Movement disorders

Introduction

From our observations and personal experience Parkinson’s Disease (PD) patients have complex medical needs and are often mismanaged during acute admissions.Medications are wrongly prescribed, particularly out of hours, leading to increased mortality and morbidity.¹

The aim of this project was to assess junior doctors’ understanding of managing the acutely unwell PD patient, with a particular focus on common prescribing errors. We addressed gaps in knowledge by providing teaching sessions and reassessing learning.

Methods

We designed a 9-point questionnaire which assessed confidence and prescribing knowledge. This was given to 14 participants in 2 different settings; informally on the wards and at an FY1 teaching session.  Following this, education was delivered either in the form of 5-minute tutorials on the wards which we named ‘educational soundbites’ (ES) or as a 30-minute interactive case study (ICS) delivered in a lecture hall. Participants were then asked to repeat the same questionnaire and results were compared.

Results

Pre-education, clear gaps in knowledge were identified. None of the participants were aware of the use of Madopar as a rescue drug. There was little awareness of Parkinsonism-Hyperpyrexia Syndrome and of the consequences of missed medications. Knowledge of alternative routes of administration in nil-by-mouth PD patients was poor, as was awareness of contra-indicated drugs.

Of the 14 participants, 7 were given the ES session and 7 the ICS. Following both of these interventions there was an overall increase in confidence levels and understanding of safe prescribing in PD.

Conclusion

PD is one of the most common neurodegenerative disorders in the world and its prevalence is rising.²  It is therefore essential that junior doctors are proficient at managing these patients in the acute setting. This quality improvement project highlights that there are concerning gaps in knowledge surrounding this, particularly in regards to prescribing. Knock-on effects can lead to increased patient morbidity and mortality. This project has demonstrated that educational interventions are simple and effective at addressing this issue.  We would therefore propose that teaching surrounding this subject should be a mandatory component of medical training programmes across the UK.

References

1. Medication Management Performance in Parkinson's Disease: Examination of Process Errors - PubMed (nih.gov)
2. Change in the incidence of Parkinson’s disease in a large UK primary care database | npj Parkinson's Disease (nature.com)

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:

Recent evidence suggests extensive grey matter abnormalities in Parkinson’s Disease Psychosis (PDP), as well as dysfunction of dopaminergic and serotonergic receptors. However, findings remain unclear. This meta-analysis aimed to identify neuroanatomical correlates of PDP and to examine the relationship between grey matter and key candidate receptors.

Method:

Peak coordinates were extracted from structural magnetic resonance imaging (MRI) studies (identified through systematic searches on PubMed, Web of Science, and Embase) for PDP patients and Parkinson's Disease patients without psychosis (PDnP) and were analysed using Seed-based d mapping with permutation of subject images (SDM-PSI). Gene expression data for dopaminergic (D1/D2) and serotonergic (5-HT2a/5-HT1a) receptors were extracted from the Allen Human Brain Atlas, probe-to-gene re-annotation data were downloaded from Arnatkevic̆iūtė et al. (Neuroimage, 2019;189:353-67) and parcellated on 78 regions of the Desikan-Killiany brain atlas. Effect-size estimates, extracted from the SDM-PSI analysis for these 78 regions as a measure of grey matter in PDP patients, were entered in multiple regression models.

Results:

10 studies were included in the meta-analysis (PDP, n= 211; mean age = 69.01 years, 52.1% males; PDnP, n = 298, mean age = 67.34 years, 41.9 % males). Reduction in grey matter was observed in parieto-temporo-occipital regions in PDP patients (uncorrected, p < 0.05). When controlling for PD medications, expressed in Levodopa equivalent daily dose (LEDD), results remained significant (uncorrected, p < 0.05). 5-HT2a and 5-HT1a gene receptor expressions were associated with estimates of grey matter volume (5-HT2a, b=-0.20, p=0.01, adjusted for LEDD, b=-0.18, p=0.03; 5-HT1a, b=0.11, p=0.02, adjusted for LEDD, b=0.12, p=0.01).

Conclusion:

We observed lower cortical volume in parieto-temporo-occipital areas, which are involved in information processing, integration, and attention in PDP compared to PDnP patients. We also reported an association between regional brain expression of serotonergic receptors and grey matter volume suggesting a role of serotonin in PDP.

Introduction

It is well recognised that patients with Parkinson’s disease (PD) have significant symptom burden in advanced stages of their disease. Integration of movement disorder and palliative care services has been limited by concerns about resource and sustainability. We present our experience of establishing a movement disorders palliative care multidisciplinary meeting. Method In 2019 we established a multidisciplinary virtual bimonthly meeting between movement disorders and palliative care specialists. Referrals were accepted from movement disorder specialists, community Parkinson’s practitioners and palliative care specialists. Referring clinicians all actively applied primary palliative care approaches within their existing services.

Aims of the meeting were to facilitate holistic management of complex needs, support advance care planning (ACP) and consider referral to specialist palliative care services. Result 37 patients in total were discussed over a 2-year period (although the service was limited for a time due to COVID pressures). On average 3 new patients were discussed per meeting. Reasons for referral included motor and non-motor symptoms, support with ACP, medication advice, caregiver concerns and emotional distress.

Meeting outcomes included medication adjustments, expediting reviews, hospice support, carer support, and referral to other services. Since the meetings started 23 (62%) patients have died. Of these, 30% died in hospital compared with the national average of 43.4%. The average between discussion at the meeting and death was 139 days. The meeting has generated education opportunities, triggered joint assessments and a professionals’ framework for the palliative management of patients with a movement disorder.

Conclusions

We present the experience of an MDT embedded within an early integrated palliative care service for movement disorders. The MDT has strengthened partnership working and findings suggest that alongside active primary palliative care, specialist palliative care for PD can be sustainable and resource efficient in a UK setting.