Severely Affected by Parkinson Disease: The Patient's View and Implications for Palliative Care

A systematic practice review: Providing palliative care for people with Parkinson's disease and their caregivers

BACKGROUND

People with Parkinson's disease has significant and increasing physical, psychosocial and spiritual needs, as well as problems with coordination and continuity of care. Despite the benefits that palliative care could offer, there is no consensus on how it should be delivered.

AIM

The aim of this study is to provide a pragmatic overview of the evidence to make clinical recommendations to improve palliative care for people with Parkinson's disease and their caregivers.

DESIGN

A systematic review method was adopted to determine the strength of evidence, supported by feedback from an expert panel, to generate the 'do', 'do not do' and 'do not know' recommendations for palliative care.

DATA SOURCES

Searches were conducted via OVID to access CINAHL, MEDLINE, EMBASE and the Cochrane Library from 01/01/2006 to 31/05/2021. An additional search was conducted in December 2022. The search was limited to articles that included empirical studies of approaches to enabling palliative care.

RESULTS

A total of 62 studies met inclusion criteria. There is evidence that education about palliative care and movement disorders is essential. palliative care should be multi-disciplinary, individualised and coordinated. Proactive involvement and support of caregivers throughout the illness is recommended. Limited data provide referral indicators for palliative care integration. Discussions about advance care planning should be held early.

CONCLUSIONS

Consideration of palliative care integration based on symptom burden and personal preferences, coordination and continuity of care are needed to maintain the quality of life of people with Parkinson's disease and their caregivers.

Community-based neuropalliative care

Community-based palliative care is defined as palliative care delivered outside of the hospital and outpatient clinics. These settings include the home, nursing homes, day programs, volunteer organizations, and support groups. There is strong evidence outside of the neuropalliative context that community-based palliative care can reduce hospital costs and admissions at the end of life. Research that focuses on specialized community-based palliative care for neurologic disease have similar findings, although with significant variability across conditions and geographic locations. Several of these studies have investigated home-based care for neurologic conditions including dementia, Parkinson's disease, multiple sclerosis, brain tumors, and motor neuron disease. Other work has focused on incorporating palliative care models into the treatment of patients with neurologic diseases within nursing home settings. Similar to nonneurologic community-based palliative care, little has been published on patient and caregiver quality-of-life outcomes in such models of care, although the emerging data are generally positive. Future studies should explore how best to provide comprehensive, cost-effective, scalable, and replicable models of community-based neuropalliative care, patient and caregiver outcomes in such models, and how care can be adapted between and within specific patient populations and healthcare systems.

Tracking Emergence of New Motor and Non-Motor Symptoms Using the MDS-UPDRS: A Novel Outcome Measure for Early Parkinson’s Disease?

Background:

Summary scores of current clinical rating scales do not appear sensitive enough to quantify changes in disease progression in early Parkinson’s disease (PD) clinical trials. An alternate approach might be to track the appearance of new or emergent symptoms (ES) over time as a measure of disease progression.

Objective:

Explore the potential utility of patient reported ES as an outcome measure during the early phase of PD.

Methods:

We analyzed data from the MDS-UPDRS Parts IB (non-motor) and II (motor) Experiences of Daily Living scales over two years in the STEADY-PD3 study. We assessed the number of ES reported in each part of the scale in both participants who started symptomatic treatment and those who did not (STx-yes/no) in two periods: between 0 and 12-months (Year 1), and 13 and 24-months (Year 2).

Results:

Of 331 participants, 87% developed ES, and 55% started STx in Year 1. The median number of Part IB ES did not significantly differ between STx groups, but ES in Part II were significantly more frequent in the STx-yes group. Of 148 participants who remained STx-no into Year 2, 77% developed ES, and 42% started STx. Again, Part II, but not Part IB ES were more frequent the STx-yes group. Using these results, a sample size of ∼90 per group would be required to detect a 30% reduction in combined Part IB and II ES over 12 months.

Conclusion:

Assessing ES of patient-reported experiences of daily living may provide a useful marker for tracking PD progression.

Predictive Model of Quality of Life in Patients with Parkinson's Disease

Parkinson's disease is a chronic, progressive, and disabling neurodegenerative disease which evolves until the end of life and triggers different mood and organic alterations that influence health-related quality of life. The objective of our study was to identify the factors that negatively impact the quality of life of patients with Parkinson's disease and construct a predictive model of health-related quality of life in these patients.

METHODS

An analytical, prospective observational study was carried out, including Parkinson's patients at different stages in the Albacete Health Area. The sample consisted of 155 patients (T0) who were followed up at one (T1) and two years (T2). The instruments used were a purpose-designed data collection questionnaire and the "Parkinson's Disease Questionnaire" (PDQ-39), with a global index where a higher score indicates a worse quality of life. A multivariate analysis was performed by multiple linear regression at T0. Next, the model's predictive capacity was evaluated at T1 and T2 using the area under the ROC curve (AUROC).

RESULTS

Predictive factors were: sex, living in a residence, using a cane, using a wheelchair, having a Parkinson's stage of HY > 2, having Alzheimer's disease or a major neurocognitive disorder, having more than five non-motor symptoms, polypharmacy, and disability greater than 66%. This model showed good predictive capacity at one year and two years of follow-up, with an AUROC of 0.89 (95% CI: 0.83-0.94) and 0.83 (95% CI: 0.76-0.89), respectively.

CONCLUSIONS

A predictive model constructed with nine variables showed a good discriminative capacity to predict the quality of life of patients with Parkinson's disease at one and two years of follow-up.

Advanced Care Planning in Parkinson's Disease: In-depth Interviews With Patients on Experiences and Needs

Introduction: Advance care planning (ACP) is an iterative process of discussing the needs, wishes, and preferences of patients regarding disease-specific and end-of-life issues. There is ample evidence that ACP improves the quality of life and promotes the autonomy of patients with cancer and motor neuron disease who have a high disease burden and shortened life expectancy. In Parkinson's disease (PD) though, knowledge about the experiences and preferences of patients regarding ACP is scarce, despite the major disease burden associated with PD.

Aim: This study aims to explore the experiences, needs, and preferences of PD patients regarding the content and timing of ACP.

Methods: In-depth interviews were conducted with a purposively selected sample of patients diagnosed with PD. Using a semi-structured topic list, the participants were asked about their prospects for a future living with PD and with whom they wanted to discuss this. Qualitative analysis was performed in parallel with data collection using a data-driven constant comparative approach. The transcribed interviews were coded and analyzed by two researchers using MAXQDA software.

Results: Of all 20 patients (13 males; age 47–82; disease duration 1–27 years), most expressed a wish to talk about ACP with a healthcare provider, enabling them to anticipate the uncertain future. The majority of patients preferred their healthcare provider to initiate the discussion on ACP, preferably at an early stage of the disease. Nearly all patients expressed the wish to receive more information regarding the long-term impact of PD, although, the preferred timing varied between patients. They also perceived that their neurologist was primarily focused on medication and had little time to address their need for a more holistic approach toward living with PD.

Conclusion: Our results suggest that PD patients are in need of discussing ACP with their healthcare provider (HCP), even in the early stages of the disease. In addition, PD patients perceive a lack of information on their disease course and miss guidance on available supportive care. We recommend HCPs to inquire the information requirements and preferences of patients regarding ACP regularly, starting soon after diagnosis.

Using an economic evaluation approach to support specialist nursing services for people with Parkinson's in a regional community

Aim

This study aims to provide economic evidence of the cost‐effectiveness of employing specialist Parkinson's nurses in a regional community in Australia.

Study design

This retrospective study utilized hospital service usage data to compare outcomes for people with Parkinson's disease before and after the employment of a specialist Parkinson's nurse in a regional community.

Methods

A representative sample was drawn from the target population of people with a diagnosis of Parkinson's admitted to a regional hospital over a 4‐year period (2013–2014 and 2016–2017). A multiple regression approach and cost–benefit analysis were used to examine hospital costs related to length of stay based on hospital records. All costs were attributed to resource allocation according to service category and the national funding system. Quantitative data were analysed using Strata Analytics.

Results

Statistical findings demonstrated a reduction in hospital length of stay ranging from 0.37 (AUD$1924) to 0.755 day (AUD$3926) after the establishment of the specialist Parkinson's nurse. The cost–benefit analysis showed a net dollar benefit, or savings in hospital costs, of up to $8600.00 per person over a 3‐year period, as a result of the specialist Parkinson's nurse intervention.

Conclusion

The statistical results show significant cost benefits associated with reduced length of hospital stay following introduction of the specialist Parkinson's nurse. These findings support advocacy for sustainable specialist Parkinson's nurse positions and have the potential to inform and influence policy and systemic changes within the health care system.

Impact

The benefits of embedding specialist nursing services for people with Parkinson's disease in primary health settings include the direct impact on the potential to avoid hospital admissions due to worsening symptoms, improving quality of life for the person with Parkinson's and slowing the trajectory of the disease. Additional benefits are increased access to specialist services and reduced family caregiver burden.

Preferences for Communication About End-of-Life Care in Atypical Parkinsonism

BACKGROUND

Studies on preferences regarding discussions on end-of-life care (EOLC), advance care planning (ACP), medical assistance in dying (MAiD), and brain donation have not yet been conducted in patients with atypical parkinsonism (AP).

OBJECTIVE

The aim of this study was to know the preferences of patients with AP regarding discussions on EOLC, ACP, MAiD, and brain donation.

METHODS

This cross-sectional study was conducted in patients clinically diagnosed with AP. An adapted questionnaire that assessed various potential factors that affect patients' preferences regarding EOLC and ACP was sent through postal mail to 278 patients.

RESULTS

A total of 90 completed questionnaires were returned. Most patients preferred to discuss at the time of diagnosis information about the disease, its natural course, treatment options, and prognosis. In contrast, they preferred that EOLC and ACP be discussed when the disease has progressed. No demographic or disease-related factors were found to be predictors of the patient's preferences. Notably, most patients (63.3%) had previous actual discussions on these issues. Less than a third of patients were open to discussions about MAiD and brain donation; older age and the importance of spirituality and religion decreased the odds of discussing these.

CONCLUSIONS

Our study demonstrates that patients with AP have preferences regarding the timing of the discussion of the different themes surrounding EOLC and ACP. A needs-based approach in initiating and conducting timely discussions on these difficult but essential issues is proposed. A thorough explanation and recognition of a patient's beliefs are recommended when initiating conversations about MAiD and brain donation. © 2021 International Parkinson and Movement Disorder Society.

Evolution of Quality of Life in Persons with Parkinson's Disease: A Prospective Cohort Study

Parkinson's disease (PD) is a chronic neurodegenerative disorder that results in important functional symptoms, altered mood, and deterioration in quality of life (QoL). This study aimed to determine the evolution of the QoL in persons with PD in the Albacete health district over a two-year period and identify associated sociodemographic, clinical, and socio-health characteristics. A cohort study was conducted of patients at different stages of PD in the Albacete health district. Calculated sample size: 155 patients. Instruments: A purpose-designed questionnaire for data collection and the "Parkinson Disease Questionnaire" (PDQ-39), which measures 8 dimensions and a global index where a higher score indicates worse quality of life. Three measurements were made: baseline, one year, two years. A descriptive and bivariate analysis was conducted. Ethical aspects: informed consent, anonymized data. Results: Mean age 69.51 (standard deviation, SD 8.73) years, 60% male, 75.5% married, and 85.5% lived with family. The most frequent motor symptoms were slow movement (86.23%), postural instability (55.5%), tremor (45.5%), and dyskinesia (24.6%). Among the non-motor symptoms were fatigue (66.2%), pain, daytime somnolence, constipation, and apathy, with approximately 50% each. The mean QoL score at baseline was 27.47 (SD 16.14); 95% CI (confidence interval) 24.91-30.03. At two years, global QoL had slightly worsened (28.3; SD 17.26; 95% CI 25.41-31.18), with a statistically significant worsening in mobility, activities of daily living, and communication, whereas social support improved.

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.

A Pilgrim's Journey-When Parkinson's Disease Comes to an End in Nursing Homes

Our interdisciplinary mixed-methods exploratory study was aimed at gaining empirical data on the medical and nursing demands of residents who are in a late stage of Parkinson Disease (PD) and are cared for in residential homes in Salzburg (Austria). In earlier studies it has been concluded that symptom burden of late stage PD patients is similar to or even higher compared with oncological patients. However, although all nine residents who took part in our study had severe limitations in performing their daily activities and experienced enormous restrictions in their mobility, they were quite content with their present living situations and did not show significant symptom burden. From the ethnographic family interviews that we conducted the following features emerged: a strong closeness in the family, an improved quality of life when the patients lived in the nursing home and fears about the future. Therefore, we concluded that living in a nursing home that provides for the needs of these patients is the best option for PD patients in the final stages of their disease as well as for their relatives.

Recent developments in solid lipid nanoparticle and surface-modified solid lipid nanoparticle delivery systems for oral delivery of phyto-bioactive compounds in various chronic diseases

Solid lipid nanoparticle (SLN) delivery systems have a wide applicability in the delivery of phyto-bioactive compounds to treat various chronic diseases, including diabetes, cancer, obesity and neurodegenerative diseases. The multiple benefits of SLN delivery include improved stability, smaller particle size, leaching prevention and enhanced lymphatic uptake of the bioactive compounds through oral delivery. However, the burst release makes the SLN delivery systems inadequate for the oral delivery of various phyto-bioactive compounds that can treat such chronic diseases. Recently, the surface-modified SLN (SMSLN) was observed to overcome this limitation for oral delivery of phyto-bioactive compounds, and there is growing evidence of an enhanced uptake of curcumin delivered orally via SMSLNs in the brain. This review focuses on different SLN and SMSLN systems that are useful for oral delivery of phyto-bioactive compounds to treat various chronic diseases.