Transitions in Parkinson's disease in primary care: protocol of a longitudinal mixed methods study

Analysis of Transition of Patients with Parkinson's Disease into Institutional Care: A Retrospective Pilot Study

Parkinson's disease (PD) is a neurodegenerative disease which gives a person a high risk of becoming care-dependent. During disease progression, the amount of care concerning activities of daily living can increase, possibly resulting in transition of the people with Parkinson's disease (PwP) to a care facility. However, there is a lack of knowledge concerning the factors leading to institutionalization of PwP and the consequences for them and their informal caregivers. The aim of this cross-sectional retrospective study was to investigate reasons leading to the transition into an institutional care facility, the process of decision-making and its effects on PwP symptoms and caregiver burden. Participating PwP had to be institutionalized for at most one year after transition at study inclusion. Participants completed a range of semiquantitative questionnaires as well as the caregiving tasks questionnaire. Fourteen patient-caregiver pairs were included. PwP suffered from late-stage PD symptoms with high dependence on help, experiencing several hospitalizations before transition. Analyses revealed a significant decrease in caregiver burden and depressive symptoms of the caregivers after PwP institutionalization. Factors influencing the transition were, e.g., fear of PwP health issues and concerns about caregivers' health. This study presents new insights into the process of institutionalization and its influence on caregiver burden, including aspects for discussions of physicians with PwP and their caregivers for counselling the decision to move to institutional care.

Patterns and predictors of referrals to allied health services for individuals with Parkinson's disease: A Parkinson's foundation (PF) QII study

INTRODUCTION

Rehabilitation therapies are critical for optimizing quality-of-life and daily functions for individuals living with Parkinson's disease (PD). Thus, understanding the patterns of and under what conditions physicians make rehabilitation referrals is important for optimizing care.

METHOD

We analyzed data from 5020 participants (4 countries) collected from 1/3/2016 to 4/20/2018 as part of the Parkinson's Foundation Quality Improvement Initiative (PF QII). Data were analyzed for single discipline and multidiscipline referrals to speech language pathology (SLP), physical therapy (PT), and occupational therapy (OT). Group comparisons (referred vs. not-referred) and regression procedures were implemented to determine demographic and clinical variables that were associated with an increased likelihood of rehabilitation referral.

RESULTS

35.3% of participants were referred to rehabilitation services. Of these, 25.1% received a multidiscipline referral. There was a statistically significant effect of disease stage on both single discipline (χ²(2) = 45.1, p < 0.0001) and multidiscipline (χ²(2) = 74.2, p < 0.0001) referrals, with higher rates in later stages. Referred vs. not-referred participants differed significantly on a number of variables; however, only falls in the 6-months prior, advanced- and moderate-stage disease, older age, hospital admissions, and higher caregiver burden were associated with an increased likelihood of rehabilitation referral (adjusted odds ratios ≥ 1, Range = 1.08 to 1.62).

CONCLUSIONS

Despite evidence supporting multidiscipline and proactive rehabilitation in PD, the majority of referrals were made to a single service and may be reactions to falls or advancing disease. Data suggest there may be missed opportunities for optimizing care through proactive rehabilitation interventions.

Being in control of Parkinson's disease: A qualitative study of community-dwelling patients' coping with changes in care

Background: Chronically ill patients have to cope with transfers in the level or setting of care. Patients with prevalent disorders such as diabetes mellitus can be supported by their general practitioner (GP) when experiencing such care changes, as the GP already offers them disease-specific care. For community-dwelling patients with low-prevalent diseases such as Parkinson’s disease (PD) – for which disease-specific care is provided by medical specialists – tailoring support to handle care changes requires more insight into patients’ coping.

Objectives: To explore PD patients’ coping with care changes.

Methods: A qualitative interview study was performed in 2013–2015 with a purposive sample of 16 community-dwelling PD patients in the Netherlands. A research assistant visited patients every month to explore if they had experienced a care change. If so, patients were interviewed face-to-face. An inductive approach to comparative content analysis was used.

Results: Patients encountered a variety of care changes such as changes in the level of unpaid care, the purchase of tools, modification of pharmacotherapy or admission to hospital. Being able to anticipate, initiate and independently handle care changes contributes to patients’ sense of control and acceptance of the post-change situation. Patients, who commenced care changes themselves, had more realistic expectations of it.

Conclusion: Community-dwelling PD patients seem to be able to cope with the care changes they face. Offering education to facilitate their anticipation and initiation of changes in care and their ability to act independently, can contribute to patients’ wellbeing. GPs can play a role in this.

Health-Related Quality of Life Is Severely Affected in Primary Orthostatic Tremor

Background

Primary orthostatic tremor (POT) is a movement disorder characterized by unsteadiness upon standing still due to a tremor affecting the legs. It is a gradually progressive condition with limited treatment options. Impairments in health-related quality of life (HQoL) seem to far exceed the physical disability associated with the condition.

Methods

A multi-center, mixed-methodology study was undertaken to investigate 40 consecutive patients presenting with POT to four movement disorder centers in France. HQoL was investigated using eight quantitative scales and a qualitative study which employed semi-structured interviews. Qualitative data were analyzed with a combination of grounded-theory approach.

Results

Our results confirm that HQoL in POT is severely affected. Fear of falling was identified as the main predictor of HQoL. The qualitative arm of our study explored our initial results in greater depth and uncovered themes not identified by the quantitative approach.

Conclusion

Our results illustrate the huge potential of mixed methodology in identifying issues influencing HQoL in POT. Our work paves the way for enhanced patient care and improved HQoL in POT and is paradigmatic of this modern approach for investigating HQoL issues in chronic neurological disorders.

Parkinson's disease: patient and general practitioner perspectives on the role of primary care

BACKGROUND

Specialized Parkinson's disease (PD) care offers advantages to patients. However, specialized health care providers may be unaware of patients' personal context and comorbidity, leading to conflicting treatment regimens. Patients may benefit from a more holistic approach.

OBJECTIVE

To clarify the role community-dwelling PD patients see for general practitioners (GPs) in PD care and to clarify the role GPs see for themselves.

METHODS

Qualitative interview study with 16 community-dwelling PD patients and 12 GPs in the Netherlands, using a constant comparative approach to analysis.

RESULTS

Patients expressed a preference for self-management and autonomy in decision-making. GPs chose a limited, reactive position in early-stage PD care to stimulate patient autonomy. Moreover, GPs felt insufficiently competent to extend their role. Patients also felt GPs lack expert knowledge and skills; they focus on their neurologist for PD care. In addition, GPs observed patients might not realize what accessory role the GP could have, a role GPs described as essential in being aware of patient's well-being. Patients did not describe additional roles for the GP in more advanced disease, whereas GPs mentioned a shift towards a more proactive and extended role.

CONCLUSION

Patients and GPs see a limited role for the GP in early-stage PD care because of patient autonomy and GP's lack of specific knowledge and skills. However, GPs should feel more confident of the added value of their generalist approach to care for patients with a complex chronic disorder as PD. If generalist and specialized care reinforce each other, PD patients benefit.

Focusing on transitions of care: A change is here

Transitions of care have emerged as an important point of vulnerability in the health care system where medical errors and clinical deterioration can occur. Most research in the area has focused on non-neurologically ill patients in the postdischarge transition from the inpatient to outpatient clinical environment in part due to the emergence of hospital readmissions reduction programs. A multidisciplinary strategy that addresses several common opportunities for improvement can mitigate the risk to patients during these periods and can serve as an opportunity for neurologists to take the lead in developing systems-based solutions that can ultimately enhance the quality of care for our patients.