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Kobylecki C, Goh YY, Mohammad R, Beat A, Michou E, Pavey S, Morris H, Houlden H, Chelban V. Clinical Practices and Opinions toward Gastrostomy Use in Patients with Atypical Parkinsonian Syndromes: A National Survey in the UK. Mov Disord Clin Pract 2024. [PMID: 39189113 DOI: 10.1002/mdc3.14196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 08/08/2024] [Accepted: 08/12/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Severe dysphagia poses a significant challenge for clinicians regarding feeding tube choices, practices, and timing due to a lack of evidence-based guidance. OBJECTIVES To assess national clinical practices and opinions on gastrostomy use in patients with atypical parkinsonian syndromes (APS) across the UK. METHODS Online survey was administered to clinicians and allied health professionals regarding availability of services, current use, perceived advantages, and problems associated with gastrostomy insertion. RESULTS We received responses from 47 respondents across 12 UK centers, including 44 clinicians specialized in APS. Consensus was observed regarding primary indications for gastrostomy insertion and circumstances justifying avoidance of the procedure. Limitations in recommending gastrostomy due to insufficient evidence on safety and outcomes, survival and quality of life were identified. Widespread agreement on delays in gastrostomy discussions was highlighted as a challenge in optimizing patient care, together with variability in current practices and concerns over the lack of a standardized gastrostomy pathway, emphasizing the need for further research to address existing evidence gaps. CONCLUSION This multi-center survey highlights agreement among clinicians on key aspects of indication, challenges, and limitations such as delayed decision-making and the absence of standardized pathways regarding the timing, method, and overall approach to gastrostomy insertion in APS. This study identified next steps to facilitate a more structured approach to future research toward a consensus on best practices for gastrostomy in APS. Addressing these challenges is crucial for enhancing patient outcomes and overall care quality in APS.
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Affiliation(s)
- Christopher Kobylecki
- Division of Neuroscience, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Yee Yen Goh
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Rahema Mohammad
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Alanna Beat
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Emilia Michou
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
- Department of Speech and Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Patras, Greece
| | | | - Huw Morris
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Henry Houlden
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Viorica Chelban
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
- Neurobiology and Medical Genetics Laboratory, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
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Farag M, Coleman A, Knights H, Murphy MJ, Rajagopal S, Touzé A, Shoai M, Hearst C, Salanio DM, Wild EJ, Tabrizi SJ. Outcomes of Percutaneous Endoscopic Gastrostomy in Huntington's Disease at a Tertiary Center. Mov Disord Clin Pract 2024; 11:998-1007. [PMID: 38853375 PMCID: PMC11329559 DOI: 10.1002/mdc3.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/19/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Clinically assisted nutrition and hydration via percutaneous endoscopic gastrostomy (PEG) is a therapeutic option to ameliorate the difficulties associated with enhanced catabolism, weight loss, and dysphagia in Huntington's disease (HD). OBJECTIVES The objective is to provide insights into demographics, staging (Shoulson-Fahn), complications, weight trajectories, and survival rates in people with HD (pwHD) who underwent PEG. METHODS This retrospective study included 705 consecutive pwHD who attended our HD clinic between July 2006 and March 2024, of whom 52 underwent PEG. A control group (n = 52), comprising pwHD without PEG, were closely matched for sex, stage, age, CAG length, and disease burden score at PEG. The study was registered as a service evaluation at the National Hospital for Neurology and Neurosurgery. RESULTS PEG prevalence was 15.0% (n = 52/347) among manifest pwHD: 4.8% (n = 3/62) for Stage 3; 33.3% (n = 16/48) for stage 4; and 44.1% (n = 30/68) for stage 5. Commonest indications were dysphagia, weight loss, and inadequate oral intake. Complications included chest infection, tube dislodgement, and peristomal and skin infections. Modeling of weight trajectories after PEG found no difference between PEG and non-PEG groups. Mortality rate was 34.6% (n = 18/52) in the PEG and 36.5% (n = 19/52) in the non-PEG groups (P = 0.84). Treatment duration (until study endpoint or death) was 3.48 years (interquartile range = 1.71-6.02; range = 0.23-18.8), with 65.4% (n = 34/52) alive at the study endpoint. CONCLUSION PEG in pwHD at-risk for weight loss may help slow weight loss. Prospective studies are required to strengthen PEG decision-making in pwHD. PEG survival was much longer than other dementias, highlighting the need to consider PEG independently in pwHD.
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Affiliation(s)
- Mena Farag
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Annabelle Coleman
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Harry Knights
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Michael J Murphy
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Sangeerthana Rajagopal
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Alexiane Touzé
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Maryam Shoai
- Department of Neurodegenerative Diseases, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Cara Hearst
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Desiree M Salanio
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Edward J Wild
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
| | - Sarah J Tabrizi
- Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London, United Kingdom
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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Drugs, delirium, and ethics at the end of life. J Am Geriatr Soc 2024; 72:1964-1972. [PMID: 38240387 PMCID: PMC11226357 DOI: 10.1111/jgs.18766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024]
Abstract
For older persons with delirium at the end of life, treatment involves complex trade-offs and highly value-sensitive decisions. The principles of beneficence, nonmaleficence, respect for autonomy, and justice establish important parameters but lack the structure necessary to guide clinicians in the optimal management of these patients. We propose a set of ethical rules to guide therapeutics-the canons of therapy-as a toolset to help clinicians deliberate about the competing concerns involved in the management of older patients with delirium at the end of life. These canons are standards of judgment that reflect how many experienced clinicians already intuitively practice, but which are helpful to articulate and apply as basic building blocks for a relatively neglected but emerging ethics of therapy. The canons of therapy most pertinent to the care of patients with delirium at the end of life are as follows: (1) restoration, which counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium; (2) means-end proportionality, which holds that every treatment should be well-fitted to the intended goal or end; (3) discretion, which counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions; and (4) parsimony, which maintains that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal. Carefully weighed and applied, these canons of therapy may provide the ethical structure needed to help clinicians optimally navigate complex cases.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel P. Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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Kobylecki C, Chelban V, Goh YY, Michou E, Fumi R, Theilmann Jensen M, Mohammad R, Costantini A, Vijiaratnam N, Pavey S, Pavese N, Leigh PN, Rowe JB, Hu MT, Church A, Morris HR, Houlden H. Frequency and outcomes of gastrostomy insertion in a longitudinal cohort study of atypical parkinsonism. Eur J Neurol 2024; 31:e16258. [PMID: 38407533 PMCID: PMC11235814 DOI: 10.1111/ene.16258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/21/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Multiple system atrophy (MSA), progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) show a high prevalence and rapid progression of dysphagia, which is associated with reduced survival. Despite this, the evidence base for gastrostomy is poor, and the optimal frequency and outcomes of this intervention are not known. We aimed to characterise the prevalence and outcomes of gastrostomy in patients with these three atypical parkinsonian disorders. METHOD We analysed data from the natural history and longitudinal cohorts of the PROSPECT-M-UK study with up to 60 months of follow-up from baseline. Survival post-gastrostomy was analysed using Kaplan-Meier survival curves. RESULTS In a total of 339 patients (mean age at symptom onset 63.3 years, mean symptom duration at baseline 4.6 years), dysphagia was present in >50% across all disease groups at baseline and showed rapid progression during follow-up. Gastrostomy was recorded as recommended in 44 (13%) and performed in 21 (6.2%; MSA 7, PSP 11, CBS 3) of the total study population. Median survival post-gastrostomy was 24 months compared with 12 months where gastrostomy was recommended but not done (p = 0.008). However, this was not significant when correcting for age and duration of symptoms at the time of procedure or recommendation. CONCLUSIONS Gastrostomy was performed relatively infrequently in this cohort despite the high prevalence of dysphagia. Survival post-gastrostomy was longer than previously reported, but further data on other outcomes and clinician and patient perspectives would help to guide use of this intervention in MSA, PSP and CBS.
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Affiliation(s)
- Christopher Kobylecki
- Division of Neuroscience, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Department of Neurology, Manchester Centre for Clinical NeurosciencesNorthern Care Alliance NHS Foundation TrustSalfordUK
| | - Viorica Chelban
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Neurobiology and Medical Genetics Laboratory“Nicolae Testemitanu” State University of Medicine and PharmacyChisinauRepublic of Moldova
| | - Yee Yen Goh
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Emilia Michou
- Division of Diabetes, Endocrinology and GastroenterologyUniversity of ManchesterManchesterUK
- Department of Speech and Language Therapy, School of Health Rehabilitation SciencesUniversity of PatrasPatrasGreece
| | - Riona Fumi
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Marte Theilmann Jensen
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Rahema Mohammad
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Alyssa Costantini
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | | | - Nicola Pavese
- Clinical Ageing Research UnitNewcastle UniversityNewcastleUK
| | - P. Nigel Leigh
- Department of NeuroscienceBrighton and Sussex Medical SchoolBrightonUK
| | - James B. Rowe
- Department of Clinical Neurosciences, Cambridge Centre for Parkinson‐Plus, Cambridge University Hospitals NHS TrustUniversity of CambridgeCambridgeUK
| | - Michele T. Hu
- Division of Neurology, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | | | - Huw R. Morris
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Henry Houlden
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
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5
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Hvisdak V, Huang AP, Kluger BM. Palliative Care of End Stage Parkinsonism: An Overview Including the Five Pillars Framework. Mov Disord Clin Pract 2023; 10:S63-S67. [PMID: 37637979 PMCID: PMC10448122 DOI: 10.1002/mdc3.13620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/10/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Veronica Hvisdak
- Department of NeurologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Andrew Phillip Huang
- Department of NeurologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Benzi Michael Kluger
- Department of NeurologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
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6
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Blanco Ramos B, Gómez Bellvert N. [Caregiver burden and reported quality of life in neurological patients with gastrostomy tubes.]. NUTR HOSP 2023. [PMID: 37154027 DOI: 10.20960/nh.04546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVE the aim of the study is to determine if the use of home enteral nutrition (HEN) by percutaneous endoscopic gastrostomy (PEG) reduces the burden on the caregiver and improves the patients' quality of life reported by the caregivers. MATERIAL AND METHODS a prospective, cross-sectional, descriptive, and observational study of a single cohort of 30 patients was conducted. RESULTS the results showed an improvement in nutritional status and analytical parameters. Fewer admissions (1.50 ± 0.90 vs 0.17 ± 0.38; p < 0.001) and hospital stays were reported at 3 months after gastrostomy (10.2 ± 8.02 days vs 0.27 ± 0.69 days; p < 0.001). The minutes spent by caregivers administering NEDs decreased after PEG placement by 28.5 minutes per feeding, which amounts to almost 150 minutes over a day and 5 feedings per day. In the Zarit questionnaire, there was a reduction of 13.5 points in the perception of overload. A total of 56.6 % of caregivers reported that quality of life had improved "quite a lot", compared to 6.7 % who reported little improvement, and 36.7 % who reported a lot of improvement. In the QoL-AD questionnaire, a higher score of 3.40 points was obtained. CONCLUSION the use of HEN by PEG tube reduces the time spent by the caregiver administering EN, which results in a reduced burden. In addition, the quality of life of patients reported by caregivers improved.
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7
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O'Shea N, Lyons S, Higgins S, O'Dowd S. Neurological update: the palliative care landscape for atypical parkinsonian syndromes. J Neurol 2023; 270:2333-2341. [PMID: 36688987 DOI: 10.1007/s00415-023-11574-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/24/2023]
Abstract
Atypical parkinsonian syndromes are neurodegenerative conditions, characterised by rapid disease progression and shorter life expectancy compared to idiopathic Parkinson's disease. These conditions inflict substantial physical and psychosocial burden on patients and their families; hence, there is a clear rationale for a palliative care approach from diagnosis. An interdisciplinary care model has been shown to improve symptom burden, quality of life and engagement with advance care planning, in a heterogeneous group of neurodegenerative conditions. In this update, we summarise how the landscape for treating these patients has changed and the questions that still need to be resolved.
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Affiliation(s)
- Noreen O'Shea
- Department of Neurology, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland.
- Department of Palliative Medicine, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland.
| | - Shane Lyons
- Department of Neurology, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland
| | - Stephen Higgins
- Department of Palliative Medicine, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland
- Our Lady's Hospice & Care Services, Harold's Cross, Dublin, D6WRY72, Ireland
| | - Sean O'Dowd
- Department of Neurology, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland
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Brizzi K. Outpatient neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:29-48. [PMID: 36599513 DOI: 10.1016/b978-0-12-824535-4.00002-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Palliative care is an approach to patient care that focuses on enhancing quality of life through relief of physical, emotional, and spiritual sources of distress and patient-tailored discussions about goals of care. The palliative care approach can be delivered by any provider, and can occur alongside disease-modifying therapies. For patients with a serious neurologic illness or a neurodegenerative disease, neuropalliative care is a growing field focused on providing high-quality palliative care to neurology patients. There are three models of neuropalliative care delivery in the outpatient setting: a consultative model with a palliative care specialist, an integrated model with an embedded palliative care provider, and a primary palliative care model with the patient's neurology provider. The main components of an outpatient palliative care visit include symptom assessment and treatment, communication about serious illness, advance care planning, and assessment of caregiver needs. For patients with advanced illness, palliative care can help facilitate timely referral to hospice. Through a palliative care approach, outpatient care for patients with serious neurologic disease or neurodegenerative disease can focus on the issues most important to the patient, promote improved illness understanding and planning, and can improve the overall quality of care.
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Affiliation(s)
- Kate Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.
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Brennan F, Gardiner MD, Narasimhan M. The neuropalliative multidisciplinary team-Members and their roles. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:33-59. [PMID: 36055719 DOI: 10.1016/b978-0-323-85029-2.00010-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurodegenerative conditions are prominent contributors to both morbidity and mortality worldwide. They pose a significant challenge to health professionals, health systems, and the often unpaid, untrained family members and carers. The many and varied challenges encountered are best managed by a multidisciplinary neuropalliative team, as it is impossible for a single clinician to possess and deliver the wide range of skills and services required to optimally care for these patients. This chapter discusses the assembly, maintenance, and care of such a team, as well as potential difficulties and solutions in domains such as funding, training, geographical remoteness, as well as the potential lack of awareness and acceptance by colleagues. A comprehensive description of the role of all possible team members is discussed. The chapter outlines the concept, content, and potential benefits of a multidisciplinary team in neuropalliative care. Its thesis is twofold: that multidisciplinary care is vital and, second, that the sum of the whole of a team can be greater than the individual parts with respect to organization, planning, experience, and creativity of approach. With all these factors considered, and implemented wherever possible, we may all move closer to optimizing the comfort and care of our shared neuropalliative patients.
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Affiliation(s)
- Frank Brennan
- Departments of Palliative and Rehabilitation Medicine, Calvary and St George Hospitals, Sydney, NSW, Australia; The Faculty of Medicine, St George Clinical School, The University of New South Wales, Sydney, NSW, Australia.
| | - Matthew D Gardiner
- Departments of Palliative and Rehabilitation Medicine, Calvary and St George Hospitals, Sydney, NSW, Australia; The Faculty of Medicine, St George Clinical School, The University of New South Wales, Sydney, NSW, Australia
| | - Manisha Narasimhan
- School of Psychology and Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia; Department of Neurology, Sutherland Hospital, Sydney, NSW, Australia
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