated with survival and the risk of institutionalization, and using data systematically recorded for more than 15 years. Our study also has several limitations however: there was a limited number of events (death and nursing home admissions) due to the small size of our population, raising concerns about a possible lack of power. The underlying causes of death were not known and could be associated with independent comorbidities. Furthermore, this was a retrospective study, with more than 10% lost to follow-up. Nearly 30% of our patients had a shorter follow-up period as they were included less than 5 years before the end of the collection period. However, our results indicate the increased odds for mortality in individuals with the poorest performance on the Tinetti balance scale. Conclusion Older individuals with PD experience various patterns of motor and non-motor symptoms associated with an overall increased mortality risk. Among multiple assessment tools, the Tinetti POMA test may be an accurate instrument for identifying the older individuals with PD at higher risk of dying. This instrument should be considered in clinical setting, both by physiotherapists and geriatricians, to improve the care of older adults with PD. Future prospective studies are warranted to confirm the predictive value of the Tinetti POMA in this population. Abbreviations ADL: Activities of Daily Living CI: confidence interval CIRS-G: Cumulative Illness Rating Scale for Geriatrics HR: Hazard Ratio IADL: Instrumental Activities of Daily Living MMSE: Mini Mental State Examination NH: Nursing Home PD: Parkinson’s disease POMA: Performance Oriented Mobility Assessment UPDRS: Unified Parkinson Disease Rating Scale: UPDRS TUG: Timed-Up and Go test Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and was approved by the National Commission for Information Technology and Civil Liberties (Commission Nationale de l’Informatique et des Libertés, record number=1858079), since 2006. A note of information and of no objection to the collection of data for clinical research purpose was sent to all patients included in this analysis, explaining how their final research could be used anonymously for clinical research. Informed consent was waived by the Regional Ethics Committee in Geriatric Medicine (CEGID Gérond’if, Paris 2021 #12021), considering the retrospective design of this observational study. Consent for publication: Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available, to preserve the confidentiality of study participants and the data collected from them, consistent with the information note, but are available from the corresponding author, on reasonable request. Competing interests The authors declare that they have no competing interests Funding: None Authors' contributions LL and PK processed the data of participants. LL and PK designed the study and drafted the manuscript. JE, MS, SL, ARS and ML critically reviewed and edited the manuscript, and contributed to the discussion. Acknowledgements: Not applicable References Elbaz A, Carcaillon L, Kab S, Moisan F. Epidemiology of Parkinson’s disease. 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Sex Differences in the Clinical Progression of Parkinson’s Disease. J Obstet Gynecol Neonatal Nurs JOGNN. 2016;45(5):749–56. Goetz CG, Stebbins GT. Risk factors for nursing home placement in advanced Parkinson’s disease. Neurology. 1993; 43(11):2227–9. Aarsland D, Larsen JP, Tandberg E, Laake K. Predictors of nursing home placement in Parkinson’s disease: a population-based, prospective study. J Am Geriatr Soc. 2000;48(8):938–42. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2023 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Major revision 12 Jul, 2022 Reviews received at journal 20 Jun, 2022 Reviewers agreed at journal 20 Jun, 2022 Reviewers invited by journal 28 May, 2022 Editor assigned by journal 28 May, 2022 Editor invited by journal 20 May, 2022 Submission checks completed at journal 20 May, 2022 First submitted to journal 17 May, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1665061","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":107455440,"identity":"e3df7d0c-af09-49d6-bbc6-2b6fbb8579f2","order_by":0,"name":"Louise Laurent","email":"","orcid":"","institution":"Bretonneau University Hospital, Geriatric day hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Laurent","suffix":""},{"id":107455441,"identity":"39ee2539-26b7-42b1-9505-546223bf77e5","order_by":1,"name":"Pierre Koskas","email":"","orcid":"","institution":"Bretonneau University Hospital, Geriatric day hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pierre","middleName":"","lastName":"Koskas","suffix":""},{"id":107455442,"identity":"c5256f2f-3bde-4dab-9f2e-5e77e3338b38","order_by":2,"name":"Janina Estrada","email":"","orcid":"","institution":"Bretonneau University Hospital, Geriatric day hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Janina","middleName":"","lastName":"Estrada","suffix":""},{"id":107455443,"identity":"3e877fe1-435e-4147-8599-8f33a3a94cbe","order_by":3,"name":"Mélanie Sebbagh","email":"","orcid":"","institution":"Bretonneau University Hospital, Geriatric day hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mélanie","middleName":"","lastName":"Sebbagh","suffix":""},{"id":107455444,"identity":"3829e206-02c1-4cd8-8252-157141ee094a","order_by":4,"name":"Sophie Lacaille","email":"","orcid":"","institution":"Bretonneau University Hospital, Geriatric day hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sophie","middleName":"","lastName":"Lacaille","suffix":""},{"id":107455445,"identity":"0c79d5a8-e4b6-4984-82aa-9c913f93dd64","order_by":5,"name":"Agathe Raynaud-Simon","email":"","orcid":"","institution":"Bretonneau University Hospital, Geriatric day hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Agathe","middleName":"","lastName":"Raynaud-Simon","suffix":""},{"id":107455446,"identity":"ad062388-a6dd-4782-b01a-2c5f7da0130c","order_by":6,"name":"Matthieu Lilamand","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIie3OIQvCQBTA8RsHs8ytKuhHECaCUT/LsXqsmGRhkwWLmvVbLL28ceHK2RXLxCxoNAjeblHZaTPcv9wL9+M9hEymf6xlLXI18JV6HBdZZTPBVlITIRCSk2Mj7GuI+ig70HrSkkGKk/xBJ6F7vBaXO530JLFvTWTMrKRYQzDrnsLALyCoDsNbHcnbgEl2ouNOAVgSjzUeprY8ISbZUVQkVlu0hLWBkezgVIR9SfrAyU7Qkb8H7thYR/jyfL5CRDZcDMs5RFOvlTaTD/0MTCaTyfTWC8UbS6nqyM5BAAAAAElFTkSuQmCC","orcid":"","institution":"Bretonneau University Hospital, Geriatric day hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Matthieu","middleName":"","lastName":"Lilamand","suffix":""}],"badges":[],"createdAt":"2022-05-17 10:44:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1665061/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1665061/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-023-03776-7","type":"published","date":"2023-01-30T18:39:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":21794971,"identity":"722b8532-37de-4849-aba3-86b992c17242","added_by":"auto","created_at":"2022-05-23 18:28:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36290,"visible":true,"origin":"","legend":"\u003cp\u003eMain clinical symptoms of the study participants at baseline\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1665061/v1/219228c0b81a5d444ddef082.png"},{"id":21794970,"identity":"0604557c-e34f-4dda-ba79-ff2ff20f5fa2","added_by":"auto","created_at":"2022-05-23 18:28:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34947,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival probability according to the Tinetti Performance Oriented Mobility Assessment performance\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1665061/v1/ca8717897f2680803fa703b1.png"},{"id":44719371,"identity":"e699f915-7446-496c-a7d9-d1cd9085295e","added_by":"auto","created_at":"2023-10-16 18:54:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":514502,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1665061/v1/72b14174-2cfd-4ea8-90ae-644267574cdc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTinetti balance performance is associated with mortality in older adults with Parkinson’s disease: a longitudinal study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eParkinson\u0026apos;s disease (PD) is the second most common neurodegenerative disease after Alzheimer\u0026apos;s Disease, and represents the leading cause of motor disability in older adults\u0026nbsp;(1). More than half of the patients with PD are older than 75, and it affects up to 3.5% of the population aged over than 80\u0026nbsp;(1)(2). Multimorbidity and non-motor symptoms, which are common in the elderly, worsen PD symptoms\u0026nbsp;(3)(4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSubjects with PD are likely to experience a shorter life span compared to healthy individuals of the same age, and this risk of dying increases with aging\u0026nbsp;(5)(6)(7). Indeed, 90% of deaths in PD patients occur after the age of 70, and after at least 10 years of disease progression\u0026nbsp;(8). The presence of major neurocognitive disorders and the incidence of falls increase this risk\u0026nbsp;(1)(5).\u0026nbsp;Impaired swallowing and dysphagia, leading to\u0026nbsp;aspiration pneumonitis, also shorten the lifespan\u0026nbsp;of individuals with\u0026nbsp;PD\u0026nbsp;(9). The American Academy of Neurology has highlighted higher age at onset of PD, associated comorbidities, presentation with rigidity and bradykinesia, and secondary decrease in dopaminergic sensitivity as predictors of faster motor progression, institutionalization, and \u0026nbsp;increased mortality risk\u0026nbsp;(5)(10). Other studies also showed that increased mortality in PD was independently\u0026nbsp;associated with motor disability, low motor Unified Parkinson Disease Rating Scale (UPDRS) score, as well as the presence of psychotic symptoms\u0026nbsp;(6)(8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndividuals with PD might also face a greater risk of nursing home admission and limitations in daily living activities compared to the general population, although evidence remains heterogeneous and controversial\u0026nbsp;(11)(12). Women with PD were shown to be five times more likely institutionalized than men\u0026nbsp;(13). Progression of motor symptoms, neuropsychiatric disorders (delusion and hallucinations) and older age have been associated with odds of institutionalization\u0026nbsp;(12)(14)(15). Non-motor symptoms, iatrogenic conditions and polypharmacy have also been related to poor prognosis in elderly patients with PD\u0026nbsp;(1)(4)(16).\u003c/p\u003e\n\u003cp\u003eHowever, to our knowledge there is limited evidence on predictors of mortality and institutionalization, in elderly patients with PD. These factors are crucial to help develop personalized care plans for the most at-risk individuals, or to design future clinical trials to improve these outcomes. The aim of this study was to identify the clinical characteristics of community dwelling elderly PD patients associated with higher risks of mortality and institutionalization at five years.\u0026nbsp;\u003c/p\u003e"},{"header":"Mehods","content":"\u003cp\u003e\u003cstrong\u003eDesign and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a retrospective, monocentric, observational analysis of data from community- dwelling elderly patients with PD, admitted between July 2007 and March 2019, in the geriatric day hospital of Bretonneau (Assistance Publique-H\u0026ocirc;pitaux de Paris.Nord, France). This hospital is a referral center for geriatric care in the northern Parisian district.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePD diagnosis was based on clinical examination by the referring neurologist, positive response to Levodopa treatment\u0026nbsp;(10)\u0026nbsp;and clinical confirmation by the hospital neurologist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and non-inclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria were:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Age at PD diagnosis of 65 years and older,\u003c/p\u003e\n\u003cp\u003e- Comprehensive assessment performed by our multidisciplinary team (geriatrician, neurologist and physiotherapists)\u003c/p\u003e\n\u003cp\u003eNon-inclusion criteria were:\u003c/p\u003e\n\u003cp\u003e- \u0026nbsp;Absence of available follow-up information for at least twelve months after the first evaluation\u003c/p\u003e\n\u003cp\u003e- Presence of clinical symptoms suggestive of others Parkinson syndromes,\u0026nbsp;according to the American Academy of Neurology recommendations\u0026nbsp;(10)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Evidence for another neurodegenerative disease (e.g. Alzheimer\u0026apos;s disease), at the time of the first evaluation or during the follow-up\u003c/p\u003e\n\u003cp\u003e- Non-agreement to the use of their medical data \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Insufficient fluency in French to understand and perform the tests or legal guardianship\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent an initial comprehensive geriatric assessment along their first stay in the day hospital including as follows:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- Main socio-demographic data\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Number and severity of comorbidities, using the Cumulative Illness Rating Scale (CIRS-G scale)\u003c/p\u003e\n\u003cp\u003e- Performance in Activities of Daily Living (ADL) (score 0\u0026ndash;6) and instrumental activities of daily living (IADL) (score 0\u0026ndash;4),\u003c/p\u003e\n\u003cp\u003e- Cognitive performance according to the Mini Mental State Examination (MMSE) (score 0\u0026ndash;30),\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Weight measurement and Body Mass Index calculation,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Handgrip strength of the dominant hand, measured by hydraulic dynamometer (Sissel, Sweden)\u003c/p\u003e\n\u003cp\u003e- Number of drugs taken per day and daily Levodopa equivalent dose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMotor assessment :\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e- A physiotherapist performed the following tests for all included participants :\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eUnified Parkinson Disease Rating Scale (UPDRS) motor score and UPDRS axial sub-score\u0026nbsp;(17)\u003c/li\u003e\n \u003cli\u003eTinetti Performance Oriented Mobility Assessment (POMA) balance (/16) and gait (/12) tests\u0026nbsp;(18)\u003c/li\u003e\n \u003cli\u003eTimed Up and Go (TUG) and Cognitive Timed Up and Go (same test while performing a cognitive dual task: counting backwards from 100 by 2).\u0026nbsp;Both tests were timed in seconds\u0026nbsp;(19)\u003c/li\u003e\n \u003cli\u003eGait speed was measured on a 10-meter distance, asking the patient to walk at his/her usual pace from a still position.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eMain Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary endpoint of the study was mortality, from any cause. The secondary endpoint was admission into a nursing home.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDeath and institutionalization events were retrospectively collected every 6 months, over a maximum follow-up period of 5 years, using data available on the professional medical database of the hospital (ORBIS\u0026reg; software), completed by phone interviews with the patients, their general physician, specialists or staff of rehabilitation care units or nursing homes. The date of date censoring was set for March 1\u003csup\u003est\u003c/sup\u003e 2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and clinical characteristics of patients at inclusion were subjected to descriptive statistics. Continuous variables were compared according to the living or deceased status of patients during follow-up and the degree of significance p was assessed by Student\u0026apos;s and Wilcoxon\u0026apos;s test, and by Fischer\u0026apos;s test for sex, the only discrete variable. A result was significant when p was less than 0.05. Variables showing an association with mortality with a significance level of less than 0.2 were analyzed using the Cox proportional hazard model and hazard ratios are reported with a 95% confidence interval. Data from patients lost to follow-up were censored.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using R software (version 1.2.5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations \u0026nbsp;and data sharing policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research database was approved by the National Commission for Information Technology and Civil Liberties (Commission Nationale de l\u0026rsquo;Informatique et des Libert\u0026eacute;s, record number 1858079), since 2006. Consistent with the European General Data Protection Regulation, all patients were provided written and oral information about the data management explaining how their final research could be used anonymously for clinical research. The study protocol was also approved by the Regional Ethics Committee in Geriatric Medicine (CEGID G\u0026eacute;rond\u0026rsquo;if, Paris 2021 #12021). According to the latter statements, despite full data availability in our records, sharing the clinical data of our patients would compromise the ethical standards mentioned above.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne hundred eleven patients with an initial diagnosis of PD were referred to Bretonneau day hospital between July 2007 and March 2019. Thirteen patients were not included in our analysis: 3 patients with a more likely alternative diagnosis (two with Lewy body disease and one with multiple system atrophy suspicion), 5 patients with probable Alzheimer\u0026apos;s disease, and 5 patients lost to follow-up before one year.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe median follow-up duration was 4 years. Living or deceased status during follow-up was confirmed in 58 patients (59.2%), after complete 4-year monitoring. Point censoring occurred for twenty-nine patients (29.6%) included after March 2015, when death or nursing home admission were not observed within the study duration (less than four years). Eleven patients (11.2%) were lost to follow-up between 1 and 5 years after inclusion.\u003c/p\u003e\n\u003cp\u003eMean age was 79.4 (standard deviation=5.3), ranging from 68 to 94 years old. The mean time since diagnosis of PD was 3.8 \u0026plusmn;3.6 years. Our sample comprised 57% of males. Few patients had severe motor impairment; rigidity, bradykinesia and postural instability were common, whereas resting tremor was absent in half of the population (Figure 1). Eighteen (18.4%) patients deceased during the follow up period, with a mean age at death of 84.5 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors Associated with Mortality\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn univariate analyze (Table 1), slower gait speed was significantly associated with an increased risk of mortality (p=0.04). Tinetti balance score on admission was also lower in deceased participants than in those who survived (11.6 vs. 13.6, p=0.03).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003cstrong\u003eTable 1: Patients\u0026rsquo; characteristics,\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;according to the occurrence of death or institutionalization over follow-up.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"19.726339794754846%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eM (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"11.402508551881414%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGlobal population (N=98)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"34.43557582668187%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecease\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"34.43557582668187%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstutionalization\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=80\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e79.4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e78.9 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e81.6 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e79.4 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e79.6 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eMale gender % (N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e57.1 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e52.5 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e77.8 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e57.0 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e57.9 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eTime from onset (Y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e3.8 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e3.8 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e3.7 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e3.7 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e4.2 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eUPDRS Motor score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e14.6 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e14.5 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e15.2 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e14.8 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e14.1 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eUPDRS axial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e7.9 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e7.8 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e8.3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e7.9 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e7.6 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eLevodopa equivalent dose (mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e368.5 (212.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e368.5 (224.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e368.8 (143.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e364.9 (210.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e385.9 (226.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e65.1 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e64.8 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e66.4 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e65.4 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e63.9 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eMMSE (/30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e25.6 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e25.8 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e24.8 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e25.7 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e25.1 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eGrip strength (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e22.7 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e23.1 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e20.6 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e22.9 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e21.8 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eADL (/6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e5.5 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.5 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.6 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.5 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.6 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eIADL (/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e3.3 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e3.3 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e3.1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e3.2 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e3.2 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGait speed (m/s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.8 (0.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.8 (0.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.7 (0.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.8 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.8 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eTUG (s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e18.1 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e17.5 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e20.6 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e18.1 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e18.0 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eTUGc (s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e24.9 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e24.4 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e27.0 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e24.5 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e26.1 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTinetti balance score (/16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.3 (2.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.7 (2.1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e11.6 (4.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e13.4 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e13.2 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eTinetti gait score (/12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e9.1 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e9.2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e8.6 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e9.1 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e9.2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eNumber of drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e5.1 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.1 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.3 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.1 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e5.4 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.681456200227533%\"\u003e\n \u003cp\u003eCIRS-G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.376564277588168%\"\u003e\n \u003cp\u003e6.4 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e6.2 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e7.2 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e6.4 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e6.4 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.49032992036405%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations\u003c/strong\u003e : M = mean ; SD = standard deviation ; N = number of subjects ; UPDRS = United Parkinson\u0026rsquo;s Disease Rating Scale ; MMSE = Mini Mental State Evaluation ; ADL = Activities of Daily Living ; IADL = Instrumental Activities of Daily Living ;\u0026nbsp;\u003cbr\u003eTUG = Timed Up and Go ; TUGc = Timed Up and Go Cognitive task ; CIRS-G = Cumulative Illness Rating Scale for Geriatrics\u003c/p\u003e\n\u003cp\u003eIn a multivariate model (Table 2), two factors remained independently associated with mortality: age and Tinetti balance score (HR=0.82 95% CI [0,66-0,96] p=0.02). Individuals from the lowest tertile (score below 11/16) experienced 6-fold higher mortality than those from the higher tertile (score over 14/16) (HR 6.65 95% CI [1.68-26.30], p \u0026lt; 0.01), See Table 3 and Figure 2. However, there was no significant difference regarding the Tinetti gait test. We did not find any other risk factor significantly associated with mortality in our study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost-hoc analyses of the items of the Tinetti POMA balance scale\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the single items of the Tinetti balance test were included in a multivariate model to explore their association with mortality (data not shown). The \u003cem\u003eability to maintain balance with eyes closed\u003c/em\u003e was associated with a significant reduction in mortality HR = 0.26 [0.07-0.95, p = 0.04), with a sensitivity of 22.2% (CI 6.41%-47.64%) and a specificity of 93.75% (CI 86.01%-97.94%). This association was no longer significant after Bonferroni correction for multiple comparisons.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors Associated with\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003einstitutionalization\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 19 patients (19.4%) were admitted to nursing home, within the study duration. No single factor was significantly associated with the risk of institutionalization in our study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 :\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMultivariate analysis of factors associated with mortality\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR (CI 95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e1.12 (1.01-1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eMale gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e3.06 (0.95-9.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eCIRS-G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e1.04 (0.83-1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eGait speed (m/s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e0.44 (0.02-8.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eTinetti balance score /16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e0.82 (0.66-0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;N = 90 ; 17 events.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;CI = confidence interval; CIRS-G = Cumulative Illness Rate Scale for Geriatrics; HR = Hazard Ratio\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 :\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMultivariate analysis of factors associated with mortality including tertiles of Tinetti POMA balance performance\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003eHR (CI 95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003eP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e1.07 (0.98-1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eMale gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e2.78 (0.89-8.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.671840354767184%\"\u003e\n \u003cp\u003eTinetti balance score /16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"47.671840354767184%\"\u003e\n \u003cp\u003e- First tertile \u0026nbsp;(\u0026gt; 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003eREF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003eREF\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"47.671840354767184%\"\u003e\n \u003cp\u003e- Second tertile ([11\u0026nbsp;;14[)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e1.26 (0.37-4.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"47.671840354767184%\"\u003e\n \u003cp\u003e- Third tertile (\u0026lt;11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e6.65 (1.68-26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.055432372505543%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations\u003c/strong\u003e : CI = confidence interval ; HR = Hazard Ratio\u0026nbsp;\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eIn this retrospective, observational study of elderly patients with PD, we observed a significant association between poor performance on the Tinetti POMA balance test and increased mortality. Moreover, individuals from the lowest tertile (score of less than 11/16) experienced 6-fold higher mortality than their counterparts with the best performance (score greater than 14/16). This association was independent of age, gender or multimorbidity. No other single factor was associated with mortality risk or institutionalization during the follow-up period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo our knowledge, there are no risk-assessment tools for clinicians to identify older patients with PD at risk of poor clinical outcomes, such as mortality or nursing home admission. Although the UPDRS, or the comprehensive assessment of physical and cognitive performances play a key role in routine assessment, none of them demonstrated a predictive value for adverse outcomes in this population\u0026nbsp;(20)(21). In our study, the 5-year mortality was 18.3 % and the time lapse between diagnosis of PD and death ranged from 1.5 to 13.5 years, reflecting a major clinical heterogeneity, which was already described elsewhere\u0026nbsp;(7)(22). Nonetheless, the mean duration of 6.9 years in our analysis is shorter than in other published studies (12 years from the onset of the disease)\u0026nbsp;(23)(24). This difference may reflect the faster adverse consequences of PD symptoms in elderly patients compared with younger ones\u0026nbsp;(23)(25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe severity of motor impairment was suggested as a prognostic factor for disease progression, disability or impaired quality of life in several studies\u0026nbsp;(10)(11)(26). However, the most used tool in this setting is the UPDRS motor score, which was not associated with mortality in our study of elderly subjects with PD. Axial motor impairment alters mobility and was also proposed as a prognostic factor\u0026nbsp;(25). Yet, the measured axial UPDRS sub-score was not associated with mortality in our sample. Although the UPDRS motor score remains essential in the follow-up of patients with PD, our results highlighted the role of other tests in the evaluation of patients with this disease. In our analysis, a poor Tinetti balance (but not gait) performance was significantly associated with higher mortality. Another study suggested a link between reduced physical function assessed with the Tinetti test and an increased mortality risk in individuals with PD\u0026nbsp;(26). However, the latter study included younger patients with PD (mean age 74 vs 79.4 in our study) and did not dissociate the two subparts of the Tinetti Performance Oriented Mobility Assessment. Thus, our results show the importance of static balance disorder in elderly patients\u0026nbsp;(27). Although gait, balance and posture disorders frequently co-exist in PD, they are not systematically associated, and when they are, one disorder may be predominant. However, balance is often tested using the clinical pull test, which has a low inter-rater reliability and gives little insights regarding the patient\u0026apos;s balance in everyday life\u0026nbsp;(29)(30). On the other hand, the Tinetti balance test can be performed in less than 5 minutes, in a routine consultation. A score below 11/16 is likely to indicate a high risk of mortality and should encourage the neurologist or the geriatrician to propose reinforced individualized treatment plan, to minimize the risk of fall, including physical activity, physiotherapy and rehabilitation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe did not find any other factor associated with mortality in our population. Gait speed, although significantly lower in participants who died at 5 years in our study, was no longer significantly associated with mortality, in our multivariate model. The interaction between the Tinetti score and gait speed was non-significant (p=0.19), despite a significant correlation between the two variables (r=0.52 p \u0026lt;0.001). However, several studies supported an association between gait speed and survival in elderly subjects\u0026nbsp;(31)(32). Our study population included individuals with slow gait speed (mean=0.8 m/s), and most of them can be considered at risk of falling. We assume that as gait speed was globally slow in elderly patients with PD, as a consequence of PD, multimorbidity and advancing age, this measure lost its predictive value of increased risk of death, which was found in the general population\u0026nbsp;(33).\u003c/p\u003e\n\u003cp\u003eExcept older age, other non-physical characteristics: gender, cognitive performance, daily living abilities, medication (including Levodopa equivalent prescribed dose) were not associated with mortality risk in our study population. There is conflicting evidence in the literature regarding the influence of gender on disease progression(13)(34). Cognitive status as reflected by the MMSE was generally good in our patients, with a mean score above 25/30 at inclusion. Data from the literature suggest that MMSE is insignificantly altered in the early stages of PD(1)(33). The functional autonomy of the patients included in our study as reflected by the ADL and IADL scores was also globally preserved, probably explaining the absence of a significant association with mortality risk. Equally, other studies did not find any association between the initial dose of Levodopa and mortality risk (16).\u003c/p\u003e\n\u003cp\u003eWe did not find any factor associated with institutionalization during follow-up. Nursing home admission depends on multiple factors, beyond the mere consequences of motor or cognitive decline. Evidence regarding the causal factors of nursing home admission in PD is controversial\u0026nbsp;(35)(36). In particular, home care support, either family or professional, can enable disabled patients to remain at home. Social and financial situation, which was not evaluated in our study, also plays a key role in the patients\u0026apos; outcomes. Conversely, social isolation or low income may result in a faster admission to a nursing home.\u003c/p\u003e\n\u003cp\u003eThe main strength of our study is that, to our knowledge, it is the first one carried out specifically in elderly PD patients, focusing on factors associated with survival and the risk of institutionalization, and using data systematically recorded for more than 15 years.\u003c/p\u003e\n\u003cp\u003eOur study also has several limitations however: there was a limited number of events (death and nursing home admissions) due to the small size of our population, raising concerns about a possible lack of power. The underlying causes of death were not known and could be associated with independent comorbidities. \u0026nbsp;Furthermore, this was a retrospective study, with more than 10% lost to follow-up. Nearly 30% of our patients had a shorter follow-up period as they were included less than 5 years before the end of the collection period. However, our results indicate the increased odds for mortality in individuals with the poorest performance on the Tinetti balance scale.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOlder individuals with PD experience various patterns of motor and non-motor symptoms associated with an overall increased mortality risk. Among multiple assessment tools, the Tinetti POMA test may be an accurate instrument for identifying the older individuals with PD at higher risk of dying. This instrument should be considered in clinical setting, both by physiotherapists and geriatricians, to improve the care of older adults with PD. Future prospective studies are warranted to confirm the predictive value of the Tinetti POMA in this population. \u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eADL: Activities of Daily Living\u003c/p\u003e\n\u003cp\u003eCI: \u0026nbsp;confidence interval\u003c/p\u003e\n\u003cp\u003eCIRS-G: Cumulative Illness Rating Scale for Geriatrics\u003c/p\u003e\n\u003cp\u003eHR: Hazard Ratio\u003c/p\u003e\n\u003cp\u003eIADL: Instrumental Activities of Daily Living\u003c/p\u003e\n\u003cp\u003eMMSE: Mini Mental State Examination\u003c/p\u003e\n\u003cp\u003eNH: Nursing Home\u003c/p\u003e\n\u003cp\u003ePD: Parkinson\u0026rsquo;s disease\u003c/p\u003e\n\u003cp\u003ePOMA: Performance Oriented Mobility Assessment\u003c/p\u003e\n\u003cp\u003eUPDRS: Unified Parkinson Disease Rating Scale: UPDRS\u003c/p\u003e\n\u003cp\u003eTUG: Timed-Up and Go test\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and was approved by the National Commission for Information Technology and Civil Liberties (Commission Nationale de l\u0026rsquo;Informatique et des Libert\u0026eacute;s, record number=1858079), since 2006. A note of information and of no objection to the collection of data for clinical research purpose was sent to all patients included in this analysis, explaining how their final research could be used anonymously for clinical research. Informed consent was waived by the Regional Ethics Committee in Geriatric Medicine (CEGID G\u0026eacute;rond\u0026rsquo;if, Paris 2021 #12021), considering the retrospective design of this observational study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available, to preserve the confidentiality of study participants and the data collected from them, consistent with the information note, but are available from the corresponding author, on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLL and PK processed the data of participants. LL and PK designed the study and drafted the manuscript. \u0026nbsp;JE, MS, SL, ARS and ML critically reviewed and edited the manuscript, and contributed to the discussion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eElbaz A, Carcaillon L, Kab S, Moisan F. Epidemiology of Parkinson\u0026rsquo;s disease. Rev Neurol (Paris). 2016;172(1):14\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDorsey ER, Constantinescu R, Thompson JP, et al. Projected number of people with Parkinson disease in the most populous nations, 2005 through 2030. Neurology. 2007;68(5):384\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSantos-Garc\u0026iacute;a D, Su\u0026aacute;rez-Castro E, Ernandez J, et al. 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Mov Disord Off J Mov Disord Soc. 2008;23(6):837\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGoetz CG, Tilley BC, Shaftman SR, et al. Movement Disorder Society-sponsored revision of the Unified Parkinson\u0026rsquo;s Disease Rating Scale (MDS-UPDRS): Scale presentation and clinimetric testing results. Mov Disord. 2008;23(15):2129\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKegelmeyer DA, Kloos AD, Thomas KM, Kostyk SK. Reliability and Validity of the Tinetti Mobility Test for Individuals With Parkinson Disease. 2007;12.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCardon-Verbecq C, Loustau M, Guitard E, et al. Predicting falls with the cognitive timed up-and-go dual task in frail older patients. Ann Phys Rehabil Med. 2017;60(2):83\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBloem BR, Marinus J, Almeida Q, et al. Measurement instruments to assess posture, gait, and balance in Parkinson\u0026rsquo;s disease: Critique and recommendations. Mov Disord Off J Mov Disord Soc. 2016;31(9):1342\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ede Lau LML, Schipper CMA, Hofman A, Koudstaal PJ, Breteler MMB. Prognosis of Parkinson disease: risk of dementia and mortality: the Rotterdam Study. Arch Neurol. 2005;62(8):1265\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDriver JA, Kurth T, Buring JE, Gaziano JM, Logroscino G. Parkinson disease and risk of mortality: a prospective comorbidity-matched cohort study. Neurology. 2008;70(16 Pt 2):1423\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMacleod AD, Taylor KSM, Counsell CE. Mortality in Parkinson\u0026rsquo;s disease: a systematic review and meta-analysis. Mov Disord Off J Mov Disord Soc. 2014;29(13):1615\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDiem-Zangerl A, Seppi K, Wenning GK, et al. Mortality in Parkinson\u0026rsquo;s disease: a 20-year follow-up study. Mov Disord Off J Mov Disord Soc. 2009;24(6):819\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOosterveld LP, Allen JC, Reinoso G, et al. Prognostic factors for early mortality in Parkinson\u0026rsquo;s disease. Parkinsonism Relat Disord. 2015;21(3):226\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGray WK, Hildreth A, Bilclough JA, Wood BH, Baker K, Walker RW. Physical assessment as a predictor of mortality in people with Parkinson\u0026rsquo;s disease: a study over 7 years. Mov Disord Off J Mov Disord Soc. 2009;24(13):1934\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHorak FB, Mancini M, Carlson-Kuhta P, Nutt JG, Salarian A. Balance and Gait Represent Independent Domains of Mobility in Parkinson Disease. Phys Ther. 2016;96(9):1364\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eThenganatt MA, Jankovic J. Parkinson disease subtypes. JAMA Neurol. 2014;71(4):499\u0026ndash;504.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKimmell K, Pulusu VK, Bharucha KJ, Ross ED. Postural instability in Parkinson Disease: to step or not to step. J Neurol Sci. 2015;357(1\u0026ndash;2):146\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSmith BA, Carlson-Kuhta P, Horak FB. Consistency in Administration and Response for the Backward Push and Release Test: A Clinical Assessment of Postural Responses. Physiother Res Int J Res Clin Phys Ther. 2016;21(1):36\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePaul SS, Canning CG, Sherrington C, Lord SR, Close JCT, Fung VSC. Three simple clinical tests to accurately predict falls in people with Parkinson\u0026rsquo;s disease. Mov Disord Off J Mov Disord Soc. 2013;28(5):655\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTan MP, Kamaruzzaman SB, Zakaria MI, Chin A-V, Poi PJH. Ten-year mortality in older patients attending the emergency department after a fall. Geriatr Gerontol Int. 2016;16(1):111\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStudenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDahodwala N, Pei Q, Schmidt P. Sex Differences in the Clinical Progression of Parkinson\u0026rsquo;s Disease. J Obstet Gynecol Neonatal Nurs JOGNN. 2016;45(5):749\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGoetz CG, Stebbins GT. Risk factors for nursing home placement in advanced Parkinson\u0026rsquo;s disease. Neurology. 1993; 43(11):2227\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAarsland D, Larsen JP, Tandberg E, Laake K. Predictors of nursing home placement in Parkinson\u0026rsquo;s disease: a population-based, prospective study. J Am Geriatr Soc. 2000;48(8):938\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Parkinson’s disease, older adults, Tinetti, balance","lastPublishedDoi":"10.21203/rs.3.rs-1665061/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1665061/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Parkinson’s disease (PD) is associated with a 3-fold increased risk of death and this mortality risk is closely related to advancing age. Evidence is lacking regarding the factors associated with the risks of mortality or nursing-home (NH) admission, in elderly patients with PD. We aimed at identifying the clinical characteristics associated with these outcomes, in older community dwelling patients with PD.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Retrospective, observational analysis of data from patients referred to our geriatric day hospital. Motor assessment included Unified Parkinson Disease Rating Scale (UPDRS) score and UPDRS axial sub-score, Tinetti Performance Oriented Mobility Assessment (POMA) balance and gait tests, and gait speed.\u0026nbsp;Levodopa equivalent dose, comorbidity, cognitive performance, functional status (basic and instrumental Activities of Daily Living) were examined. Cox proportional hazards models were performed to identify the factors associated with 5-year mortality and NH admission rate. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e We included 98 patients (mean age 79.4±5.3) of whom 18 (18.3%) died and 19 (19.4%) were admitted into NH over the 5-year follow-up. In multivariate Cox models, poor balance on the Tinetti POMA scale (HR=0,82 95%CI (0.66-0.96), p=0.02) and older age (HR= 1,12 95%CI (1.01-1.25), p=0,04) were the only variables significantly associated with increased mortality risk. A Tinetti balance score below 11/16 was associated with a 6.7 hazard for 5-year mortality (p\u0026lt;0.01). No specific factor was associated with NH admissions.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The Tinetti POMA test may be an accurate instrument for identifying the older individuals with PD at higher risk of mortality, and should be considered in clinical setting.\u0026nbsp;\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Tinetti balance performance is associated with mortality in older adults with Parkinson’s disease: a longitudinal study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-23 18:28:12","doi":"10.21203/rs.3.rs-1665061/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-12T08:38:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-06-21T01:51:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8cd94575-5b3b-4309-859e-84b78ed2b166","date":"2022-06-21T01:36:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-05-29T01:00:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-29T00:53:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-05-20T07:23:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-20T07:20:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2022-05-17T10:38:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f4a7b73e-6787-417c-a38f-cda9b0467871","owner":[],"postedDate":"May 23rd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:52:09+00:00","versionOfRecord":{"articleIdentity":"rs-1665061","link":"https://doi.org/10.1186/s12877-023-03776-7","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2023-01-30 18:39:43","publishedOnDateReadable":"January 30th, 2023"},"versionCreatedAt":"2022-05-23 18:28:12","video":"","vorDoi":"10.1186/s12877-023-03776-7","vorDoiUrl":"https://doi.org/10.1186/s12877-023-03776-7","workflowStages":[]},"version":"v1","identity":"rs-1665061","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1665061","identity":"rs-1665061","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}