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Kobylecki C, Goh YY, Mohammad R, Beat A, Michou E, Pavey S, Morris H, Houlden H, Chelban V. Clinical Practices and Opinions toward Gastrostomy Use in Patients with Atypical Parkinsonian Syndromes: A National Survey in the UK. Mov Disord Clin Pract 2024; 11:1266-1273. [PMID: 39189113 PMCID: PMC11489604 DOI: 10.1002/mdc3.14196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 08/08/2024] [Accepted: 08/12/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Severe dysphagia poses a significant challenge for clinicians regarding feeding tube choices, practices, and timing due to a lack of evidence-based guidance. OBJECTIVES To assess national clinical practices and opinions on gastrostomy use in patients with atypical parkinsonian syndromes (APS) across the UK. METHODS Online survey was administered to clinicians and allied health professionals regarding availability of services, current use, perceived advantages, and problems associated with gastrostomy insertion. RESULTS We received responses from 47 respondents across 12 UK centers, including 44 clinicians specialized in APS. Consensus was observed regarding primary indications for gastrostomy insertion and circumstances justifying avoidance of the procedure. Limitations in recommending gastrostomy due to insufficient evidence on safety and outcomes, survival and quality of life were identified. Widespread agreement on delays in gastrostomy discussions was highlighted as a challenge in optimizing patient care, together with variability in current practices and concerns over the lack of a standardized gastrostomy pathway, emphasizing the need for further research to address existing evidence gaps. CONCLUSION This multi-center survey highlights agreement among clinicians on key aspects of indication, challenges, and limitations such as delayed decision-making and the absence of standardized pathways regarding the timing, method, and overall approach to gastrostomy insertion in APS. This study identified next steps to facilitate a more structured approach to future research toward a consensus on best practices for gastrostomy in APS. Addressing these challenges is crucial for enhancing patient outcomes and overall care quality in APS.
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Affiliation(s)
- Christopher Kobylecki
- Division of Neuroscience, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Department of Neurology, Manchester Centre for Clinical NeurosciencesNorthern Care Alliance NHS Foundation TrustSalfordUK
| | - Yee Yen Goh
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Rahema Mohammad
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Alanna Beat
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Emilia Michou
- Division of Diabetes, Endocrinology and GastroenterologyUniversity of ManchesterManchesterUK
- Department of Speech and Language Therapy, School of Health Rehabilitation SciencesUniversity of PatrasPatrasGreece
| | | | - Huw Morris
- Department of Clinical and Movement Neurosciences, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Henry Houlden
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Viorica Chelban
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Neurobiology and Medical Genetics Laboratory“Nicolae Testemitanu” State University of Medicine and PharmacyChisinauMoldova
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Kobylecki C, Chelban V, Goh YY, Michou E, Fumi R, Theilmann Jensen M, Mohammad R, Costantini A, Vijiaratnam N, Pavey S, Pavese N, Leigh PN, Rowe JB, Hu MT, Church A, Morris HR, Houlden H. Frequency and outcomes of gastrostomy insertion in a longitudinal cohort study of atypical parkinsonism. Eur J Neurol 2024; 31:e16258. [PMID: 38407533 PMCID: PMC11235814 DOI: 10.1111/ene.16258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/21/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Multiple system atrophy (MSA), progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) show a high prevalence and rapid progression of dysphagia, which is associated with reduced survival. Despite this, the evidence base for gastrostomy is poor, and the optimal frequency and outcomes of this intervention are not known. We aimed to characterise the prevalence and outcomes of gastrostomy in patients with these three atypical parkinsonian disorders. METHOD We analysed data from the natural history and longitudinal cohorts of the PROSPECT-M-UK study with up to 60 months of follow-up from baseline. Survival post-gastrostomy was analysed using Kaplan-Meier survival curves. RESULTS In a total of 339 patients (mean age at symptom onset 63.3 years, mean symptom duration at baseline 4.6 years), dysphagia was present in >50% across all disease groups at baseline and showed rapid progression during follow-up. Gastrostomy was recorded as recommended in 44 (13%) and performed in 21 (6.2%; MSA 7, PSP 11, CBS 3) of the total study population. Median survival post-gastrostomy was 24 months compared with 12 months where gastrostomy was recommended but not done (p = 0.008). However, this was not significant when correcting for age and duration of symptoms at the time of procedure or recommendation. CONCLUSIONS Gastrostomy was performed relatively infrequently in this cohort despite the high prevalence of dysphagia. Survival post-gastrostomy was longer than previously reported, but further data on other outcomes and clinician and patient perspectives would help to guide use of this intervention in MSA, PSP and CBS.
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Affiliation(s)
- Christopher Kobylecki
- Division of Neuroscience, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Department of Neurology, Manchester Centre for Clinical NeurosciencesNorthern Care Alliance NHS Foundation TrustSalfordUK
| | - Viorica Chelban
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Neurobiology and Medical Genetics Laboratory“Nicolae Testemitanu” State University of Medicine and PharmacyChisinauRepublic of Moldova
| | - Yee Yen Goh
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Emilia Michou
- Division of Diabetes, Endocrinology and GastroenterologyUniversity of ManchesterManchesterUK
- Department of Speech and Language Therapy, School of Health Rehabilitation SciencesUniversity of PatrasPatrasGreece
| | - Riona Fumi
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Marte Theilmann Jensen
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Rahema Mohammad
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Alyssa Costantini
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | | | - Nicola Pavese
- Clinical Ageing Research UnitNewcastle UniversityNewcastleUK
| | - P. Nigel Leigh
- Department of NeuroscienceBrighton and Sussex Medical SchoolBrightonUK
| | - James B. Rowe
- Department of Clinical Neurosciences, Cambridge Centre for Parkinson‐Plus, Cambridge University Hospitals NHS TrustUniversity of CambridgeCambridgeUK
| | - Michele T. Hu
- Division of Neurology, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | | | - Huw R. Morris
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Henry Houlden
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
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Pasricha TS, Guerrero-Lopez IL, Kuo B. Management of Gastrointestinal Symptoms in Parkinson's Disease: A Comprehensive Review of Clinical Presentation, Workup, and Treatment. J Clin Gastroenterol 2024; 58:211-220. [PMID: 38260966 PMCID: PMC10855995 DOI: 10.1097/mcg.0000000000001961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024]
Abstract
Gastrointestinal symptoms in Parkinson's disease (PD) are among the most prevalent and debilitating of complications and present unique diagnostic and management challenges. Patients with PD commonly experience dysphagia, nausea, bloating, and constipation related to pathologic involvement of the enteric nervous system. In turn, gastrointestinal complications may impact motor fluctuations and the efficacy of levodopa therapy. This review will explore the common gastrointestinal manifestations of PD with an emphasis on clinical presentation, workup, and treatment strategies.
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Affiliation(s)
- Trisha S. Pasricha
- Division of Gastroenterology, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | | | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
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O'Shea N, Lyons S, Higgins S, O'Dowd S. Neurological update: the palliative care landscape for atypical parkinsonian syndromes. J Neurol 2023; 270:2333-2341. [PMID: 36688987 DOI: 10.1007/s00415-023-11574-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/24/2023]
Abstract
Atypical parkinsonian syndromes are neurodegenerative conditions, characterised by rapid disease progression and shorter life expectancy compared to idiopathic Parkinson's disease. These conditions inflict substantial physical and psychosocial burden on patients and their families; hence, there is a clear rationale for a palliative care approach from diagnosis. An interdisciplinary care model has been shown to improve symptom burden, quality of life and engagement with advance care planning, in a heterogeneous group of neurodegenerative conditions. In this update, we summarise how the landscape for treating these patients has changed and the questions that still need to be resolved.
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Affiliation(s)
- Noreen O'Shea
- Department of Neurology, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland.
- Department of Palliative Medicine, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland.
| | - Shane Lyons
- Department of Neurology, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland
| | - Stephen Higgins
- Department of Palliative Medicine, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland
- Our Lady's Hospice & Care Services, Harold's Cross, Dublin, D6WRY72, Ireland
| | - Sean O'Dowd
- Department of Neurology, Tallaght University Hospital, Tallaght, Dublin 24, D24NR0A, Ireland
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Abstract
Advanced Parkinson's disease (PD) often brings a set of motor and non-motor features that are particularly challenging to manage. Medication options can be limited by side-effects and quality of life can be severely affected by an accumulating burden of nonmotor symptoms. Here, we reviewed the literature and our clinical experience with the aim of providing a practical approach to the management of advanced PD. We provide guidelines for treatment of physical and neurobehavioral concerns, that occur in advanced PD.
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Vaughan CL, Bruno V. What neurologists wish palliative care physicians knew. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:93-104. [PMID: 36055723 DOI: 10.1016/b978-0-323-85029-2.00005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
As the incidence of neurologic (particularly neurodegenerative) diseases continues to rise, so too will the palliative needs in this patient population. To appropriately care for these patients and families, neurologists and palliative care providers will need to strengthen collaboration. Palliative care providers not formally trained in neurology may feel ill-equipped to manage some of the distinct neuropalliative care needs of these patients. Here, we provide insights into the unique characteristics of patients with neurologic disease and emphasize the relevance of the palliative care skillset in this population to aid the collaboration between palliative care providers and neurologists.
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Affiliation(s)
- Christina L Vaughan
- Department of Neurology and Medicine, Anschutz Medical Center, University of Colorado, Aurora, CO, United States; Department of Neurology, VA Eastern Colorado Health System, Aurora, CO, United States.
| | - Veronica Bruno
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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Kim DS, Kunicki ZJ, Philips OW, Jones RN, Friedman JH, Kluger B, Akbar U. Racial and geographic disparities with gastrostomy tube placement in dementia and parkinsonian disorders. Parkinsonism Relat Disord 2021; 91:28-31. [PMID: 34479055 DOI: 10.1016/j.parkreldis.2021.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Many patients with advanced dementia and Parkinson's disease and related disorders (PDRD) are receiving gastrostomy tube (GT) placement annually, despite its lack of proven benefit for preventing aspiration, enhancing nutrition, or prolonging survival. Given clinical practice variability in the care of people with neurodegenerative disorders, we sought to examine racial and geographic disparities in GT placement for these populations in the United States. METHOD Data were extracted from a publicly-available national database using diagnostic and procedural codes from 2006 to 2010. GT placement rates and odds ratios were calculated for two groups: PDRD and non-parkinsonian dementia (NPD). RESULTS In the PDRD group, odds of GT placement were higher among patients coded as Black (OR 1.69, CI 0.80-3.56, p = 0.17) and Asian (OR 2.17, CI 0.70-6.78, p = 0.18) than Whites; although these tendencies did not reach statistical significance. In the NPD group, GT placement among Black patients was significantly more likely (OR 2.88, CI 1.90-4.36, p < 0.001) than their white counterparts, while Asian patients were significantly less likely (OR 0.12, CI 0.02-0.91, p = 0.04). Compared to the Northeast region, there were significantly lower odds of GT placement in the Midwest region (OR 0.37, CI 0.24-0.58, p < 0.001) in the NPD group only. No difference in odds was observed between the sexes in both groups. CONCLUSION This study showed geographic and racial disparities in GT placement among PDRD and NPD patients. Further studies should aim to clarify best practices for GT placement in PDRD and causes of practice differences within and between PDRD and NPD groups.
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Affiliation(s)
- Duk Soo Kim
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
| | - Zachary J Kunicki
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Oliver W Philips
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
| | - Richard N Jones
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Joseph H Friedman
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA; Butler Hospital, Providence, RI, USA
| | - Benzi Kluger
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Umer Akbar
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA; Butler Hospital, Providence, RI, USA.
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Kim DS, Jones RN, Shireman TI, Kluger BM, Friedman JH, Akbar U. Trends and outcomes associated with gastrostomy tube placement in common neurodegenerative disorders. Clin Park Relat Disord 2020; 4:100088. [PMID: 34316666 PMCID: PMC8299983 DOI: 10.1016/j.prdoa.2020.100088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/18/2020] [Accepted: 12/12/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Dysphagia causing aspiration pneumonia is a common complication in the advanced stages of neurodegenerative disorders. Historically, physicians attempted to prevent this complication with gastrostomy tube (GT) placement. Its use is supported in amyotrophic lateral sclerosis (ALS), not supported in Alzheimer's disease (AD), and without disease-specific guidelines in Parkinson's disease (PD). METHOD The rate of GT placement in these three populations over two decades, from 1990 to 2010, was calculated using a binomial regression model with the data extracted using diagnosis and procedural codes from a national database. The median length-of-stay (LOS) and discharge destinations were compared. RESULTS The rate of GT placement was 6.0% lower annually in AD, 3.4% in PD, and 0.2% in ALS (all p ≤ 0.007). The analysis of hospital LOS and discharge destination showed 3.2 to 5.5 days longer LOS with GT placement in all groups (all p ≤ 0.01), and three to four times lower odds of going home with GT placement in AD and PD groups (OR 0.28, 95% CI 0.14-0.55, and OR 0.22, CI 0.11-0.42 respectively), while unchanged in ALS group (OR 1.1, 95% CI 0.6-1.9). CONCLUSION Despite the downward trend of GT placement over two decades, thousands of AD and PD patients still underwent GT placement annually, and this was associated with longer LOS in all groups and increased likelihood of being discharged to a nursing facility in AD and PD. Further research is necessary to understand the effects of GT on physician practices and patient expectations in advanced AD and PD.
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Affiliation(s)
- Duk Soo Kim
- Brown University, Department of Neurology, Providence, RI, United States
- Rhode Island Hospital, Providence, RI, United States
| | - Richard N. Jones
- Brown University, Department of Neurology, Providence, RI, United States
- Brown University, Department of Psychiatry and Human Behavior, Providence, RI, United States
| | - Theresa I. Shireman
- Brown University, Department of Health Services, Policy & Practice, Providence, RI, United States
- Brown University, Center for Gerontology & Health Care Research, Providence, RI, United States
| | - Benzi M. Kluger
- University of Colorado, Department of Neurology, Aurora, CO, United States
| | - Joseph H. Friedman
- Brown University, Department of Neurology, Providence, RI, United States
- Butler Hospital, Providence, RI, United States
| | - Umer Akbar
- Brown University, Department of Neurology, Providence, RI, United States
- Rhode Island Hospital, Providence, RI, United States
- Butler Hospital, Providence, RI, United States
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Brown L, Oswal M, Samra AD, Martin H, Burch N, Colby J, Lindahl A, Skelly R. Mortality and Institutionalization After Percutaneous Endoscopic Gastrostomy in Parkinson's Disease and Related Conditions. Mov Disord Clin Pract 2020; 7:509-515. [PMID: 32626795 DOI: 10.1002/mdc3.12971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/26/2020] [Accepted: 03/28/2020] [Indexed: 11/06/2022] Open
Abstract
Background Percutaneous endoscopic gastrostomy (PEG) can facilitate feeding and medication administration in dysphagic patients with Parkinson's disease and related disorders. Information on survival, institutionalization, and complications post PEG might inform feeding decisions. Method A total of 93 patients with Parkinson's disease and related disorders were identified by review of PEG registers and by searching the administrative databases in 2 large UK university hospitals (2005-2017); 83 case notes were available for retrospective review. Care processes and outcomes were assessed. Results The following were the diagnoses: 58 (70%) had Parkinson's disease, 10 (12%) had progressive supranuclear palsy, 5 (6%) had multiple system atrophy, 3 (4%) had dementia with Lewy bodies, and 7 (8%) had vascular parkinsonism. The median age was 78 years (interquartile range 72-82); 29 (35%) were women. Care processes included a future care plan in place prior to admission for 18 patients (22%), and PEG was placed during emergency admission in 68 patients (82%). The outcomes included median survival at 422 days; 30-day mortality rate was 6% (5 patients); and of 56 patients admitted from home, 18 (32%) were discharged to institutions (nursing or care homes). The most common complication was aspiration pneumonia for 18 (22%) of patients. Age, sex, diagnosis, admission type, comorbidities, and place of residence did not predict survival. Discharge to own home and follow-up by the home enteral feeding team were associated with longer survival. Conclusion We recommend markers of advanced disease should prompt advanced care planning. Discussions about PEG feeding should include information about post-PEG survival, complications, and risk of institutionalization. Further research is needed on quality-of-life post PEG and ways to reduce aspiration pneumonia. All PEG patients should have nutrition team follow-up.
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Affiliation(s)
- Lisa Brown
- Department of Neurology, Royal Derby Hospital, University Hospitals of Derby and Burton Derby DE22 3NE United Kingdom
| | - Michelle Oswal
- Department of Neurology, University Hospitals of Coventry and Warwickshire Coventry CV2 2DX United Kingdom
| | - Amrit-Deep Samra
- Department of Neurology, University Hospitals of Coventry and Warwickshire Coventry CV2 2DX United Kingdom
| | - Hannah Martin
- Department of Neurology, University Hospitals of Coventry and Warwickshire Coventry CV2 2DX United Kingdom
| | - Nicola Burch
- Department of Gastroenterology, University Hospitals of Coventry and Warwickshire Coventry CV2 2DX United Kingdom
| | - Joe Colby
- Department of Gastroenterology, University Hospitals of Coventry and Warwickshire Coventry CV2 2DX United Kingdom
| | - Andrea Lindahl
- Department of Neurology, University Hospitals of Coventry and Warwickshire Coventry CV2 2DX United Kingdom
| | - Rob Skelly
- Department of Medicine for the Elderly, Royal Derby Hospital, University Hospitals of Derby and Burton Derby DE22 3NE United Kingdom
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Mendlik MT, McFarlin J, Kluger BM, Vaughan CL, Phillips JN, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Neurologic Illnesses. J Palliat Med 2020; 22:193-198. [PMID: 30707071 DOI: 10.1089/jpm.2018.0617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with neurologic illnesses are commonly encountered by palliative care (PC) clinicians though many clinicians feel uncomfortable caring for these patients. Understanding how to diagnose, treat, communicate with, and prognosticate for neurology patients will improve the confidence and competence of PC providers in the neurology setting. This article offers PC providers 10 useful tips that neurologists with PC training think all PC providers should know to improve care for patients with neurologic illness.
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Affiliation(s)
- Matthew T Mendlik
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica McFarlin
- 2 Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Benzi M Kluger
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christina L Vaughan
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joel N Phillips
- 4 Mercy Health Hauenstein Neurosciences, Grand Rapids, Michigan
| | - Christopher A Jones
- 5 Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Choo XY, Lim SY, Chinna K, Tan YJ, Yong VW, Lim JL, Lau KF, Chung JY, Em JM, Tan HT, Lim JH, Tan SB, Tan CT, Tan AH. Understanding patients’ and caregivers’ perspectives and educational needs in Parkinson’s disease: a multi-ethnic Asian study. Neurol Sci 2020; 41:2831-2842. [DOI: 10.1007/s10072-020-04396-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/03/2020] [Indexed: 12/28/2022]
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