Prediction of cognition in Parkinson's disease with a clinical-genetic score: a longitudinal analysis of nine cohorts

Cognitive decline is a debilitating manifestation of disease progression in Parkinson's disease. We aimed to develop a clinical-genetic score to predict global cognitive impairment in patients with the disease.In this longitudinal analysis, we built a prediction algorithm for global cognitive impairment (defined as Mini Mental State Examination [MMSE] ≤25) using data from nine cohorts of patients with Parkinson's disease from North America and Europe assessed between 1986 and 2016. Candidate predictors of cognitive decline were selected through a backward eliminated Cox's proportional hazards analysis using the Akaike's information criterion. These were used to compute the multivariable predictor on the basis of data from six cohorts included in a discovery population. Independent replication was attained in patients from a further three independent longitudinal cohorts. The predictive score was rebuilt and retested in 10 000 training and test sets randomly generated from the entire study population.3200 patients with Parkinson's disease who were longitudinally assessed with 27 022 study visits between 1986 and 2016 in nine cohorts from North America and Europe were assessed for eligibility. 235 patients with MMSE ≤25 at baseline and 135 whose first study visit occurred more than 12 years from disease onset were excluded. The discovery population comprised 1350 patients (after further exclusion of 334 with missing covariates) from six longitudinal cohorts with 5165 longitudinal visits over 12·8 years (median 2·8, IQR 1·6-4·6). Age at onset, baseline MMSE, years of education, motor exam score, sex, depression, and β-glucocerebrosidase (GBA) mutation status were included in the prediction model. The replication population comprised 1132 patients (further excluding 14 patients with missing covariates) from three longitudinal cohorts with 19 127 follow-up visits over 8·6 years (median 6·5, IQR 4·1-7·2). The cognitive risk score predicted cognitive impairment within 10 years of disease onset with an area under the curve (AUC) of more than 0·85 in both the discovery (95% CI 0·82-0·90) and replication (95% CI 0·78-0·91) populations. Patients scoring in the highest quartile for cognitive risk score had an increased hazard for global cognitive impairment compared with those in the lowest quartile (hazard ratio 18·4 [95% CI 9·4-36·1]). Dementia or disabling cognitive impairment was predicted with an AUC of 0·88 (95% CI 0·79-0·94) and a negative predictive value of 0·92 (95% 0·88-0·95) at the predefined cutoff of 0·196. Performance was stable in 10 000 randomly resampled subsets.Our predictive algorithm provides a potential test for future cognitive health or impairment in patients with Parkinson's disease. This model could improve trials of cognitive interventions and inform on prognosis.National Institutes of Health, US Department of Defense.We thank all study participants, their families, and friends for their support and participation, and our study coordinators. The co-investigators and contributors from Parkinson's Disease Biomarkers Program, Harvard Biomarkers Study, Drug Interaction with Genes in Parkinson's Disease (DIGPD), Parkinson Research Examination of CEP-1347 Trial (PreCEPT) and a longitudinal follow-up of the PRECEPT study cohort (PostCEPT), Parkinsonism Incidence, Cognition and Non-motor heterogeneity in Cambridgeshire (PICNICS), Cambridgeshire Parkinson's Incidence from GP to Neurologist (CamPaIGN), PROfiling PARKinson's disease study (PROPARK), as well as acknowledgments for Parkinson's Progression Marker Initiative and Deprenyl and Tocopherol Antioxidative Therapy of Parkinsonism (DATATOP) are listed in the appendix. This work was supported in part by National Institutes of Health grants U01 NS082157, U01NS095736 (to CRS), US Department of Defense grants W81XWH-1–0007 (BR) and W81XWH-15–10007 (to CRS); MEMO Hoffman Foundation (to CRS); Brigham and Women's Hospital Departmental Funds (to BB). The Harvard Biomarkers Study is supported by the Harvard NeuroDiscovery Center, the Parkinson's Disease Biomarkers Program U01 NS082157, U01NS100603 of the National Institute of Neurological Disorders and Stroke (NINDS), and the Massachusetts Alzheimer's Disease Research Center P50 AG005134 grant of the National Institute on Aging, Harvard Aging Brain Study grant P01 AG036694. The PreCEPT and PostCEPT cohort was funded by Cephalon Inc and Lundbeck for the parent PRECEPT clinical trial and follow-up PostCEPT cohort, and the Department of Defense Neurotoxin Exposure Treatment Parkinson's Research Program (W23RRYX7022N606), NINDS Data and Organizing Center's (NS050095), the Parkinson's Disease Foundation (New York, NY, USA). Additional funding information for the PreCEPT and PostCEPT cohort and corresponding investigators is listed in Ravina et al. The CamPaIGN and PICNICS studies received funding support from the Wellcome Trust, MRC, Parkinson's UK, Cure-PD, the Patrick Berthoud Trust, the Van Geest Foundation, and National Institute for Health Research funding of a Biomedical Research Centre at the University of Cambridge and Addenbrooke's Hospital. DIGPD cohort was promoted by the Assistance Publique Hôpitaux de Paris, and funded by the French clinical research hospital programme (code AOR08010). The research leading to these results has received funding from the programme Investissements d'Avenir ANR-10-IAIHU-06. DATATOP was supported by NIH grant NS24778. The PROPARK study was funded by the Prinses Beatrix Fonds (project number WAR05–0120), the van Alkemade-Keuls Foundation (Stichting Alkemade-Keuls), and the International Parkinson Foundation (Stichting ParkinsonFonds)

Examining the Reserve Hypothesis in Parkinson's Disease: A Longitudinal Study

[[abstract]]Background: Whether reserve plays a role in Parkinson's disease (PD) patients has received less attention than in dementia and has been mainly examined in relation with cognitive function. Objective: To investigate whether reserve plays a role in the severity and progression of motor, cognitive, and nonmotor PD symptoms by examining whether education level (proxy of reserve) is associated with baseline performance and rate of progression. Methods: We used data from a longitudinal cohort of PD patients (≤5-year disease duration at baseline) annually followed up to 5 years (n = 393; 41% women; mean age = 62.3 years, standard deviation = 10.0; mean disease duration = 2.6 years, standard deviation = 1.5). We examined the relationship of education with time to reach Hoehn and Yahr stage ≥3 using Cox regression and with baseline severity and progression of motor (Movement Disorder Society-Unified Parkinson's Disease Rating Scale parts II and III, gait speed), cognitive (Mini-Mental State Examination), and nonmotor (depression, anxiety, nonmotor symptoms scale, quality of life) symptoms using mixed models. Results: Education level was not associated with age at onset or diagnosis. Compared with the low-education group, the incidence of Hoehn and Yahr ≥3.0 was 0.42 times lower (95% confidence interval, 0.22-0.82, P = 0.012) in the high-education group. Higher education was associated with better baseline motor function (P 0.15). Similar results were observed for cognition. Education was not associated with nonmotor symptoms. Conclusions: Higher education is associated with better baseline motor/cognitive function in PD, but not with rate of decline, and with a lower risk of reaching Hoehn and Yahr ≥3 during the follow-up. Our observations are consistent with a passive reserve hypothesis for motor/cognitive symptoms. © 2019 International Parkinson and Movement Disorder Society

Longitudinal analysis of impulse control disorders in Parkinson disease

[[abstract]]Objective: To investigate the longitudinal dose-effect relationship between dopamine replacement therapy and impulse control disorders (ICDs) in Parkinson disease (PD). Methods: We used data from a multicenter longitudinal cohort of consecutive patients with PD with ≤5 years' disease duration at baseline followed up annually up to 5 years. ICDs were evaluated during face-to-face semistructured interviews with movement disorder specialists. Generalized estimating equations and Poisson models with robust variance were used to study the association between several time-dependent definitions of dopamine agonist (DA) use, taking dose and duration of treatment into account, and ICDs at each visit. Other antiparkinsonian drugs were also examined. Results: Among 411 patients (40.6% women, mean age 62.3 years, average follow-up 3.3 years, SD 1.7 years), 356 (86.6%) took a DA at least once since disease onset. In 306 patients without ICDs at baseline, the 5-year cumulative incidence of ICDs was 46.1% (95% confidence interval [CI] 37.4-55.7, DA ever users 51.5% [95% CI 41.8-62.1], DA never users 12.4% [95% CI 4.8-30.0]). ICD prevalence increased from 19.7% at baseline to 32.8% after 5 years. ICDs were associated with ever DA use (prevalence ratio 4.23, 95% CI 1.78-10.09). Lifetime average daily dose and duration of treatment were independently associated with ICDs with significant dose-effect relationships. Similar analyses for levodopa were not in favor of a strong association. ICDs progressively resolved after DA discontinuation. Conclusion: In this longitudinal study of patients with PD characterized by a high prevalence of DA treatment, the 5-year cumulative incidence of ICDs was ≈46%. ICDs were strongly associated with DA use with a dose-effect relationship; both increasing duration and dose were associated with ICDs. ICDs progressively resolved after DA discontinuation

Examining the reserve hypothesis in Parkinson’s disease: a longitudinal study

[[abstract]]Background Whether reserve plays a role in Parkinson's disease (PD) patients has received less attention than in dementia and has been mainly examined in relation with cognitive function. Objective To investigate whether reserve plays a role in the severity and progression of motor, cognitive, and nonmotor PD symptoms by examining whether education level (proxy of reserve) is associated with baseline performance and rate of progression. Methods We used data from a longitudinal cohort of PD patients (≤5‐year disease duration at baseline) annually followed up to 5 years (n = 393; 41% women; mean age = 62.3 years, standard deviation = 10.0; mean disease duration = 2.6 years, standard deviation = 1.5). We examined the relationship of education with time to reach Hoehn and Yahr stage ≥3 using Cox regression and with baseline severity and progression of motor (Movement Disorder Society–Unified Parkinson's Disease Rating Scale parts II and III, gait speed), cognitive (Mini‐Mental State Examination), and nonmotor (depression, anxiety, nonmotor symptoms scale, quality of life) symptoms using mixed models. Results Education level was not associated with age at onset or diagnosis. Compared with the low‐education group, the incidence of Hoehn and Yahr ≥3.0 was 0.42 times lower (95% confidence interval, 0.22–0.82, P = 0.012) in the high‐education group. Higher education was associated with better baseline motor function (P  0.15). Similar results were observed for cognition. Education was not associated with nonmotor symptoms. Conclusions Higher education is associated with better baseline motor/cognitive function in PD, but not with rate of decline, and with a lower risk of reaching Hoehn and Yahr ≥3 during the follow‐up. Our observations are consistent with a passive reserve hypothesis for motor/cognitive symptoms. © 2019 International Parkinson and Movement Disorder Societ