Movement disorders

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:

Parkinson's disease (PD) is associated with an increased risk of osteoporosis and fractures to factors like falls resulting from postural instability, polypharmacy, and muscle weakness. Reduced bone mineral density (BMD), often caused by vitamin D deficiency, disease severity, and low BMI, further elevates fracture risk in PD patients. This project aims to improve awareness and bone health testing in PD patients by focusing on vitamin D, bone profile assessments, DEXA scans, and FRAX scores for fracture risk evaluation and management.

Methodology:

This QIP involved two cycles focused on managing Parkinson’s disease (PD) patients. The first cycle interventions focused on educating doctors through sessions and a poster, while the second cycle introduced personalized treatment plans for PD patients, recorded in their clinical notes. A comparative analysis of post-intervention data was conducted to evaluate the effectiveness of both interventions.

Results:

Bone profile testing was successfully completed in 100% of patients after both interventions. In cycle 1, 63.3% of patients required vitamin D testing, compared to 25% in cycle 2. Of these, 14.3% received testing after the first intervention, and 100% after the second. However, none of the patients had their FRAX scores calculated or DEXA scans scheduled. The teaching session increased overall confidance amongst junior doctors in diagnosing osteoporosis from 60% to 70%, and managing osteoporosis from 10% to 80%. It also improved the overall awareness on how to use the FRAX tool from around 50% to 90%. 

Conclusion:

Personalized treatment plans and targeted interventions led to significant improvements in vitamin D testing. However, notable gaps remain in adherence to FRAX calculation and organizing DEXA scans. Future efforts should focus on these limitations and ensuring complete bone health assessments for PD patients. The teaching sessions proved to be highly effective, significantly enhancing participants' understanding of bone health issues in Parkinson's disease.

Background: NICE Quality Standard (QS) 164 – QS1 states; Adults with Parkinson's have a point of contact with specialist services. This will facilitate continuity of care and access to information, advice, care and support when they need it. QS4 states; Adults with Parkinson's disease in hospital or a care home should take levodopa within 30 minutes of their individually prescribed administration time.

Introduction: To increase opportunities in meeting NICE QS’s consistently, Parkinson’s Specialist Nurses introduced Parkinson’s Champions. Individual studies consistently find that champions are important positive influences on implementation effectiveness. Over half of people with Parkinson’s don’t get their medications on time in hospital. This can cause stress, anxiety, immobility, severe tremors, and in some extreme cases death.

Method

Supportive structures that enabled the development and maintenance of our Champions Network:-

Clear Role Profile and Measurable Objectives

Provision of Resources/Tools

Ongoing Education/Training

Peer Support/Networking

Recognition/Appreciation 

PDNS leadership/support

Energy & Perseverance

Results: The Get it On Time Audit (GIOT) looked at Parkinson’s medications given more than 30 minutes early, on time and more than 30 minutes late. Following multiple interventions including promoting leadership and education within each dept, input to medicines policy, incident reporting and development of a learning module, On time medication administration improved from 58% to 80.05% compliance.

Champions were not experts in Parkinson’s when we started, through the process of undertaking the role, they have gained expertise and serve as an ongoing resource to their peers.

Conclusion: Our aim of having champions who enhance staff’s knowledge and skills so care delivered to persons with Parkinson’s is consistently safe and effective is being realised.

Investment in them, as demonstrated by audit results, is rewarded with more consistent meeting of NICE QS 164 and thus improved patient outcomes.

Our Champions network model will be shared with the Parkinson’s Excellence Network.

Background: Idiopathic Parkinson’s disease (IPD) increases fall risk and is associated with osteoporosis and fragility fractures (FF). Despite the high risk of adverse outcomes from untreated osteoporosis in IPD patients, bone health is clinically overlooked. This study aimed to evaluate the adequacy of bone health assessment among Aneurin Bevan University Health Board (ABUHB) patients.
Methods: This observational cohort study retrospectively analysed data from IPD patients at the ABUHB movement disorder clinic, between May 2022 and January 2024. Data collected included: demographics, disease severity, FF, FRAX® score, and bone protection. Clinic letters were also reviewed for mentions of bone health.

Results: The study included 57 patients with a mean age of 78.5 years; 70.2% were male. The mean Charlson Comorbidity Index was 5.1 and the mean Hoen and Yarh score was 2.3. Of these patients, 24.6% had osteopenia/osteoporosis, 36.8% had &gt;0 FF, and 3.5% had fractures before PD diagnosis. The mean time from IPD diagnosis to the first FF was 3 years and 7 months. The mean duration of IPD diagnosis was 5.75 years, with those having FF showing a mean duration of 7.12 years compared to 5.21 years for those without FF. 75% of fractures were major osteoporotic fractures. Bone protection was used by 14% of patients: 100% of high-risk, 21.0% of moderate-risk, and 8.10% of low-risk patients (based on FRAX® scores). Bone health was mentioned in 22.8% of all clinic letters and in 33.3% of letters for those with &gt;0 fragility fractures.
Conclusion: There is a positive correlation between the duration of IPD and the occurrence of  FF. The study highlights a need to improve bone health management in IPD patients, especially those at moderate risk of fractures, as only 21.0% of moderate-risk patients are receiving bone protection. Increased awareness of bone health in this cohort must be promoted.

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

Parkinson’s disease (PD) is the most common neurodegenerative movement disorder and is associated with significant disability. The prevalence of PD is rising and the literature demonstrates potential sex and race disparities in patient outcomes. There is a paucity of data about the demographic trends in PD-related mortality in the United States (US). This descriptive study aimed to report the national demographic trends in PD-related mortality over a 20-year period.

Methods

From January 1999 to December 2020, the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research (CDC-WONDER) Underlying Cause of Death database was queried. Data were extracted to determine the PD-related age adjusted mortality rate (AAMR) stratified by age, sex, ethnicity and geographic area, with the 1999 deaths as the reference group. Annual percentage change (APC) for AAMR was then calculated using Joinpoint regression.

Results

From 1999 to 2020, there were 515,884 PD-related deaths in the study period. AAMR increased from 5.3 per 100,000 population in 1999 to 9.8 per 100,000 in 2020. Males had consistently higher AAMR than females and white race had consistently higher overall AAMR (7.6 per 100,000), followed by American Indians/Alaska Natives (4.4 per 100,000), Asians/Pacific Islanders (4.1 per 100,000) and Black/African Americans (3.4 per 100,000). The Midwest had the highest AAMR followed by West, South and Northeast. Utah, Idaho and Minnesota had the highest state-level AAMR.

Conclusion

This study using a national dataset identified significant age, sex, race and geographic disparities in PD-related mortality in the US. Older age, male sex, white race and Midwest locality were associated with the highest AAMR.

Background: NICE guidance for administration of dopaminergic medications is within thirty minutes of the prescribed time. Patients with Parkinson's Disease are frequent attenders of the ED, often leading to admission for a variety of reasons. Medication timing as an inpatient is frequently sub optimal, leading to potential harm of the patient and prolonged inpatient stays. Interventions previously seen to be beneficial include medication posters and alarms, tested across multiple wards at a different trust. This project aims to assess three interventions looking to improve the administration time of dopaminergic medication at Aintree University Hospital. Method: Three interventions were assessed: education, medication timesheets ad medication timers. These were assessed on one surgical and one medical ward. Baseline data was collected prior to implementation, then following each data was recollected. Nursing staff opinion and knowledge were also assessed using surveys at baseline, following education and at the end of the project. Results: Baseline data showed an average of 18.75% of doses given out of range on the surgical unit. Education proved to be useful, reducing the average to 12.5%. Medication timers were the most promising intervention, improving the average to 10.7%. However, when plotted on a control chart the changes appear unconvincing for significance. Surveys showed an initial reluctance for the use of timers, but following their use they then became the preferred intervention. Obstacles to their use were identified, such as loss of instructions and difficulty in changing the settings. Conclusion: This project has found evidence to support the use of medication timers to facilitate more accurate administration of dopaminergic medications. However further assessment is required with a follow up QI project given the uncertainty seen on the control charts.

INTRODUCTION Dementia in Parkinsons is common and under-recognised with a significant impact on person and their carer. Contrary to other services, Cardiff and Vale Parkinson's services run an integrated Parkinson's clinic where People with Parkinsons (PwP) developing dementia continue to be managed by the same clinical team.

METHODOLOGY An review of 425 patients diagnosed with dementia with a background of Parkinson's over last 10 years was undertaken. A random sample of 50 patients assessed for demographics, duration of Parkinson's, presentation of dementia and outcomes including place of residence and mortality data. RESULT Of 50 patients, the majority were male (28) with mean age of 75 years. The mean duration of Parkinson's prior to diagnosis of dementia was 6 years and from PD Dementia to death 3 years. The Median Clinical Frailty score on the diagnosis of dementia was 5. Pre-dementia diagnosis, there were no patients in care settings with 50% independently living at home, and the other half dependent on care support. Following dementia diagnosis, only 1 patient was living independently at home, with 19/50 (38%) in care facilities and 30/50 (60%) living at home with support. There was a trend towards increasing hospital admissions and increased need for support from the Parkinson's team following dementia diagnosis (pre-diagnosis 24 admissions, post-diagnosis 31 admissions) increased contact to Parkinson's team (323 versus 360).

CONCLUSION The onset of dementia appears to mark a significant shift in disease burden resulting in an increased rate of institutionalisation and care needs. The trend towards increasing hospital admissions in this cohort alongside increasing contact with the care team reflects increasing frailty, carer and disease burden. The onset of dementia should be a trigger for clinicians and service providers to proactively plan for future care provision. This needs further evaluation and we are analysing our wider sample currently.

Background

Patients living with Parkinson's disease (PD) who are sarcopenic are at significantly higher risk of falling (Cai et al., Frontiers in Neurology,2021,12,598035). Handgrip strength is a useful tool to assess for sarcopenia but is not commonly measured in clinical practice, despite the consequences that sarcopenia poses. This study aims to incorporate handgrip strength into the assessment of outpatients living with PD. Secondary objectives are to increase the understanding of whether exercise is associated with increased handgrip strength and to implement interventions for patients who are identified as sarcopenic; to improve their health outcomes.

Methods

Questionnaires were designed to gather quantitative data about patients' demographics, how frequently they fall, disease severity and their weekly exercise. These were given to patients attending the movement disorders clinic at Crawley hospital, between February and October 2023. Patients without a diagnosis of PD were excluded. Their grip strength was measured using a standardised technique with a calibrated manometer. Data was input to Microsoft Excel and analysed using Spearman's rank and Kruskal-Wallis test.

Results

Handgrip strength was obtained for 125 of 271 patients (46%) attending clinic over this period. Initially healthcare workers took 9.2 minutes to complete the questionnaire but this improved to 4.3 minutes after updating the form. Sixteen patients were excluded, leaving 51 females and 58 males; both with a mean age of 80. Grip strength reduced with PD severity when adjusted for gender; this was significant in males (H=51.9, p=0.00) but not females (H=4.8,p=0.31). Grip strength was weakly correlated with exercise, although not significant (r2=0.15,p=0.15) but did not appear to be related to frequency of falls (r2=0.01,p=0.92).

Conclusions

Handgrip measurement can be successfully implemented into outpatient assessment. Handgrip strength could be used to monitor the effect of lifestyle change in individuals. Limitations include self-reporting bias; which activities each individual classifies as exercise.