Clinical milestones in Parkinson's disease: A 7-year population-based incident cohort study

Introduction: Clinical staging of Parkinson's disease (PD) is important for patient management and prognosis. The non-motor and functional features visual hallucinations, recurrent falls, dementia and nursing home placement are currently not included in clinical staging schemes, but have been suggested as clinical milestones with important prognostic implications in advanced PD. In this study, we sought to evaluate the potential of these four milestone events for clinical staging and prognosis during the early years of the disease. Methods: We recruited 185 patients with incident PD and monitored prospectively every six months through seven years for emergence and consequences of four clinical milestones. Results: One or more milestones were reached in 53.0%. Of the patients who reached the milestones, visual hallucinations appeared after a median of 3.3 (interquartile range 1.3-4.9) years from diagnosis, recurrent falls after 3.8 (2.8-5.2) years, dementia after 4.0 (2.1-4.8) years and nursing home placement after 5.4 (3.9-6.7) years. Presence of any milestone was associated with occurrence of other milestones (relative risks 1.9-6.3; all p <= 0.001). Experiencing two or more milestones increased the risk of death during the study (relative risk 2.7, p = 0.03). Conclusions: In early PD, visual hallucinations, recurrent falls, dementia and nursing home placement appear closely interrelated, possibly reflecting a shared neuropathological disease stage. All events convey important and sinister information on PD status and prognosis and are relatively easily accessible during routine clinical consultations. Therefore, they appear highly useful as clinical PD milestones and could possibly be incorporated into a novel disease rating scale. (c) 2017 Elsevier Ltd. All rights reserved.