A systematic review of interventions to reduce hospitalisation in Parkinson's disease

The Effectiveness of Inpatient Rehabilitation in Parkinson's Disease: A Systematic Review of Recent Studies

Background

Parkinson's disease (PD) is a progressive disease, which is associated with the loss of activities of daily living independency. Several rehabilitation options have been studied during the last years, to improve mobility and independency.

Objective

This systematic review will focus on inpatient multidisciplinary rehabilitation (MR) in people with Parkinson's disease (PwPD), based on recent studies from 2020 onwards.

Methods

Search strategy in three databases included: multidisciplinary rehabilitation, Parkinson's Disease, inpatient rehabilitation, motor-, functional- and cognitive performance, cost-effectiveness, Quality of Life, and medication changes/Levodopa equivalent daily doses.

Results

Twenty-two studies were included, consisting of 13 studies dealing with inpatient MR and 9 studies on inpatient non-MR interventions. Inpatient PD multidisciplinary rehabilitation proved to be effective, as well as non-MR rehabilitation.

Conclusions

This review confirms the efficacy of inpatient MR and non-MR in PD, but is skeptical about the past and current study designs. New study designs, including new physical training methods, more attention to medication and costs, new biomarkers, artificial intelligence, and the use of wearables, will hopefully change rehabilitation trials in PwPD in the future.

Opicapone versus entacapone: Head-to-head retrospective data-based comparison of healthcare resource utilization in people with Parkinson's disease new to catechol-O-methyltransferase (COMT) inhibitor treatment

BACKGROUND AND PURPOSE

Motor fluctuations are a significant driver of healthcare resource utilization (HCRU) in people with Parkinson's disease (pwPD). A common management strategy is to include catechol-O-methyltransferase (COMT) inhibition with either opicapone or entacapone in the levodopa regimen. However, to date, there has been a lack of head-to-head data comparing the two COMT inhibitors in real-world settings. The aim of this study was to evaluate changes in HCRU and effect on sleep medications when opicapone was initiated as first COMT inhibitor versus entacapone.

METHODS

In this retrospective cohort study, we assessed HCRU outcomes in pwPD naïve to COMT inhibition via UK electronic healthcare records (Clinical Practice Research Datalink and Hospital Episodes Statistics databases, June 2016 to December 2019). HCRU outcomes were assessed before (baseline) and after COMT inhibitor prescription at 0-6 months, 7-12 months and 13-18 months. Opicapone-treated pwPD were algorithm-matched (1:4) to entacapone-treated pwPD.

RESULTS

By 6 months, treatment with opicapone resulted in 18.5% fewer neurology outpatient visits compared to entacapone treatment; this effect was maintained until the last follow-up (18 months). In the opicapone group, the mean levodopa equivalent daily dose decreased over the first year and then stabilized, whereas the entacapone-treated group showed an initial decrease in the first 6 months followed by a dose increase between 7 and 18 months. Neither COMT inhibitor had a significant impact on sleep medication use.

CONCLUSIONS

This head-to-head study is the first to demonstrate, using 'real-world' data, that initiating COMT inhibition with opicapone is likely to decrease the need for post-treatment HCRU versus initiation of COMT inhibition with entacapone.

Inpatient Mortality in Parkinson's Disease

Introduction

Although a majority of the American public prefer to die at home, a large percentage of Parkinson's disease patients die in acute care hospitals. We examine trends in the clinical and demographic characteristics of Parkinson's disease patients who die in a hospital to identify populations potentially vulnerable to unwanted inpatient mortality.

Methods

Patients with Parkinson's disease admitted to a hospital from 2002-2016 were identified from the National Inpatient Sample (n = 710,013) along with their associated clinical and demographic characteristics. The main outcome examined was mortality during inpatient admission. From these data, logistic regression models were estimated to obtain the odds ratios of inpatient mortality among clinical and demographic attributes, and their change over time.

Results

Characteristics significantly associated with increased odds of inpatient mortality included increased age (OR = 1.70 for 55-65, 2.52 for 66-75, 3.99 for 76-85, 5.72 for 86+, all P < 0.001), length of stay ≤5 days (reference; 6 + days OR = 0.37, P < 0.001), white race or ethnicity (reference; Black OR = .84 P < .001, Hispanic OR = 0.91 P = 0.01), male (reference; female OR = 0.93 P < 0.001), hospitalization in Northeast (reference; Midwest OR = 0.78, South 0.84, West OR = 0.82; all P < 0.001), higher severity of illness (moderate OR = 1.50, major OR = 2.32, extreme OR = 5.57; all P < 0.001), and mortality risk (moderate OR = 2.88, major OR = 10.92, extreme OR = 52.30; all P < 0.001). Fitted probabilities overall declined over time.

Conclusion

Differences exist among PD patient populations regarding likelihood of in-hospital mortality that are changing with time. Insight into which PD patients are most at risk for inpatient mortality may enable clinicians to better meet end-of-life care needs.

Falls Predict Acute Hospitalization in Parkinson's Disease

BACKGROUND

There is a need for identifying risk factors for hospitalization in Parkinson's disease (PD) and also interventions to reduce acute hospital admission.

OBJECTIVE

To analyze the frequency, causes, and predictors of acute hospitalization (AH) in PD patients from a Spanish cohort.

METHODS

PD patients recruited from 35 centers of Spain from the COPPADIS-2015 (COhort of Patients with PArkinson's DIsease in Spain, 2015) cohort from January 2016 to November 2017, were included in the study. In order to identify predictors of AH, Kaplan-Meier estimates of factors considered as potential predictors were obtained and Cox regression performed on time to hospital encounter 1-year after the baseline visit.

RESULTS

Thirty-five out of 605 (5.8%) PD patients (62.5±8.9 years old; 59.8% males) presented an AH during the 1-year follow-up after the baseline visit. Traumatic falls represented the most frequent cause of admission, being 23.7% of all acute hospitalizations. To suffer from motor fluctuations (HR [hazard ratio] 2.461; 95% CI, 1.065-5.678; p = 0.035), a very severe non-motor symptoms burden (HR [hazard ratio] 2.828; 95% CI, 1.319-6.063; p = 0.008), falls (HR 3.966; 95% CI 1.757-8.470; p = 0.001), and dysphagia (HR 2.356; 95% CI 1.124-4.941; p = 0.023) was associated with AH after adjustment to age, gender, disease duration, levodopa equivalent daily dose, total number of non-antiparkinsonian drugs, and UPDRS-IIIOFF. Of the previous variables, only falls (HR 2.998; 95% CI 1.080-8.322; p = 0.035) was an independent predictor of AH.

CONCLUSION

Falls is an independent predictor of AH in PD patients.

Trends in health service use among persons with Parkinson's disease by rurality: A population-based repeated cross-sectional study

BACKGROUND

The global burden of Parkinson's disease (PD) has more than doubled over the past three decades, and this trend is expected to continue. Despite generally poorer access to health care services in rural areas, little previous work has examined health system use in persons with PD by rurality. We examined trends in the prevalence of PD and health service use among persons with PD by rurality in Ontario, Canada.

METHODS

We conducted a repeated, cross-sectional analysis of persons with prevalent PD aged 40+ years on April 1st of each year from 2000 to 2018 using health administrative databases and calculated the age-sex standardized prevalence of PD. Prevalence of PD was also stratified by rurality and sex. Negative binomial models were used to calculate rate ratios with 95% confidence intervals comparing rates of health service use in rural compared to urban residents in 2018.

RESULTS

The age-sex standardized prevalence of PD in Ontario increased by 0.34% per year (p<0.0001) and was 459 per 100,000 in 2018 (n = 33,479), with a lower prevalence in rural compared to urban residents (401 vs. 467 per 100,000). Rates of hospitalizations and family physician visits declined over time in both men and women with PD in rural and urban areas, while rates of emergency department, neurologist, and other specialist visits increased. Adjusted rates of hospitalizations were similar between rural and urban residents (RR = 1.04, 95% CI [0.96, 1.12]), while rates of emergency department visits were higher among rural residents (RR = 1.35, 95% CI [1.27, 1.42]). Rural residents had lower rates of family physician (adjusted RR = 0.82, (95% CI [0.79, 0.84]) and neurologist visits (RR = 0.74, 95% CI [0.72, 0.77]).

INTERPRETATION

Lower rates of outpatient health service use among persons residing in rural regions, contrasting with higher rates of emergency department visits suggest inequities in access. Efforts to improve access to primary and specialist care for persons with PD in rural regions are needed.

Causes, factors, and complications associated with hospital admissions among patients with Parkinson's disease

Introduction

Patients with Parkinson's disease (PD) are at a higher risk of hospital admissions compared to the general population. We studied the causes and factors associated with admissions among patients with PD over 6 years.

Methods

We included all PD admissions between 1 January 2016 and 31 December 2021. Other causes of parkinsonism were excluded. Causes of admissions were divided into PD-related (direct or indirect) or non-PD-related. The type of admission was categorized into emergency or elective.

Results

We identified 605 hospital admissions (259 patients with PD); 345 (57.0%) were PD-related and 260 (43%) were non-PD-related. Emergency PD admissions contributed to 50.4% of all admissions, most commonly from respiratory infection (23%). PD admissions in comparison to non-PD admissions were associated with worse disease severity (HY ≥ 3; p < 0.001), longer disease duration [8.71 (SD 6.23) vs. 6.60 (SD 5.39) years; p < 0.001], and longer hospital stay [7.70 (SD 5.89) vs. 6.42 (SD 7.63) days; p = 0.020]. Non-PD admissions were associated with more comorbidities (97.3%; p = 0.013). There were 124 (20.5%) complications and 31 deaths (5.1%). A total of 29 deaths were due to respiratory infection and 3 deaths were due to COVID-19 pneumonia. Emergency admission (PD- and non-PD-related; p = 0.001) and respiratory-related causes (p < 0.001) were predictors of unfavorable hospital admission outcomes (death and complications).

Conclusion

Respiratory infection was the leading cause of hospital admission and a significant independent predictor of unfavorable hospital admission outcomes (death and complications). PD-related admissions were associated with disease severity and led to more complications and longer hospital stays. Non-PD-related admissions were associated with comorbidities.

Analyses of hospitalization in Alzheimer's disease and Parkinson's disease in a tertiary hospital

Background

To characterize the pattern of hospitalization in patients with Alzheimer's disease (AD) or Parkinson's disease (PD), and compare the differences to see whether AD patients and PD patients have a different picture of hospitalization.

Methods

The clinical features of all consecutive patients from January 2017 to December 2020 were reviewed. We identified AD patients and PD patients from an electronic database in a tertiary medical center.

Results

The study group comprised 995 AD patients and 2,298 PD patients who were admitted to the hospital for the first time, and re-hospitalized 231 AD patients and 371 PD patients were also included. AD patients were older than PD patients when they were hospitalized (p < 0.001). AD patients had longer lengths of stay, higher re-hospitalization rates, and higher intrahospital mortality rates than PD patients during hospitalization even after adjusting age and gender. PD patients had higher levels of total cost than AD patients due to the cost of the deep brain stimulation (DBS) insertion. Hospitalizations for AD patients occurred most often in the department of geriatrics, while most PD patients were admitted to the department of neurology. Hospitalization due to the presence of comorbid conditions was much higher in AD patients, but a larger proportion of PD patients were hospitalized due to PD disease itself.

Conclusions

The present study found that AD patients and PD patients have a significantly different picture of hospitalization. It is important to implement different management for hospitalized AD and PD, and different emphasis should be given when establishing primary prevention strategies, informing care needs, and guiding healthcare resource planning.

Parkinson's Disease Medication Adherence Scale: Conceptualization, Scale Development, and Clinimetric Testing Plan

Background

Medication adherence is a crucial component in the management of patients with chronic diseases needing a long-term pharmacotherapy. Parkinson's disease (PD) is a chronic, degenerative disease with complex drug treatment that poses challenging barriers to patient adherence. The adoption of best practices of scale development can contribute to generate solid concepts and, in the long run, a more stable knowledge base on the underlying constructs of medication adherence in PD measured by the items of the first scale to be created for this purpose.

Purpose

To present the development process and clinimetric testing plan of the Parkinson's Disease Medication Adherence Scale (PD-MAS).

Method

We adopted a hybrid approach plan based on the United States Food and Drug Administration and Benson and Clark Guide that will create a patient-reported outcome instrument. We presented an overview of consecutive and interrelated steps, containing a concise description of each one. International research centers from Brazil and United States were initially involved in the planning and implementation of the methodological steps of this study.

Results

We developed a four-phase multimethod approach for the conceptualization and the clinimetric testing plan of the PD-MAS. First, we describe the development process of the conceptual framework of the PD-MAS underpinning the scale construct; second, we formalized the development process of the first version of the PD-MAS from the generation of item pools to the content validation and pre-testing; third, we established the steps for the first pilot testing and revision; fourth, we describe the steps plan for the first pilot testing and revision, to finally describe its clinimetric testing plan and validation.

Conclusion

The overview presentation of the development phases and the clinimetric testing plan of the PD-MAS demonstrate the feasibility of creating an instrument to measure the multidimensional and multifactorial components of the medication adherence process in people with PD.

The Cause and Duration of Emergency Admissions to Hospital in People with Idiopathic Parkinson's Disease, Under the Care of a UK Service, During the First Year of the COVID-19 Pandemic

BACKGROUND

People with Parkinson's disease (PD) have higher rates of hospitalisation and healthcare utilisation compared to the general population. The COVID-19 pandemic caused significant changes in admissions to hospital and access to healthcare. People with PD are some of the most vulnerable to such changes. There is no pre-existing data on the cause and duration of admission to hospital of people with PD during the COVID-19 pandemic.

OBJECTIVE

To determine the cause, duration, and outcome of hospital admissions to Northumbria Healthcare NHS Foundation Trust (NHCFT) for people with idiopathic Parkinson's disease (IPD) in 2020.

METHODS

All people with IPD who had an emergency admission to NHCFT between 01/01/2020 and 31/12/2020 were identified. Demographic and disease characteristics, the number, duration, cause of admission and the location prior to admission were collected from an audit of medical notes.

RESULTS

271 people with IPD had one or more emergency admissions to NHCFT between 01/01/2020 and 31/12/2020. There was a total of 453 emergency admissions, with a median duration of 5 (IQR 2-13) days. The most common causes of admission to hospital were PD-related motor dysfunction (includes falls with no other underlying cause or associated injury) and injury (includes falls with fracture), at 78 (17.2%) and 70 (15.5%) respectively.

CONCLUSIONS

People with IPD had a short duration but high number of emergency admissions to hospital. Our chronological data on number of admissions shows a peak in admissions during August 2020. As a result of these findings and emerging data we suggest that individuals with PD deconditioned during 2020.

Predicting Unplanned Health Care Utilization and Cost: Comparing Patient-reported Outcomes Measurement Information System and Claims

OBJECTIVES

There is little literature describing if and how payers are utilizing patient-reported outcomes to predict future costs. This study assessed if Patient-reported Outcomes Measurement Information System (PROMIS) domain scores, collected in routine practice at neurology clinics, improved payer predictive models for unplanned care utilization and cost.

STUDY DESIGN

Retrospective cohort analysis of private Health Plan-insured patients with visits at 18 Health Plan-affiliated neurology clinics.

METHODS

PROMIS domains (Anxiety v1.0, Cognitive Function Abilities v2.0, Depression v1.0, Fatigue v1.0, Pain Interference v1.0, Physical Function v2.0, Sleep Disturbance v1.0, and Ability to Participate in Social Roles and Activities v2.0) are collected as part of routine care. Data from patients' first PROMIS measures between June 27, 2018 and April 16, 2019 were extracted and combined with claims data. Using (1) claims data alone and (2) PROMIS and claims data, we examined the association of covariates to utilization (using a logit model) and cost (using a generalized linear model). We evaluated model fit using area under the receiver operating characteristic curve (for unplanned care utilization), akaike information criterion (for unplanned care costs), and sensitivity and specificity in predicting top 15% of unplanned care costs.

RESULTS

Area under the receiver operating curve values were slightly higher, and akaike information criterion values were similar, for PROMIS plus claims covariates compared with claims alone. The PROMIS plus claims model had slightly higher sensitivity and equivalent specificity compared with claims-only models.

CONCLUSION

One-time PROMIS measure data combined with claims data slightly improved predictive model performance compared with claims alone, but likely not to an extent that indicates improved practical utility for payers.

Reasons for hospitalization and factors of mortality in patients with Parkinson's disease in the Philippines

Aim: We aimed to determine the reasons for hospitalizations and factors of mortality of Filipino Parkinson's disease (PD) patients in a tertiary hospital. Methods: We conducted a retrospective review of medical records of PD patients admitted to our institution between 2016 and 2018. Demographic and clinical data were analyzed. Results: We included 166 PD patients. The most common cause of admission was infectious (pneumonia, urinary tract, and skin-soft tissue infections) (n = 65, 39.2%). The most common cause of mortality was sepsis (n = 9, 5.4%). Renal comorbidity was a significant factor of mortality (OR: 3.67, 95% CI: 1.11-12.12; p = 0.033). Conclusion: Interventions designed to reduce the risk of complications in PD patients should be prioritized to potentially decrease the probability of eventual hospitalization.

Emergency Room Visit Prevention for Older Patients with Parkinsonism in a Geriatric Clinic

BACKGROUND

Older persons with parkinsonism (PWP) are at high risk for hospitalization and adverse outcomes. Few effective strategies exist to prevent Emergency Department (ED) visits and hospitalization. The interdisciplinary Geriatrics Clinic for Parkinson's ("our clinic") was founded to address the complexity of parkinsonism in older patients, supported by a pharmacist-led telephone intervention (TI) service. Our primary objective was to study whether TI could avert ED visits in older PWP.

METHODS

Using a prospective, observational cohort, we collected data from all calls in 2016, including who initiated and reasons for the calls, patient demographics, number of comorbidities and medications, diagnoses, duration of disease, and intervention provided. Calls with intention to visit ED were classified as "crisis calls". Outcome of whether patients visited ED was collected within 1 week, and user satisfaction by anonymous survey within 3 weeks.

RESULTS

We received 337 calls concerning 114 patients, of which 82 (24%) were "crisis calls". Eighty-one percent of calls were initiated by caregivers. Ninety-three percent of "crisis calls" resolved without ED visit after TI. The main reasons for "crisis calls" were non-motor symptoms (NMS) (39%), adverse drug effects (ADE) (29%), and motor symptoms (18%). Ninety-seven percent of callers were satisfied with the TI.

CONCLUSION

Pharmacist-led TI in a Geriatrics Clinic for Parkinson's was effective in preventing ED visits in a population of older PWP, with high user satisfaction. Most calls were initiated by caregivers. Main reasons for crisis calls were NMS and ADE. These factors should be considered in care planning for older PWP.

Variations in hospitalization rates across Parkinson's Foundation Centers of Excellence

INTRODUCTION

Patients with Parkinson's disease (PD) are at increased risk for hospitalization and often experience worsening of PD when hospitalized. It is therefore important to identify strategies to prevent hospitalization.

METHODS

Hospital encounter rates in different Parkinson's Foundation Centers of Excellence in United States, Canada, Israel and the Netherlands were analyzed as part of the Parkinson Foundation Parkinson's Outcomes Project (PF-POP). Multivariate logistic regression was used to estimate the odds ratio for hospitalization, adjusted for risk factors.

RESULTS

Baseline age, disease duration, other relative than spouse/partner as care giver, cancer, arthritis, other comorbidities, falls, use of levodopa, use of dopamine agonist, use of COMT inhibitor, occupational therapy before the baseline visit, PDQ-39, MSCI total score and time between visits were significantly associated with the risk of hospital encounters. After adjustment for these factors, two centers had significantly lower odds for hospitalization admission and ER visit (minimum OR 0.3) and four centers had significantly higher odds (maximum OR 1.5) than the average center. Four centers had significantly lower hazard ratios for time to re-hospitalization compared to the average center. Reducing hospital admission rates in those centers with higher than average rates would reduce overall hospitalizations by 11%. Applied to PD patients over 65 nationwide this represents a potential for cost savings of greater than $1 billion over 48 months.

CONCLUSION

Encounter rates vary even across expert centers and suggest that practices carried out in some centers may reduce the risk of hospitalization. Further research will be necessary to identify these practices and implement them more widely to improve care for people with PD.

Reducing medication errors for hospital inpatients with Parkinsonism

BACKGROUND

Patients with Parkinsonism are 1.5 times more likely than comparators to be hospitalised and have a significantly longer length of stay in hospital. Medication delays, inappropriate medication omission, and administration of contraindicated medications likely contribute to these poor outcomes. Education and hospital system interventions may reduce these errors.

AIM

To determine the effectiveness of a multimodal education and awareness campaign in reducing medication errors in patients with Parkinsonism at Hutt Hospital.

METHODS

We performed an audit of hospital medication charts to establish the baseline medication error rate and patient outcomes over a 3-month period. We then delivered an intervention consisting of staff education sessions, a sticker alert system and increased priority for pharmacist review of patient drug charts. We repeated the audit after the intervention.

RESULTS

In the initial audit, the medication error rate was 22.5%, the clinical complication rate was 45% and one death was directly attributable to medication error. At follow up, the medication error and complication rates were 9.3% (absolute difference 13% (95% conflict of interest (CI) 10-16.4), P < 0.001) and 38% (absolute difference 7% (95% CI -19 to 34), P = 0.59), respectively, and there were no attributable deaths. The average length of stay before and after the intervention was 13 and 8 days respectively (absolute difference 5.7 days (95% CI -1.8 to 13.3), P = 0.135).

CONCLUSIONS

There was a high in-hospital medication error rate for Parkinsonian patients. The intervention resulted in a statistically significantly improvement in the medication error rate. The estimated reductions in complication rate and length of stay may be clinically important. Similar interventions may be beneficial in other institutions.

Symptom progression in advanced Parkinson's disease: Dyadic perspectives

This qualitative descriptive study investigated the self-reported symptoms of people with advanced Parkinson's disease. Fifteen dyads (person with Parkinson's and family caregiver) participated in two semi-structured interviews over a six-month time period; content analysis was used to explore the progression and new onset of symptoms. Reported symptoms in descending order included gait deterioration, falls, speech impairment, cognitive decline, functional decline, gastrointestinal and genitourinary changes, and swallowing impairment. The presence of multiple, compounding symptoms present challenges for maintaining safety in the home, highlighting the need for in-home services to assist with symptom management. Change in self-reported symptom experience was not significantly different after a six-month time frame. Symptom progression in advanced Parkinson's disease may take longer than six months to appreciatively manifest. Therefore, future research should explore the progression of advanced Parkinson's disease longitudinally over of period of time that exceeds six months.

Interventions to minimize complications in hospitalized patients with Parkinson disease

Background

In this study, we sought to evaluate the efficacy of inpatient interventions on hospitalization-related complications in patients with Parkinson disease (PD). Hospitalized patients with PD have an increased risk of complications. Although several interventions have been suggested in the literature, data-driven recommendations are limited.

Methods

This study was designed as a prospective cohort study. A hospital-wide alert system was incorporated into the electronic medical record (EMR) system. The alert was triggered when a patient with PD or on dopaminergic therapy was admitted prompting the inpatient pharmacy to confirm medication details. A warning was also triggered if antidopaminergic medications were ordered. In-services were performed for nursing staff and physicians regarding these measures. Charts of patients with PD admitted 6 months before and after the intervention were reviewed to serve as the 2 comparison groups.

Results

There were 73 patients (mean 73.2 years) preintervention group and 103 patients (mean 72.3 years) postintervention group. There were no significant differences in reasons for admission, admission to neurologic vs non-neurologic floor, or admitting service between the groups. The percentage of patients for whom contraindicated medications were ordered decreased from 42.5% to 17.5% (p < 0.001). Medication administration with doses given over 30 minutes late decreased from 46% to 39% (p = 0.068). Medications ordered correctly were 42.9% vs 54.7% (p = 0.131) before and after the intervention. Length of stay was 5.3 vs 5.2 days (p = 0.896), and mean complications were 0.38 vs 0.37 (p = 0.864).

Conclusion

An intervention involving EMR alerts and in-service didactics for nurses and physicians decreased the frequency of contraindicated medications ordered in hospitalized patients with PD, but it did not change other hospital outcomes or complications.

Sex-Specific Patient Journeys in Early Parkinson's Disease in the Netherlands

Objective: To reconstruct a sex-specific patient journey for Dutch persons with Parkinson's disease (PD) during the first 5 years after diagnosis.

Method: We analyzed a national administrative medical claims database containing data of all patients newly diagnosed with PD between 2012 and 2016 in the Netherlands. We performed time-to-event analysis to identify the moments when patients received care from neurologists, allied healthcare therapists or general practitioners. We also extracted relevant clinical milestones: unexpected hospitalization for PD, pneumonia, orthopedic injuries, nursing home admission, and death. Using these data, we constructed the patient journey stratified for sex.

Results: We included claims data of 13,518 men and 8,775 women with newly diagnosed PD in the Netherlands. While we found little difference in neurologist consultations, women visited general practitioners and physiotherapists significantly earlier and more often (all p-values < 0.001). After 5 years, 37.9% (n = 3,326) of women had visited an occupational therapist and 18.5% (n = 1,623) a speech and language therapist at least once. This was 33.1% (n = 4,474) and 23.7% (n = 3,204) for men. Approximately 2 years after diagnosis, PD-related complications (pneumonia, orthopedic injuries, and PD-related hospitalization) occurred for the first time (women: 1.8 years; men: 2.3 years), and after 5 years, 72.9% (n = 6,397) of women, and 68.7% (n = 9,287) of men had experienced at least one.

Discussion: Considering the strengths and limitations of our methods, our findings suggest that women experience complications and access most healthcare services sooner after diagnosis and more frequently than men. The identified sex differences extend the debate about phenotypical differences in PD between men and women.

Multicentre, randomised controlled trial of PDSAFE, a physiotherapist-delivered fall prevention programme for people with Parkinson's

OBJECTIVE

To estimate the effect of a physiotherapist-delivered fall prevention programme for people with Parkinson's (PwP).

METHODS

People at risk of falls with confirmed Parkinson's were recruited to this multicentre, pragmatic, investigator blind, individually randomised controlled trial with prespecified subgroup analyses. 474 PwP (Hoehn and Yahr 1-4) were randomised: 238 allocated to a physiotherapy programme and 236 to control. All participants had routine care; the control group received a DVD about Parkinson's and single advice session at trial completion. The intervention group (PDSAFE) had an individually tailored, progressive home-based fall avoidance strategy training programme with balance and strengthening exercises. The primary outcome was risk of repeat falling, collected by self-report monthly diaries, 0-6 months after randomisation. Secondary outcomes included Mini-BESTest for balance, chair stand test, falls efficacy, freezing of gait, health-related quality of life (EuroQol EQ-5D), Geriatric Depression Scale, Physical Activity Scale for the Elderly and Parkinson's Disease Questionnaire, fractures and rate of near falling.

RESULTS

Average age is 72 years and 266 (56%) were men. By 6 months, 116 (55%) of the control group and 125 (61.5%) of the intervention group reported repeat falls (controlled OR 1.21, 95% CI 0.74 to 1.98, p=0.447). Secondary subgroup analyses suggested a different response to the intervention between moderate and severe disease severity groups. Balance, falls efficacy and chair stand time improved with near falls reduced in the intervention arm.

CONCLUSION

PDSAFE did not reduce falling in this pragmatic trial of PwP. Other functional tasks improved and reduced fall rates were apparent among those with moderate disease.

TRIAL REGISTRATION NUMBER

ISRCTN48152791.

The introduction of a Parkinson's disease email alert system to allow for early specialist team review of inpatients

BACKGROUND

Patients with Parkinson's disease (PWP) have complex healthcare needs, and compared to the general population, are more likely to have an unplanned emergency department (ED) attendance to hospital, along with poorer outcomes. Innovative methods of notification, when patients have an ED attendance are needed to allow for earlier specialist team interventions. This study describes the introduction of an email alert (e-alert) for a specialist Parkinson's team. In addition, the reason for admission, specialist team interventions, length of stay, frequency of readmission, discharge destination, mortality and the bed cost per ED attendance or admission episode will be explored.

METHODS

The e-alert was developed in collaboration with academics, a Parkinson's specialist team and hospital Information technology (IT) specialists, by employing existing software and IT system platforms. Patients were identified from an existing hospital patient administration and a specialist movement disorder database. Specific variables along with routine patient data were collected including demographics, clinical variables, specialist team interventions, reason for admission, length of stay, discharge destination, unscheduled readmission, mortality and bed cost per day.

RESULTS

The initial programming and setup of the e-alert was estimated to be around £3000. In its first six months, the e-alert identified 75 ED attendances, with the most common reasons being, falls and infections. The overall mean LOS was 6.8 days, with 25/75 patients being readmitted within 28 days. The most common specialist team clinical interventions were changes in medication, assessment for postural hypotension, neuropsychiatric and swallowing assessments. The majority of patients (92%) were discharged to their normal place of residence. The crude mortality rate for the cohort was approximately twice that of the hospital average. The total ED and acute bed cost was estimated to be £354,805.88, with exponential rises in healthcare costs when LOS was greater than one day.

CONCLUSIONS

The Parkinson's e-alert was found to a useful adjunct to existing hospital data systems in identifying PWP who have unplanned emergency attendances. Additionally, this system can also be employed as a service evaluation tool. However, further evaluation is needed to determine if this system can improve patient outcomes during their unplanned emergency attendance to hospital.

Dance is more than therapy: Qualitative analysis on therapeutic dancing classes for Parkinson's

OBJECTIVES

To understand the benefits and limitations of therapeutic dancing classes for people with Parkinson's disease (PD) and how best to design and implement classes.

DESIGN

A stakeholder forum explored the opinions of 18 allied health clinicians, dance instructors, people with PD and caregivers. Data were thematically analysed and interpreted within a grounded theory framework.

RESULTS

Four main themes were identified: (1) the need to consider the stage of disease progression when designing classes; (2) recognition that dance is more than just therapy; (3) the benefits of carefully selecting music to move by; (4) ways to design classes that are both feasible and engaging. These themes give rise to the theory that dancing classes can provide more than just therapeutic benefits. Dance affords creative expression and enables people to immerse themselves in the art-form, rather than focussing on the disease. The results highlight the benefits of enabling individuals with PD to be able to express themselves in a supportive environment that does not see them solely through the lens of Parkinson's. The feasibility of dance programs can be increased by educating dancing teachers about PD and the unique needs of people living with this condition.

CONCLUSION

Well-structured dance classes can promote social-connectedness and joy, in addition to facilitating movement to music and physical activity. Consumers advised that careful planning of the classes and tailoring them to participant needs optimizes outcomes.

Hospitalization and rehospitalization in Parkinson disease patients: Data from the National Parkinson Foundation Centers of Excellence

Background

Patients with Parkinson disease (PD) are at high risk of hospital encounters with increasing morbidity and mortality. This study aimed to determine the rate of hospital encounters in a cohort followed over 5 years and to identify associated factors.

Methods

We queried the data from the International Multicenter National Parkinson Foundation Quality Improvement study. Multivariate logistic regression with backward selection was performed to identify factors associated with hospital encounter prior to baseline visit. Kaplan-Meier estimates were obtained and Cox regression performed on time to hospital encounter after the baseline visit.

Results

Of the 7,507 PD patients (mean age 66.5±9.9 years and disease duration 8.9±6.4 years at baseline visit), 1919 (25.6%) had a history of a hospital encounter prior to their baseline visit. Significant factors associated with a history of a hospital encounter prior to baseline included race (white race: OR 0.49), utilization of physical therapy (OR 1.47), history of deep brain stimulation (OR 1.87), number of comorbidities (OR 1.30), caregiver strain (OR 1.17 per standard deviation), and the standardized Timed Up and Go Test (OR 1.21). Patients with a history of hospitalization prior to the baseline were more likely to have a re-hospitalization (HR1.67, P<0.0001) compared to those without a prior hospitalization. In addition, the time to hospital encounter from baseline was significantly associated with age and number of medications. In patients with a history of hospitalization prior to the baseline visit, time to a second hospital encounter was significantly associated with caregiver strain and number of comorbidities.

Conclusion

Hospitalization and re-hospitalization were common in this cohort of people with PD. Our results suggest addressing caregiver burden, simplifying medications, and emphasizing primary and multidisciplinary care for comorbidities are potential avenues to explore for reducing hospitalization rates.