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Original Investigation
June 26, 2017

Association of Autonomic Dysfunction With Disease Progression and Survival in Parkinson Disease

Author Affiliations
  • 1Reta Lila Weston Institute of Neurological Studies, UCL Institute of Neurology, London, United Kingdom
  • 2Queen Square Brain Bank for Neurological Disorders, UCL Institute of Neurology, London, United Kingdom
  • 3Department of Neuroinflammation, UCL Institute of Neurology, London, United Kingdom
JAMA Neurol. Published online June 26, 2017. doi:10.1001/jamaneurol.2017.1125
Key Points

Question  Is development of autonomic dysfunction associated with disease progression and survival in patients with Parkinson disease?

Findings  In this study of 100 patients with autopsy-confirmed Parkinson disease, earlier development of autonomic dysfunction was associated with an increase in the risk of reaching a disease milestone of 14% per year and an increase in the risk of death of 8% per year.

Meaning  Earlier autonomic dysfunction is associated with more rapid disease progression and shorter survival in patients with Parkinson disease.

Abstract

Importance  Evidence suggests that development of autonomic dysfunction (AutD) may negatively affect disease course and survival in patients with synucleinopathies. However, the few available studies on Parkinson disease (PD) have conflicting results, comprise a small number of patients, have short follow-up periods, and lack pathologic confirmation of the diagnosis.

Objective  To examine the association of time of onset of AutD with disease progression and survival in PD.

Design, Setting, and Participants  This retrospective review of clinical data from 100 consecutive patients with an autopsy-confirmed diagnosis of PD from the archives of the Queen Square Brain Bank in London, United Kingdom, from January 1, 2006, to June 3, 2016, included patients with PD regularly seen by hospital specialists (neurologists or geriatricians) in the United Kingdom throughout their disease until death. Patients with dementia before or within 1 year after onset of motor symptoms, monogenic forms of PD, comorbidities that affect autonomic function, a coexisting neuropathologic diagnosis, or insufficient clinical information were excluded.

Main Outcomes and Measures  Survival and time from diagnosis to specific disease milestones were calculated to assess disease progression. Autonomic dysfunction was defined as autonomic failure at autonomic function testing or 2 of the following symptoms: urinary symptoms, constipation, upper gastrointestinal tract dysfunction, orthostatic hypotension, sweating abnormalities, or erectile dysfunction. Multivariable Cox proportional hazards regression models on the risk of a disease milestone and death were used.

Results  A total of 100 patients (60 [60.0%] male; mean [SD] age at diagnosis, 63.9 [10.3] years; mean [SD] disease duration, 14.6 [7.7] years) were studied. Autonomic dysfunction developed in 85 patients (mean [SD] time from diagnosis, 6.7 [7.7] years) and was associated with older age at diagnosis, male sex, poor initial levodopa treatment response, and postural instability and gait difficulty motor PD subtype in linear regression analysis, but staging of α-synuclein pathologic changes was unrelated. Earlier AutD increased the risk of reaching the first milestone (hazard ratio, 0.86; 95% CI, 0.83-0.89; P < .001) and shortened survival (hazard ratio, 0.92; 95% CI, 0.88-0.96; P < .001). Older age at diagnosis and poorer levodopa treatment response were the other factors associated with shorter survival in adjusted multivariate analysis.

Conclusions and Relevance  Earlier AutD is associated with a more rapid development of disease milestones and shorter survival in patients with PD.

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