Brain Small Chain Fatty Acid Metabolism in Parkinson Disease: Ketones
Phase: NA
Conditions: Parkinson Disease, Lewy Body Dementia, Parkinson Disease Dementia
Sponsor: University of Michigan

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
1 
 
Brain Small Chain Fatty Acid Metabolism in Parkinson Disease: Ketones 
NCT05778695 
07/23/2024 
 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
2 
 
 
CLINICAL PROTOCOL 
 
STUDY TITLE 
Brain Small Chain Fatty Acid Metabolism in Parkinson Disease: Ketones 
Study Agents:  Ketone Ester, [18F]FDG 
 
University of Michigan IRB HUM #00213035 
 
Principal Investigator:  
Nicolaas I Bohnen, MD, PhD  
 
Professor, Department of Radiology 
Professor, Department of Neurology 
University of Michigan 
Ann Arbor, MI  
 
Institution: University of Michigan 
 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
3 
Brain Small Chain Fatty Acid Metabolism in Parkinson's Disease: Ketones 
 
Cognitive decline, progressing usually to dementia, is a common disabling feature of Parkinson's 
disease (PD).  Progression to dementia generally reflects progressive cortical pathologies.  We and 
others showed that cognitive decline is accompanied and heralded by deficits in regional neocortical 
glucose metabolism, demonstrated with [18F]fluorodeoxyglucose (FDG) PET imaging 1, 2.  These 
deficits are widely believed to reflect synaptic loss.  Convergent imaging data, however, suggests 
relative preservation of neocortical synapses with abnormal neuronal glucose metabolism.  Recent 
studies of PD and Alzheimer disease (AD) subjects with synaptic terminal SV2A PET ligands indicate 
preservation of cortical synaptic terminals at early to moderate disease stages. Ketone bodies, which 
are short chain fatty acids (SCFAs) are the major alternative brain energy substrates. Comparative 
studies of brain SCFA and glucose uptake in Mild Cognitive Impairment and early AD subjects 
indicates relative preservation of regional brain SFCA metabolism in subjects with abnormal regional 
glucose uptake, suggesting relative preservation of synapses.   
This accumulated PET data is broadly consistent with the concept that mitochondrial dysfunction is a 
major feature of, and likely a pathogenetic mechanism in PD.  Other data suggests relevant 
dysfunction of glucose uptake and metabolism mechanisms in PD.  One implication is that enhancing 
neuronal SCFA metabolism will circumvent abnormalities in glucose uptake and initial metabolism, 
enhancing and restoring neuronal mitochondrial function.  This would potentially provide symptomatic 
benefits and might be a disease-modifying therapy (Figure 1).  There are other good reasons to 
pursue SCFA therapy in PD.  SFCAs may be significant modulators of inflammatory, oxidative, and 
transcriptional regulatory processes linked to neurodegeneration in PD (Figure 1).  Recent 
experimental work suggests important links between mitochondrial dysfunction and pathogenic 
inflammatory mechanisms in PD.  SCFA therapy may address the brain-gut axis dysbiosis that seems 
to characterize PD.    
Capitalizing on our experience with PD clinical research and development 
of novel PET methods, we propose an integrated series of experiments to 
measure brain SCFA metabolism and to assess target engagement of 
SCFA therapy in older adults and in persons with Parkinson disease 
(PwPD) as well as a subset of persons with Parkinson’s-related dementias 
(Parkinson’s disease dementia (PDD) or Lewy Body dementia (LBD)).   
 
Aim 1: To explore glucose metabolism and clinical measures before and 
after open-label treatment with the ketone monoester (KE), ®-3-hydroxybut®(R)-3-hydroxy- butyrate 
or D-β-hydroxybutyrate in a small pilot study in patients with PD (n=16), LBD/PDD (n=10), and normal 
control older adults (n=4). To examine glucose metabolic changes including mean daily glucose for 
the first 7 days of wearing a continuous glucose monitor and fasting glucose that can be 
complemented by FDG PET in the subset undergoing PET imaging.   
Hypothesis 1: Glucose metabolism (mean daily glucose and/or fasting glucose) may improve after 
approximately 30-day intervention with KE  25 g t.i.d. p.o. with meals in patients with PD and normal 
older adults. 
 
Exploratory hypothesis: KE supplementation may affect cognition, autonomic, sleep, metabolic and 
other measures. 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
4 
Impact:  Positive findings in this small exploratory pilot trial may support future target engagement 
studies of ketone supplementation in PD and normal adults.   
 
 
Background 
 
Dopamine replacement therapy (DRT) refractory features are major disabling aspects of PD.  Health-
related quality of life (QoL) studies and surveys of PwPD, caregivers, and clinicians involved in PD care 
identify DRT-refractory features as the most disabling aspect of PD and a high priority target for 
research aimed at improving the lives of PwPD 6. One of the most important, and possibly most feared, 
DRT-refractory feature is dementia. Cross-sectional studies indicate high prevalence of dementia in 
PD, with increasing prevalence associated with disease progression 8. In the prospective Sydney study 
of a clinical trial cohort, at least 80% of PwPD followed developed dementia after 15 years disease 
duration 10. In a prospective follow-up of a Norwegian community-based cohort 14, 60% developed 
dementia at 12 years post diagnosis, and in the British CamPaiGN study of a community based 
inception cohort, approximately 50% met criteria for dementia at 10 years after study enrollment 17. In 
non-demented PwPD, careful neuropsychological characterization demonstrates a high rate of 
cognitive impairments in the form of PD associated Mild Cognitive Impairment (PD-MCI) 19. It is likely 
that all PwPD with disease of several years’ duration will experience some form of significant cognitive 
impairment, if not overt dementia.   
The pathophysiology underlying cognitive impairments and dementia is thought to largely reflect the 
progression of -synucleinopathy in PD.  The general evolution of cognitive impairments/dementia and 
their relationship to -synucleinopathy is captured by the “Dual Syndrome” model of Kehagia et al  20.  
This model, in turn, is based on the Braak et al. model of gradually advancing -synucleinopathy in PD.  
Braak et al. hypothesized rostral spread of -synucleinopathy from initial lower brainstem involvement 
to later invasion of forebrain and cortical structures 21.  In the Kehagia et al. correlative model, initial 
cognitive impairments reflect frontostriatal circuit dysfunctions consequent to nigrostriatal dopaminergic 
denervation with later cognitive dysfunctions and dementia 22 reflecting much broader cortical 
dysfunctions secondary to both loss of important subcortical afferent terminals 23, notably basal 
forebrain cholinergic corticopetal afferents, and increasing burden of -synucleinopathy within cortical 
neurons.   
While the Braak et al. and Kehagia et al. models are simplifications, they likely capture essential 
features of the pathogenesis and pathophysiology of cognitive impairments in PwPD.  It is likely that 
overt neurodegeneration is proceeded by some period of neuronal dysfunction.  Recent data suggest 
that neuronal dysfunction/neurodegeneration occur initially as “synaptopathy” with initial dysfunction 
and degeneration occurring at the level of neuronal terminals/synapses 24, 25.  This formulation suggests 
that there may be a period of terminal-synaptic dysfunction prior to loss of terminals-synapses in which 
appropriately targeted therapies might partially restore the function of dysfunctional synapses, 
producing symptomatic improvements.   
Recent convergent data suggest that this concept of dysfunctional, but anatomically intact (sleeping or 
stunned) terminals-synapses may be particularly relevant to the cortical deficits underlying advancing 
cognitive impairments in PwPD. We and others showed that cognitive decline in PD is accompanied 
by and preceded by regional neocortical deficits of glucose uptake, demonstrated with 
[18F]fluorodeoxyglucose positron emission 
Figure 2: Serial FDG PET in PwPD and progressive cognitive decline. 
Progressive glucose metabolic reductions from within reference range at 
baseline (Yr 0), through stages of mild cognitive impairment (Yr 2 and Yr 4), 
and clinical diagnosis of dementia (Yr 5) in PwP converting to dementia over 
5 years 1. 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
5 
tomography (FDG-PET; Figure 2) 1, 2.  These FDG PET 
deficits are widely assumed to reflect terminal-synaptic 
degeneration, but recent in vivo human imaging data 
suggests that a significant component of neocortical 
FDG-PET 
deficits 
is 
metabolic 
dysfunction 
of 
anatomically 
intact 
terminals-synapses. 
 
The 
development of the synaptic terminal SV2A protein PET 
ligand [11C]UCB-J allowed independent estimates of 
regional synaptic terminal densities. In mild Alzheimer 
disease (AD) spectrum, subjects expected to exhibit 
several regional neocortical FDG-PET deficits. [11C[UCB-
J PET revealed synaptic terminal deficits restricted to the 
hippocampal formation 26. Similarly, initial studies with 
[11C]UCB-J PET in mild PD subjects revealed synaptic 
terminal deficits restricted to the substantia nigra27, 28. 
The recent development of alternative methods for imaging brain metabolic processes also supports 
the concept of sleeping-stunned synapses in neurodegenerative disorders.  Brain energy consumption 
is primarily devoted to maintaining the ionic gradients needed for neurotransmission-synaptic function.  
Under normal circumstances, glucose is the primary substrate for brain metabolism.  Under fasting 
conditions, however, ketone bodies such as -hydroxybutyrate (BHB) and other species of short chain 
fatty acids (SCFAs), substitute for glucose directly within mitochondria. Cunnane and colleagues 
developed [11C]acetoacetate (AcAc) PET as a non-invasive method to study SCFA metabolism in vivo.  
In studies comparing [18F]FDG PET and [11C]AcAc PET in mild AD spectrum subjects, this group 
demonstrated normal regional [11C]AcAc uptake in subjects with significant regional FDG PET deficits 
29.  This result is consistent with SV2A/[11C]UCB-J PET imaging results and supports the conclusion 
that a significant component of regional FDG PET deficits reflect dysfunctional (sleeping-stunned), as 
opposed to anatomically lost synapses. In turn, these results suggest that therapies circumventing 
regional glucose metabolism deficits might improve synaptic function in neurodegenerative disorders 
where comparative metabolic imaging studies demonstrate regional glucose uptake (FDG PET) deficits 
greater than SCFA metabolism (AcAc PET or analogous methods) deficits. SCFA supplementation 
(see below) may be such a therapy.   
In PD, the concepts of synaptic dysfunction associated with metabolic deficits and potential 
remediation by circumventing metabolic dysfunction using a fuel repartitioning approach are 
consistent with a substantial body of data implicating metabolic defects in PD pathogenesis.  
Mitochondrial dysfunctions secondary to electron transport chain deficits are felt to be a major 
pathogenetic mechanism in sporadic PD with some monogenetic forms of PD resulting directly from 
mitochondrial dysfunctions 30-32.  Glucose transporters, essential for glucose transport across the 
blood-brain barrier and into CNS cells, may be down-regulated in PD 33.  Boosting neuronal energy 
metabolism by bypassing glycolysis and feeding directly into the Krebs cycle is a plausible approach 
to enhancing mitochondrial function.  This is feasible via dietary ketone body-SCFA supplementation.  
These SCFAs are directly transported across the blood-brain barrier and into astrocytes and neurons 
via monocarboxylate transporters (MCTs).  In addition, fasting or ketone body based (ketogenic) diets 
induce brain metabolism of ketone bodies-SCFAs, thereby reducing reliance on glucose as the 
primary energy substrate.  This is amply demonstrated in experimental studies and is demonstrated 
more recently with effects of a ketogenic diet on AcAc PET in normal human volunteers 34.  Ketone 
body-SCFA supplementation may plausibly “awaken” sleeping-stunned synapses and produce 
symptomatic improvements in PD.  Given the association between regional cortical metabolic deficits 
and cognitive decline in PD, we are targeting cognitive decline as the ultimate target for symptomatic 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
6 
relief of this important feature of PD via SCFA supplementation.   
 
Ketogenic diet and SCFA interventions in neurodegeneration: 
The ketogenic diet based on preferential intake of predominant medium and long-chain fatty acids 
and minimization of carbohydrates has become a subject of recent research in metabolic and 
neurodegenerative disorders. Preliminary positive findings have been reported mainly from short-
duration studies. Despite the benefits of this diet, health care professionals still question its safety due 
to the elevated serum ketones it induces and the limited dietary fiber intake 35. To compound the 
controversy, patient compliance with the program is poor due to the restrictive nature of the diet, 
symptoms related to energy deficit, and gastrointestinal adversity during the introductory and energy 
substrate transition phase of the diet. A ketone ester, like the ketone monoester (KE), (R)-3-
hydroxybutyl-(R)-3-hydroxy-butyrate, is a drink that, after ingestion, is cleaved by gut esterases into 
equimolar βHB and (R)-1,3-butanediol. Both molecules enter the portal circulation, and the latter is 
converted in the liver into βHB. Therefore, KE supplementation offers the advantage that no dietary 
restrictions are needed and can be taken together with regular meals. This approach of t.i.d. oral KE 
supplementation together with the study participant’s regular diet has been successfully and safely 
used in 1-month trials in healthy human volunteers as well as in patients with type 2 diabetes mellitus 
36, 37. 
 
Overall strategy 
 
Overview  
The overarching goal of this small exploratory open-label pilot study is to explore [18F]FDG PET 
glucose metabolism and clinical measures before and after open-label treatment with the ketone 
ester (R)-3-hydroxybutyl (R)-3-hydroxybutyrate (KE) 25 g t.i.d. po in a small open label phase I pilot 
study in PD and normal control older adults. Positive findings in this small exploratory pilot trial may 
support target engagement studies of ketone supplementation in normal adults, PD, and PDD/LBD.  
Additionally, the goal of the optional sub-study (see complete protocol for sub-study on page 19) is to 
assess the feasibility of an exercise and supplement intervention in a subset of participants. 
 
Timetable: This study, to be conducted over a 2-year period, will include a net total of n=30 subjects 
(NC, n=4; PD, n=16; LBD/PDD, n= 10; gross n=42 to allow for attrition). Details of the enrollment and 
major test procedures are listed in table 1 below. Additionally, 10 participants will be recruited to 
complete the optional sub-study. 
 
Milestone of recruitment success are net completion of 9 persons for year 1. 
 
Table 1: Study enrollment & 
main assessments 
NC 
PD 
 
PDD/LBD 
TOTAL 
 
 
Baseline clinical assessment 
with (optional) [18F]FDG PET-
CT & brain MRI  
NC=4 
PD=16 
 
PDD/LBD=10 
n=30 
 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
7 
30-day (± 7 days) KE 25 g tid 
po intervention with pre/post 
clinical assessments) 
NC=4 
PD=16 
PDD/LBD=10 
n=30 
 
 
Post-intervention clinical 
assessment with (optional) 
[18F]FDG PET-CT & brain MRI 
NC=4 
PD=16 
PDD/LBD=10 
n=30 
 
 
 
 
 
 
 
 
 
Total subject net recruitment 
aims  
NC=4 
 
PD=16 
PDD/LBD=10 
n=30* 
 
 
*Net recruitment n=30; gross recruitment to account for attrition n=42. We will aim to complete 10 
participants in the optional sub-study, all who will be recruited from the net recruitment pool. 
 
Design: Exploratory open-label KE drink 25 g t.i.d. po (titrated up from 12.5g t.i.d) supplementation pilot 
study.  
 
Methods: After screening for study eligibility and obtaining informed consent (including eConsent), 
study participants will undergo the baseline clinical (vital signs, respiration, and general neurological 
assessment and optional imaging protocol (separate days). For patients taking dopaminergic 
medication, the motor component of the test battery will be performed in the dopaminergic medication 
'off' state in the morning after withholding their dopaminergic medications in the PD overnight, i.e., 
temporarily postponing the morning dose until the motor exam has completed.  The remainder of the 
test battery will be performed in the medication 'on' state. Participants will also complete some testing 
in a fasted state. For participants who were not consented prior arriving for their baseline visit, study 
staff will obtain a waiver of consent during the screening call for fasting and withholding dopaminergic 
medications prior to their visit. Qualified personnel who have been trained in the use of the 
instruments and have undergone inter-rater reliability evaluations will perform the assessments.  
 
There will be a total of 5 visits for this pilot study. The first two visits will consist of the initial clinical 
assessment and optional imaging split over 2 days (no specific sequence or preset time interval).  At 
visit 1 or 2, participants will be instructed to wear physical activity and sleep trackers (ActivPal, which 
is a sensor that will be put on the upper leg and a ring called Oura ring, which will be worn at a finger) 
for approximately 1 week prior to visit 3. Participants will also wear a continuous glucose monitor during 
the same time. After the participants complete the approximate 1 week of physical activity, sleep and 
glucose monitoring they will return for visit 3, where a limited repeat clinical test battery will be 
administered. At visit 3 the participant will also be instructed to start the approximately 30-day 
supplementation of KE drink as well as to wear the sleep tracking ring throughout their time taking the 
supplement. Participants who are willing and eligible to take part in the optional single-day sub-study 
will complete the optional sub-study at visit 3, where they will still get the first dose of the KE drink in 
lab. See page 19 of protocol for more information on the optional sub-study. The physical activity tracker 
and the continuous glucose monitor will also be worn during the last week of the KE supplementation 
period. At the end of the approximately 30-day KE supplementation, the participants will return for visits 
4 (repeat clinical assessment) and 5 (repeat optional imaging) again split over 2 days. There is no pre-
set sequence which assessment (clinical or imaging) comes first. Blood tests will be collected for 
assessments of genetic variables (e.g. ApoE). Blood and/or urine assessments will also be used for 
metabolomics, inflammatory markers, and/or screening measures. Blood continuous glucose data will 
be collected blinded to the participant, except for the first week of taking the ketone ester as this 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
8 
information is needed for safety monitoring purposes. Participants will also take readings of their 
glucose and ketone body levels using a Keto-Mojo device (see Table 2 for more information). 
 
Labs to be performed: 
• 
CBC w/ Diff 
• 
CMP w/ eGFR 
• 
High-sensitivity CRP 
• 
Hemoglobin A1c 
• 
RBC Magnesium 
• 
Phosphorus 
• 
Albumin 
• 
TSH 
• 
T4 
• 
Reverse T3 
• 
Lipid Panel 
• 
Urinalysis 
• 
Beta-2 Microglobulin 
• 
Homocysteine 
• 
Vit D (25-hydroxyvitamin D) 
• 
Folate 
• 
Uric acid – serum 
Additionally, there will be an optional single-day sub-study involving combining the KE supplement with 
a coffee supplement and cardiovascular exercise. This optional sub-study will take place at Visit 3. 
Participants can still complete the rest of the study if they are not able or do not wish to participate in 
the sub-study. See page 20 of protocol for a complete sub-study protocol and schedule of events. 
 
Details for the schedule of activities for the KE supplement intervention study are shown below (Table 
2). 
 
 
Table 2 Schedule 
of activities 
Visit 1* / 
Visit 2*: 
Baseline 
assessm
ent 
(clinical) 
 
Visit 1* / Visit 
2* 
Baseline 
assessment 
(imaging – 
OPTIONAL) 
At-home 
wearable 
sensor 
use (7 
days ± 3 
days) 
Visit 3 
Pre- 
intervention  
assessment4 
(including 
optional sub-
study if 
applicable) 
At-home 
30 (± 7 
days) 
KE   
(25 g tid po) 
intervention3 
 
Visit 4* / Visit 
5* 
Post- 
intervention 
clinical 
assessment 
(while on   
KE) 
Visit 4* / Visit 
5* 
Post- 
intervention 
imaging 
assessment 
(while on KE, 
OPTIONAL) 
Approximate time 
commitment 
4-6 
hours 
3-6 hours 
- 
4-5 hours 
- 
4-6 hours 
3- 6 hours  
Test location 
Domino
s 
Farms 
UM hospital 
Home 
Dominos 
Farms 
Home 
Dominos 
Farms 
UM hospital 
Informed Consent 
(or prior 
eConsent) 
X 
 
 
 
 
 
 
Eligibility 
X 
 
 
 
 
 
 
OPTIONAL 
[18F]FDG 
PET-CT 1.2 
(brain/body)* 
 
X 
 
 
 
 
X 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
9 
DEXA  
X 
 
 
 
 
X 
 
OPTIONAL MRI 
brain* 
 
X 
 
 
 
 
X 
Blood/urine 
sample collection1 
X 
 
 
 
 
X 
 
Ketone Ester 
Drink 
 
 
 
X (first dose 
taken in lab; 
may be 
taken during 
optional 
sub-study) 
X 
X 
X 
Continuous 
glucose monitor  
for 7±3 days 
 
 
X 
 
X (first ~7 
days of 
taking drink 
[unblinded] 
and last ~7 
days of 
taking drink) 
X 
 
Keto-Mojo 
glucose/ketone 
body monitoring*** 
 
 
 
X (before 
and after 
initial dose 
of KE in lab; 
optional) 
X (first ~7 
days of 
taking drink 
and weekly 
throughout 
intervention; 
optional) 
X (prior to 
testing) 
X (prior to 
imaging) 
Sleep tracking ring 
 
 
 
X 
X 
X (worn for 
duration of 
using 
ketone ester 
drink) 
X 
 
Activity tracker for 
7±3 days 
 
 
X 
 
X (last ~7 
days of 
taking drink) 
 
 
Motor MDS 
UPDRS2 
X 
 
 
X (optional) 
 
X 
 
Balance test 
MiniBESTest 
(sensored; 
optional for 
PDD/LBD/MCI 
patients)2 
X 
 
 
X (optional) 
 
X 
 
Pegboard testing2 
X 
 
 
X (optional) 
 
X 
 
Foot Tapping2 
(optional for 
PDD/LBD/MCI 
patients) 
X 
 
 
X (optional) 
 
X 
 
Finger Tapping2 
X 
 
 
X (optional) 
 
X 
 
Electronic Gait 
Mat/sensored 
walk2  
(optional for 
PDD/LBD/MCI 
patients) 
X 
 
 
X (optional) 
 
X 
 
Beck Depression 
Inventory II scale 
X 
 
 
X 
 
X 
 
Spielberger Trait 
Anxiety Scale 
X 
 
 
X 
 
X 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
10
Sleepiness scales 
X 
 
 
 
 
X 
 
 MoCa, 
PDCRS (limited 
cognition) 
X 
 
 
X (optional) 
 
X 
 
Cognitive test 
battery** 
X 
 
 
X (optional) 
 
X 
 
PCFRS functional 
scale 
X 
 
 
 
 
X 
 
Clinical Dementia 
Rating (CDR) 
Scale**** 
X 
 
 
 
 
X 
 
Quality of life 
scale PDQ-39 
X 
 
 
 
 
X 
 
Adverse event 
assessment 
X 
 
 
X 
 
X 
 
Phone Call / email 
drug monitoring 
 
 
 
 
X 
 
 
Drug 
accountability 
 
 
 
X 
 
X 
 
Pregnancy test in 
women of 
childbearing 
potential 
 
X 
(within 48 
hours of 
PET) 
 
X 
 
 
X 
(within 48 
hours of 
PET) 
Note 
1: Fasting in morning 
2: Dopaminergic off state in PD  
3: Participants will take 12.5g BID for day 1 of intervention, 12.5g TID for days 2 through 7 and increase dose to 25g on 
day 8 of intervention  
4: Visit 3 will have optional motor and cognitive testing for individuals who have more than 2 months between their 
baseline clinical assessment and pre-intervention clinical assessment. For those individuals who do not have to complete 
motor testing, they will not be required to withhold dopaminergic medication. For individuals taking part in the optional 
sub-study during the pre-intervention visit, they will still be required to withhold their medication and fast the morning of 
the visit. 
*Visits 1-2 and 4-5. There is no pre-set sequence which assessment (clinical or imaging) comes first. There may be a time 
interval of up to two months between Visits 1 and Visits 3, depending on scheduling 
**Portions of cognitive test battery will be optional for LBD/PDD/MCI participants in anticipation of fatigue 
***Keto-mojo usage will be optional if it is deemed too difficult for participant to administer by themselves. It will be 
required prior to post-intervention imaging and clinical visit (V4/5), but may be performed by research staff as needed 
****Clinical Dementia Rating Scale will only be completed by LBD/PDD/MCI subjects 
 
 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
11
Details of the neuropsychological test battery is shown in Table 3. 
 
Outcome measures: Primary outcome 
measures will be mean glucose 
metabolism for the first 7 days of wearing 
the continuous glucose monitor. Glucose 
metabolic changes include daily mean 
over first 7 days of wearing the continuous 
glucose monitor and/or, as an exploratory 
measure, fasting glucose based on FDG 
PET metabolism in the subset undergoing 
PET imaging. Clinical Dementia Rating 
scale at baseline and post-intervention will 
also serve as a primary outcome measure 
for subjects with LBD, PDD, and MCI. 
 
 
Exploratory outcome measures include: 1) 
Clinical and lab measures; Cognition 
dependent mobility functions: This test 
battery will include postural sway using the iSWAY and instrumented Timed Up and Go test (iTUG) 
Mobility Lab modules (APDM, Inc., Portland, OR) 38-40, dynamic balance using the Mini-BESTest 41 with 
sensored subtests, and electronic gait mat assessment using the Protokinetics Zeno™ Walkway 
(Protokinetics LLC, Havertown, PA) for spatiotemporal gait measurements.   
 
KE intervention: The active ingredient of the KE drink used in this study is the ketone monoester or 
(R)-3-hydroxybutyl (R)-3-hydroxybutyrate or D-β-hydroxybutyrate ester, a substance that was 
determined to be “Generally Recognized as Safe (GRAS)” by the FDA (GRN No.515). The KE is a 
drink that, after ingestion, is cleaved by gut esterases into equimolar βHB and (R)-1,3-butanediol. 
Both molecules enter the portal circulation, and the latter is converted in the liver into βHB 42. Thus, 
each equivalent of KE yields two equivalents of βHB 43. Compared to similar ingredients, such as the 
ketone diester or ketone salts, the ketogenic supplements such as MCTs and ketogenic diets, the KE 
induces acutely the most robust ketosis. The KE has been administered to one 63-year-old male patient 
with moderate-severe sporadic Alzheimer during a 20-month period. The patient and caregiver tried a range of 
doses, including the dose of 25 g p.o. three times daily. This dose level, which was the starting dose for the 
patient, elicited a robust behavioral improvement when first started and resulted in plasma βHB level of 3 mM. 
This particular patient tolerated the KE well and exhibited a rapid and sustained behavioral improvement 44.  
KE has also been administered to exercising PwPD resulting in improved exercise endurance performance 
compared to placebo 45. A common KE dose of 25g t.i.d. p.o., which is being used in this study, can 
safely elevate plasma βHB up to 4.0 mM or more 36, a concentration that is at least 8-times higher 
than that achieved with other ketogenic supplements 46. The acute induction of ketosis achieved with 
the KE is roughly the equivalent of ketosis achieved after two weeks on a strict (high-fat, low-carb) 
ketogenic diet 47 or few days of complete fasting (starvation) 48. A single KE drink used in this study 
contains 25 g of KE, which in addition to the active ingredient contains water, flavorings, and 
preservatives. The KE is produced in a GMP-compliant facility in the U.S. (Ketonaid.com). 
The pharmacology and safety of KE has been thoroughly studied in animals 49 and, for one month, in 
healthy human adults 36 and in patients with type 2 diabetes mellitus. Safety and tolerability of 
sustained exogenous ketosis was assessed using ketone monoester drinks for 28 days in healthy 
adults. 24 healthy adults, aged 18-70 years, drank 25 ml (26.8 g) of the KE, three times a day for 28 
Table 3: Neuropsychological characterization 
Overall mental status 
Montreal Cognitive Assessment Scale 3 
PD-Cognitive Rating Scale 4  
Intelligence 
WAIS-IV: Information5*** 
Attention & Cognitive 
Control 
n-back test 7 (optional), Stroop Color Word Interference 
Test 9** 
WAIS-IV: Digit Span5*** 
Language 
Boston Naming Test (30 item) 11*** 
Controlled Oral Word Association Test (Phonemic & 
Semantic) 
Learning & Memory 
California Verbal Learning Test – II 12*** 
 
Visuospatial/Construction 
Clock drawing 13 
Benton Judgment of Line Orientation 15 
Executive/Working 
Memory 
D-KEFS: Color Word Test, Verbal Fluency Test, Trail 
Making Test, Sorting Test 16*** 
WAIS-IV Matrix Reasoning***, Digit Backwards 5*** 
Information processing 
speed 
D-KEFS: Trail Making Test 16 
WAIS-III: Digit Symbol-Coding 5, 18*** 
Reaction time  
*Neuropsychological test battery will be optional at Visit 3 
** Colorblind participants will complete Condition 1 only 
***Portions of the neuropsychological test battery will be optional for 
PDD/LBD patients in anticipation of fatigue 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
12
days (a total of 2.1 L). Anthropomorphic measurements, plus fasting blood and urine analyses were 
made weekly. It was found that elevating blood βHB concentrations from 0.1 to 4.1 (±1.1) mM three 
times a day for 28 days had no effect on body weights or composition, fasting blood glucose, 
cholesterol, triglyceride or electrolyte concentrations, nor blood gases or kidney function, which were 
invariably normal 36. In addition, a 28-day study in patients with type 2 diabetes also on 26.8 g t.i.d. po 
found that all participants had >90% adherence, defined as consumption of at least 76 of the 
maximum 84 KE drinks. Thus, the KE drink was well-tolerated. Adverse symptoms were self-recorded 
by participants following each of their drinks and were ranked as ‘mild’, ‘moderate’ or ‘severe’. Overall 
occurrence of adverse symptoms is expressed relative to the total number, 1,588, of drinks 
consumed throughout the entire study; mild nausea (5/1,588 = 0.3%), mild headache (5/1,588 = 
0.3%) and mild gastric discomfort (9/1,588 = 0.5%) were the only reported symptoms 37. Mild nausea 
was reported following 6 of the 2,016 drinks consumed in the 28-day healthy control study 36.  
 
Research staff will administer the first dose of KE drink at Visit 3 in lab to monitor subjects (day 1), 
and then subjects will be sent home and asked to take a second dose of KE drink with their next meal 
(day 1). For days 2 through 7, participants will take 12.5g (25mL) TID, and on day 8, the dose will be 
increased to 25g (50mL) TID as tolerated. KE dose will be titrated down to a tolerated level if 
necessary. Participants will be asked to take the KE doses with meals to decrease side-effects of 
hypoglycemia. If participants are experiencing feelings of low glucose levels and/or a blood glucose 
reading of <65mg/dL (via unblinded continuous glucose monitor and/or KetoMojo reading), 
participants will be asked to skip the KE dose and wait until their next meal to take a dose. Glucose 
and ketone body levels will be monitored for the first ~7days using Keto-Mojo (optional) to decrease 
chances of hypoglycemia, as well as taken weekly for the duration of the KE intervention (optional). 
Glucose and ketone body levels will also be monitored prior to the post-intervention clinical testing 
and imaging. Staff will ask participants to limit their alcohol consumption to a maximum of one glass 
per day and take the final daily dose at least 4 hours prior to sleep. 
 
Magnetic resonance imaging (MRI) will be performed on a 3 Tesla Philips Achieva system (Philips, 
Best, The Netherlands). A 3D inversion recovery-prepared turbo-field-echo was performed in the 
sagittal 
plane 
using 
TR/TE/TI=9.8/4.6/1041ms; 
turbo 
factor=200; 
single 
average; 
FOV=240x200x160mm; acquired Matrix = 240x200x160 slices and reconstructed to 1mm isotropic 
resolution. MR-spectroscopy and other sequences will also be performed. Resting-state fMRI scans 
will serve as a secondary outcome measure and be acquired using a 32-channel head coil and multi-
band sequence 50, with nominal parameters: (TR/TE/FA = 720/34/52, 2mm isotropic resolution, 72 
slices). Data are collected with eyes fixated on a cross for 10 minutes 51. Pre-processing follows our 
standard pipeline that includes physiologic noise reduction and thorough motion correction 52, 53.  Graph 
theory analysis will be used to identify the most highly connected nodes following published methods. 
Briefly, ROIs will be represented as nodes and pairwise correlations, based upon the mean time series 
for each ROI, will serve as weights over corresponding edges, thresholded by FDR correction, p<0.05 
52, 53. Change from baseline will serve as the primary measure of interest. Magnetic resonance 
spectroscopy (MRS) may optionally complement the MRI sequence. MRS may be performed either at 
University Hospital or North Campus fMRI Laboratory. 
 
PET imaging will be performed in 3D imaging mode on a Biograph 6 TruePoint PET/CT scanner 
(Siemens Molecular Imaging, Inc., Knoxville, TN), which acquire 63 transaxial slices (slice thickness: 
2.4 mm) over a 15.2 cm axial field-of-view. Images were corrected for scatter and motion. The PET 
imaging frames will be spatially coregistered within subjects with a rigid-body transformation to reduce 
the effects of subject motion during the imaging session 54. Statistical parametric mapping (SPM) 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
13
software (SPM12; Wellcome Trust Centre for Neuroimaging, University College, London, England 
[https://www.fil.ion.ucl.ac.uk/spm/software/spm12/] will be used for PET-MRI registration using the 
cropped T1-weighted MR volumetric scan. Freesurfer software (http://surfer.nmr.mgh.harvard.edu) will 
be used to define cortical and subcortical volumes-of-interest (VOI).  
 
MRI-based PET partial volume correction: We will use the Müller-Gärtner partial volume correction 
technique, which is based on the assumption that white matter uptake is homogeneous and uses 
gray matter (GM), white matter (WM) and cerebrospinal fluid (CSF) to correct the partial volume effect 
in GM tissues 55. Using the segmented images and the assumed PET resolution, the method 
calculates the spill-out from WM to GM and subsequently subtracts it from the GM. Similarly, it also 
calculates the spill-out from the GM to the surrounding tissues and compensates for the difference to 
the GM. The result is a grey matter image with corrected activity values in all voxels.  
 
Statistical analysis 
We will use a paired t-test to assess for changes in glucose metabolism before and after the KE 
supplementation.  Glucose metabolic changes include 7-10 daily average and fasting glucose based 
on continuous glucose monitoring that can be complemented by cerebral FDG PET SUVr in the subset 
undergoing PET imaging.  
 
As a post hoc and only exploratory analyses we will regress differences in with KE -induced changes 
of the various clinical and laboratory outcome measures.  
Sample size estimation: This experiment is a first in human study of this drug for treatment of glucose 
changes in a neurodegenerative condition. Based on the 28-day t.i.d. KE intervention study 
performed in patients with type 2 diabetes mellitus 37,  and similar effect size in our cohort and using a 
power of 0.8 and a two-sided alpha of 0.05 for our primary analysis that will compare pre and post 
KE, we arrive at a total sample size of 30.  
Scientific rigor: All tests and neuroimaging procedures used in this proposal have been validated and 
protocols have been published. Both PET and MR neuroimaging assessments will follow established 
and published acquisition protocols. Neuroimaging analysis will include well-validated and widely used 
software packages and processing pipelines such as SPM12, FreeSurfer, FSL, and AFNI. All 
equipment for mobility testing is commercially available and vendor-provided (validated) outcome 
parameters will be used. The neuropsychological test battery includes tailored components for use in 
PwPD 56. We will rigorously guard against Type I and Type II errors and correct all our statistical 
inferences with family-wise error and false discovery rate corrections where appropriate. This 
reproducible and rigorous methodological and analysis approach will ensure results and conclusions 
that can be replicated by other investigations.   
 
 
Pitfalls, problems, and alternative strategies 
 
Ineligibility and attrition rate: 
 
Protection of Human Subjects 
 
i) Human Subjects 
Description of subject populations:  

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
14
i) 
Healthy control persons, M/F, age 45 years and over without a history of neurological or 
psychiatric disease or significant GI disease or uncontrolled medical comorbidity will be 
recruited (net n=4).  
ii) 
PD (net n=16) Diagnosis of PD in PD participants (M/F, age 45 years and over) will be based 
on the United Kingdom Parkinson's Disease Society Brain Bank Diagnostic Research Criteria 
(patients with clinically significant dementia will be excluded from PD subset and may 
participate in LBD/PDD subset (i.e., fails informed assent screening criteria and has 
significant evidence of iADL functions, such as ability to take own medications while 
administering the pre-consent screening questionnaire).  
iii) 
Persons diagnosed with Lewy Body Dementia (LBD) based on the Fourth consensus report 
of the DLB Consortium inclusion criteria for probable DLB or Parkinson’s Disease Dementia 
(PDD) based on the criteria set by Emre et al. for PDD (M/F, age 45 years and over; net=10). 
 
Exclusion criteria: 
1. Exclusion for all subjects: (a) Evidence of large vessel stroke or mass lesion on MRI; (b) 
Regular use of anti-cholinergic drugs or taking high dose (>100mg QD) of quetiapine (c) 
history of significant GI disease, (d) significant metabolic or uncontrolled medical comorbidity, 
(e) poorly controlled diabetes, (f) pregnancy or breast feeding, (g) suicidal ideation as 
determined by Beck Depression Inventory Question 9, (h) current excessive alcohol use as 
determined by investigator, and (I) subjects with contra-indications to MR imaging, including 
pacemakers, metal fragments in the body, or severe claustrophobia (for participants 
undergoing imaging); (i) participants with significant prior radiation exposure may not be 
eligible for the optional imaging portion of this study. 
  
Recruitment: Subjects will be recruited from the University of Michigan Movement Disorder clinics, UM 
research studies website, Data Direct, and/or advertisement/flyers. 
 
ii) Sources of Materials: 
 
Information gathered specifically for this research project includes test results from clinical test scales, 
psychometric cognitive measures, neurobehavioral rating scales, clinical motor data, questionnaires, 
and data derived from PET and brain MRI. 
 
iii) Potential Risks (as described in informed consent document): 
 
Confidentiality of Research Information:  The research data to be collected from subjects will consist of 
confidential information relating to clinical, motor, cognitive, neurobehavioral, and neuro-imaging 
functions.  These research data are not intended for entry into the subjects’ clinical medical records.  
However, the data remain potentially discoverable. This may lead to violation of privacy and 
embarrassment of the subject. 
 
Clinical Testing: Risks regarding the clinical assessment are limited to fatigue, frustration and 
momentary embarrassment that may occur when one experiences difficulty performing a task or 
learning a new skill. There is an infrequent risk that the blood sample method may cause minor 
bruising at the injection site. There is a very rare risk for infection. There is a rare risk that you may 
feel dizzy, lightheaded, or faint after the blood draw. There is an infrequent risk of pain or infection 
associated with finger prick using Keto-Mojo. 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
15
 
Motor Testing:  Many of the tests are comparable to normal standing and walking conditions that you 
may experience in everyday-life. Nonetheless, there is an infrequent risk of falling or near-falling 
during these tests which may result in fall-related injuries. There is a very rare risk that the sensors to 
measure overall movement and balance may become detached and that you may trip. You may also 
trip on the pressure sensitive mat. 
 
Risks associated with clinical, neuropsychological and behavioral testing: This study involves cognitive 
tests and questionnaires. The cognitive tests are not harmful, but some people find them frustrating 
and concerning. Risks regarding the neuropsychological and behavioral assessment are limited to 
fatigue, frustration and momentary embarrassment that may occur when one experiences difficulty 
performing a task or learning a new skill. Some people may be uncomfortable/embarrassed disclosing 
personal information or become nervous about memory testing and may experience discomfort or 
become tired. Study team members are very well experienced in the assessment of older individuals 
and persons with dementia, understanding the need for breaks, gentle reassurance, or reinforcement. 
All assessments will be stopped if requested by the participant.   
 
MRI scan: There is a substantial risk to persons who have metallic objects inside their bodies, as the 
magnet in the MR scanner can cause these to move. Consequently, participants with pacemakers or 
metallic objects located in the eye, ear, brain, or blood vessel walls will be excluded from the optional 
imaging portion. Participants who developed claustrophobic anxiety during scanning found that this fear 
dissipated within 15 min while remaining in the scanner, or as necessary, after exiting the scanner. 
There also is the potential that imaging could reveal a previously unrecognized but pre-existing 
abnormality. Many such abnormalities are not clinically significant, but they may cause anxiety or 
require further investigation by a personal physician. If one of the investigators identifies such an 
abnormality, they will contact the personal physician, who will arrange for appropriate care. 
 
PET-CT scans & venipuncture: Insertion of a catheter for intravenous injection of the PET 
radiopharmaceutical may be commonly associated with slight pain or bruising at the puncture site and 
rare chance of infection. Participation in this research study will involve low level exposure to radiation 
associated with the PET, CT, and DEXA scans.  
 
The use of [18F]FDG  is considered to be generally safe and effective as approved by the University of 
Michigan Radioactive Drug Research Committee in accordance with Food and Drug Administration 
regulations (21 CFR 361.1).  Certified staff will be in attendance at all times during the study.  A 
physician will be available, and an emergency cart is located in the PET Facility for treatment of any 
adverse reactions that may occur. 
 
During the course of this study, the participant will be exposed to radiation from the two [18F]FDG 
PET-CT and two DEXA scans. The risks associated with the amount of radiation exposure 
participants receive in this study are considered very rare and comparable to everyday radiation 
exposure risks.  
The biological effect of radiation in humans is measured in terms of Sieverts (Sv) or mSv (1/1000 Sv), 
which is a unit of uniform whole body exposure. The radiation exposure a participant will receive from 
the CT, and [18F]FDG PET scan is equivalent to a uniform whole body dose of 12.3 mSv, which is 
approximately 24.6 % of the annual radiation exposure (50 mSv) permitted to radiation workers by 
federal regulations. The participant will be instructed to use the bathroom and urinate as soon as 
possible after the PET scans in order to minimize bladder exposure. The radiation the participant will 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
16
be exposed to from each DEXA scan is 0.0310 mSv, which is significantly less than 1% of the 
permitted annual radiation exposure.  
 
There is no known minimum level of radiation exposure that is recognized as being totally free of the 
risk of causing genetic defects (cellular abnormalities) or cancer.  However, the risk associated with 
the amount of radiation exposure that participants will receive from this study is considered to be low. 
The risk of a side effect from this level of radiation exposure is very rare. The risk from radiation 
exposure of this amount is considered to be similar to other everyday risks, such as driving a car. 
 
No PET studies will be performed on pregnant, nursing, or potentially pregnant women. 
A urine pregnancy test will be performed on all women of childbearing potential within 48 hours prior 
to the PET scanning session. 
Risks associated with the ketone ester: The risks to participants are low. Studies in humans have 
shown evidence of nausea, gastro-intestinal discomfort, abdominal distention, diarrhea, dizziness, 
lightheadedness, sweating, headache, keto flu-like symptoms, heartburn, shakiness, sleep changes, 
other symptoms of hypoglycemia, and/or increased glucose levels.  Poor or bitter taste is a more 
common side-effect. Therefore, the KE drink may be diluted. The KE in this study has received GRAS 
(Generally Regarded As Safe, GRN No.515) certification from the FDA 57, is commercially available in 
the United States and prior work has shown that the 25g tid po dosing regimen proposed in this study 
has been found to be safe and generally well-tolerated in healthy controls and patients with type 2 
diabetes mellitus 36, 37. If side effects occur, the study team will decrease the dose and/or ask 
participants to skip a dose until their next meal. 
Data Study Monitoring Plan (DSMP): Drs. Bohnen and Albin will act as the Data Safety Monitoring 
Plan members for this study. All adverse events and other study related events will be discussed at 
monthly investigator meetings. Adverse events will be classified according to standard criteria and 
reported to the IRBMED (relevant University of Michigan IRB) according to standard guidelines. 
Serious adverse events will be reported within 24 hours. 
For risk of suicidality (if participants select answer responses 2 or 3 for question 9 on the Beck 
Depression Inventory, i.e. 'I would like to kill myself' (answer 2) or 'I would like to kill myself if I had a 
chance' (answer 3) then the staff will hand out the UM Depression brochure, refer to the contact 
information and inform Dr. Bohnen or Dr. Albin who will discuss this with the participant. The face-to-
face or video conversation with the physicians will occur during that visit and will not be deferred. 
There will be a safety plan in place before the patient leaves the building. 
 
 
References 
 
1. 
Bohnen NI, Koeppe RA, Minoshima S, Giordani B, Albin RL, Frey KA, Kuhl DE. Cerebral glucose metabolic features 
of Parkinson disease and incident dementia: longitudinal study. J Nucl Med. 2011;52(6):848-55. Epub 2011/05/17. doi: 
jnumed.111.089946 [pii] 
10.2967/jnumed.111.089946. PubMed PMID: 21571793. 
2. 
Albin RL, Minoshima S, D'Amato CJ, Frey KA, Kuhl DE, Sima AAF. Fluoro-deoxyglucose positron emission 
tomography in diffuse Lewy body disease. Neurology. 1996;47:462-6. 
3. 
Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The 
Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 
2005;53(4):695-9. Epub 2005/04/09. doi: JGS53221 [pii] 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
17
10.1111/j.1532-5415.2005.53221.x. PubMed PMID: 15817019. 
4. 
Pagonabarraga J, Kulisevsky J, Llebaria G, Garcia-Sanchez C, Pascual-Sedano B, Gironell A. Parkinson's disease-
cognitive rating scale: a new cognitive scale specific for Parkinson's disease. Mov Disord. 2008;23(7):998-1005. Epub 
2008/04/03. doi: 10.1002/mds.22007. PubMed PMID: 18381647. 
5. 
Wechsler D. Wechsler Adult Intelligence Scale-Third Edition. San Antonio, TX: Psychological Corporation; 1997. 
6. 
Gallagher DA, Lees AJ, Schrag A. What are the most important nonmotor symptoms in patients with Parkinson's 
disease and are we missing them? Mov Disord. 2010;25(15):2493-500. Epub 2010/10/06. doi: 10.1002/mds.23394. 
PubMed PMID: 20922807. 
7. 
Kirchner WK. Age differences in short-term retention of rapidly changing information. J Exp Psychol. 
1958;55(4):352-8. Epub 1958/04/01. doi: 10.1037/h0043688. PubMed PMID: 13539317. 
8. 
Aarsland D, Creese B, Politis M, Chaudhuri KR, Ffytche DH, Weintraub D, Ballard C. Cognitive decline in Parkinson 
disease. Nat Rev Neurol. 2017;13(4):217-31. Epub 2017/03/04. doi: 10.1038/nrneurol.2017.27. PubMed PMID: 
28257128; PMCID: PMC5643027. 
9. 
Bohnen N, Jolles J, Twijnstra A. Modification of the Stroop Color Word Test improves differentiation between 
patients with mild head injury and matched controls. The Clin Neuropsychologist. 1992;6:178-84. 
10. 
Hely MA, Reid WG, Adena MA, Halliday GM, Morris JG. The Sydney multicenter study of Parkinson's disease: the 
inevitability of dementia at 20 years. Mov Disord. 2008;23(6):837-44. Epub 2008/03/01. doi: 10.1002/mds.21956. 
PubMed PMID: 18307261. 
11. 
Saxton J, Ratcliff G, Munro CA, Coffey EC, Becker JT, Fried L, Kuller L. Normative data on the Boston Naming Test 
and two equivalent 30-item short forms. Clin Neuropsychol. 2000;14:526-34. 
12. 
Delis DC, Kramer JH, Kaplan E, Ober BA. California Verbal Learning Test Manual, Adult Version. Second ed. San 
Antonio: The Psychological Corporation; 2000. 
13. 
Freedman M, Leach L, Kaplan E, Winocur G, Shulman KI, Delis DC. Clock drawing: A neuropsychological analysis. 
New York: Oxford University Press; 1994. 
14. 
Buter TC, van den Hout A, Matthews FE, Larsen JP, Brayne C, Aarsland D. Dementia and survival in Parkinson 
disease: a 12-year population study. Neurology. 2008;70(13):1017-22. Epub 2008/03/26. doi: 
10.1212/01.wnl.0000306632.43729.24. PubMed PMID: 18362281. 
15. 
Benton AL, Hamsher K, Varney NR, Spreen O. Contributions to Neuropsychological Assessment. New York: 
Oxford University Press; 1983. 
16. 
Delis DC, Kaplan E, Kramer JH. Delis-Kaplan Executive Function System (D-KEFS): Examiner's manual. San 
Antonio, TX: The Psychological Corporation; 2001. 
17. 
Williams-Gray CH, Mason SL, Evans JR, Foltynie T, Brayne C, Robbins TW, Barker RA. The CamPaIGN study of 
Parkinson's disease: 10-year outlook in an incident population-based cohort. J Neurol Neurosurg Psychiatry. 
2013;84(11):1258-64. Epub 2013/06/20. doi: 10.1136/jnnp-2013-305277 
jnnp-2013-305277 [pii]. PubMed PMID: 23781007. 
18. 
Chriett S, Dabek A, Wojtala M, Vidal H, Balcerczyk A, Pirola L. Prominent action of butyrate over beta-
hydroxybutyrate as histone deacetylase inhibitor, transcriptional modulator and anti-inflammatory molecule. Sci Rep. 
2019;9(1):742. Epub 2019/01/27. doi: 10.1038/s41598-018-36941-9. PubMed PMID: 30679586; PMCID: PMC6346118. 
19. 
Baiano C, Barone P, Trojano L, Santangelo G. Prevalence and clinical aspects of mild cognitive impairment in 
Parkinson's disease: A meta-analysis. Mov Disord. 2020;35(1):45-54. Epub 2019/11/20. doi: 10.1002/mds.27902. 
PubMed PMID: 31743500. 
20. 
Kehagia AA, Barker RA, Robbins TW. Cognitive impairment in Parkinson's disease: the dual syndrome hypothesis. 
Neurodegener Dis. 2013;11(2):79-92. Epub 2012/10/06. doi: 10.1159/000341998 
000341998 [pii]. PubMed PMID: 23038420. 
21. 
Braak H, Del Tredici K, Rub U, de Vos RA, Jansen Steur EN, Braak E. Staging of brain pathology related to sporadic 
Parkinson's disease. Neurobiol Aging. 2003;24(2):197-211. PubMed PMID: 12498954. 
22. 
Williams-Gray CH, Evans JR, Goris A, Foltynie T, Ban M, Robbins TW, Brayne C, Kolachana BS, Weinberger DR, 
Sawcer SJ, Barker RA. The distinct cognitive syndromes of Parkinson's disease: 5 year follow-up of the CamPaIGN cohort. 
Brain. 2009;132(Pt 11):2958-69. Epub 2009/10/09. doi: awp245 [pii] 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
18
10.1093/brain/awp245. PubMed PMID: 19812213. 
23. 
van der Zee S, Müller MLTM, Kanel P, van Laar T, Bohnen NI. Cholinergic Denervation Patterns Across Cognitive 
Domains in Parkinson's Disease. Mov Disord. 2021;36(3):642-50. Epub 2020/11/03. doi: 10.1002/mds.28360. PubMed 
PMID: 33137238; PMCID: PMC7988481. 
24. 
Tagliaferro P, Burke RE. Retrograde Axonal Degeneration in Parkinson Disease. J Parkinsons Dis. 2016;6(1):1-15. 
Epub 2016/03/24. doi: 10.3233/jpd-150769. PubMed PMID: 27003783; PMCID: PMC4927911. 
25. 
Wong YC, Luk K, Purtell K, Burke Nanni S, Stoessl AJ, Trudeau LE, Yue Z, Krainc D, Oertel W, Obeso JA, Volpicelli-
Daley LA. Neuronal vulnerability in Parkinson disease: Should the focus be on axons and synaptic terminals? Mov Disord. 
2019;34(10):1406-22. Epub 2019/09/05. doi: 10.1002/mds.27823. PubMed PMID: 31483900; PMCID: PMC6879792. 
26. 
Chen MK, Mecca AP, Naganawa M, Finnema SJ, Toyonaga T, Lin SF, Najafzadeh S, Ropchan J, Lu Y, McDonald JW, 
Michalak HR, Nabulsi NB, Arnsten AFT, Huang Y, Carson RE, van Dyck CH. Assessing Synaptic Density in Alzheimer 
Disease With Synaptic Vesicle Glycoprotein 2A Positron Emission Tomographic Imaging. JAMA Neurol. 2018;75(10):1215-
24. Epub 2018/07/18. doi: 10.1001/jamaneurol.2018.1836. PubMed PMID: 30014145; PMCID: PMC6233853 Foundation 
and research support from Eli Lilly and clinical trials from Merck, outside the submitted work. Dr Huang reports research 
grants from the UCB and Eli Lilly outside the submitted work. Drs Huang and Carson have a patent for a newer version of 
the tracer pending. Dr Carson reports grants from National Institutes of Health for the conduct of the study. Dr Carson 
also reports having received grants from AstraZeneca, Astellas, Eli Lilly, Pfizer, Taisho, and UCB, outside the submitted 
work. Dr van Dyck reports consulting fees from Kyowa Kirin, Roche, Merck, Eli Lilly, and Janssen and grants for clinical 
trials from Biogen, Novartis, Eli Lilly, Merck, Eisai, Janssen, Roche, Genentech, Toyama, and TauRx, outside the submitted 
work. No other disclosures are reported. 
27. 
Matuskey D, Tinaz S, Wilcox KC, Naganawa M, Toyonaga T, Dias M, Henry S, Pittman B, Ropchan J, Nabulsi N, 
Suridjan I, Comley RA, Huang Y, Finnema SJ, Carson RE. Synaptic Changes in Parkinson Disease Assessed with in vivo 
Imaging. Ann Neurol. 2020;87(3):329-38. Epub 2020/01/19. doi: 10.1002/ana.25682. PubMed PMID: 31953875; PMCID: 
PMC7065227 conception, acquisition and reporting of this study. 
28. 
Delva A, Van Weehaeghe D, Koole M, Van Laere K, Vandenberghe W. Loss of Presynaptic Terminal Integrity in 
the Substantia Nigra in Early Parkinson's Disease. Mov Disord. 2020;35(11):1977-86. Epub 2020/08/09. doi: 
10.1002/mds.28216. PubMed PMID: 32767618. 
29. 
Croteau E, Castellano CA, Fortier M, Bocti C, Fulop T, Paquet N, Cunnane SC. A cross-sectional comparison of 
brain glucose and ketone metabolism in cognitively healthy older adults, mild cognitive impairment and early 
Alzheimer's disease. Exp Gerontol. 2018;107:18-26. Epub 2017/07/16. doi: 10.1016/j.exger.2017.07.004. PubMed PMID: 
28709938. 
30. 
Pickrell AM, Youle RJ. The roles of PINK1, parkin, and mitochondrial fidelity in Parkinson's disease. Neuron. 
2015;85(2):257-73. Epub 2015/01/23. doi: 10.1016/j.neuron.2014.12.007. PubMed PMID: 25611507; PMCID: 
PMC4764997. 
31. 
Franco-Iborra S, Vila M, Perier C. The Parkinson Disease Mitochondrial Hypothesis: Where Are We at? 
Neuroscientist. 2016;22(3):266-77. Epub 2015/03/13. doi: 10.1177/1073858415574600. PubMed PMID: 25761946. 
32. 
Youle RJ. Mitochondria-Striking a balance between host and endosymbiont. Science. 2019;365(6454). Epub 
2019/08/17. doi: 10.1126/science.aaw9855. PubMed PMID: 31416937. 
33. 
Koepsell H. Glucose transporters in brain in health and disease. Pflugers Arch. 2020;472(9):1299-343. Epub 
2020/08/14. doi: 10.1007/s00424-020-02441-x. PubMed PMID: 32789766; PMCID: PMC7462931. 
34. 
Courchesne-Loyer A, Croteau E, Castellano CA, St-Pierre V, Hennebelle M, Cunnane SC. Inverse relationship 
between brain glucose and ketone metabolism in adults during short-term moderate dietary ketosis: A dual tracer 
quantitative positron emission tomography study. J Cereb Blood Flow Metab. 2017;37(7):2485-93. Epub 2016/09/16. 
doi: 10.1177/0271678x16669366. PubMed PMID: 27629100; PMCID: PMC5531346. 
35. 
Cavaleri F, Bashar E. Potential Synergies of beta-Hydroxybutyrate and Butyrate on the Modulation of 
Metabolism, Inflammation, Cognition, and General Health. J Nutr Metab. 2018;2018:7195760. Epub 2018/05/29. doi: 
10.1155/2018/7195760. PubMed PMID: 29805804; PMCID: PMC5902005. 
36. 
Soto-Mota A, Vansant H, Evans RD, Clarke K. Safety and tolerability of sustained exogenous ketosis using ketone 
monoester drinks for 28 days in healthy adults. Regul Toxicol Pharmacol. 2019;109:104506. Epub 20191023. doi: 
10.1016/j.yrtph.2019.104506. PubMed PMID: 31655093. 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
19
37. 
Soto-Mota A, Norwitz NG, Evans R, Clarke K, Barber TM. Exogenous ketosis in patients with type 2 diabetes: 
Safety, tolerability and effect on glycaemic control. Endocrinol Diabetes Metab. 2021;4(3):e00264. Epub 20210520. doi: 
10.1002/edm2.264. PubMed PMID: 34277987; PMCID: PMC8279633. 
38. 
Salarian A, Horak FB, Zampieri C, Carlson-Kuhta P, Nutt JG, Aminian K. iTUG, a sensitive and reliable measure of 
mobility. IEEE Trans Neural Syst Rehabil Eng. 2010;18(3):303-10. Epub 2010/04/15. doi: 10.1109/TNSRE.2010.2047606. 
PubMed PMID: 20388604; PMCID: 2922011. 
39. 
Mancini M, Salarian A, Carlson-Kuhta P, Zampieri C, King L, Chiari L, Horak FB. ISway: a sensitive, valid and 
reliable measure of postural control. J Neuroeng Rehabil. 2012;9:59. Epub 2012/08/24. doi: 10.1186/1743-0003-9-59 
1743-0003-9-59 [pii]. PubMed PMID: 22913719; PMCID: 3481400. 
40. 
Mancini M, Fling BW, Gendreau A, Lapidus J, Horak FB, Chung K, Nutt JG. Effect of augmenting cholinergic 
function on gait and balance. BMC Neurol. 2015;15(1):264. doi: 10.1186/s12883-015-0523-x. PubMed PMID: 26697847; 
PMCID: 4690312. 
41. 
Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance 
Evaluation Systems Test: the mini-BESTest. J Rehabil Med. 2010;42(4):323-31. Epub 2010/05/13. doi: 
10.2340/16501977-0537. PubMed PMID: 20461334; PMCID: 3228839. 
42. 
Clarke K, Tchabanenko K, Pawlosky R, Carter E, Todd King M, Musa-Veloso K, Ho M, Roberts A, Robertson J, 
Vanitallie TB, Veech RL. Kinetics, safety and tolerability of (R)-3-hydroxybutyl (R)-3-hydroxybutyrate in healthy adult 
subjects. Regul Toxicol Pharmacol. 2012;63(3):401-8. Epub 2012/05/09. doi: 10.1016/j.yrtph.2012.04.008. PubMed 
PMID: 22561291; PMCID: PMC3810007. 
43. 
Norwitz NG, Hu MT, Clarke K. The Mechanisms by Which the Ketone Body D-β-Hydroxybutyrate May Improve 
the Multiple Cellular Pathologies of Parkinson's Disease. Front Nutr. 2019;6:63. Epub 2019/05/30. doi: 
10.3389/fnut.2019.00063. PubMed PMID: 31139630; PMCID: PMC6527784. 
44. 
Newport MT, VanItallie TB, Kashiwaya Y, King MT, Veech RL. A new way to produce hyperketonemia: use of 
ketone ester in a case of Alzheimer's disease. Alzheimers Dement. 2015;11(1):99-103. Epub 2014/10/11. doi: 
10.1016/j.jalz.2014.01.006. PubMed PMID: 25301680; PMCID: PMC4300286. 
45. 
Norwitz NG, Dearlove DJ, Lu M, Clarke K, Dawes H, Hu MT. A Ketone Ester Drink Enhances Endurance Exercise 
Performance in Parkinson's Disease. Front Neurosci. 2020;14:584130. Epub 2020/10/27. doi: 
10.3389/fnins.2020.584130. PubMed PMID: 33100965; PMCID: PMC7556340. 
46. 
Kapogiannis D, Avgerinos KI. Brain glucose and ketone utilization in brain aging and neurodegenerative diseases. 
Int Rev Neurobiol. 2020;154:79-110. Epub 20200710. doi: 10.1016/bs.irn.2020.03.015. PubMed PMID: 32739015. 
47. 
Wiers CE, Vendruscolo LF, van der Veen JW, Manza P, Shokri-Kojori E, Kroll DS, Feldman DE, McPherson KL, 
Biesecker CL, Zhang R, Herman K, Elvig SK, Vendruscolo JCM, Turner SA, Yang S, Schwandt M, Tomasi D, Cervenka MC, 
Fink-Jensen A, Benveniste H, Diazgranados N, Wang GJ, Koob GF, Volkow ND. Ketogenic diet reduces alcohol withdrawal 
symptoms in humans and alcohol intake in rodents. Sci Adv. 2021;7(15). Epub 20210409. doi: 10.1126/sciadv.abf6780. 
PubMed PMID: 33837086; PMCID: PMC8034849. 
48. 
Cahill GF, Jr. Fuel metabolism in starvation. Annu Rev Nutr. 2006;26:1-22. doi: 
10.1146/annurev.nutr.26.061505.111258. PubMed PMID: 16848698. 
49. 
Clarke K, Tchabanenko K, Pawlosky R, Carter E, Knight NS, Murray AJ, Cochlin LE, King MT, Wong AW, Roberts A, 
Robertson J, Veech RL. Oral 28-day and developmental toxicity studies of (R)-3-hydroxybutyl (R)-3-hydroxybutyrate. 
Regul Toxicol Pharmacol. 2012;63(2):196-208. Epub 20120411. doi: 10.1016/j.yrtph.2012.04.001. PubMed PMID: 
22504461; PMCID: PMC3809901. 
50. 
Feinberg DA, Setsompop K. Ultra-fast MRI of the human brain with simultaneous multi-slice imaging. J Magn 
Reson. 2013;229:90-100. Epub 2013/03/12. doi: 10.1016/j.jmr.2013.02.002. PubMed PMID: 23473893; PMCID: 
PMC3793016. 
51. 
Patriat R, Molloy EK, Meier TB, Kirk GR, Nair VA, Meyerand ME, Prabhakaran V, Birn RM. The effect of resting 
condition on resting-state fMRI reliability and consistency: a comparison between resting with eyes open, closed, and 
fixated. Neuroimage. 2013;78:463-73. Epub 2013/04/20. doi: 10.1016/j.neuroimage.2013.04.013. PubMed PMID: 
23597935; PMCID: PMC4003890. 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
20
52. 
Roy CW, Seed M, Kingdom JC, Macgowan CK. Motion compensated cine CMR of the fetal heart using radial 
undersampling and compressed sensing. J Cardiovasc Magn Reson. 2017;19(1):29. Epub 2017/03/21. doi: 
10.1186/s12968-017-0346-6. PubMed PMID: 28316282; PMCID: PMC5357808. 
53. 
Hillary FG, Medaglia JD, Gates KM, Molenaar PC, Good DC. Examining network dynamics after traumatic brain 
injury using the extended unified SEM approach. Brain Imaging Behav. 2014;8(3):435-45. Epub 2012/11/10. doi: 
10.1007/s11682-012-9205-0. PubMed PMID: 23138853. 
54. 
Minoshima S, Koeppe RA, Fessler JA, Mintun MA, Berger KL, Taylor SF, Kuhl DE. Integrated and automated data 
analysis method for neuronal activation studying using O15 water PET. In: Uemura K, Lassen NA, Jones T, Kanno I, editors. 
Quantification of brain function to tracer kinetics and image analysis in brain PET. Tokyo: Excerpta Medica; 1993. p. 409-
18. 
55. 
Muller-Gartner H, Links J, Prince J, Bryan R, McVeigh E, Leal J, Davatzikos C, Frost J. Measurement of radiotracer 
concentration in brain gray matter using positron emission tomography:  MRI based correction of partial volume effects. 
J Cereb Blood Flow Metab. 1992;12:571-83. 
56. 
Watson GS, Cholerton BA, Gross RG, Weintraub D, Zabetian CP, Trojanowski JQ, Montine TJ, Siderowf A, 
Leverenz JB. Neuropsychologic assessment in collaborative Parkinson's disease research: a proposal from the National 
Institute of Neurological Disorders and Stroke Morris K. Udall Centers of Excellence for Parkinson's Disease Research at 
the University of Pennsylvania and the University of Washington. Alzheimers Dement. 2013;9(5):609-14. Epub 
2012/11/21. doi: 10.1016/j.jalz.2012.07.006. PubMed PMID: 23164549; PMCID: PMC3612566. 
57. 
Avgerinos KI, Mullins RJ, Egan JM, Kapogiannis D. Ketone Ester Effects on Biomarkers of Brain Metabolism and 
Cognitive Performance in Cognitively Intact Adults ≥ 55 Years Old. A Study Protocol for a Double-Blinded Randomized 
Controlled Clinical Trial. J Prev Alzheimers Dis. 2022;9(1):54-66. doi: 10.14283/jpad.2022.3. PubMed PMID: 35098974; 
PMCID: PMC9359666. 
Optional Sub-Study Protocol (to be completed at Visit 3 Pre-intervention) 
1.  Background  
Parkinson disease (PD) is a neurodegenerative disease which leads to progressive motor, 
neuropsychologic, and autonomic dysfunction. At this time, there are no disease modifying agents 
available and treatment is primarily through symptomatic management including dopamine 
replacement therapy. Mitochondrial dysfunctions secondary to electron transport chain deficits are 
considered to be a major pathogenetic mechanism in sporadic PD with some monogenetic forms 
of PD resulting directly from mitochondrial dysfunctions [1,2,3]. To mitigate this dysfunction, an 
individual with PD (William Curtis) has employed a strategy of intermittent fasting, exercise, and 
dietary modification in combination with medication to manage his disease. Dietary modifications 
include coffee with grass fed clarified butter and grass-fed coffee creamer and a ketone ester 
supplement each morning. This is also in addition to daily morning exercise. He has history of PD 
for 23 years and has used this strategy for over 7 years and during this time has had relative 
stability of his motor symptoms as measured by UPDRS. Rationale behind this regimen includes 
increase in NAD and NADPH through entrainment of the circadian rhythm and regular exercise 
which then drives neurotransmitter synthesis when coupled with sustained ketosis (achieved via 
slow-release fatty acid ketone precursors in buttered coffee combined with fast-release ketone 
ester). Moreover, butyric acid or other molecules in the fat-fortified coffee may enact other 
mechanistic effects that have yet to be fully understood. We would first like to evaluate the target 
engagement and tolerability of this regimen in people with PD. 
 
 
2. Study Design 
Study Overview  

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
21
This is a single-arm and open-label test for target engagement of the Modified Curtis Protocol in 
PD. The Modified Curtis Protocol consists of a single dose of a fatty acid and coffee supplement 
followed by a single dose of ketone ester (KE) which is then followed by cardiovascular exercise.  
 
Aim 1: To evaluate target engagement and the effect of the Modified Curtis Protocol on ketosis in 
Parkinson disease as assessed by serum beta hydroxybutyrate (BHB).   
• Hypothesis 1: Participants will experience an increase in serum BHB levels 60 minutes after 
ingestion of KE.  
• Aim 1 Outcome Measure: Change from baseline to 1 hour assessment in BHB levels.  
• Aim 1 Analytic Approach: We will compare mean baseline serum BHB levels to mean BHB 
levels measured at the 60 minute assessment. We will use the Wilcoxon rank sum test (non-
parametric equivalent of standard two sample t test) to evaluate our Aim 1 hypothesis. We will 
have values available at 2-hours and 4-hours as well to test the duration of the effect. We will 
also collect serum glucose values at each of the four time points (baseline, 1 hours, 2 hours, 
and 4 hours).  
 
Aim 2: To evaluate the tolerability of the Modified Curtis Protocol in PD.  
• Hypothesis 2: Participants will not experience worsening in Movement Disorder Society 
Unified Parkinson Disease Rating Scale part III (MDS-UPDRSIII) scores. 
• Aim 2 Outcome Measure: Change from baseline to 1 hour in MDS-UPDRSIII scores.  
• Aim 2 Analytic Approach: Similarly to Aim 1, we will compare baseline MDS-UPDRSIII scores 
to those obtained at the 60-minute assessment using the Wilcoxon rank sum test. Similar to 
Aim 1, we will also have values available at 2-hours and 4-hours as well to test the duration of 
the effect. We will collect additional clinical measures and measures of tolerability including 
timed up a go test (TUG), finger tapping test (FTT), mini Addenbrooke’s Cognitive Examination 
(mini-ACE), gastrointestinal symptom rating scale (GSRS), and adverse event report.  
 
Sample Size  
For the purposes of calculating a sample size, we used parametric testing by means of a paired 
sample t-test. Please note that to reduce the risk of type 1 error due to outliers in our dataset, we 
propose to use analogous non-parametric testing in our final test of Aim 1. Based on previously 
studies looking at change in BHB after consumption of this ketone ester, we expect an increase in 
0.5 mmol [4]. This would also be the minimum change needed to achieve ketosis. Using a two-
side alpha of 0.05, a power of 0.80, and a proposed standard deviation of 0.5 mmol in BHB serum 
levels, a sample size of 10 participants will be sufficient to test our Aim 1 hypothesis.  
 
 
Schedule of Activities 
Evaluation 
Screen and Informed 
Consent 
In Person 
Study Visit  
Telephone 
Follow Up Visit 
Setting 
In-Person/Phone 
In-person  
Phone 
Discuss Study Overview 
x 
 
 
Assess for Eligibility  
x 
 
 
Informed Consent 
x 
 
 
Modified Curtis Protocol  
 
x 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
22
MDS-UPDRSI, II, IV (Baseline) 
 
x 
 
MDS-UPDRSIII (Baseline, 1, 2, and 4 
hours) 
 
x 
 
Mini-ACE (Baseline, 2, and 4 hours) 
 
x 
 
TUG (Baseline, 1, 2, and 4 hours) 
 
x 
 
FTT (Baseline, 1, 2, and 4 hours) 
 
x 
 
Serum ketones and glucose (Baseline, 
1, 2, and 4 hours) via Keto Mojo Meter 
 
x 
 
GSRS (Baseline, 1, 2, and 4 hours) 
 
x 
x 
Report of side effects (1, 2, and 4 hours) 
 
x 
 
Follow Up Report of Potential Side 
Effects  
 
 
x 
 
 
 
 
 
Participants screening and informed consent will occur per the original protocol document and 
be introduced as an optional sub-study. This will all occur in advance of the in-person study 
visit and prior to any clinical testing. The in-person study visit will occur in the lab of Dr. 
Bohnen at Domino Farms. This is the primary site for PD human subjects research visits in our 
UM Movement Disorders Neurology group. Participants will be asked to withhold their usual 
parkinsonian medications (dopaminergic medications or amantadine) the morning of the in-
person study visit and are to bring them to the study visit in order to take them immediately 
after completion of the day’s activities. This is requested in order to prevent a medication 
induced fluctuation in motor score from impacting the repeated MDS-UPDRSIII clinical 
assessments. They will also be required to arrive in the fasted state per the Modified Curtis 
Protocol. They will then undergo baseline testing including the MDS-UPDRSI-IV, the Mini-ACE 
test, the TUG, the FTT, the GSRS, and blood testing. The order of these test may vary 
depending on the participant and visit context. This is collectively estimated to take 30-60 
minutes from arrival.  
 
The next hour will consist of the Modified Curtis Protocol at which time participants will first 
consume the fat and coffee supplement. Thirty minutes later, they will consume the KE. Fifteen 
minutes later they will begin 5 minutes of stretching in preparation for 10 minutes of low 
intensity exercise. The exercise component will be on a stationary bicycle and will be interval 
training type exercise but at low intensity given possible deconditioned state of participants. It 
will start with 2 minutes of cycling with minimal added resistance while increasing cadence 
from 30 to 60 rotations per minute (rpm). There will then be two cycles of 30 seconds of 
modestly increased resistance with a cadence of 80 rpm followed by 2.5 minutes of minimal 
resistance at a cadence of 70 rpm. This will be followed by a cool down still at minimal 
resistance decreasing cadence from 60 to 30 rpm.  
 
Sixty minutes after consumption of KE, or 30 minutes after completion of the Modified Curtis 
Protocol, participants will undergo repeat testing including the MDS-UPDRSIII, TUG, FTT, 
GSRS, a side effect assessment, and serum glucose/ketone body lab testing via Keto-Mojo. 
This same testing plus the Mini-ACE will also recur after 120 minutes (2 hour) and 240 minutes 
(4 hour) from the time of time the KE drink was finished. After the 4-hour testing is complete, 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
23
participants will be allowed to take their held medications, can resume their normal diet, and 
will be dismissed for the day. 
 
Our study team will follow up with participants by phone in the 48 hours following the in-person 
Study Visit to ask about potential side effects and to repeat the GSRS as well as ask the 
closing question which is a Likert scale survey question regarding likeliness that the participant 
feels they could repeat this protocol on a daily basis. Once the follow-up phone call ends, the 
sub-study will be complete. 
 
Visit 3 in the original study document consists of psychiatric clinical testing as well as optional 
motor and cognitive testing. Participants who opt to take part in this sub-study will be exempt 
from completing the original planned assessments for this day as per the Schedule of Activities 
(SoA) (besides the Beck Depression Inventory II and Spielberger Trait Anxiety scale which will 
be completed by all participants at visit 3). The administration of the ketone product and blood 
lab testing for this visit would be per the sub-study protocol as opposed to the original protocol. 
Participants would still receive the sleep tracking ring, pregnancy testing (if applicable), and 
drug accountability before starting the original intervention protocol. 
 
For individuals who cannot tolerate the Curtis protocol intervention, study staff will send home 
the participants without the KetoneAid supplement and call them within 48 hours to monitor 
any side effects from testing. Participants may be asked to come back in to the lab to take the 
KE supplement without any additional testing to assess tolerability of the ketone ester drink 
alone. 
 
 
Modified Curtis Protocol Components:  
 
Ketone Ester:  
Please see original document for additional information regarding the exogenous ketone 
supplement by the brand KetoneAid (D‐β‐Hydroxybutyrate‐(R)‐1,3 Butanediol). There will be 
no change to the dose of D‐β‐Hydroxybutyrate‐(R)‐1,3 Butanediol which, per the original 
protocol, is a single 12.5 g dose.  
 
Fat and Coffee Supplement: 
The original protocol uses a combination of coffee, grass-fed butter and cream, and coconut 
oil. Coffee has been suggested to have multiple benefits in PD [6]. Coconut oil is a source of 
medium chain triglycerides which serve as precursors to ketone bodies. Lastly, grass fed dairy 
is a source of low carbohydrate and high fat calories which are lower in unsaturated fat. 
Ingredients for the chosen supplement include coconut oil powder, grass fed butter powder, 
instant organic coffee powder, medium chain triglyceride oil powder, natural coffee flavor, and 
real salt. The supplement is called Keto Coffee and made by the brand Fat Fuel. One serving 
is 234 calories and contains 120 mg of caffeine.  
 
 
3. Enrollment Criteria 
Inclusion criteria: 
1. Diagnosis of PD (M/F, age 45 years and over) will be based on the United Kingdom Parkinson’s 
Disease Society Brain Bank Diagnostic Research Criteria (patients with clinically significant 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
24
dementia will be excluded, i.e., fails informed assent screening criteria and has significant 
evidence of difficulty with iADL functions, such as ability to take own medications while 
administering the pre-consent questionnaire). 
2. Persons diagnosed with Lewy Body Dementia (LBD) based on the Fourth consensus report of 
the Dementia with Lewy Body (DLB) Consortium inclusion criteria for probably DLB or 
Parkinson’s Disease Dementia (PDD) based on the criteria set by Emre et al. for PDD (M/F, age 
45 years and over)  
 
Exclusion criteria: 
1. All exclusion criteria from original protocol applies to sub-study 
2. Significant metabolic or uncontrolled medical condition, including significant cardiovascular 
disease or significant musculoskeletal disorder which would make it unsafe to participate in 
cardiovascular exercise 
3. Lactose intolerance 
 
4. Potential Risks  
 
Please see original document for risks associated with confidentiality of research information, 
clinical testing, motor testing, neuropsychological testing, and the ketone ester supplement.  
 
Exercise: 
Common risks of cardiovascular exercise include fatigue, general discomfort, temporary muscle 
soreness and pain. Infrequent risks include muscle strain and rare events include musculoskeletal 
injury or cardiovascular event. Risks to participants have been minimized by limiting the duration 
of exercise and by limiting participation of those with higher risk of these events through exclusion 
criteria. Moreover, participants will be guided through gentle stretching prior to initiating exercise 
to minimize the risk of injury. The HIIT intervals have been intentionally designed with a gentle 
level of intensity to ensure tolerability for PwP. HIIT is a type of cardiovascular exercise which was 
shown to have no difference in adverse events when compared to moderate intensity exercise in 
middle age and older adults with diabetes. [7] 
 
Fat and Coffee Supplement:  
Common risks with consumption of this coffee supplement primarily include possibility of poor 
taste and worsening of tremor. Infrequent side effects of caffeine include anxiety, palpitations, 
headaches, dizziness, and insomnia. Infrequent side effects of this supplement include stomach 
discomfort, nausea, bloating, and diarrhea. These risks are limited by limiting the participants to a 
single serving in the morning which consists of 120 mg of coffee which is equivalent to a standard 
cup of coffee.  
5. Data Study Monitoring Plan: 
Drs. Bohnen and Albin will act as the Data Safety Monitoring Plan members for this study. All 
adverse events and other study related events will be discussed at monthly investigator meetings. 
Adverse events will be classified according to standard criteria and reported to the IRBMED 
(relevant University of Michigan IRB) according to standard guidelines. Serious adverse events 
will be reported within 24 hours. 
 

Nicolaas Bohnen, MD, Ph.D. 
UM HUM #00213035 
PROTOCOL VERSION #: 1.5 
 
25
6. References 
1. Pickrell AM, Youle RJ. The roles of PINK1, parkin, and mitochondrial fidelity in Parkinson's disease. Neuron. 
2015;85(2):257-73. Epub 2015/01/23. doi: 10.1016/j.neuron.2014.12.007. PubMed PMID: 25611507; PMCID: 
PMC4764997. 
2. Franco-Iborra S, Vila M, Perier C. The Parkinson Disease Mitochondrial Hypothesis: Where Are We at? 
Neuroscientist. 2016;22(3):266-77. Epub 2015/03/13. doi: 10.1177/1073858415574600. PubMed PMID: 25761946. 
3. Youle RJ. Mitochondria-Striking a balance between host and endosymbiont. Science. 2019;365(6454). Epub 
2019/08/17. doi: 10.1126/science.aaw9855. PubMed PMID: 31416937. 
4. Crabtree CD, Blade T, Hyde PN, Buga A, Kackley ML, Sapper TN, Panda O, Roa-Diaz S, Anthony JC, Newman 
JC, Volek JS, Stubbs BJ. Bis Hexanoyl (R)-1,3-Butanediol, a Novel Ketogenic Ester, Acutely Increases Circulating r- 
and s-ß-Hydroxybutyrate Concentrations in Healthy Adults. J Am Nutr Assoc. 2023 Feb;42(2):169-177. doi: 
10.1080/07315724.2021.2015476. Epub 2022 Mar 25. PMID: 35512774. 
5. Curtis WM, Seeds WA, Mattson MP, Bradshaw PC. NADPH and Mitochondrial Quality Control as Targets for a 
Circadian-Based Fasting and Exercise Therapy for the Treatment of Parkinson's Disease. Cells. 2022 Aug 
4;11(15):2416. doi: 10.3390/cells11152416. PMID: 35954260; PMCID: PMC9367803.  
6. Ren X, Chen JF. Caffeine and Parkinson's Disease: Multiple Benefits and Emerging Mechanisms. Front Neurosci. 
2020 Dec 17;14:602697. doi: 10.3389/fnins.2020.602697. PMID: 33390888; PMCID: PMC7773776. 
7. Hwang CL, Lim J, Yoo JK, Kim HK, Hwang MH, Handberg EM, Petersen JW, Holmer BJ, Leey Casella JA, Cusi K, 
Christou DD. Effect of all-extremity high-intensity interval training vs. moderate-intensity continuous training on 
aerobic fitness in middle-aged and older adults with type 2 diabetes: A randomized controlled trial. Exp Gerontol. 2019 
Feb;116:46-53. doi: 10.1016/j.exger.2018.12.013. Epub 2018 Dec 18. PMID: 30576716; PMCID: PMC6404965.