Movement disorders

1. Introduction

Parkinson’s Disease (PD) is a complex neurodegenerative disorder which impacts nearly all aspects of quality of life. Given the known challenges and risks of complications with PD, it is crucial to improve management prior to admission for surgery, in particular accurate medication timing and dose. Therefore a quality improvement project on this subject was initiated.

2. Method

A retrospective analysis was conducted of Surgical attendances to Worthing hospital with the aim to identify patients with Parkinson’s disease (PD) admitted under their care. Each patient’s hospital records were manually screened using Evolve Live software and WellSky EPMA to extract the information pertaining to PD medications for the audit. Statistical analysis was conducted using Microsoft Excel. The cycle was repeated following interventions of posters and education of surgical teams.

3. Results

In both cycles there were patients attending for elective surgery or admitted into hospital. The following is regarding patients who were admitted to hospital and were on PD medications. For the first cycle, 27 admissions were identified and 20 in the second cycle. In the first cycle, 5/27 (18.5%) had their medications accurately documented, which improved to 9/20 (45%) in the second cycle. First cycle, 16/27 (59%) patients had their medications prescribed correctly, which was similar to 12/20 (60%) patients in the second. 17/27 (62.7%) patients missed doses in the 1st cycle, and 9/20 (45%) patients in the 2nd cycle.

4. Conclusion(s)

From the first cycle, it was identified that PD in patients was not recognised as promptly as it should. It was reflected in the high proportion of incorrect prescribing and issues due to delay in medications. In the second cycle, following our interventions, there was improved awareness of PD with fewer prescribing issues and complications during admission.

INTRODUCTION: Guidance around optimal management of patients with cognitive impairment within a Parkinson’s disease (PD) multidisciplinary team (MDT) is lacking. This project aimed to improve the service pathway by integrating a Parkinson’s disease specialist psychiatrist (PDSP) within the MDT rather than referring patients to a separate mental health service.

METHODS: Data including mental health symptoms, time to review, diagnosis, treatment, and follow-up were collected over 12 months from the electronic clinical records of all patients referred to the PDSP with cognitive impairment. This data set was subject to descriptive analysis and economic evaluations.

RESULTS: 47 patients with Parkinson’s and cognitive impairment were referred to the PDSP - median waiting time to review was one month. Fourteen patients were diagnosed with mild cognitive impairment, 5 with dementia, and 28 with another condition or requiring further diagnostic assessment. Review with the PDSP prevented onward referral to another service in 29 cases, saving an estimated £1140 and reducing duplication of assessments.

CONCLUSIONS: Integration of a PDSP into a PD MDT avoided the need to refer the majority of patients to a separate mental health service, led to fewer health care professional contacts, reduced duplication, and cost savings. It is likely that the model led to earlier diagnoses and treatment. Evidence as to patient and carer experience is not yet available.

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. Falls are a common complication of Parkinson’s disease, driven in part by an underlying cholinergic deficit that contributes to gait and cognitive impairment. Phase 2 studies have established that amelioration of this deficit using cholinesterase inhibitors may reduce falls.

Methods.  CHIEF-PD (CHolinesterase Inhibitor to prEvent Falls in Parkinson's Disease) is a phase 3 randomised, double-blind placebo-controlled trial of rivastigmine to prevent falls in Parkinson's disease that recruited from NHS sites. Relationships between the Principal Investigators’ specialty and the participants baseline characteristics were evaluated using linear, logistic and ordinal logistic regression. Cognitive impairment was defined as MoCA ≤26, while falls in the prior 12 months were separated into ordinal quartiles (1-2, 3-5, 6-12, 13+).

Results. Recruitment to CHIEF-PD commenced in January 2020 and completed in April 2023. Recruitment increased up until the start of the pandemic and thereafter there were 2 peaks. Potential participants were identified through clinic lists, databases, via national and local media and charities. 600 participants were enrolled across 38 sites. Sites enrolled between 1 and 74 participants, each. The median recruitment rate was 19 participants per month (IQR 6-27). 14 (37%) sites had Principal Investigators that were neurologists and 24 (63%) sites had PIs that were geriatricians. Most participants (76%) were over the age of 65 years. Compared with neurologists, geriatricians recruited older patients (difference in means 2.08 (95% CI 0.68, 3.48); p=0.004), with similar levels of cognitive impairment (OR 1.20 (95% CI 0.85, 1.69); p=0.293) and a lower fall rate (OR 0.46 (95% CI 0.34, 0.62); p<.001) at baseline.

Conclusion. Recruitment of older participants to a clinical trial an investigational medicinal product (ctimp) throughout the covid-19 pandemic across 38 uk centres was feasible using multiple strategies. characteristics varied according sub-speciality principal investigator site.

Introduction  

People with Parkinson’s (PWP) are twice as likely to fracture and over twice as likely to develop osteoporosis (1. Henderson et al, Parkinsonism & Related Disorders, 2019, Vol.64, pp.181-187). This is associated with significant morbidity (1). Assessment of bone health is often overlooked in clinic (2. UK Parkinson’s Excellence Network, 2019, pp.4-56), deeming it a priority area for improvement. Our project focuses on implementing routine bone health assessment for PWP in clinic, to achieve better standards of care.  

Methods  

This was a 12-week medical student led project, supported by the specialist multi-disciplinary Parkinson’s team (MDT) in Cardiff and Vale. To establish baseline current practice, a retrospective fracture risk assessment was completed for 141 patients using the Bone-Park algorithm (1). To screen bone health, we developed a bone health proforma, incorporating the FRAX tool. We trialled proforma integration in clinic, by gaining patient feedback and analysing logistics. Administration was done in a patient, healthcare assistant (HCA) and clinician led format.  

Results  

The retrospective analysis showed that 61.7% (n=87/141) of patients required bone health intervention. Of these patients, 41.4% required vitamin D supplementation. 40.2% required bone density measurement. 18.4% required bone strengthening treatment. This was subsequently initiated. Issues identified with self-administered forms (n=8/30) were physical difficulty in completing forms and confusion around medical terminologies, which clinician led administration (n=14/30) could support. HCA’s (n= 8/30) required MDT support to complete forms. 

Conclusion  

As PWP have an increased fracture risk (1), our results provide compelling evidence that routine bone health assessment should be better integrated into Parkinson’s management. Clinician led administration of our proforma was the best model of integration. This was based on patient preference, a reduction in duplication and improved accuracy. Further bone health education is needed within our MDT, which we aim to incorporate through our Parkinson’s web application.   

Background:

Patients not yet receiving medication provide insight to drug-naïve early physiology of Parkinson's Disease (PD). Decisions to start medication and assessment of response to its initiation can be challenging for physicians and patients alike.

Aim:

To identify objective, sensor-derived features of upper limb bradykinesia, postural stability, and gait that can inform decision-making in a movement disorder clinic. Methods: We used a single finger sensor to identify upper limb features and an array of six body-worn sensors to measure postural stability and gait. Patients were tested over nine visits, at three-monthly intervals, as part of a standard neurological examination.

Results:

Three upper limb bradykinetic features (finger tapping speed, pronation supination speed, and pronation supination amplitude) and three gait features (gait speed, arm range of motion, duration of stance phase) were found to progress in unmedicated early-stage PD patients. In all features, progression was masked after the start of medication.

Conclusion:

Commencing antiparkinsonian medication is known to lead to masking of progression signals in clinical measures in de novo PD patients. In this study, we show how this effect can be measured using digital devices. The testing kit can be used in movement disorder clinics to inform decision-making and progression monitoring in early PD.

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

Parkinson’s Disease (PD) is recognised by the motor symptoms of tremor, rigidity and bradykinesia. However, the prevalence of psychiatric symptoms such as low mood, anxiety and memory problems in PD is also common (20-80%). We integrated one clinical session per week from a Parkinson’s specialist psychiatrist (PDSP) into our existing MDT service, and aimed to evaluate the impact of this model on care for patients with PD.

Method

We initiated a series of Plan Do Study Act (PDSA) cycles to establish a referral pathway to our PDSP. Using electronic clinical records we collected data from a cohort of PD patients seen by our PDSP over 6 months to map symptoms, time to review, diagnosis, treatment and follow-up. We estimated the number of referrals to other services that did not need to be made over the same period due to access to our PDSP

Results

Fifty-one patients with PD were referred to our PDSP with the following symptom(s): memory impairment (53%), low mood (42%), hallucinations (10%), anxiety (8%) - all were seen within eight weeks. Of the 27 patients referred with memory impairment, review by our PDSP meant that 15 did not need onward referral to a separate mental health service. Of 14 patients with low mood (without memory impairment), review by our PDSP meant that 12 did not need onward referral.

Conclusion

Prior to the integration of a PDSP into our PD MDT patients with psychiatric symptoms needed to be referred to another clinical service, often with a long wait for assessment and treatment. With access to a PDSP, 51 patients were reviewed within eight weeks, and 27 did not need onward referral to another service. We do not yet have evidence as to how patient outcomes differ before and after integration of a PDSP into our team

Introduction:

Cognitive impairment and dementia are prevalent in Parkinson’s disease (PD) and significantly impact patients’ quality of life. Accurate prognostic indicators of cognitive decline in this population are needed. Electroencephalography (EEG), a non-invasive measure of brain activity, is one such measure. The current study aimed to systematically review which EEG indices are associated with mild cognitive impairment (PD-MCI) and dementia in PD (PDD).

Method:

A systematic literature search was conducted in Embase, MEDLINE, PsycINFO and Web of Science in November 2022 to identify studies using EEG to assess cognition in PD-MCI and PDD.

Results:

Of the 1716 studies retrieved, 30 were eligible for inclusion. Spectral power in delta, theta, alpha, beta and gamma bands was most frequently investigated (n=13), followed by functional connectivity (n=9) and event related potentials (ERPs; n=6). Slowing of spectral power, characterised by global increases in delta and theta bands with a concomitant decrease in alpha and beta bands, was found in PD-MCI and PDD (n=11). Reduced functional connectivity between anterior and posterior regions was also associated with cognitive impairment in PD (n=2), together with decreased functional connectivity in the alpha band (n=9) in PD-MCI and PDD. However, two studies displayed normal functional connectivity of delta sources in PD-MCI and PDD respectively. ERP studies revealed deficits in attention and semantic processing associated with PD-MCI/PDD.

Conclusions:

This review demonstrates that slowing of EEG activity, reduced functional connectivity and aberrant ERPs are associated with PD-MCI and PDD. Study limitations include small sample sizes and discrepancies in the criteria used to define PD-MCI, together with the wide variety of EEG tasks, montages and analysis pipelines used between sites. Overall, this study highlights the potential application of EEG to predict and monitor cognition in PD. Further work should be undertaken to determine the sensitivity, specificity and prognostic value of these EEG indices.

Introduction

The UK Parkinson's audit assesses whether patients with Parkinson's Disease (PD) are managed according to standards. Referring patients to physiotherapy (PT) and advising those with daytime sleepiness not to drive are two of these. In our clinic, patients identified as drivers are advised to inform the DVLA and will undergo a MOCA, sleep questionnaire and driving assessment. 

Project Aim

Are we making early physiotherapy referrals and documenting driving status in newly diagnosed outpatients? 

Methods

Online notes of newly diagnosed patients over a 12 month period were reviewed. A clinic checklist was created and displayed in the clinic as a poster with the mnemonic:

Lasting Power of attorney

Driving

Osteoporosis

Physiotherapy

Anticipatory care planning

Following introduction of the checklist a further cycle has taken place. 

Results

In the initial cycle, 34 newly diagnosed patients were identified. 4 were nursing home residents and excluded from results. Of those remaining, 83% had documentation of driving status. 2 patients were drivers and one had evidence of completed driving assessments. 20 patients were referred to physiotherapy and a further 3 patients were offered (76%). 50% of referrals were within the first month of diagnosis. Following checklist introduction, 21 new PD patients were identified over 6 months. The clinic team were sent updated data throughout to encourage ongoing improvements. 95% had documentation of driving status. 9 were drivers. 6 had full driving assessment completed. 16 (76%) patients were referred to physiotherapy. 75% of these were referred within the first month.

Conclusions

Repeat data collection has shown improvement in both driving status documentation and early physiotherapy referral. The checklist reminds us of important aspects of outpatient care in PD that may otherwise get forgotten. Ongoing data collection will hopefully continue to improve.