Understanding the role of the Parkinson's disease nurse specialist in the delivery of apomorphine therpy

Old problems, new solutions: harnessing technology and innovation in Parkinson's disease-evidence and experiences from Thailand

The prevalence of Parkinson's disease (PD) is increasing rapidly worldwide, but there are notable inequalities in its distribution and in the availability of healthcare resources across different world regions. Low- and middle-income countries (LMICs), including Thailand, bear the highest burden of PD so there is an urgent need to develop effective solutions that can overcome the many regional challenges associated with delivering high-quality, and equitable care to a diverse population with limited resources. This article describes the evolution of healthcare delivery for PD in Thailand, as a case example of a LMIC. The discussions reflect the author's presentation at the Yoshikuni Mizuno Lectureship Award given during the 8th Asian and Oceanian Parkinson's Disease and Movement Disorders Congress in March 2023 for which he was the 2023 recipient. The specific challenges faced in Thailand are reviewed along with new solutions that have been implemented to improve the knowledge and skills of healthcare professionals nationally, the delivery of care, and the outcomes for PD patients. Technology and innovation have played an important role in this process with many new tools and devices being implemented in clinical practice. Without any realistic prospect of a curative therapy in the near future that could halt the current PD pandemic, it will be necessary to focus on preventative lifestyle strategies that can help reduce the risk of developing PD such as good nutrition (EAT), exercise (MOVE), good sleep hygiene (SLEEP), and minimizing environmental risks (PROTECT), which should be initiated and continued (REPEAT) as early as possible.

Integrating technology into a successful apomorphine delivery program in Thailand: a 10-year journey of achievements with a five-motto concept

Introduction

Apomorphine, a potent dopamine agonist, is a therapeutic option for patients with Parkinson's disease and motor fluctuations. However, the adoption of and adherence to this therapy have been limited by the need for complex delivery devices and specialized care as well as resource consumption, posing challenges for new physicians. Thailand is a unique example of a developing nation that has successfully implemented and continued the use of this therapy by employing cooperative technology that has dramatically enhanced apomorphine delivery services.

Methods

Establishing apomorphine delivery services requires significant resources and step-by-step solutions. We began our services by implementing various strategies in three chronological stages: the initial stage (2013-2015), intermediate stage (2016-2019), and current stage (2020-present), each presenting unique challenges. Together, we also implemented a proposed set of five mottos to strengthen our apomorphine delivery service. Using additive technology, we developed a patient registry platform that combined electronic data acquisition, video and remote monitoring using wearable sensors, and in-house mobile applications to support our service.

Results

At the initial stage, we assembled a team to enhance the efficacy and confirm the safety of apomorphine treatment in our hospital. At the intermediate stage, we expanded our apomorphine delivery services beyond just the patients at our hospital. We supported other hospitals in Thailand in setting up their own apomorphine services by educating both physicians and nurses regarding apomorphine therapy. With this educational undertaking, increased apomorphine-related knowledge among medical professionals, and a greater number of hospitals providing apomorphine services, an increasing number of patients were administered apomorphine in subsequent years. Currently, we are providing effective apomorphine delivery to improve patient outcomes and are seamlessly integrating technology into clinical practice. Incorporating integrative technologies in our apomorphine delivery program yielded positive results in data collection and support throughout patient care, in tracking patients' statuses, in the long-term use of this treatment, and in increasing medication adherence rates.

Conclusion

This perspective paper describes how technology can help provide supportive healthcare services in resource-constrained environments, such as in Thailand, offering a step-by-step approach to overcoming several limitations. The valuable insights from our 10-year journey in successfully integrating technology into apomorphine delivery services can benefit new physicians seeking to replicate our success.

Practical use of apomorphine infusion in Parkinson's disease: lessons from the TOLEDO study and clinical experience

Subcutaneous apomorphine infusion is a device-aided therapy for Parkinson's disease that can be considered when motor fluctuations become persistent and are no longer adequately controlled by oral/transdermal medication. Apomorphine infusion is less invasive than enteral levodopa, deep brain stimulation or focused ultrasound, and is often indicated even when neurosurgical approaches are contraindicated. This article aims to provide practical guidance for doctors and nurses initiating and treating patients with apomorphine infusion, and is based on both trial data and clinical experience from movement disorders specialists. A post hoc analysis of data from the TOLEDO randomized clinical trial of apomorphine infusion was conducted along with an analysis of 'real world' experience from 13 movement disorders specialists using a questionnaire that focused on starting patients on apomorphine infusion. Practical guidelines for starting treatment with apomorphine infusion are provided taking into consideration the regional disparities in healthcare. Apomorphine infusion is straightforward to administer but to be successful it requires concordance from the patient and family, and clinical support from an experienced team of doctors and nurses, particularly in the early months of treatment.

Towards improved access to device-aided therapies in advanced PD: the importance of cooperation of different disciplines

Managing the many issues in advanced Parkinson's disease (PD) requires education, continuous support, and specialized outpatient care involving a variety of allied healthcare professionals. It would be greatly appreciated if general neurologists and professionals from various disciplines who work with people diagnosed with Parkinson's disease (PwP) could remain knowledgeable about the existing therapies and their respective roles within the treatment continuum. The movement disorders specialist and the PD nurse are key actors in the coordination of a targeted and patient-empowering multidisciplinary approach for advanced PD. Affordable and timely access to these therapies for the PwP who may need them is presently a challenge for health systems. Education, training, and support for all the involved stakeholders in the process of PD care may improve quality of life both for PwP and caregivers, and reduce inadequate, expensive, time-consuming, and unsuccessful prolongation of standard medical therapies.

Feasibility and benefits of home initiation of subcutaneous apomorphine infusion for patients with Parkinson's disease: the APOKADO study

Continuous subcutaneous apomorphine infusion (CSAI) is used to treat patients with Parkinson's disease (PD) who are experiencing motor fluctuations. However, the need to initiate this treatment during a hospital stay may restrict patients' access to it. To assess the feasibility and benefits of initiating CSAI in the patient's own home. A French prospective multicenter longitudinal observational study (APOKADO) among patients with PD who required subcutaneous apomorphine, comparing in-hospital versus home initiation. Clinical status was assessed according to the Hoehn and Yahr score), the Unified Parkinson's Disease Rating Scale Part III, and the Montreal Cognitive Assessment. We assessed patients' quality of life with the 8-item Parkinson's Disease Questionnaire, rated the improvement in their clinical status on the 7-point Clinical Global Impression-Improvement scale, recorded adverse events, and ran a cost-benefit analysis. 145 patients with motor fluctuations were included in 29 centers (office and hospital). Of these, 106 (74%) were initiated onto CSAI at home, and 38 (26%) in hospital. At inclusion, the two groups were comparable for all demographic and PD characteristics. After 6 months, quality of life, adverse events and early dropout rates were similarly rare-across the two groups. Patients in the home group improved more quickly their quality of life and became more autonomous in managing the device than those in the hospital group, and their care costed less. This study shows that home (versus in-hospital) initiation of CSAI is feasible, improves patients' quality of life more quickly, with the same level of tolerance. It is also less expensive. This finding should make it easier for patients to access this treatment in the future.

Device-Aided Therapies in Parkinson's Disease-Results from the German Care4PD Study

Data on the use of device-aided therapies (DATs) in people with Parkinson's disease (PwP) are scarce. Analyzing data from the Care4PD patient survey, we (1) evaluated application frequency and type of DAT in a larger, nationwide, cross-sectoral PwP sample in Germany; (2) analyzed the frequency of symptoms indicative for advanced PD (aPD) and need for DAT amongst the remaining patients and (3) compared the most bothersome symptoms and need for professional long-term care (LTC) of patients with and without suspected aPD. Data from 1269 PwP were analyzed. In total, 153 PwP (12%) received DAT, mainly deep brain stimulation (DBS). Of the remaining 1116 PwP without DAT, >50% fulfilled at least one aPD criterion. Akinesia/rigidity and autonomic problems were most bothersome for PwP with and without suspected aPD, with more tremor in the non-aPD and more motor fluctuations and falls in the aPD group. To recapitulate, the German DAT application rate is rather low, although a large proportion of PwP fulfills aPD criteria indicating a need for intensified treatment strategies. Many reported bothersome symptoms could be overcome with DAT with benefits even for LTC patients. Thus, precise and early identification of aPD symptoms (and therapy-resistant tremor) should be implemented in future DAT preselection tools and educational trainings.

[Role of the MS nurse specialist in the patient's care pathway]

The specialized nurse in MS is a new profession practiced in MS clinics and outpatients specialized coordination structures. She is part of a specialized multi-professional team. The nurse must master a broad knowledge of the disease and the treatments. Have skills in therapeutic education, communication and coordination. She has a detailed knowledge of the resources of the care offer. The MS nurse thus participates in the assessment of the patient's needs for the implementation of a personalized care plan combining response to medical, paramedical, psychological and social needs.

The Role of Parkinson Nurses for Personalizing Care in Parkinson’s Disease: A Systematic Review and Meta-Analysis

Background: Quality of life (QoL) of persons with Parkinson’s disease (PD) is diminished by (non-)motor symptoms, that require personalized care. Parkinson Nurses (PN) may be pivotal promoting tailored care offerings. This systematic review and meta-analysis investigates PD care models and aims at furnishing current concepts of PN to offer personalized care. Objective: The purpose of this study is to identify the various roles and functions that PN may hold for personalized PD care. Methods: We performed a systematic literature review, utilizing: PubMed, Web of Science, The Cochrane Library, and PsycINFO. The review qualitatively evaluated articles, which described personalized care models involving PNs and was guided by the personalized care management model. A meta-analysis compared patient-reported QoL (quantified using the 39-item Parkinson’s Disease Questionnaire) between personalized care interventions involving PN versus standard care with. Results: Twenty-seven publications were identified, including six randomized, controlled trials ascertaining with health related QoL (n = 1830 PwPs). The qualitative evaluation revealed that PN contribute to all aspects of personalized care. The meta-analysis showed no improved QoL in personalized care models compared to standard care, thought a great heterogeneity among study design and interventions was outlined (Standardized Mean Difference = –0.8935; 95% Confidence Interval, –2.1177 to 0.3307; z = –1.43, p = 0.1526). Conclusion: PN fulfil important functions in personalized PD care. For the future, a clear role definition will be necessary to adjust training for PN across healthcare systems and care settings but especially to realize their full potential for PD care.

A Narrative Review of Specialist Parkinson’s Nurses: Evolution, Evidence and Expectation

Extended nursing roles have existed since the 1940s. The first specialist nurse for Parkinson’s disease, a complex neurodegenerative disease, was appointed in the United Kingdom (UK) in 1989. A review was undertaken using MEDLINE and Cumulative Index to the Nursing and Allied Health Literature (CINAHL), relating to the role and evidence for Parkinson’s disease nurse specialists (PDNSs). PDNSs fulfil many roles. Trials of their effectiveness have failed to show a positive benefit on health outcomes, but their input appears to improve the wellbeing of people with Parkinson’s. Now embedded in the UK Parkinson’s multidisciplinary team, this care model has since been adopted widely, including successful dissemination of training to countries in Sub-Saharan Africa. The lack of evidence to support the benefit of PDNSs may reflect an insufficient duration and intensity of the intervention, the outcome measures selected or the need to combine PDNS input with other evidence-based interventions. Whilst the current evidence base for their effectiveness is limited, their input appears to improve subjective patient wellbeing and they are considered a vital resource in management. Better evidence in the future will support the development of these roles and may facilitate the application of specialist nurses to other disease areas.

The importance of community nurses in supporting Parkinson's patients on complex therapies

A newly updated non-oral treatment pathway for people with Parkinson's who have complex needs provides clear, instructive guidance on identifying, assessing, treating and managing individuals on these therapies. While specialists provide much of the care within these pathways, district and community nurses are essential to ensure that patients progressing to more complex phases of the condition are identified and referred for specialist assessment, as well as being instrumental in the monitoring and ongoing management required once a new therapy is in place.

Parkinson’s disease in primary health care and nursing care: a scoping review

ABSTRACT Objective: to map and analyze the scientific literature on nursing care aimed at people with Parkinson’s disease in Primary Health Care. Method: this is a scoping review using the Joanna Briggs Institute methodology, carried out between July and October 2020, and updated in November 2021 in six databases from nursing care and Parkinson’s disease descriptors, and their respective acronyms and synonyms in English, Portuguese and Spanish. Results: a total of 44 publications were included in this review, which identified as nursing care in Primary Care: assessment of motor and non-motor functions; management of activities of daily living and instrumental activities of daily living; disease self-management education for people with Parkinson’s and their care partners; supervised group approach; and personal factor management. Conclusion: Nursing care for people with Parkinson’s at the primary level essentially involves actions that include providing focused care at an individual and group level, encompassing clinical assessment, patient education, patient involvement in the social context of care, and developing positive relationships with family members and caregivers.

Early factors for predicting discontinuation to subcutaneous Apomorphine infusion in Parkinson's disease: A prospective analysis of the Thai Apomorphine Registry

INTRODUCTION

Although continuous subcutaneous apomorphine infusion (CSAI) is an effective therapy for Parkinson's disease (PD) with motor fluctuations, data from Asian cohorts is limited. The therapy is often discontinued due to the complexity of its delivery.

METHODS

Fifty-one PD patients undergoing CSAI as an add-on therapy were enrolled in the Thai Apomorphine Registry, an electronic database that recorded clinical characteristics and parameters during the 14-consecutive-day titration and long-term follow-up. Factors at the time of titration were documented in order to identify predictors of long-term discontinuation.

RESULTS

Following initiation, PD patients were administered a mean CSAI dose of 5.89 mg/h (SD 1.36) over a mean time of 12.28 h (SD 1.90) each day. The mean follow-up period was 626.2 days (SD 619.17). Significant reductions in UPDRS-I, II, III, and IV scores, total NMSQ score, PDQ-8 score, daily off and dyskinesia hours, Timed Up and Go test, walking step test, levodopa-equivalent daily dose, number of times a day the levodopa was taken versus pre-CSAI values were observed (p < 0.05, each). Thirty-five (68.6%) patients discontinued during the follow-up period. Relative risks of variables recorded at the time of titration that determined discontinuation of CSAI therapy were an absence of full-time caregivers, achieving a daily off hours reduction <3.5 h, and NMSQ scores at the time of CSAI titration ≥9.5 points.

CONCLUSION

Identifying factors that predict discontinuation of CSAI at the time of its initiation may help physicians to better understand the patient's drug response and how to manage them long-term.

The effectiveness of specialized nursing interventions for patients with Parkinson disease: A randomized controlled study protocol

BACKGROUND

The purpose of this experiment is to evaluate the impact of the care of Parkinson disease nurse specialist on improving motor symptoms and life quality for patients with Parkinson disease (PD).

METHOD

This is a randomized controlled research, and it will be conducted from April 2021 to October 2021 at Sichuan Provincial People's Hospital. The experiment was granted through the Research Ethics Committee of Sichuan Provincial People's Hospital (004510293). All the patients suffer from PD, age 18 years or older, both female and male, regardless of the duration or severity of this disease are eligible. The exclusion criteria contains: lack sufficient knowledge to complete questionnaires, serious physical comorbidities or refuse to take part in the program. In our experiment, the major result measures are motor symptoms and life quality. For the measurement of life quality, we will utilize Parkinson disease Questionnaire-39, the most extensively utilized the scale of life quality in PD. The evaluation of motor symptoms severity is carried out with the revision of Unified Parkinson Disease Rating Scale sponsored by Movement Disorder Society.

RESULTS

Table 1 indicates clinical outcomes at different time points.

CONCLUSION

The Parkinson's disease nurse specialist care may promote the life quality in the PD patients.

TRIAL REGISTRATION NUMBER

researchregistry 6284.

Specialized Staff for the Care of People with Parkinson's Disease in Germany: An Overview

Access to specialized care is essential for people with Parkinson´s disease (PD). Given the growing number of people with PD and the lack of general practitioners and neurologists, particularly in rural areas in Germany, specialized PD staff (PDS), such as PD nurse specialists and Parkinson Assistants (PASS), will play an increasingly important role in the care of people with PD over the coming years. PDS have several tasks, such as having a role as an educator or adviser for other health professionals or an advocate for people with PD to represent and justify their needs. PD nurse specialists have been established for a long time in the Netherlands, England, the USA, and Scandinavia. In contrast, in Germany, distinct PDS models and projects have been established. However, these projects and models show substantial heterogeneity in terms of access requirements, education, theoretical and practical skills, principal workplace (inpatient vs. outpatient), and reimbursement. This review provides an overview of the existing forms and regional models for PDS in Germany. PDS reimbursement concepts must be established that will foster an implementation throughout Germany. Additionally, development of professional roles in nursing and more specialized care in Germany is needed.

Establishing apomorphine treatment in Thailand: understanding the challenges and opportunities of Parkinson's disease management in developing countries

INTRODUCTION

The increasing global burden of Parkinson's disease (PD) poses a particular challenge for developing countries, such as Thailand, when delivering care to a geographically diverse populace with limited resources, often compounded by a lack of expertise in the use of certain PD medications, such as device-aided therapies (DAT).

AREAS COVERED

A panel of local, regional, and international PD experts convened to review the unmet needs of PD in Thailand and share insights into effective delivery of DAT, focusing on experience with apomorphine infusion. Despite its proven efficacy and safety, implementation of apomorphine infusion as a new option was not straightforward. This has prompted a range of health-care professional and patient-focused initiatives, led by the Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders in Bangkok, to help establish a more coordinated approach to PD management throughout the country and ensure patients have access to suitable treatments.

EXPERT OPINION

Overcoming the challenges of education, proficiency, resource capacity and standard of care for PD patients in developing countries requires a coordinated effort both nationally and beyond. The best practices identified in Thailand following the introduction of apomorphine infusion might be helpful for other countries when implementing similar programs.

Management of Advanced Therapies in Parkinson's Disease Patients in Times of Humanitarian Crisis: The COVID-19 Experience

Background

Although the COVID-19 pandemic is affecting a relatively small proportion of the global population, its effects have already reached everyone. The pandemic has the potential to differentially disadvantage chronically ill patients, including those with Parkinson's disease (PD). The first health care reaction has been to limit access to clinics and neurology wards to preserve fragile patients with PD from being infected. In some regions, the shortage of medical staff has also forced movement disorders neurologists to provide care for patients with COVID-19.

Objective

To share the experience of various movement disorder neurologists operating in different world regions and provide a common approach to patients with PD, with a focus on those already on advanced therapies, which may serve as guidance in the current pandemic and for emergency situations that we may face in the future.

Conclusion

Most of us were unprepared to deal with this condition given that in many health care systems, telemedicine has been only marginally available or only limited to email or telephone contacts. In addition, to ensure sufficient access to intensive care unit beds, most elective procedures (including deep brain stimulation or the initiation of infusion therapies) have been postponed. We all hope there will soon be a time when we will return to more regular hospital schedules. However, we should consider this crisis as an opportunity to change our approach and encourage our hospitals and health care systems to facilitate the remote management of chronic neurological patients, including those with advanced PD.

Delivering patient-centered care in Parkinson's disease: Challenges and consensus from an international panel

An international panel of movement disorders specialists explored the views and perceptions of people with Parkinson's disease (PD) about their condition and its treatment, including the potential mismatch between the clinician's view of the patient's condition and their own view of what aspects of the disease most affect their daily lives. The initiative was focused on Asian countries, so participants comprised experts in the management of PD from key centers in Asia, with additional insight provided by European and the North American movement disorders experts. Analysis of peer-reviewed publications on patient perceptions of PD and the factors that they consider important to their wellbeing identified several contributing factors to the mismatch of views, including gaps in knowledge of PD and its treatment, an understanding of the clinical heterogeneity of PD, and the importance of a multidisciplinary approach to patient care. The faculty proposed options to bridge these gaps to ensure that PD patients receive the personalized treatment they need to achieve the best possible outcomes. It was considered essential to improve patient knowledge about PD and its treatment, as well as increasing the awareness of clinicians of PD heterogeneity in presentation and treatment response. A multidisciplinary and shared-care approach to PD was needed alongside the use of patient-centered outcome measures in clinical trials and clinical practice to better capture the patient experience and improve the delivery of individualized therapy.

What can the treatment of Parkinson's disease learn from dementia care; applying a bio-psycho-social approach to Parkinson's disease

BACKGROUND

Within contemporary medical practice, Parkinson's disease (PD) is treated using a biomedical, neurological approach, which although bringing numerous benefits can struggle to engage with how people with PD experience the disease. A bio-psycho-social approach has not yet been established in PD; however, bio-psycho-social approaches adopted within dementia care practice could bring significant benefit to PD care.

METHODS

This paper summarises existing bio-psycho-social models of dementia care and explores how these models could also usefully be applied to care for PD. Specifically, this paper adapts the bio-psycho-social model for dementia developed by Spector and Orrell (), to suggest a bio-psycho-social model, which could be used to inform routine care in PD.

RESULTS

Drawing on the biopsychosocial model of Dementia put forward by Spector and Orrell (), this paper explores the application of a bio-psycho-social model of PD. This model conceptualises PD as a trajectory, in which several interrelated fixed and tractable factors influence both PD's symptomology and the various biological and psychosocial challenges individuals will face as their disease progresses. Using an individual case study, this paper then illustrates how such a model can assist clinicians in identifying suitable interventions for people living with PD.

CONCLUSION

This model concludes by discussing how a bio-psycho-social model could be used as a tool in PD's routine care. The model also encourages the development of a theoretical and practical framework for the future development of the role of the PD specialist nurse within routine practice.

IMPLICATIONS FOR PRACTICE

A biopsychosocial approach to Parkinson's Disease provides an opportunity to move towards a holistic model of care practice which addresses a wider range of factors affecting people living with PD. The paper puts forward a framework through which PD care practice can move towards a biopsychosocial perspective. PD specialist nurses are particularly well placed to adopt such a model within routine clinical practice, and should therefore be encouraged within PD services.

Magnetic Resonance Imaging as a Noninvasive Method for Longitudinal Monitoring of Infusion Site Reactions Following Administration of a Novel Apomorphine Formulation

Infusion site reactions are common following subcutaneous infusion of drugs. Such reactions can lead to discontinuation of the treatment. Therefore, assessment of such reactions is essential during preclinical safety studies, and magnetic resonance imaging (MRI) can assist in evaluation. Here, in vivo and ex vivo MRI evaluations were used in addition to classical histopathology to assess the infusion site reaction to ND0701, a novel formulation of apomorphine base developed for the treatment of Parkinson’s disease, in comparison to the commercial apomorphine hydrochloride (HCl) formulation. Both formulations, each at two concentrations, were continuously administered subcutaneously for 20 hr to each of 3 male and 3 female domestic pigs. Based on MRI evaluations, there was a gradual decrease in the volume of the subcutaneous lesions over 4 weeks, with smaller lesions and quicker resolution with ND0701 at concentrations 2.5- to 5-fold higher when compared to the commercial apomorphine HCl formulation. Histopathological evaluation of ND0701 revealed only minimal inflammation at the sites of infusion, whereas the commercial apomorphine HCl caused persistent inflammatory reactions and necrosis. This study provides support to the use of MRI in preclinical testing of subcutaneous drugs when evaluating local site reactions.