Original Study - Brief Report Association of Pisa Syndrome With Mortality in Patients With Parkinson’s Disease Alice Laudisio MD a, *, Maria Rita Lo Monaco MD b , Davide L. Vetrano MD b, c , Maria Stella Pisciotta MD d , Vincenzo Brandi MD b , Antonella Gemma MD e , Domenico Fusco MD b , Roberto Bernabei MD b , Raffaele Antonelli Incalzi MD a , Giuseppe Zuccalà MD b a Unit of Geriatrics, Department of Medicine, Campus Bio-Medico di Roma University, Rome, Italy b Department of Geriatrics, Neurosciences, and Orthopaedics, Catholic University of Medicine, Rome, Italy c Aging Research Center, Karolinska Institutet and Stockholm University, Sweden d Department of Geriatrics, Foundation Poliambulanza of Brescia, Brescia, Italy e Department of Homecare Service, Azienda Sanitaria Locale Roma E, Rome, Italy Keywords: Pisa syndrome Parkinson’s disease survival abstract Objectives: In Parkinson’s disease, Pisa syndrom (PS) has been associated with disease stage and severity, combined treatment with levodopa and dopamine agonists, gait disorders, and comorbidities. Some forms of PS are potentially reversible; nevertheless, little is known about the impact of this syndrome on survival. Design: Prospective study with a median follow-up of 2 years. Setting and participants: Patients with Parkinson’s disease, age 65 years and older (N ¼ 189), attending a geriatric day hospital. Measurements: According to established criteria, PS was diagnosed in the presence of at least 10  lateral flexion of the trunk reducible by passive mobilization or supine positioning. Cox regression was adopted to assess the association of PS with all-cause mortality. Results: PS was diagnosed in 40 patients (21%); over the follow-up, 21 (11%) subjects died. In Cox regression, PS was associated with higher mortality [hazard ratio (HR) 4.10; 95% confidence interval (CI) ¼ 1.36-12.38], after adjusting; other variables associated with mortality were age (HR ¼ 1.19, 95% CI ¼ 1.08-1.32), beta blockers (HR ¼ 4.35, 95% CI ¼ 1.23-15.39), and albumin levels (HR ¼ 0.05, 95% CI ¼ 0.01-0.33). The association of PS with mortality remained significant also after adjusting for variables associated with this syndrome (HR ¼ 4.04, 95% CI ¼ 1.33-12.25). Conclusions/Implications: PS represents a risk factor for earlier mortality in Parkinson’s disease; further studies are needed to ascertain the underlying causes and whether treatment of this condition might improve survival. Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine. Pisa syndrome (PS) is a postural disorder recognized in several neurodegenerative and neurologic disorders, including Parkinson’s disease (PD). 1 It is characterized by lateral deviation of the spine with a corresponding tendency to lean to one side; its presence is increasingly being diagnosed in patients with PD. 2 The pathologic pathways of PS in PD have not yet been fully characterized; either central or peripheral mechanisms might account for this condition. 3 Even though previous studies addressed the association of PS with demographic and clinical variables (ie, age, body mass index, comorbidities, disease duration and severity, L-dopa dosages, postural control, subjective visual vertical), 1,4,5 no information is currently available about its impact on survival of patients with PD. We explored the association between PS and 2-year mortality in subjects with PD. Secondary aims were to assess the characteristics associated with PS and whether such characteristics might account for any increase in mortality rates associated with PS. Eventually, because PS belongs to axial symptoms, which are associated with reduced survival, we aimed to assess whether the association, if any, of PS with survival was independent of other axial symptoms. The authors declare no conflicts of interest. * Address correspondence to Alice Laudisio, MD, Unit of Geriatrics, Department of Medicine, Campus Bio-Medico University, Via Álvaro del Portillo, 200-00128 Rome, Italy. E-mail address: lavoralice@gmail.com (A. Laudisio). https://doi.org/10.1016/j.jamda.2019.01.141 1525-8610/Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine. JAMDA journal homepage: www.jamda.com JAMDA xxx (2019) 1e5