SP - Parkinson's Disease

Introduction: Sialorrhoea is a common non motor complication experienced by people with Parkinson’s disease (PD).  Despite its prevalence there is conflicting evidence on how to effectively treat it. Our aim was to establish the efficacy and safety outcomes of pharmacological interventions used to treat sialorrhoea in people with idiopathic PD.

Methods: We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42016042470). We searched 7 electronic databases from inception until July 2022. Quantitative synthesis was performed where data allowed using random effects models.

Results: From 1374 records we included 13 studies (n=405 participants). Studies were conducted in Europe, North America and China. There was marked heterogeneity in the interventions used, follow up times and outcome measures investigated. The main source of risk of bias identified was reporting bias. 5 studies were included in the quantitative synthesis. Summary estimates showed administration of botulinum toxin significantly reduced saliva production, improved patient reported functional outcomes and was associated with an increase in adverse events.

Conclusion: Sialorrhoea in PD is an important condition, but current data does not allow for strong recommendations on optimal pharmacological treatments. There is significant heterogeneity in outcomes measures used to evaluate the burden of sialorrhoea with lack of consensus on what constitutes clinically meaningful change. More research is required to better understand the underlying mechanism and potential treatments of sialorrhoea in idiopathic PD

Introduction: Turning is essential to mobility, constituting 35-45% of all daily steps. Falls during turning are more severe with 7.9x greater risk of hip fracture. Reduced quality of turning has been observed in people with Parkinson’s disease (PwP). Findings suggest head and trunk control during turning are different in PwP compared to controls, however it is unclear how this relates to clinical measures. Methods: 36 PwP completed an intermittent walking task with 180 degree turns (ICICLE-Gait). An inertial measurement unit attached to the head evaluated head rotations (>30 degrees). Turning features were extracted using a validated algorithm. Spatiotemporal (duration, velocity) and signal-based features reflecting movement intensity (root mean square [RMS] in the mediolateral [ML], anterior-posterior [AP] and vertical [VT] planes from the gyroscope) were extracted. Relationships between turning and clinical measures (Activities of Balance confidence (ABC), Mini Mental State Exam (MMSE), Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) II and III, Levodopa Equivalent Daily Dose (LEDD)) were evaluated using Spearman’s rho. Results: There were 2/6 spatiotemporal and 13/25 signal features with weak-to-moderate correlations with clinical measures. Lower cognition and reduced balance confidence were associated with slower head rotations (rho=0.416-465, p<.05) and lower head movement intensity (lower rms: rho=0.340, p<0.05). higher disease severity (higher mds updrs-ii, iii scores) was associated with slower rotations (rho="-0.322:-0.436," p<0.05) increased ledd greater conclusion: rotation velocity are important features of turning that correlate clinical outcomes relevant in parkinson’s. places a demand on sensory, cognitive motor systems which affected pwp. further analysis will explore whether correlations exist for other segments during (i.e. torso), (such as axial rigidity), gait. 

INTRODUCTION

People with Parkinson’s disease (PwPD) often report low levels of physical activity and poor health and 90% of PwPD will fall at least once[1]. Interventions to reduce falls in PwPD often involve physical therapy and exercise, however the environment is an independent risk factor for falls[2]. Exploring whether fall circumstances differ in PwPD due to health status and physical activity level will inform occupational health services and the design and development of environmental modifications.

METHODS

An online survey was developed to evaluate falls in adults ≥60y. Of 358 respondents, 117 were diagnosed with PD. The survey covered basic descriptors, fall history and contextual information about falls. Health (good/ average/ poor) and physical activity (active/ inactive) status were self-reported and used to stratify respondents.

RESULTS

68% of respondents with PD had fallen and of these 90% had poor health or were physically inactive. The 3 most problematic environments (steps/stairs, uneven/sloped surfaces and objects on the floor) and 4 most common pre fall activities (turning, walking, moving too quickly and transferring) were the same regardless of health or physical activity status, although more frequently reported by those with poor health or physically inactive.

Misjudging objects and falling over trip hazards was more common in PwPD of poor health than those of average/good health. Falls on steps and stairs were more common in physically inactive PwPD than those who were physically active.

CONCLUSION

This survey has highlighted several problematic aspects of the home environment contributing to falls in PwPD. Routine person-environment risk assessments are required to identify home hazards early. Research through co-design with PwPD and relevant stakeholders is required to develop novel home modifications targeting problematic environments so interventions may be prescribed effectively.

[1] Allen 2013 PMID:23533953 [2] van der Marck 2014 PMID:24484618

Introduction  Converting oral Parksinon’s disease (PD) medications to transdermal Rotigotine is sometimes required when patients have swallowing difficulties. Correct dosing is important to avoid under-treatment and deterioration of PD symptoms. Conversely, excessive dopamine agonist can cause hallucinations and confusion. In the UK, 2 main dose conversion calculators exist: PD Med Calc1 and OPTIMAL2, both utilising different formulae. We compared both to identify any dose discrepancies in their recommendations, and select one for use within revised trust guidelines.  Methods  We conducted a retrospective analysis of 22 cases from pharmacy data of 1400 prescriptions issued between January 2021 - July 2022 for patients switched from oral PD medications to a Rotigotine Patch whilst admitted to a UK teaching hospital. We calculated the recommended Rotigotine patch dose from each patient’s usual oral medication regimen using both the PD Med Calc1 and OPTIMAL2 calculators to identify discrepancies.  Results  In 86% of cases (19/22) there was a difference between doses suggested by both calculators. Of these, 95% (18/19) showed OPTIMAL recommended doses 20-200% higher than PD Med Calc. In 5% (1/19) OPTIMAL recommended a marginally lower dose than PD Med Calc.   Conclusions  In dopamine agonist naive patients, PD Med Calc recommended a lower starting Rotigotine dose than OPTIMAL. Most admitted PD patients on patch conversion were older adults, and this population is particularly vulnerable to the side effects of excessive dopamine agonist exposure. The authors recommended using PD Med Calc within revised trust guidelines to minimise negative sequelae and ensure dosing consistency.  1 PD 'Nil by Mouth' Medication Dose Calculator http://pdmedcalc.co.uk/ 2 OPTIMAL Calculator - A Guideline for the OPTIMAL management of inpatients with Parkinson's Disease. http://www.parkinsonscalculator.com/index.html  

The UK Parkinson's Disease Clinical Studies Group

The UK has a successful trial scene for Parkinson’s Disease, Multiple System Atrophy and Progressive Supranuclear Palsy neuroprotective studies, but with the growing number of trials, a formal, national structure is required to ensure the successful delivery of the studies. With funding from Cure Parkinson’s, the UK-PD-CSG launched in April-2022. The UK-PD-CSG’s goal is to further develop and support Parkinson’s clinical research across the UK and ensure more people with Parkinson’s (PwP) have the opportunity to participate in clinical trials.

The group has 65+ members, including neurologists, geriatricians, specialist nurses and Allied Health Professionals, stakeholder representatives (Cure Parkinson's, Parkinson's UK, BGS Movement Disorders SIG, ABN Movement Disorders SIG, PD Nursing Specialist Association) and PwP, all with a particular interest and expertise in PD, MSA and PSP clinical research. The group is operated by chair Professor Oliver Bandmann, Coordinator Emma Davies and co-deputy chairs Professors Camille Carroll and Tom Foltynie.

The UK-PD-CSG regular, virtual meetings provide a forum to disseminate research information, opportunities, and resources to enhance the information flow throughout research studies by establishing effective communication streams. The meetings facilitate meaningful discussion and collaboration between researchers, PwP and research organisations.

A strength of the group is the geographical spread of members, with all 18 NIHR Clinical Research Network Regions represented by at least one member. In addition to experienced researchers, the group supports individuals who are new to research to grow the number of research active sites across the UK.

The UK-PD-CSG continues to grow and works to engage more individuals interested in PD, MSA and PSP clinical research. To enable the sustained growth of the clinical trial scene, the UK-PD-CSG plays an integral, strategic role in ensuring the UK maintains and develops a trial-ready workforce and infrastructure to successfully deliver clinical research and provide more research opportunities to PwP.

Website: https://sites.google.com/sheffield.ac.uk/uk-pd-csg

X (Twitter): @UK_PD_CSG

LinkedIn:  UK Parkinson's Disease Clinical Studies Group

Instagram: @UK_PD_CSG

Introduction

The burden of PD has exponentially risen from 2.5 million in 1990, to 6.1 million in 2016 (PD Collaborators. Lancet Neurol. 2018; 17(11):939-53). This is due to ageing population, increased longevity, increased duration of the disease and improved diagnosis. The aim of our study was to identify the trend on deaths related to PD and Parkinsonism over the last decade.

Methods

We collected our data from the Office of the National Statistics, using codes G20 (PD), G21 (Secondary Parkinsonism) and G22 (Parkinsonism classified elsewhere), to extract the number of deaths coded under these conditions from 2013 to 2021. The data was only available for England and Wales.

Results

Total number of deaths including all codes from 2013 to 2021 were 4518, 4950, 5542, 5734, 5936, 6508, 6207, 7414 and 7117. Deaths coded under G.20 are far higher compared to deaths coded under the others.

Conclusion

The number of deaths related to PD has been gradually increasing and has nearly doubled over the last 9 years. Although Covid 19 may have contributed to this increase over the last two years, there is an overall rising trend. We think this is primarily due to people with PD living longer leading to an increased prevalence and duration of the condition. This is linked to sarcopenia, frailty, immobility, cognitive impairment and dysphagia contributing to increased mortality in later years. Another reason could be due to more accurate documentation in death certificates. Even though there has been concerns that deaths certificates have not been accurately coded to include PD, (Hobson, Meara. 2018; 8(2):e018969), there is probably an improvement after the introduction of Medical Examiner services. It is important to recognize the increasing burden of PD to enable us to plan and invest in resources to improve the care of these patients.

Exercise is beneficial for Parkinson’s disease (PD), but many people struggle to achieve the 150 minutes per a week recommendation. Symptoms of PD or co-morbidity may be barriers for exercise; and physiotherapists can provide expert assessment and tailoring of exercise to accommodate these needs. We developed a remote physiotherapy intervention using videoconference (Attend Anywhere). An ongoing feasibility trial is assessing this intervention, and a process evaluation seeks to understand the broader context and acceptability of the intervention. Here we present a qualitative study of participants of the feasibility study. We invited participants from the feasibility trial to individual semi-structured telephone or videoconference interview. 14 participants were interviewed. Transcripts were analysed by thematic analysis within two main themes: physical activity and use of digital technology. Participants spoke about their attitudes towards their diagnosis. Individuals who had come to terms with their PD were more engaged with the exercise regime than participants who expressed a sense of denial. Participants who mentioned the benefits of exercise for reducing or delaying PD symptoms were more likely to report a positive attitude to exercise. In contrast, individuals with co-morbidity, or caring roles, found it more difficult to commit to regular exercise; flexibility of the exercise routine was valued. For the theme of digital technology some participants reported struggling with, technical problems such as interruptions in internet connection, having constrained space to exercise and staying in view of the camera for the physiotherapist. Whilst some participants lacked digital confidence, or expressed a preference for in-person treatment, other participants reported no difficulties or found it more convenient than travelling to clinic.

Introduction

Delirium is prevalent in patients with idiopathic Parkinson’s disease (iPD) who are admitted to hospital. The hypoactive subtype of delirium is associated with poorer outcomes in hospitalised patients The aim of this study was to evaluate different outcomes across delirium subtypes in unplanned hospital admissions in patients living with iPD

Methods

Data was collated prospectively on all patients with idiopathic Parkinson’s disease admitted to our hospital’s medical wards between 1st January 2019 and 30th March 2020. Electronic case-note review and in-person assessments were used to determine a diagnosis of delirium, the delirium subtype, and key outcomes including length of stay (LOS) and mortality. Data was analysed with respect to both index admissions and those readmitted during the study period.

Results

123 patients with iPD (male 52.8 %, mean age 77.9 years) accounted for 189 admissions. Delirium was present in 91/189 admissions (48%). There was no difference in Hoen & Yahr or Clinical Frailty Scale levels between groups with and without delirium. The prevalence of dementia was higher in the delirium group (48.3% vs 25.5%). Hypoactive delirium was the most common subtype (49.5%); hyperactive (13.2%), mixed (11%) and neutral (neither hypo- nor hyperactive) 26.4%. 12-month mortality in the index admissions was highest in the hypoactive subtype (57.1%). Median LOS (all admissions) was 11.5 days in patients with delirium vs 5.5 days in those without. A mixed delirium phenotype had longest LOS (mean 30.7 days) compared with other subtypes.

Conclusions

The hypoactive subtype of delirium predominates in hospitalised patients with iPD. Length of stay was longest in those experiencing a mixture of hyperactive and hypoactive subtypes, and mortality was highest in the hypoactive group. Healthcare settings need robust systems screening for delirium in Parkinson’s patients, with prevention and management processes to reduce morbidity and mortality in this complex group.

Background

The Covid-19 pandemic led to many consultations being conducted remotely. Cognitive impairment is recognised as a potential barrier to remote healthcare interactions and is common but heterogeneous in Parkinson’s. Little is known about these consultations in real life. We explored the experiences of remote consultations for people with Parkinson’s and cognitive impairment, investigating the perspectives of people with Parkinson’s, caregivers and healthcare professionals.

Method

Semi-structured interviews were conducted remotely (video or telephone) with 11 people with Parkinson’s and cognitive impairment, 10 family caregivers and 24 Healthcare Professionals in 2020-2021, using purposive sampling. Interviews were audio-recorded, transcribed and analysed using thematic analysis.

Results

Four themes were identified: (1) The Nature of Remote Interactions; (2) Challenges Exacerbated by Being Remote; (3) Expectation versus Reality; and (4) Optimising for the Future. Remote consultations were considered ‘transactional’ and less personal, with difficulties building rapport, and perceived to have a different role to in-person consultations. The loss of non-verbal communication and ability of Healthcare Professionals to ‘sense’ led to remote consultations being perceived as riskier by all groups. Specific to this population, issues arise from both communication and cognitive impairment; balancing of the person with Parkinson’s and caregiver voice; and around significant discussions, for example, regarding the future. Remote consultations were reported to have been more successful than anticipated in all three groups. Obstacles were not always as expected, for example age was less of a barrier than anticipated. Potential improvements for these three groups and healthcare services were identified, for example, consideration of camera positioning for video calls; and service flexibility to allow consultations to be timed to optimal medication function.

Conclusion

Advantages and challenges of remote consultations for this population are identified. Consultations could be improved with increased support, practice, preparation, awareness of issues, and more time and flexibility within services.

Introduction  

Many people with parkinsonism require care as the disease progresses with much provided unpaid by family and friends. Caring for someone can have a negative impact on physical and psychosocial wellbeing. Caregiver burden can impact ability to continue this role, which can precipitate hospitalisation or institutionalisation of the recipient.  

Methods  

In this single-site study, primary, informal caregivers, defined as those providing any care or support, were enrolled alongside the person with parkinsonism or individually. Self-reported questionnaires included the 22-item Zarit Burden Interview (ZBI), which can range from 0-88, with higher scores representing greater burden. Linear regression was used to explore the association between recipient characteristics/need and caregiver burden.  

Results  

Of 1,032 eligible patients approached, 813 participants indicated whether they had an informal caregiver (708) or not (105). 376 caregivers consented (53.1%), of whom 323 have returned questionnaires, with patient data available for 301.    

The median age of caregivers was 72.9 (range 27.0- 91.1 years), 238 (73.7%) female. 275 (85.1%) were the spouse/partner of the patient. 216 (66.9%) were the sole caregiver. The median time per week spent caring was 21 hours (interquartile range 7, 41 hours). 18 (5.6%) of caregivers provided 24-hour care daily and 113 (35.0%) had provided support for over 5 years. Median ZBI score was 18, (interquartile range 8-31).  The care recipient’s duration of parkinsonism was associated with higher burden score (0.36 increase per year of parkinsonism; 95% CI 0.05, 0.66; p value 0.022), as was the time per week spent caring (0.15 increase for each additional hour; 95% CI 0.11, 0.20; p value <0.001).  

Conclusions 

Many informal caregivers in this study were the sole caregiver and many were themselves older adults. Burden increased with increasing duration of parkinsonism and as time spent caring increased. This highlights the ongoing need to improve support for this group.