Predictors of falls and fractures in bradykinetic rigid
syndromes: a retrospective study
D R Williams, H C Watt, A J Lees
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See end of article for
Professor A J Lees, Reta
Lila Weston Institute of
Neurological Studies, 46
Cleveland Street, London
W1T 4JF, UK; alees@ion.
Received 13 June 2005
In revised form
3 November 2005
13 November 2005
J Neurol Neurosurg Psychiatry 2006;77:468–473. doi: 10.1136/jnnp.2005.074070
Background: Falls and fractures contribute to morbidity and mortality in bradykinetic rigid syndromes.
Methods: The authors performed a retrospective case notes review at the Queen Square Brain Bank for
Neurological Disorders and systematically explored the relation between clinical features and falls and
fractures in 782 pathologically diagnosed cases (474 with Parkinson’s disease (PD); 127 progressive
supranuclear palsy (PSP); 91 multiple system atrophy (MSA); 46 dementia with Lewy bodies (DLB); 27
vascular parkinsonism; nine Alzheimer’s disease; eight corticobasal degeneration).
Results: Falls were recorded in 606 (77.5%) and fractures in 134 (17.1%). In PD, female gender,
symmetrical onset, postural instability, and autonomic instability all independently predicted time to first
fall. In PD, PSP, and MSA latency to first fall was shortest in those with older age of onset of disease.
Median latency from disease onset to first fall was shortest in Richardson’s syndrome (12 months), MSA
(42), and PSP-parkinsonism (47), and longest in PD (108). In all patients fractures of the hip were more
than twice as common as wrist and forearm fractures. Fractures of the skull, ribs, and vertebrae occurred
more frequently in PSP than in other diseases.
Conclusion: Measures to prevent the morbidity associated with falls and fractures in bradykinetic rigid
syndromes may be best directed at patients with the risk factors identified in this study.
bradykinetic rigid syndromes, falls occur frequently and are
associated with a poorer quality of life.3 4The risk of bone
fracture increases with a history of falls, impairment of
mobility, low body mass index, and low bone mineral
density.5 6In patients with disturbances of gait due to
parkinsonism, fractures are more common than in those
with gait disturbances due to other neurological conditions
such as peripheral neuropathies.7In PD the femur is the most
commonly fractured bone8–10but in the community the
forearm is more frequently broken. This difference is thought
to be due to the manner in which patients with PD fall.11 12
Despite the greater frequency of falls in atypical parkinson-
ism, falls and their relation to bone fractures have not been
systematically analysed in progressive supranuclear palsy
(PSP), multiple system atrophy (MSA), corticobasal degen-
eration, or vascular parkinsonism (VP).10 13Falling within the
first year of disease is required by the National Institute for
Neurological Disorders and Stroke (NINDS) diagnostic
criteria for a diagnosis of probable PSP, although in practice
only 61% of patients with this diagnosis had fallen that early
on.2 14Together with a supranuclear gaze palsy, nuchal
dystonia, and early frontostriatal cognitive deficits, falls
complete the cardinal clinical quartet of PSP first described
by Richardson.15We have recently defined a subgroup of
patients designated PSP-parkinsonism (PSP-P), in whom the
PSP tau pathology more frequently causes early asymmetrical
levodopa responsive bradykinesia and in whom falls,
cognitive changes, and supranuclear gaze palsy occur later
than in classic Richardson’s syndrome (RS).14A number of
factors contribute to falls in other bradykinetic rigid
syndromes. Gait unsteadiness and cognitive impairment
contribute to falls in corticobasal degeneration (CBD),
dementia with Lewy bodies (DLB) and in those with
pathological changes diagnostic of Alzheimer’s disease (AD)
he diagnoses of Parkinson’s disease (PD) and progressive
supranuclear palsy (PSP) are contingent on the presence
of postural instability and falls.1 2In these and other
who present with parkinsonism. In MSA, on the other hand,
orthostatic hypotension and cerebellar or parkinsonian gait
disorder are important precipitants.16
We have retrospectively analysed data from a large number
of pathologically diagnosed PD, PSP, MSA, CBD, DLB, VP,
and AD patients and have investigated the relation between
pathological diagnosis and the bones fractured. We have also
quantified the temporal evolution of falls in each disease
group and analysed the relation between time from disease
onset to first fall (latency) and disease.
SUBJECTS AND METHODS
A retrospective analysis was performed using the clinical files
of 782 patients with a lifetime diagnosis of a bradykinetic
rigid syndrome or parkinsonism with a pathologically
confirmed diagnosis (PD, n=474; PSP, n=127; MSA,
n=91; DLB, n=46; VP, n=27; AD, n=9; CBD, n=8)
archived at the Queen Square Brain Bank for Neurological
Disorders. Patients were recruited from around the United
Kingdom and died between 1988 and 2003. A few cases (2%
of total) could not be included in the analysis because of
insufficient clinical data (10 PD, three PSP, one MSA, one
AD, one VP). The PSP group were further divided according
to the number of clinical features reported associated with
each clinical phenotype: RS (supranuclear gaze palsy,
abnormality of saccadic eye movements, cognitive changes
in first two years), PSP-P (tremor and non-axial dystonia in
the first two years, asymmetric onset, and response to
Abbreviations: AD, Alzheimer’s disease; CBD, corticobasal
degeneration; DLB, dementia with Lewy bodies; MSA, multiple system
atrophy; PD, Parkinson’s disease; PSP, progressive supranuclear palsy;
PSP-P, PSP-parkinsonism; RS, Richardson’s syndrome; VP, vascular
D R Williams, H C Watt, A J Lees, Institute of Neurology, University
College London, London, UK
H C Watt, Medical Statistics Unit, London School of Hygiene and
Tropical Medicine, London, UK
Competing interests: none declared
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