Movement disorders

Background This quality improvement (QI) work was done at the South Edinburgh Parkinson’s clinic.

Introduction Idiopathic Parkinson’s disease (IPD) is a secondary risk factor for osteoporosis (Torsney KM et al. Journal Neurology Neurosurgery Psychiatry 2014; 85: 1159–1166). The 2022 UK Parkinson’s audit highlighted bone health as an area of QI for IPD (www.Parkinsons.org.uk).

Methods A Plan-Do-Study-Act (PDSA) structure was adopted and project charter created. Baseline data was collected from 20 patients attending the IPD clinic between June- September 2023, reviewing details of assessments in the last three years. The Parkinson’s Excellence network bone health form was used to assess osteoporosis risk (www.Parkinsons.org.uk). Patient records were prospectively assessed pre-annual clinic between June-July 2024. The assessment outcome was documented in the patient’s records to guide discussion. After clinic the form was updated and interventions actioned.

Results From baseline data, only 2 of 20 patients had a bone health assessment as part of recent annual reviews. Using the assessment form, 33 patient notes were reviewed. 22 patients were excluded based on the form’s screening criteria or lack of formal IPD diagnosis. 11 patients had a full assessment completed. Three patients were given lifestyle advice only. 7 patients (63.6%) had a FRAX score for a major osteoporotic fracture >10% and a DEXA scan was suggested for all. 3 of these patients were deemed high risk, ideally to be started on bone health treatment immediately. On average it took 3minutes and 47seconds to complete the form.

Conclusions The assessment forms were straightforward to complete and helped identify IPD patients at increased risk of osteoporosis. The Lothian Parkinson’s service is considering how best to implement this into the structure of annual reviews and will be undertaking further assessments with larger patient numbers. The impact on the service and clinical time needs to be better understood.

Reported delirium prevalence in inpatients with Parkinson’s disease (PD) varies widely across the literature and is often underreported. Delirium is associated with an increased risk of institutionalisation, dementia, and mortality, but to date there are no comprehensive prospective studies in PD. We aimed to determine delirium prevalence in PD compared to older adults and its associated risk with adverse outcomes. Participants from the ‘Defining Delirium and its Impact in Parkinson’s Disease’ (DELIRIUM-PD) and the ‘Delirium and Cognitive Impact in Dementia’ (DECIDE) studies were included. People with PD (DELIRIUM-PD) or older adults from the Cognitive Function and Ageing Study II – Newcastle cohort (DECIDE) admitted to hospitals in Newcastle were approached to take part. Delirium was assessed prospectively using the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition criteria. Outcomes were determined by medical note reviews and home visits 12 months post discharge. Cox regression or binary logistic regression were used to evaluate the effect of delirium on institutionalisation, dementia, and mortality, independent of covariates. Delirium developed in 66.9% (n=81/121) of PD participants compared to 38.7% (n=77/199) of controls (p<.001). Delirium was associated with a significant increased risk of developing dementia in one year in PD (OR=6.1 (1.3-29.5), p=.024) and in controls (OR=13.4 (2.5-72.6), p=.003). However, in only PD participants, delirium was associated with a significantly higher risk of institutionalisation (OR=10.7 (2.1-54.6), .004) and mortality (HR=3.3 [95% CI 1.3-8.6], p=.014). This is the first comprehensive prospective study of delirium in PD, showing that over two-thirds develop delirium during hospitalisation compared to a third of older adults. Delirium in PD is associated with a significant risk of dementia, institutionalisation, and death in one year.

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

People with Parkinson's disease are more likely to have osteoporosis and falls. They also have a higher risk of fractures, and their outcomes are poorer than in the general population. Despite this, only half of the patients seen in Parkinson's clinic have a bone health assessment. The aim of this project was to improve bone health assessments in the Parkinson's clinic at Mansfield Community Hospital.

Method

One plan - do-study-act cycle was completed with the implementation of a Parkinson's fracture risk assessment tool in the clinic. 19 clinic notes were evaluated over an 8-week period. The notes were scored on whether bone health was addressed using the assessment tool. Feedback was collected from the clinicians about utilising the assessment tool in clinic. The FRAX (Fracture risk assessment) tool was also used to calculate the risk of fractures in the patients selected.

Results

16/19 (84%) notes had used the risk assessment tool in clinic. There was an improvement in the bone health assessments in clinic from 5% (1/19) at baseline to 29% (5/17). The Parkinson's risk assessment tool's identification of individuals who were high risk of fractures, correlated with those identified as high risk using FRAX. The clinicians had positive reviews of the tool, but they highlighted the time constraints.

Conclusion

Whilst the use of the assessment tool has shown some improvement in the number of bone health assessments happening in clinic; it hasn't resulted in all patients having an assessment. This is likely due to the time constraints in clinic. This project was successful in highlighting the current problem to the clinicians and has led the development of a further separate clinic, where bone heath can be addressed. The risk assessment tool plays an important role in identifying high risk patients who would be referred into this service.

Local Situation:  

2023 audit showed 57% of Parkinson’s disease medications were given within acceptable time frame of thirty minutes of prescribed time. The target for this project is a sustained improvement (demonstrated by a run chart showing improvement over two months) with a minimum of 80% of these medications being given in 30 minute time window. 

Methods: 

Effective strategies from other centres and Parkinson’s UK resources were adopted to trail as PSDA interventions in our hospital: visual bedside timing reminder aids, educational sessions for nursing and medical teams, posters to raise awareness of importance medication timing amongst all ward MDT members. The number of missed, early, late and on time doses for all inpatients with Parkinson’s disease was checked twice a week to assess response to each of these interventions. Real time feedback was also collected from nursing staff with each intervention cycle. 

Results: 

The hospital is currently achieving an average of 70% of doses in time. Prompting use of visual aids with ward tours has helped reinforce behaviour change.  

Conclusions and future PSDA: 

Feedback from staff showed that visual reminders and alerts can lose impact when there are many already being used. We plan to trial bedside timers for the next cycle which are to be introduced at the medication reconciliation step in the patient journey. To maintain momentum and accountability the hospital systems team is supporting the development of a live monitoring system report for dosing lapses at any time in trust. 

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.