Disability and use of healthcare resources in Brazilian patients with Parkinson's disease

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.

The Causes and Impact of Crisis for People with Parkinson's Disease: A Patient and Carer Perspective

BACKGROUND

The reasons for acute hospital admissions among people with Parkinson's disease are well documented. However, understanding of crises that are managed in the community is comparatively lacking. Most existing literature on the causes of crisis for people with Parkinson's disease (PwP) uses hospital data and excludes the individual's own perspective on the crisis trigger and the impact of the crisis on their care needs.

OBJECTIVE

To identify the causes and impact of crises in both community and hospital settings, from a patient and carer perspective.

METHODS

A total of 550 UK-based PwP and carers completed a survey on (a) their own personal experiences of crisis, and (b) their general awareness of potential crisis triggers for PwP.

RESULTS

In addition to well-recognised causes of crisis such as falls, events less widely associated with crisis were identified, including difficulties with activities of daily living and carer absence. The less-recognised crisis triggers tended to be managed more frequently in the community. Many of these community-based crises had a greater impact on care needs than the better-known causes of crisis that more frequently required hospital care. PwP and carer responses indicated a good general knowledge of potential crisis triggers. PwP were more aware of mental health issues and carers were more aware of cognitive impairment and issues with medications.

CONCLUSION

These findings could improve care of Parkinson's by increasing understanding of crisis events from the patient and carer perspective, identifying under-recognised crisis triggers, and informing strategies for best recording symptoms from PwP and carers.

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.

Average annual cost of Parkinson's disease in São Paulo, Brazil, with a focus on disease-related motor symptoms

Background

Although Parkinson's disease is the second most prevalent neurodegenerative disease worldwide, its cost in Brazil - South America's largest country - is unknown.

Objective

The goal of this study was to calculate the average annual cost of Parkinson's disease in the city of São Paulo (Brazil), with a focus on disease-related motor symptoms.

Subjects and methods

This was a retrospective, cross-sectional analysis using a bottom-up approach (ie, from the society's perspective). Patients (N=260) at two tertiary public health centers, who were residents of the São Paulo metropolitan area, completed standardized questionnaires regarding their disease-related expenses. We used simple and multiple generalized linear models to assess the correlations between total cost and patient-related, as well as disease-related variables.

Results

The total average annual cost of Parkinson's disease was estimated at US$5,853.50 per person, including US$3,172.00 in direct costs (medical and nonmedical) and US$2,681.50 in indirect costs. Costs were directly correlated with disease severity (including the degree of motor symptoms), patients' age, and time since disease onset.

Conclusion

In this study, we determined the cost of Parkinson's disease in Brazil and observed that disease-related motor symptoms are a significant component of the costs incurred on the public health system, patients, and society in general.

Clinical Complexity and Use of Antipsychotics and Restraints in Long-Term Care Residents with Parkinson's Disease

BACKGROUND

Patients with Parkinson's disease (PD) and/or Parkinsonism are affected by a complex burden of comorbidity. Many ultimately require institutional care, where they may be subject to the application of physical restraints or the prescription of antipsychotic medications, making them more vulnerable to adverse outcomes.

OBJECTIVES

The objectives of this paper are to: 1) describe the clinical complexity of older institutionalized persons with PD; and 2) examine patterns and predictors of restraint use and prescription of antipsychotics in this population.

METHODS

Population-based cross-sectional cohort study. Residents with PD and/or Parkinsonism living in long-term care (LTC) facilities in 6 Canadian provinces and 1 Northern Territory and Complex Continuing Care (CCC) facilities in Manitoba and Ontario, Canada. The RAI MDS 2.0 instrument was used to assess all LTC residents and CCC residents. Clinical characteristics and the prevalence of major comorbidities were examined. Multivariate modeling was used to identify the characteristics of PD residents most associated with the prescription of antipsychotics and the use of restraints in LTC and CCC facilities.

RESULTS

Residents with PD in LTC and CCC exhibit a high prevalence of dementia, major psychiatric disorders, stroke, heart failure, chronic obstructive pulmonary disease and diabetes mellitus. More than 90% of LTC and CCC residents with PD had cognitive impairment; with more than half having moderate to severe impairment. Residents with PD were more likely to receive antipsychotics than those without PD. Antipsychotic use was associated with psychosis and aggressive behaviours, but also with unsteady gait and higher comorbidity and medication count. Similarly, although more common in CCC than LTC facilities, both psychosis and aggressive behaviours were associated with restraint use, as was greater cognitive and functional impairment, and urinary incontinence. Younger age, male gender, and lower physician access were all associated with greater antipsychotic and restraint use.

CONCLUSIONS

LTC and CCC residents with PD are very complex medically. Use of antipsychotics and restraints is common, and their use is often associated with factors other than psychosis or aggression.

Systematic Review and Critical Analysis of Cost Studies Associated with Parkinson's Disease

Parkinson's disease (PD) is the second most prevalent neurodegenerative disease worldwide, affecting more than four million people. Typically, it affects individuals above 45, when they are still productive, compromising both aging and quality of life. Therefore, the cost of the disease must be identified, so that the use of resources can be rational and efficient. Additionally, in Brazil, there is a lack of research on the costs of neurodegenerative diseases, such as PD, a gap addressed in this study. This systematic review critically addresses the various methodologies used in original research around the world in the last decade on the subject, showing that costs are hardly comparable. Nonetheless, the economic and social impacts are implicit, and important information for public health agents is provided.

How do demographic transitions and public health policies affect patients with Parkinson's disease in Brazil?

Brazil is currently experiencing a significant demographic transition characterized by a decrease in fertility rates and an exponential increase in the number of elderly citizens, which presents a special challenge for the health care professionals. More than other portions of the population, the elderly are most commonly affected by chronic diseases such as Parkinson’s disease. Policymakers contend that Brazil is reasonably well-prepared regarding elderly health care, with policies that aim to ensure the quality of life and the well-being of this portion of the population. However, what happens in practice falls short of what the Brazilian Constitution sets forth. Specifically, there is a clear contradiction between what the law recognizes as being a citizen’s rights and the implementation of guidelines. Because health financing in Brazil remains relatively low, the civil society tries to fill in the gaps as much as possible in the treatment of elderly patients suffering from chronic diseases such as Parkinson’s disease. In this review, we outline the current legislation in Brazil regarding the elderly and in particular, patients with Parkinson’s disease, in the context of a rapidly aging population.

Prodromal symptoms and early detection of Parkinson's disease in general practice: a nested case-control study

BACKGROUND

Timely diagnosis of Parkinson's disease (PD), facilitating early intervention, depends largely on the GP's awareness of early symptomatology. For general practice, it is unknown which prodromal symptoms (symptoms preceding the typical motor symptoms of PD) demand the GP's alertness.

OBJECTIVE

To assess prodromal symptoms that should alert the GP to the possibility of PD in primary care patients.

METHODS

A nested case-control study was carried out in a population of approximately 12000 patients registered in the Continuous Morbidity Registration database affiliated with the University of Nijmegen in the Netherlands. The database pools subject data from four primary care practices. The subjects comprised all 86 patients diagnosed with PD between 1972 and 2007, and 78 controls, matched by sex, age, socioeconomic status and primary care practice. The primary measures of outcome were the prodromal symptoms presenting in the two years prior to the diagnosis of PD. The number (and type) of referrals and diagnostic tests were also assessed.

RESULTS

In the two-year period prior to diagnosis, PD patients more often presented with functional somatic symptoms, constipation, hyperhidrosis and sleep disorders than controls. Patients also more frequently experienced more than one prodromal symptom and were more often referred within the primary care team or to a medical specialist.

CONCLUSIONS

Prodromal symptoms of PD are encountered in general practice. GPs should be alert when patients present with multiple prodromal symptoms in a two-year period, especially considering the benefits of early intervention, and the future possibilities for disease-modifying therapy.

Functional Decline Predicts Emergency Department Use in Veterans With Dementia

BACKGROUND

We examined emergency room (ER) utilization by persons with dementia (PWDs) using caregiver and patient characteristics as predictors.

METHODS

A secondary analysis of 296 veteran-caregiver dyads. Caregivers recorded PWD baseline characteristics and noted ER visits over the next year. Two sets of regression models analyzed categorical ER use and repeat ER use.

RESULTS

In the univariate analysis, categorical use of the ER was predicted by patients' functional status (P ≤ .008) and Veterans Affairs priority grouping (P ≤ .02). Repeat ER admissions were predicted by functional status (P ≤ .04), number of chronic conditions (P ≤ .01), and caregiver-reported relationship strain (P ≤ .04). In multivariate analysis, categorical ER use was predicted by functional status (P ≤ .02), priority grouping (P ≤ .03), and number of chronic conditions (P ≤ .06).

CONCLUSIONS

Functional status most strongly predicted ER use, highlighting the promise of home-based interventions to improve activities of daily living. Number of chronic conditions and caregiver-reported relationship strain are potential targets of intervention during discharge process.

Drug and treatment costs in Parkinson's disease patients in Sweden

BACKGROUND

Parkinson's disease (PD) is a chronic neurodegenerative disease expected to cause great costs. The aim of this study was to calculate drug and treatment costs in patients with PD in Sweden.

METHOD

All healthcare contacts of patients with PD in Stockholm County, Sweden, were extracted from registers together with information on reimbursements from the authorities to the caregivers. PD-related costs were calculated together with non-PD-related costs. Cost per patient was calculated and extrapolated to the whole Swedish population, taking population demographics into consideration. In addition, nationwide PD drug sales statistics were included.

RESULTS

The PD prevalence of Stockholm County was estimated to 196 per 100,000 inhabitants, resulting in an estimated total of about 22,000 patients with PD in Sweden. The cost per patient was estimated to SEK 76,000 of which drug costs accounted for SEK 15,880. The annual direct costs in patients with PD in Sweden were SEK 1.7 billion in 2009.

CONCLUSION

Our study estimates high direct costs in patients with PD in Sweden, SEK 1.7 billion, 52% for inpatient care, 27% for outpatient care and 21% for drugs. With an ageing population and the medical progress, the financial burden on society will most probably increase in the future. This study might initiate and provide information for discussions about future cost allocations and healthcare priorities.

Clinical problems in the hospitalized Parkinson's disease patient: systematic review

The problems Parkinson's disease (PD) patients encounter when admitted to a hospital, are known to be numerous and serious. These problems have been inventoried through a systematic review of literature on reasons for emergency and hospital admissions in PD patients, problems encountered during hospitalization, and possible solutions for the encountered problems using the Pubmed database. PD patients are hospitalized in frequencies ranging from 7 to 28% per year. PD/parkinsonism patients are approximately one and a half times more frequently and generally 2 to 14 days longer hospitalized than non-PD patients. Acute events occurring during hospitalization were mainly urinary infection, confusion, and pressure ulcers. Medication errors were also frequent adverse events. During and after surgery PD patients had an increased incidence of infections, confusion, falls, and decubitus, and 31% of patients was dissatisfied in the way their PD was managed. There are only two studies on medication continuation during surgery and one analyzing the effect of an early postoperative neurologic consultation, and numerous case reports, and opinionated views and reviews including other substitutes for dopaminergic medication intraoperatively. In conclusion, most studies were retrospective on small numbers of patients. The major clinical problems are injuries, infections, poor control of PD, and complications of PD treatment. There are many (un-researched) proposals for improvement. A substantial number of PD patients' admissions might be prevented. There should be guidelines concerning the hospitalized PD patients, with accent on early neurological consultation and team work between different specialities, and incorporating nonoral dopaminergic replacement therapy when necessary.

Lower extremity isokinetic muscle strength in patients with Parkinson's disease

We evaluated lower extremity isokinetic muscle strength to determine affected muscle groups and their dependence on movement velocity, and to establish the relationship between muscle strength and clinical severity, as well as muscle strength and falls, in Parkinson's disease (PD). Twenty-five patients diagnosed with PD and 24 healthy volunteers were enrolled in this study. Lower extremity muscle strength was measured using an isokinetic dynamometer. Each participant's clinical status was examined in accordance with the Unified Parkinson's Disease Rating Scale; fall history was also recorded. We observed a significant decrease in isokinetic muscle strength in the patient group, especially in both hip and knee flexors and extensors. Decreased muscle strength was independent of velocity, and correlated with clinical severity and falls. Movement velocity-independent lower extremity isokinetic muscle weakness has been observed in patients with PD, especially in the knee and hip joints. The evaluation of isokinetic muscle strength may be a useful tool for the assessment of clinical severity and falls in PD.