Movement disorders

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: 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 

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  

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 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.

Background: Sialorrhoea is the increase of drooling due to poor clearance of saliva and is a common symptom in people with Parkinson’s Disease. It can lead to a decline in confidence, as well as increasing the risk of aspiration pneumonia. Botulinum injections are currently used in select patients to control the sialorrhoea, and the purpose of this project was to assess the benefit this treatment has had on patients.

Methods: Data was collected from 40 patients who have received treatment at the sialorrhoea clinic and included Drooling Severity and Frequency Scale (DSFS), EQ5D and Visual Analogue score (VAS) - quality of life scores that are routinely collected before and after each injection. Using the Welsh Clinical Portal, data was collected on mood, swallow problems, dementia and comorbidities.

Results: Out of a total of 86 injections, 66 resulted in a decreased DSFS score showing better controlled sialorrhoea after most injections. Among the discharged patients, there was an equal distribution between those discharged due to successful and unsuccessful treatment (n=9 each). In 74% of successful injections it took less than a week to take effect and 63% of successful injections lasted 3 months or longer. The average onset of sialorrhoea after a Parkinson’s Disease diagnosis was 7.7 years and out of 40 patients, 11 experienced low mood and 19 had swallowing difficulties before treatment. Over a cumulative 40 years of treatment across all patients, there were only 4 reported admissions due to pneumonia.

Conclusion: Most injections resulted in an improved DSFS score with the average decrease in the score being 1.9 in successful injections. As many patients with sialorrhoea experience low mood, effectively controlling the sialorrhoea can improve patients’ quality of life and confidence, as well as reducing hospital admissions due to aspiration pneumonia.

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.

OBJECTIVE: To assess in Alzheimer’s disease (AD), the treatment impact of donanemab, an amyloid plaque-reducing monoclonal antibody, on readily interpretable item-measures and constructs that matter to patients, care-partners, and clinicians.

BACKGROUND: Positive outcomes were reported from TRAILBLAZER-ALZ2, a randomized, double-blind, placebo-controlled, 18-month, phase 3 study evaluating donanemab as an investigational treatment for mild cognitive impairment (MCI) or mild dementia due to AD. In 1736 participants, donanemab significantly slowed the rate of clinical decline (by 22-36%) as measured by the integrated AD Rating Scale (iADRS) and the Clinical Dementia Rating Scale—Sum-of-Boxes (CDR-SB); both measures of cognition and function as indications of global clinical severity. In these subsequent post-hoc exploratory analyses, the impact of donanemab treatment on individual iADRS cognition and function items, CDR domains, and risks of advancing to greater disease severity were assessed.

METHODS: Mixed model repeated measures and Cox proportional hazard modeling methodology assessed treatment effects on iADRS items and CDR domains.

RESULTS: Donanemab treatment was associated with significant beneficial effects on: 1) iADRS cognitive items related to episodic memory and executive function, and instrumental activities of daily living items related to communication and others (e.g., being left alone, making a meal, using household appliances); 2) all CDR-SB cognitive and functional domains (i.e., memory, orientation, judgment/problem solving, community affairs, home/hobbies, and personal care); and 3) lowering risk of progression to a more advanced clinical stage of disease.

CONCLUSIONS: These analyses explored the impact of donanemab treatment on constructs that matter to and are considered more readily interpretable by patients, care-partners, and clinicians. These results provide further support that treating those with MCI or mild dementia due to AD with donanemab can meaningfully reduce risk of progression to more severe clinical stages (e.g. moderate stage dementia), and potentially allow greater independence for a longer period of time.

Introduction:

Parkinson’s disease (PD) patients with or without psychosis are at higher risk of recurrent falls and fracture and as a consequence higher mortality and morbidity NICE (13) Henderson et al. (2019). We conducted a qualitative study to understand barriers and facilitators of introducing ‘bone health assessment’ for PD patients.

Method

We conducted a pilot study to identify and implement a bone health assessment tool to communicate falls and fracture risks to GPs. • SWOT and Stakeholder analysis was conducted to identify an appropriate bone health assessment tool . • PDSA cycles were completed to assess barriers and facilitators of bone health assessment in all PD clinical areas. • 4 Participants were identified from all possible PD clinical settings and trained on how to use the FRAX assessment tool. • Semi structured interviews were conducted to explore themes from 6 week pilot study.

Results

Bone health assessments were not conducted routinely in PD clinical settings in our Trust Literature review/ SWOT and Stake holder analysis identified ‘FRAX’ score as an appropriate bone health assessment tool for PD patients. Interviews with participants identified time constraints during the clinical consultation as a major barrier to conducting bone health assessment using the FRAX assessment tool. All participants agreed that this improved communication with patients and GPs in understanding bone health and risk of falls and fractures. Face to face PD Nurse Clinics were deemed the most appropriate clinical settings for these assessments.

Conclusion

As a result of this service improvement project bone health is now assessed in all PD Nurse clinics. This has enabled GPs to start the most appropriate bone protection treatment for PD patients

INTRODUCTION The Cardiff and Vale Parkinson's service is an integrated, multidisciplinary service providing support and input from initial diagnosis to end of life care, undertaking comprehensive, specialist assessments for patients. Traditional care models have focused on physical disease, with neuropsychiatric symptoms often requiring input from other (e.g. Mental Health) teams to manage even the less- complex symptoms of dementia. Our service aims to manage both physical and neuropsychiatric symptoms via non-pharmacologic and pharmacologic means.

METHODOLOGY From our total clinic population, a cohort of 425 people with established idiopathic Parkinson's who were subsequently diagnosed with Parkinson's dementia (PDD)in the decade 2013-2023 was identified. From this cohort we assessed a sample of 50 people (56% male, 44% female, mean age 75 years) for advanced demographics, disease duration, presenting dementia features and the diagnostic method.

RESULT From our database of 3668 clinic patients, 425 people with PDD were identified. 76% people with PDD (n=325) were prescribed acetylcholinesterase inhibitors. Subgroup analysis (n=50) demonstrated that cognition was assessed by a range of tests: ACE (60%), MoCA (22%), clinical opinion alone (16%) or RUDAS (2%). Neuroimaging was undertaken in 50% patients, predominantly to exclude other pathologies. The mean time from PD diagnosis to PDD diagnosis was 6.5 years, and survival from PDD was a mean of 3 years.

CONCLUSION When cognitive impairment or dementia develops in Parkinson's, care provision by the same team ensures continuity for People with Parkinson's (PwP) and their families or carers. PwP live for an average of 3 years post-dementia diagnosis and so joint training in both 'traditional' Parkinson's care and diagnosis and management of dementia allows for a truly holistic approach in managing the complex interplay between motor, non-motor and neuropsychiatric features that manifests later in this condition.