Barriers to Accessing Healthcare Services for People with Parkinson's Disease: A Scoping Review

Association of patient characteristics, social drivers of health, and geographic location on access to device-aided therapies among medicare beneficiaries with advanced Parkinson's disease

INTRODUCTION

Surgical device-aided therapies (DATs), including carbidopa-levodopa enteral suspension (CLES) and deep brain stimulation (DBS), are efficacious treatment options for people with advanced Parkinson's disease (aPD). While provider and patient preference influence treatment choices, DAT use remains low and social drivers of health (SDOH) may present barriers to access. This study aimed to evaluate the relationship of patient characteristics and SDOH-including geographic distance to facilities that provide DATs-with likelihood of receiving DAT.

METHODS

Adults diagnosed with PD and meeting aPD clinical indicators were identified among 100 % Medicare Fee-for-Service beneficiaries linked to Inovalon's SDOH data warehouse between 01/01/2018-12/31/2020. Multivariate logistic regression models determined factors associated with DAT vs no-DAT initiation.

RESULTS

Of 503,245 Medicare beneficiaries with PD, 22 % met proxy criteria for aPD, with 2 % (2450) receiving DAT (CLES 24 %; DBS 76 %). Nationwide aPD prevalence was 309 per 100,000 Medicare beneficiaries. There were 413 DAT facilities nationwide (average 8 facilities/state), and aPD patients traveled 98 miles on average to a facility (range 11-255 miles). aPD patients under age 75 were 2-3x more likely to receive DAT, while those identifying as female, Black race, have moderate to severe comorbidity, and lower household incomes were less likely to receive DAT.

CONCLUSIONS

Findings suggest low utilization of DATs among US Medicare beneficiaries with aPD. Even states with more DAT facilities often require patients to travel long distances. Identifying and minimizing access disparities, particularly for women, racial minorities, and people with low socioeconomic status may improve DAT utilization and outcomes for patients with aPD.

Accelerated symptom improvement in Parkinson's disease via remote internet-based optimization of deep brain stimulation therapy: a randomized controlled multicenter trial

BACKGROUND

Deep brain stimulation (DBS) has emerged as an important therapeutic intervention for neurological and neuropsychiatric disorders. After initial programming, clinicians are tasked with fine-tuning DBS parameters through repeated in-person clinic visits. We aimed to evaluate whether DBS patients achieve clinical benefit more rapidly by incorporating remote internet-based adjustment (RIBA) of stimulation parameters into the continuum of care.

METHODS

We conducted a randomized controlled multicenter study (ClinicalTrails.gov NCT05269862) involving patients scheduled for de novo implantation with a DBS System to treat Parkinson's Disease. Eligibility criteria included the ability to incorporate RIBA as part of routine follow-up care. Ninety-six patients were randomly assigned in a 1:1 ratio using automated allocation, blocked into groups of 4, allocation concealed, and no stratification. After surgery and initial configuration of stimulation parameters, optimization of DBS settings occurred in the clinic alone (IC) or with additional access to RIBA. The primary outcome assessed differences in the average time to achieve a one-point improvement on the Patient Global Impression of Change score between groups. Patients, caregivers, and outcome assessors were not blinded to group assignment. Most of the data collection took place in the patient's home environment.

RESULTS

Access to RIBA reduces the time to symptom improvement, with patients reporting 15.1 days faster clinical benefit (after 39.1 (SD 3.3) days in the RIBA group (n = 48) and after 54.2 (SD 3.7) days in the IC group (n = 48)). None of the reported adverse events are related to RIBA.

CONCLUSIONS

This study demonstrates safety and efficacy of internet-based adjustment of DBS therapy, while providing clinical benefit earlier than in-clinic optimization of stimulation parameters by increasing patient access to therapy adjustment.

Wearable devices may aid the recognition of fluctuation-related pain in Parkinson's disease-An exploratory, cross-sectional analysis of two prospective observational studies

Fluctuation-related pain (FRP) affects more than one third of people with Parkinson's disease (PwP, PD) and has a harmful effect on health-related quality of life (HRQoL), but often remains under-reported by patients and neglected by clinicians. The National Institute for Health and Care Excellence (NICE) recommends The Parkinson KinetiGraphTM (the PKGTM) for remote monitoring of motor symptoms. We investigated potential links between the PKGTM-obtained parameters and clinical rating scores for FRP in PwP in an exploratory, cross-sectional analysis of two prospective studies: "The Non-motor International Longitudinal, Real-Life Study in PD-NILS" and "An observational-based registry of baseline PKG™ in PD-PKGReg". 63 PwP (41.3% female; age: 64.24±9.88 years; disease duration, DD: 6.83±5.63 years; Hoehn and Yahr Stage, H&Y: 2 (1-4); Levodopa Equivalent Daily Dose 535 (0-3230) mg) were included. PwP with FRP (n = 23) had longer DD (8.88 (1.29-19.05) vs. 3.16 (0.34-28.92), p = 0.001), higher severity of motor symptoms (H&Y 3 (1-4) vs. 2 (1-4), p = 0.015; SCOPA Motor total score 21.35±10.19 vs. 13.65±8.99, p = 0.003), more dyskinesia (SCOPA Motor Item 18 ≥1 60.9% vs. 7.5%, p<0.001), and worse HRQoL (PDQ-8 Total Score 10.74±5.98 vs. 6.78±5.13, p = 0.007) then PwP without FRP (n = 40). In the multivariate logistic regression, after the adjustment for DD, H&Y and SCOPA-Motor total score, the presence of FRP was significantly associated with the PKGTM-derived Fluctuation-dyskinesia score (Exp (B) = 1.305, 95% CI for Exp (B) 1.012-1.683, p = 0.040) and the Bradykinesia score (Exp (B) = 0.917, 95% CI for Exp (B) 0.842-0.999, p = 0.048). The PKGTM system may potentially advance the way we screen for, assess, and treat FRP in clinical practice.

Effectiveness of a home-based computerized cognitive training in Parkinson's disease: a pilot randomized cross-over study

Introduction

Cognitive symptoms are common in Parkinson's Disease (PD), and digital interventions like telerehabilitation other an accessible way to manage these symptoms. This study aimed to assess the effectiveness of a Home-Based Computerized Cognitive Training (HB-CCT) program in individuals with PD using a pilot randomized cross-over design.

Methods

Twenty-five participants (mean age 69.32 ± 7.21 years, mean MDS-UPDRS III 33.76 ± 14.25) with PD and mild cognitive impairment were enrolled. They underwent neuropsychological assessments at three time points (5-week intervals): Baseline, after the HB-CCTi, and after Standard Care. The HB-CCT consisted of the Neurotablet® platform that was used to target cognitive domains such as Attention, Memory, Perception, Executive Functioning and Language. All participants completed both the Neurotablet intervention and Standard Care blocks in a randomized order. After a Shapiro-Wilk test, non-parametric repeated measures analyses of variance (Friedman's test) and post-hoc comparisons corrected with the Benjamini-Hochberg approach were performed to compare the effects on primary and secondary cognitive outcomes over experimental intervention and Standard Care.

Results

The results from the Friedman analysis revealed significant improvements in Word List Immediate Recall, Digit Span Forward and Complex Figure Recall (all p < 0.001) following the HB-CCT, compared to the Baseline. Additionally, Naming performance showed significant improvement after the HB-CCT (p = 0.02). Significant differences were also observed when comparing the HB-CCT with Standard Care, with improved performance in TMT-A (p = 0.02), Phonemic Fluency (p < 0.01), and Digit Span Forward (p < 0.01).

Discussion

These findings suggest that HB-CCT via Neurotablet can effectively enhance specific cognitive abilities in PD, supporting the role of digital, home-based interventions as feasible strategies to mitigate cognitive decline.

How well is the female population represented in clinical trials with infusion therapies for Parkinson's disease? A systematic review and metanalysis

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disorder affecting both sexes, but differences exist between male and female in clinical manifestations, functional impact of symptoms and hormonal influences. Therefore, representativeness of females in PD trials indirectly determines the external validity of the clinical research in this field.

OBJECTIVE

To estimate the representativeness of female in infusion therapy trials for advanced PD.

METHODS

PubMed and EMBASE databases were searched (1980 to September 2023), along with congress abstracts, to identify controlled clinical trials and large non-controlled studies on infusion therapies in PD enrolling >100 patients. Random-effect meta-analysis was conducted to estimate mean pooled prevalence of females included in the studies. Subgroup analyses were conducted accordingly to study design and intervention.

RESULTS

We included 15 studies (six studies on levodopa-carbidopa intestinal gel, six on subcutaneous levodopa, two on subcutaneous apomorphine, and one on levodopa-carbidopa-entacapone intestinal gel). Sex was not a randomisation stratification factor in any of these studies. Only one study explored differences in the outcome estimated according to sex. Overall, the proportion of female included was 38% (95% CI:33%-43%; I2 = 74%), without differences between studies assessing different type of interventions (p = 0.72) or between study design (p = 0.35). In two studies, females represented the majority of included patients.

CONCLUSION

Female with advanced PD are underrepresented in infusion therapy trials. Most trials have overlooked sex-based biological differences that can impact clinical and functional outcomes, raising concerns about the generalizability of these findings to real-world contexts.

Priorities in healthcare provision in Parkinson's disease from the perspective of Parkinson Nurses: A focus group study

Background

Through their expertise and diverse skills, Parkinson Nurses are key care providers for people with Parkinson's disease. They are seen as an important profession for person-centered and multidisciplinary care, considered priorities in Parkinson's care delivery. Currently, however, little is known about the priorities that this profession itself defines for the care of Parkinson's patients and how they perceive their own role in the care process.

Objective

To explore the perspective of Parkinson Nurses on care priorities in people with Parkinson's disease.

Design

Qualitative study.

Settings

The iCare-PD study served as the object of study by establishing an interdisciplinary, person-centered and nurse-led care model in several European countries and Canada. The nurses who participated in this model were part of the study.

Participants

Six Parkinson Nurses participated in the study.

Methods

We conducted a thematic focus group, adopting the paradigm of pragmatism to draft an interview guide. The focus group was based on the inspiration card method and followed recommendations for co-creation processes.

Results

Parkinson Nurses define care priorities for Parkinson's in areas of education, multi-professionalism, and need-orientation. They see themselves as mediators and coordinators of care delivery processes.

Conclusions

In line with international recommendations, Parkinson Nurses prioritize key aspects of multidisciplinary and person-centered care. At the same time, however, the nurses also name care priorities that go beyond the international recommendations. It is therefore crucial to integrate the perspective of this important profession into recommendations for the delivery of healthcare for people with Parkinson's.Tweetable abstract How do specialized nurses define priorities for person-centered Parkinson's care? Answers are sought in this qualitative study by @MarlenaMunster.

Lower Healthcare Access and Its Association With Individual Factors and Health-Related Quality of Life in Adults With Rare Diseases in Switzerland

Objectives

This study aims to determine clusters of access to healthcare among adults with rare diseases in Switzerland, identify associated individual characteristics of access, and impact on health-related quality of life (HRQoL).

Methods

Swiss adults (N = 341) diagnosed with a rare disease completed an online survey including the Perception of Access to Healthcare Questionnaire (PAHQ) and Short Form Health Survey (SF-12). We employed partition around medoids algorithm to identify patient clusters based on the PAHQ. Various sociodemographic/disease-related factors and HRQoL were assessed.

Results

We identified two patient clusters: higher (n = 227) and lower access (n = 114). Significantly associated with lower access were an unstable disease course (p < 0.05), increased number of misdiagnoses (p < 0.05), and diseases affecting the nervous system (p < 0.01). Membership in the lower access cluster was significantly associated with worse HRQoL (p < 0.05).

Conclusion

Findings highlight the need for comprehensive assessment of healthcare access in adults with rare diseases and identifies potential targets for tailored interventions.

Self-perceived barriers to healthcare access for patients with post COVID-19 condition

BACKGROUND

Many patients with post COVID-19 condition (PCC) require healthcare services. However, qualitative studies indicate that patients with PCC encounter many barriers to healthcare access. This cross-sectional study aimed to determine how many PCC patients report barriers to healthcare access and which barriers are reported, and to explore differences between subgroups.

METHODS

Data were collected via an online survey from 10,462 adult patients with a confirmed or suspected COVID-19 infection in the Netherlands, who experienced persisting symptoms ≥ 3 months after the initial infection. To study self-perceived barriers, a list of eleven possible barriers was used, covering multiple aspects of healthcare access. Differences between subgroups based on sociodemographic characteristics, medical characteristics, PCC symptoms (fatigue, dyspnoea, cognitive problems, anxiety and depression), and healthcare use (general practitioner, paramedical professional, medical specialist, occupational physician and mental health professional) were studied through multivariable multinomial (0 vs. 1 vs. > 1 barrier) and binomial regression analyses (for each individual barrier).

RESULTS

A total of 83.2% of respondents reported at least one barrier to healthcare access. Respondents reported a median of 2.0 (IQR = 3.0) barriers. The barriers "I didn't know who to turn to for help" (50.9%) and "No one with the right knowledge/skills was available" (36.8%) were most frequently reported. Respondents with younger age, higher educational level, not hospitalized during acute COVID-19 infection, longer disease duration, who had more severe PCC symptoms, and who did not consult an occupational physician or paramedical professional, were more likely to report barriers. Analyses per barrier showed that women were more likely to report financial and help-seeking barriers, while men were more likely to report barriers related to availability of care. Hospitalized respondents were less likely to report barriers related to availability of care, but not less likely to report financial or help-seeking barriers.

CONCLUSIONS

This study shows that the majority of patients with PCC experiences barriers to healthcare access. Particular attention should be paid to younger, non-hospitalized patients with a long disease duration and severe PCC symptoms. Efforts to remove barriers should focus not only on improving availability of care, but also on helping patients navigate care pathways.

Fostering Inclusivity in Research Engagement for Underrepresented Populations in Parkinson's Disease: The FIRE-UP PD study

BACKGROUND

Members of vulnerable populations are underrepresented in Parkinson's disease (PD) research. A complex web of research barriers perpetuates this gap. Community-based research methods are one approach to addressing this issue. The present PD study was designed to examine the effectiveness of community-based interventions to overcome barriers and increase research participation among underrepresented groups (URGs).

METHODS

Eight study sites across the US were selected and paired based on proposed interventions with specific URGs. Surveys assessed knowledge and attitudes toward PD research. Finally, researchers examined whether the present study affected recruitment to Fox Insight, an online PD research study also recruiting at each site.

RESULTS

In total, 474 participants were recruited. At post-intervention for the FIRE-UP PD Study, recruitment increased significantly in intervention compared to control sites among Black and African American non-Hispanic/Latino populations (p = 0.003), White Hispanic/Latino (p = 0.003) populations, and Not Listed Hispanic/Latino populations (p < 0.001) as well as those with an educational attainment of a high school diploma/General Education Diploma (GED) (p = 0.009), and an income <$20,000 (p = 0.005) or between $20,000-$34,999 (p < 0.001). Study surveys measuring changes in awareness and attitudes toward PD research had mixed results. In Fox Insight, 181 participants were passively recruited with a shift toward more diverse participant demographics.

CONCLUSION

Research participation demographics reflective of the general population are critical to PD investigation and treatment. The FIRE-UP PD Study showed the effectiveness of localized community engagement strategies in increasing URG recruitment to PD research. Therefore, further PD research employing community-based methods to improve diverse participant recruitment is needed.

The Care Needs of Patients With Cognitive Impairment in Late-Stage Parkinson's Disease

BACKGROUND

Cognitive impairment is common in Parkinson's disease (PD), but care needs and resource use for those with significant cognitive impairment are not well established.

METHODS

675 participants with PD from the international Care of Late-Stage Parkinsonism (CLaSP) study were grouped into those without (n = 333, 49%) and with cognitive impairment (MMSE < 24/30 or diagnosis of dementia or Mild Cognitive Impairment; n = 342, 51%) and their clinical features, care needs and healthcare utilisation compared. The relationship between cognition and healthcare consultations was investigated through logistic regression.

RESULTS

Cognitive impairment was associated with more motor and non-motor symptoms, less antiparkinsonian but higher rates of dementia and antipsychotic medication, worse subjective health status and greater caregiver burden. A considerable proportion did not have a pre-established cognitive diagnosis. Care needs were high across the whole sample but higher in the cognitive impairment group. Home care and care home use was higher in the cognitive impairment group. However, use of healthcare consultations was similar between the groups and significantly fewer participants with cognitive impairment had had recent PD Nurse consultations. Worse cognitive impairment was associated with lower frequency of recent PD nurse and multidisciplinary therapy consultation (physiotherapy, massage, occupational therapy, speech training and general nursing).

CONCLUSIONS

Those with cognitive impairment have more severe PD, higher care needs and greater social care utilisation than those with normal cognition, yet use of health care services is similar or less. Cognitive impairment appears to be a barrier to PD nurse and multidisciplinary therapy consultations. This challenges current models of care: alternative models of care may be required to serve this population.

PLAIN LANGUAGE SUMMARY

Parkinson's disease is a long-term progressive health condition. Over time, many people with Parkinson's develop problems with thinking and memory, called cognitive impairment. This can negatively impact the daily lives of the person with Parkinson's and their caregiver. It is also thought to be a barrier to accessing healthcare. How people with Parkinson's who have cognitive impairment use healthcare and detail of their care needs is not well known.We analysed data from a large sample of people with advanced Parkinson's from six European countries to investigate their symptoms, care needs and healthcare use. We compared those with cognitive impairment to (342 people) to those without cognitive impairment (333 people).We found that those with cognitive impairment had more severe Parkinson's across a range of symptoms compared to those without cognitive impairment. They also had more care needs, reported their health status to be worse, and their caregivers experienced greater strain from caring. Whilst use of other healthcare services was similar between the two groups, those with cognitive impairment were less likely to have recently seen a Parkinson's nurse than those without cognitive impairment. Further analysis showed an association between cognitive impairment and not having seen a Parkinson's nurse or therapist recently, taking psychiatric symptoms, functional disability and care home residence into account. Therapists included were physiotherapy, massage, occupational therapy, speech training and general nursing. These findings highlight unmet need. We suggest that healthcare should be more targeted to help this group of people, given their higher care needs.

Assessing the factors that influence the utilization and delivery of rehabilitation services among persons with Parkinson's disease: A scoping review

RATIONALE

Rehabilitation has the potential to significantly improve the lives of people and, most importantly, for persons with Parkinson's disease (PD). Although numerous studies have reported the benefits of rehabilitation for persons with PD (PwPD), these services are still limited and underutilized even when patients exhibit problems that require rehabilitation.

AIMS AND OBJECTIVES

This review aims to describe the (a) indication for referral for rehabilitation services, (b) patterns of referral for rehabilitation and (c) factors that facilitate or hinder the utilization and delivery of rehabilitation services among PwPD.

METHODS

A comprehensive literature search was conducted across selected databases, African Journals Online, EBSCOhost (CINAHL, Africa-wide), PubMed, SCOPUS and Web of Science. Studies published in English from January 2002 until December 2022 were applied as limiters. Reference and grey data sources tracking were also conducted. Two reviewers conducted the study selection, screening of titles, abstracts and full text and data charting. A descriptive analysis was performed. Findings were narratively presented and illustrated with tables, diagrams and descriptive formats as appropriate.

RESULTS

Twelve studies were included in the review; however, none were from Africa. Impairments and activity limitations were the key functioning problems indicated for rehabilitation. Age, gender, income, race, disease stage, specific functioning problems, quality of life and care by a neurologist were the main predictors for referral to rehabilitation. Physiotherapy, occupational therapy and speech and language therapy were the most utilized rehabilitation services and were sometimes utilized together. The rate of rehabilitation service utilization among PwPD ranged from 0.9% to 62.5%. Lack of referrals and limited rehabilitation units/professionals were the common barriers to rehabilitation service utilization.

CONCLUSION

Per the studies reviewed, utilization of rehabilitation services is generally low among PwPD. Lack of referral and nonavailability of professionals are cited as barriers to access. Adequate measures are needed to improve rehabilitation services for all PwPD.

Centering the person in development of a model of care for people with Parkinson's disease: a qualitative study

PURPOSE

Obtain the perspectives of people with Parkinson's disease (PwPD) and their care partners (CPs) about their lived experiences with Parkinson's Disease (PD) to characterize a new model of care that meets their biopsychosocial and healthcare needs.

METHODS

This phenomenological study included semi-structured focus groups exploring PD diagnosis/care experiences and conceptualizations of an ideal model of care among PwPD and CPs. Data were analyzed via thematic analysis.

RESULTS

Twenty-five individuals (PwPD, n = 18; CPs, n = 7) participated across four focus groups. Researchers developed four themes to describe participants' lived experience with, barriers to, and needs for PD care. These themes characterize key hopes for care as: 1) person-centered, 2) coordinated, 3) provides access to education and information, and 4) builds on the benefits of community.

CONCLUSIONS

Participants emphasized that, beyond clinical interactions and diagnosis-centered conversations, they wished for holistic healthcare that acknowledged the larger picture of their life with PD. An ideal model of care for PwPD should aim to be person centered, maximize collaboration and coordination across multiple disciplines, provide access to a wide range of information and resources, refer to community centers and support groups, and be designed with ease of navigation in mind.

Global prevalence and incidence of Young Onset Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

There is a lack of enough evidence regarding the epidemiology of Young-onset Parkinson's disease (YOPD) which is needed by clinicians and healthcare policymakers.

AIM

Herein, in this systematic review and meta-analysis, we aimed to estimate the global prevalence and incidence rates of YOPD.

METHODS

We searched the literature in PubMed, Scopus, and Web of Science in May 2022. We included retrospective, prospective, cross-sectional observational population-based studies that reported the prevalence or incidence of PD in individuals younger than 40 years with known diagnostic criteria.

RESULTS

After two-step screening, 50 studies were eligible to be included in our study. The age-standardized prevalence of YOPD was 10.2 per 100,000 persons globally while it was 14.7 per 100,000 population in European countries. Age-standardized prevalence estimates for 5-year age bands showed that the YOPD prevalence estimates varied from 6.1 per 100,000 population in the group aged 20-24 to 16.1 per 100,000 population in the group aged 35-39. Also, the age-standardized incidence of YOPD was 1.3 per 100,000 person-years population worldwide and 1.2 per 100,000 person-years in the European population.

CONCLUSION

Based on this systematic review and meta-analysis, the overall prevalence of YOPD is 10.2 per 100,000 population, although estimates of the prevalence and incidence in low-income countries remain scarce. To improve monitoring and certain diagnoses of YOPD, healthcare providers and policymakers should be aware that much more effective tools are required.

Patterns and determinants of health care utilization among people with Parkinson's disease: A population-based analysis in Ontario, Canada

In Ontario, despite the increasing prevalence of Parkinson's disease (PD), barriers to access-to-care for people with Parkinson's disease (PwP) and their caregivers are not well understood. The objective of this study is to examine spatial patterns of health care utilization among PwP and identify factors associated with PD-related health care utilization of individuals in Ontario. We employed a retrospective, population-based study design involving administrative health data to identify PwP as of March 31, 2018 (N = 35,482) using a previously validated case definition. An enhanced 2-step floating catchment area method was used to measure spatial accessibility to PD care and a descriptive spatial analysis was conducted to describe health service utilization by geographic area and specialty type. Negative binomial regression models were then conducted to identify associated geographic, socioeconomic, comorbidity and demographic factors. There was marked spatial variability in PD-related service utilization, with neurology and all provider visits being significantly higher in urban areas (CMF>1.20; p<0.05) and family physician visits being significantly higher (CMF >1.20; p<0.05) in more rural areas and remote areas. More frequent visits to family physicians were associated with living in rural areas, while less frequent visitation was associated with living in areas of low spatial accessibility with high ethnic concentration. Visits to neurologists were positively associated with living in areas of high spatial accessibility and with high ethnic concentration. Visits to all providers were also positively associated with areas of high spatial accessibility. For all outcomes, less frequent visits were found in women, older people, and those living in more deprived areas as years living with PD increased. This study demonstrates the importance of geographic, socioeconomic and individual factors in determining PwP's likelihood of accessing care and type of care provided. Our results can be expected to inform the development of policies and patient care models aimed at improving accessibility among diverse populations of PwP.

Home-Based Titration with Duodenal Infusion of Levodopa-Carbidopa Intestinal Gel in People with Parkinson's Disease: An Observational Feasibility Study

Background

Testing and titration of the right levodopa equivalent dose are usually performed during a hospital admission. However, optimal dose titration in people with Parkinson's disease (PwPs) may depend on home environment, emotional stress, and physical activity of everyday life.

Objective

Firstly, to evaluate the feasibility and safety of a home-based LCIG titration program and patients'/caregivers' satisfaction. Secondly, to identify barriers and facilitators for home-based titration.

Method

This study assesses the feasibility and safety of home-based titration of levodopa duodenal infusions with the use of self-reported evaluation questionnaires with open-ended questions included, registration of total time used, and number of contacts/visits. A telemedicine solution was used to remotely monitor the patients, adjust treatment, and provide support and guidance to patients and caregivers.

Results

Ten of 12 PwPs (5 females and 7 males) completed the total titration program. Eight of the 12 PwPs were dependent on help. These 8 PwPs also had a high burden of nonmotor symptoms (NMS). Cognitive impairments varied in severity (range 16-30). Time spent with home visits was on average 93.4 minutes (ranging from 35 to 180 minutes), and the length of the total titration (LCIG initiation to termination of titration) was on average 3.4 days with 2-5 (mean 3.2) contacts/visits with PD team members. The average score on the satisfaction evaluation questionnaires was lower in the caregiver group (mean 31.8) than the PwP outcome (mean 36.2).

Conclusions

Telehealth-assisted home-based titration programs are feasible due to the length of the titration period, number of contacts, and time spent in PwPs' private homes, are rated satisfactory and safe by PwPs and caregivers, and may be a substitute for in-hospital treatment. Clinical recommendations including facilitators and barriers from a patient/caregiver perspective are displayed. This trial is registered with NCT4196647.

Challenges Faced by Rural Health Care Providers Caring for Parkinson's Disease Patients in Neighbor Islands of Hawai'i

When compared to their urban counterparts, rural regions have worse health outcomes and more challenges in health care access. As the only island state in the US, Hawai'i's unique geographic layout may magnify these disparities. However, there are limited publications on the impact of urban-rural disparities in health care in Hawai'i. The study team aimed to identify the challenges rural health care providers face when managing treatment of Parkinson's disease (PD), a complex disease. A self-administered survey was sent to 247 eligible providers who practiced in Hawai'i and prescribed PD medications from 2017-2019. The survey assessed: provider's comfort level in PD management; utilization and accessibility of health care services; perspective on barriers to PD care; and perspective on telemedicine. Providers were categorized into O'ahu providers (OP, urban) and neighbor island (Hawai'i, Kaua'i, and Maui) providers (NIP, rural). The final sample size was 44 providers (18% response rate). NIP were significantly less likely than OP to report access to social workers (P=.025), geriatric services (P=.001), and psychologist/psychiatrist/mental health professionals (P=.009). There were no statistical differences in: criteria used for PD diagnosis, resources utilized for PD education, and comfort in prescribing PD medications. The findings show that NIP are just as engaged and capable in providing PD care as OP. However, NIP encounter more limitations to accessibility, which can affect the quality of PD care that their rural patients receive. Further research is needed to understand how these limitations affect health-related outcomes in PD as well as other chronic diseases.

Specialized Allied Health Care for Parkinson's Disease: State of the Art and Future Directions

People with Parkinson's disease (PD) experience a range of progressive motor and non-motor symptoms, that negatively affect their daily functioning, social participation and quality of life. Allied health therapies have emerged as an effective treatment approach-complementary to pharmacological and neurosurgical treatments-which reduces the impact of PD in daily life. In this article, we propose criteria for what constitutes specialized allied health care for PD, and we review allied health research in PD in terms of meeting these criteria and its outcomes for monodisciplinary approaches as well as multi- or interdisciplinary allied health interventions. We focus on the three most studied allied health disciplines in PD: physical therapy, occupational therapy and speech-language therapy. Overall, the available evidence underscores the importance and potential benefits of specialized allied health care for people with PD. Our proposed criteria and recommendations for future research might help in further delineating specialized allied health care.

Digital Intervention Promoting Physical Activity in People Newly Diagnosed with Parkinson's Disease: Feasibility and Acceptability of the Knowledge, Exercise-Efficacy and Participation (KEEP) Intervention

Background

Exercise promotion interventions for people with Parkinson's disease (PD) are often offered on a face-to-face basis, follow a generic "one-size-fit-all" approach, and are not typically delivered at diagnosis. Considering PD's heterogenous nature, the existing evidence on the merits of exercise on symptom management and the expressed wishes of people living with PD for access to timely and tailored evidence-based information, there is a demand for interventions that are easily accessible, scalable and co-designed with people living with PD.

Objective

Evaluate the feasibility and acceptability of a co-designed digital intervention promoting exercise and physical activity, in people newly diagnosed with PD.

Methods

Thirty people living with PD for less than one year participated in an assessor-blinded randomized feasibility trial from June 2022 to April 2023. The intervention group received the 8-week Knowledge, Exercise Efficacy and Participation (KEEP) intervention comprising 6 interactive digital modules and 4 online live group discussions facilitated by a specialist physiotherapist. Assessments were performed at baseline, post intervention and at 6-month follow up.

Results

Thirty participants were recruited to target with a 64% recruitment rate (30/47). All but one participant completed the 6-month follow-up assessment. There was high retention (97%), module completion (91%), and online discussion attendance (88%). Outcome measure collection was feasible, including accelerometer data with a daily average wear time of 23.9 hours (SD:0.295).

Conclusions

The KEEP intervention was feasible and acceptable in people newly diagnosed with PD. A larger trial is needed to assess intervention efficacy and correlation between knowledge, self-efficacy, and activity levels.

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.

Tools and criteria to select patients with advanced Parkinson's disease for device-aided therapies: a narrative review

This article provides an overview of the various screening and selection tools which have been developed over the past 25 years to identify patients with Parkinson's disease (PD) possibly eligible for device-aided therapies (DATs). For the available screening tools, we describe the target therapies (subtypes of DAT), development methods, validation data, and their use in clinical practice. In addition, the historical background and potential utility of these screening tools are discussed. The challenges in developing and validating these tools are also addressed, taking into account the differences in population, the local health care organization, and resource availability.

A Paradigm Shift in the Management of Patients with Parkinson's Disease

BACKGROUND

Technological evolution leads to the constant enhancement of monitoring systems and recording symptoms of diverse disorders.

SUMMARY

For Parkinson's disease, wearable devices empowered with machine learning analysis are the main modules for objective measurements. Software and hardware improvements have led to the development of reliable systems that can detect symptoms accurately and be implicated in the follow-up and treatment decisions.

KEY MESSAGES

Among many different devices developed so far, the most promising ones are those that can record symptoms from all extremities and the trunk, in the home environment during the activities of daily living, assess gait impairment accurately, and be suitable for a long-term follow-up of the patients. Such wearable systems pave the way for a paradigm shift in the management of patients with Parkinson's disease.

Delivering Optimal Care to People with Cognitive Impairment in Parkinson's Disease: A Qualitative Study of Patient, Caregiver, and Professional Perspectives

Background

Cognitive impairment is common in Parkinson's disease (PD) and associated with lower quality of life. Cognitive impairment in PD manifests differently to other dementia pathologies. Provision of optimal care requires knowledge about the support needs of this population.

Methods

Eleven people with PD and cognitive impairment (PwP), 10 family caregivers, and 27 healthcare professionals were purposively sampled from across the United Kingdom. Semistructured interviews were conducted in 2019-2021, audio-recorded, transcribed, and analysed using reflexive thematic analysis.

Results

Cognitive impairment in PD conveyed increased complexity for clinical management and healthcare interactions, the latter driven by multifactorial communication difficulties. Techniques that helped included slow, simple, and single messages, avoiding topic switching. Information and emotional support needs were often unmet, particularly for caregivers. Diagnostic pathways were inconsistent and awareness of cognitive impairment in PD was poor, both contributing to underdiagnosis. Many felt that PwP and cognitive impairment fell through service gaps, resulting from disjointed, nonspecific, and underresourced services. Personalised care was advocated through tailoring to individual needs of PwP and caregivers facilitated by flexibility, time and continuity within services, and supporting self-management.

Conclusions

This study highlights unmet need for people with this complex condition. Clinicians should adapt their approach and communication techniques for this population and provide tailored information and support to both PwP and caregivers. Services need to be more streamlined and collaborative, providing more time and flexibility. There is a need for wider awareness and deeper understanding of this condition and its differences from other types of dementia.

Health care experiences of people with Parkinson's disease in Australia

BACKGROUND

Little is known about the health care experiences of people with Parkinson's disease (PwP) living in Australia. Exploring health care experiences can provide insight into service gaps which can then help direct quality improvement, such as improving communication between patients and health professionals.

METHODS

This study aimed to examine the health care experiences of a sample of PwP living in Australia using the Patient-Centered Questionnaire for Parkinson's disease (PCQ-PD). Participants were recruited from four sources located in Victoria, Australia: (1) a metropolitan Movement Disorders Program (Group 1); (2) metropolitan based movement disorder neurologists working as sole practitioners and not within multidisciplinary teams (Group 2); (3) a regional based multidisciplinary PD program (Group 3); and (4) PD support groups in regional and rural Victorian towns without PD specialist programs (Group 4). Scores derived from the PCQ-PD included the overall patient-centered score (OPS), six sub-scale experience scores (SES) and the quality improvement scores (QIS). Health care experiences were compared between Groups 1, 2, 3 and 4 and multivariate linear regression models were used to explore factors contributing to patient-centeredness.

RESULTS

227 participants reported a mean (SD) OPS score of 1.8 (SD 0.5) with no significant differences between groups. The rating for the Tailored Information subscale was low, (mean 1.3, SD 0.5), with Group 2 having a significantly lower score, 1.1 (SD 0.5), compared to Group 1, 1.4 (SD 0.5) (p = 0.048). Experiences of Continuity of Care and Collaboration of Professionals were rated significantly lower by Group 2, 1.3 (SD 1.0) compared to Groups 1, 1.8 (SD 0.9) (p = 0.018) and 3, 2.1 (SD 0.8) (p = 0.002). Care aspects related to the Tailored Information subscale were prioritised for improvement by all groups. The main predictors of positive health care experiences were disease duration (coeff 0.02; 95% CI 0.00, 0.04) and living with another person (coeff 0.27: 95% CI 0.03, 0.51).

CONCLUSION

This sample of participants with PD had poor experiences of several aspects of care known to be important in the provision of quality PD care. They prioritised the improvement of personalised health care information and better continuity of care and collaboration between health professionals.

Impact of the COVID-19 pandemic on perceived access and quality of care in German people with parkinsonism

Due to the heterogeneous clinical presentation, people with Parkinsonism (PwP) develop individual healthcare needs as their disease progresses. However, because of limited health resources during the COVID-19 pandemic, many patients were put at risk of inadequate care. All this occurred in the context of inequitable healthcare provision within societies, especially for such vulnerable populations. This study aimed to investigate factors influencing satisfaction and unmet need for healthcare among PwP during the COVID-19 pandemic in Germany. Analyses relied on an anonymous online survey with a 49-item questionnaire. We aimed at describing access to health services before and during the early stages of the pandemic. To this end, a generalized linear model was used to derive significant predictors and a stepwise regression to subsummarize the main factors of perceived inadequate care. In total, 551 questionnaires showed that satisfaction with Parkinsonism-related care decreased significantly during the pandemic (p < 0.001). In particular, factors such as lower educational level, lower perceived expertise of healthcare providers, less confidence in remote care, difficulties in obtaining healthcare, and restricted access to care before the pandemic but also lower densities of neurologists at residence and less ability to overcome barriers were indicative of higher odds to perceive unmet needs (p < 0.05). The results unveil obstacles contributing to reduced access to healthcare during the COVID-19 pandemic for PwP. These findings enable considerations for improved provision of healthcare services to PwP.

Effects of Palliative Care for Progressive Neurologic Diseases: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine the association of palliative care for progressive neurologic diseases with patient- and caregiver-centered outcomes.

DESIGN

Systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies, including pilot studies.

SETTING AND PARTICIPANTS

Adults with progressive neurologic diseases (dementia, multiple sclerosis, Parkinson's disease, motor neuron disease, multiple system atrophy, and progressive supranuclear palsy) and their caregivers.

METHODS

MEDLINE, EMBASE, CINAHL PLUS, Cochrane CENTRAL, and PubMed were searched from inception to September 2021. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tools. Narrative synthesis was conducted. Patient quality of life (QoL), symptom burden, caregiver burden, and satisfaction with care were meta-analyzed using a random-effects model.

RESULTS

Fifteen trials provided data on 3431 patients (mean age, 73.9 years). Compared with usual care, palliative care was statistically significantly associated with lower symptom burden [standardized mean difference (SMD), -0.34 (95% Cl, -0.59 to -0.09)] and higher caregiver satisfaction [SMD, 0.41 (95% Cl, 0.12 to 0.71)] and patient satisfaction [SMD, 0.43 (95% Cl, -0.01 to 0.87)]. However, the associations were not significant after excluding studies with high risk of bias. Insignificant associations of palliative care with caregiver burden [SMD, -0.09 (95% Cl, -0.21 to 0.03)] and patient QoL [SMD, 0.19 (95% Cl, -0.07 to 0.44)] were observed.

CONCLUSIONS AND IMPLICATIONS

Palliative care is likely to improve symptom burden and satisfaction with care among patients with progressive neurologic diseases and their caregivers, while its effects on QoL and caregiver burden remains inconclusive. Specific intervention components including interdisciplinary team, palliative care physicians, home visits, and spiritual care appeared to be associated with increased effects on improving palliative outcomes. More rigorous designed studies are warranted to examine the effects of neuropalliative care, effective intervention components, optimal timing, and symptom triggers of palliative care referrals.

Using the Concept of Health Literacy to Understand How People Living with Motor Neurone Disease and Carers Engage in Healthcare: A Longitudinal Qualitative Study

The growing body of information-seeking and decision-making literature in motor neurone disease (MND) has not yet explored the impact of health literacy. Health literacy relates to the skills people have to access, understand, and use health information and is influenced by motivation to engage with healthcare. We aimed to better understand how people affected by MND engage in healthcare by examining longitudinal interview data using the construct of health literacy. Semi-structured interviews were conducted with 19 persons living with MND and 15 carers recruited from a specialist MND clinic using maximum variation sampling. Transcripts were deductively coded using a framework of health literacy behaviours. The analysis used a matrix-based approach for thematic analysis of longitudinal data. People living with MND and carers sought nuanced information dependent on their priorities and attitudes. Information uptake was influenced by perceived relevancy and changed over time. Time allowed opportunity to reflect on and understand the significance of information provided. The findings indicate that persons living with MND and carers benefit when information and consultations are adapted to meet their communication needs. The results highlight the potential benefits of gaining an early understanding of and accommodating the communication needs, personal preferences, and emotional readiness for information for persons living with MND and their carers.

Occupational Therapy for People with Early Parkinson’s Disease: A Retrospective Program Evaluation

Purpose

Clinical practice guidelines establish that occupational therapy (OT) services are indicated for people with early Parkinson's disease (PD). However, OT is uncommon compared to other rehabilitation services. This study describes the development and evaluation of a proactive, consultative OT program for people with early PD as a part of an integrated care approach.

Materials and Methods

The program was developed by an occupational therapist adapting practice guidelines for people with early PD. Retrospective program evaluation occurred at an outpatient rehabilitation clinic. The consultative OT program for early PD includes a 90-minute evaluation with instruction in self-management techniques, individually tailored exercises, and follow-up recommendations. The program was evaluated with the RE-AIM framework. Postprogram semistructured interviews provided patient-reported program effectiveness and satisfaction.

Results

In 2018, 23 individuals used OT out of 77 people with early PD who attended the proactive rehabilitation program. Most individuals (n = 16, 69.6%) were within Hoehn and Yahr stages 1-2 and were seen within 3 years of PD diagnosis. Participants presented with deficits in hand strength (60.0 ± 23.4 pounds) and dexterity (right hand 30.0 ± 8.0 seconds) and reported complaints about basic and/or instrumental activities of daily living (n = 15, 65.2%). Semistructured interviews (n = 16) revealed that most individuals (75%) reported high satisfaction. Of the 10 who recalled a home exercise program, 60% reported continued adherence. Consultative OT was delivered with fidelity in 22/23 individuals (96%). After one year, only two occupational therapists at one clinic had adopted the program, and the program is maintained in the organization.

Conclusion

Occupational therapists reached people in the early stages of PD when a specific program was tailored to evaluate and target their specific needs. Motor activity deficits noted in individuals with early PD support future scaling and sustainability efforts of OT within this population. Quality improvement suggestions are discussed for future implementation and clinical trials.

The Power of Access in Parkinson's Disease Care: A Retrospective Review of Telehealth Uptake During the COVID-19 Pandemic

Objective

The onset of the COVID-19 pandemic in March of 2020 forced a rapid pivot to telehealth and compelled a use-case experiment in specialty telehealth neurology movement disorders care. The aims of this study were to quantify the potential benefit of telehealth as an option to the Parkinson's disease community as shown by the first 9 months of the COVID-19 pandemic, and to quantify the potential impact of the absence of a deep brain stimulation (DBS) telehealth option on DBS patient follow-up.

Methods

New patient visits to the Inova Parkinson's and Movement Disorder's Center from April to December 2020 (9 months) were retrospectively reviewed for telehealth vs. in-person, demographics (age, gender, race, primary insurance), chief complaint, prior movement disorders specialist (MDS) consultation, imaging tests ordered, and distance/travel time from primary zip code to clinic. Additionally, DBS programming visit volume from April to December 2020 was compared to DBS programming visit volume from April to December 2019.

Results

Of the 1,097 new patients seen, 85% were via telehealth (N = 932) and 15% in person (N = 165). In the telehealth cohort, 97.75% had not consulted with an MDS before (N = 911), vs. 87.9% of in-person (N = 145). Age range was 61.8 +/- 17.9 years (telehealth), 68.8 +/- 16.0 years (in-person). Racial breakdown for telehealth was 60.7% White (N = 566), 10.4% Black (N = 97), 7.4% Asian (N = 69) and 4.5% Hispanic (N = 42); in-person was 70.9% White (N = 117), 5.5% Black (N = 9), 7.9% Asian (N = 13) and 5.5% Hispanic (N = 9). Top 5 consultation reasons, top 10 primary insurance providers and imaging studies ordered between the two cohorts were similar. Distance/travel time between primary zip code and clinic were 33.8 +/- 104.8 miles and 42.2 +/- 93.4 min (telehealth) vs. 38.1 +/- 114.7 miles and 44.1 +/- 97.6 min (in-person). DBS programming visits dropped 24.8% compared to the same period the year before (254 visits to 191 visits).

Conclusion

Telehealth-based new patient visits to a Movement Disorders Center appeared successful at increasing access to specialty care. The minimal difference in supporting data highlights the potential parity to in-person visits. With no telehealth option for DBS visits, a significant drop-off was seen in routine DBS management.

A Systematic Review on Physical Health Education Interventions for People with Parkinson's Disease: Content, Impact, and Implementation Considerations Across the Parkinson's Trajectory

BACKGROUND

Educational interventions promoting the role of physical activity (PA) aim to address knowledge, poor exercise self-efficacy, and low outcome expectations, which are well-researched barriers to PA participation in healthy and in people with chronic conditions. However, little is known about the effectiveness of educational interventions in addressing these barriers in people with Parkinson's (PwP).

OBJECTIVE

To examine the content of education interventions that promote PA behavior in PwP, and to assess their effectiveness on physical and psychosocial outcomes.

METHODS

An electronic search (12/2021) of MEDLINE, EMBASE, CINAHL, PubMed PsycINFO, the Web of Science and the Cochrane Library was conducted from 1990 to 2021. Education interventions, alone or combined with other strategies, promoting PA in PwP were included. Quality was assessed using the Johanna Briggs Institute and National Institute of Health quality assessment tools. A narrative synthesis was performed.

RESULTS

Six studies were identified. Five interventions were comprised of education and exercise sessions. Improvement in physical and psychosocial outcomes were suggested but delineating the exact impact of education was impeded due to lack of assessment.

CONCLUSION

Few interventions exist that provide knowledge, and skills promoting PA participation, and fewer are addressed towards newly diagnosed PwP. There is lack of assessment over the effectiveness of education as a tool to facilitate PA participation in PwP. Lack of assessment poses the risk of potentially disregarding effective interventions or adopting ineffective approaches without the evidence. Education interventions can boost PA engagement by increasing factors such as exercise self-efficacy, but further interventions are required to assess this model of relationship.