Quality improvement in neurology: Parkinson disease update quality measurement set: Executive summary

Palliative Care in Parkinson's Disease

Palliative care aims to alleviate suffering from symptoms not often addressed in typical clinic visits, including nonmotor symptoms, psychosocial and caregiver burden, and advanced care planning. Palliative care is appropriate at any point in Parkinson's disease, but hospice care is an important potential therapy for end-of-life care. Palliative care remains underutilized, and work is underway on developing palliative care delivery models.

Education Research: Exploring the Impact of Standardized, Condition-Specific Note Templates on Quality Metrics and Efficiency in Multiple Resident Clinics

Background and Objectives

Electronic health record documentation burden negatively affects physician satisfaction and patient care. Although well-constructed notes are important for care quality and safety, most note templates are created and maintained by individual physicians, leading to inefficiency and variable note quality. This study aimed to assess whether standardized, condition-specific note templates could enhance the efficiency and quality of notes written by neurology residents in the outpatient setting.

Methods

In a quality improvement study with a randomized, nonblinded design from July 2021 to June 2022, neurology residents were assigned standardized templates for epilepsy, headache, and Parkinson disease (PD) in 2 outpatient clinics. The standardized templates were created with input from specialists in these disorders. Efficiency was gauged based on the time and characters involved in note writing while quality was assessed by adherence to American Academy of Neurology quality metrics for each condition through chart review. A qualitative survey gathered resident opinions on the templates. Linear regression models were used in the efficiency and quality analyses.

Results

The study included 23 of 34 neurology residents. Templates were used in 36% of eligible encounters over the first 6 months of the study and 65% over the last 6 months. No significant difference in time spent on note writing was observed between the template and nontemplate groups. While both groups showed similar quality measures across most domains, the template group documented quality measures more consistently for driving status in epilepsy (92% vs 53%, p = 0.002), medication-related motor symptoms in PD (95% vs 50%, p = 0.01), and lifestyle changes in headache management (77% vs 21%, p = 0.005). Resident feedback suggested that the templates facilitated clinic workflows and prompted more thorough patient inquiry.

Discussion

Standardized, condition-specific templates improved documentation of quality metrics without increasing time spent. Despite initial low uptake of template use, an increase was observed over time, indicating potential for wider acceptance with implementation efforts. These templates, updated and maintained by subject matter experts, serve as an opportunity to incorporate quality care checklists and knowledge into a clinician's workflow. This warrants further research into template implementation and its effects on care quality and education for neurologists and generalists.

Holding back in communications with clinicians: Patient and care partner perspectives in Parkinson's disease

Objectives

To describe how patients with Parkinson's disease (PD) and care partners choose to share or withhold information from clinicians.

Methods

This is a qualitative, descriptive study nested within a multisite, randomized clinical trial of outpatient palliative care compared to standard neurologic care for PD. Interviews with patients (n = 30) and care partners (n = 30) explored experiences communicating with neurology clinicians. Thematic analyses identified themes relevant to patient-care partner-clinician communication.

Results

There were four themes relevant to sharing and/or withholding information from clinicians: (1) Suppressing Concerns During Visits, (2) Care Partner Awareness of Patients' Communication Barriers due to Cognitive Impairment, (3) Limited Sharing of Sensitive or Intimate Issues by Patients and Care Partners, and (4) Patient and Care Partner Suggestions to Overcome 'Holding Back'.

Conclusion

Limitations to communication between patients, care partners, and clinicians should be acknowledged and recognized in routine Parkinson's disease care to foster accurate disclosure of unmet palliative care and other needs. Triadic communication strategies may help patients and care partners talk about unmet palliative care needs.

Innovation

By recognizing that cognitive impairment and sensitive topics can be barriers, clinicians can adjust or adopt targeted communication strategies for identifying and discussing care needs.

Breaking barriers in Parkinson's care: the multidisciplinary team approach

Parkinson's disease is a complex neurodegenerative disorder presenting a range of motor and non-motor symptoms that greatly impact both patients and caregivers. The diverse needs arising from these symptoms make a multidisciplinary team (MDT) approach crucial for effective management. This article explores the role and benefits of MDTs in Parkinson's care, highlighting how collaborative models improve clinical outcomes and quality of life. MDTs integrate neurologists, nurse specialists, therapists, and other professionals to deliver comprehensive, patient-centered care. The inclusion of patients and caregivers fosters shared decision-making, enhancing health outcomes. However, challenges like limited controlled trials, lack of comprehensive guidelines, and under-referral remain. Innovative models, such as telehealth and community-based care, offer promising solutions, especially in underserved regions. The article advocates for further research and standardized guidelines to optimize the MDT approach for Parkinson's disease.

Increasing trends in utilization of physical and occupational therapy services in early Parkinson's disease

BACKGROUND

Best practice guidelines in Parkinson's disease (PD) calls for the immediate initiation of rehabilitation therapies (inclusive of physical (PT) and occupational therapy (OT)) to prevent or ameliorate the loss of function and quality of life associated with disease progression.

OBJECTIVE

The purpose of this study was to determine the utilization of PT and OT services within the first 2 years following PD diagnosis and to observe longitudinal trends in PT and OT utilization early following PD diagnosis.

METHODS

This retrospective cohort study accessed 12 years (2011 to 2023) of data from electronic health records at a midwestern US healthy system. Patients with new PD diagnoses and two-years of visit history were included. The primary outcome was utilization of PT or OT services within two-years of PD diagnosis. Data extracted included demographics and PD therapies. Records of 9720 patients were included in the analyses.

RESULTS

Overall, 36.9% of the cohort (n = 3586) received either physical or occupational therapy within two years of receipt of PD diagnosis. Increasing age, higher comorbidity index, female gender, use of dopamine replacement therapies, and African American race were all positively associated with receipt of PT or OT services (ps < 0.007). The longitudinal trend revealed an average year over year increase in PT/OT utilization of 1.4% between 2013 and 2021 (p < 0.001).

CONCLUSIONS

This study shows a promising increase in utilization of PT and OT services over previous reports and longitudinally, however it continues to convey how far clinical practice continues to lag behind best practice and scientific recommendation.

Current Status of Integrated Palliative Care Among Parkinson Foundation Centers of Excellence in the United States

Background and Objectives

To assess the current structures, knowledge, and readiness to integrate palliative care (PC) into Parkinson disease (PD) care at Parkinson's Foundation Centers of Excellence (COE) in the United States.

Methods

Three unique surveys were administered to health care professionals/staff at COEs to assess PC (1) resources, (2) knowledge and comfort, (3) clinical experience and processes, (4) barriers, and (5) readiness for implementation.

Results

Response rates for the 3 surveys were 97%, 98%, and 56%. In total, 41% of COEs have access to outpatient PC specialists, 71% have mental health counseling, 82% have support groups, and 9% had very limited PC resources. Overall, 74% of providers believed persons with advanced PD should receive PC, and knowledge of PC fundamentals was good across providers. For high-needs persons with PD (PWP), only 16% of physicians and 24% of advanced practice providers made referrals to PC specialists ≥75% of the time, while 9% and 16% never made such referrals. Limited time, space, financing, and staffing were seen as major barriers to PC implementation. In total, 37% of providers were satisfied with their COE's ability to provide PC services. Most COEs report a culture open to change and appear well-positioned to implement PC in a more comprehensive fashion.

Discussion

These results demonstrate the emergence of structures and processes to provide PC to persons with PD at COEs. They also identify concrete opportunities to strengthen integration of PC through educational, quality improvement, and advocacy efforts.

Reach of Palliative Care for Parkinson Disease: Results From a Large National Survey of Patients and Care Partners

Background and Objectives

People with Parkinson disease (PWP) and their care partners have high palliative care needs resulting from disabling motor and nonmotor symptoms. There is growing support for palliative care (PC) approaches to Parkinson disease. However, little is known regarding the extent to which the palliative needs of PWP and care partners are currently being met. This study's primary objective is to describe PWP's and care partners' perceptions of the extent to which their PC needs are being met. Secondary objectives are to describe their perceptions of the quality of clinical communication and their knowledge of PC.

Methods

PWPs and care partners (n = 12,995) who had consented to receiving surveys from the Parkinson's Foundation were emailed an electronic survey. PC was operationalized as comprising 5 key components: systematic assessment and management of (1) nonmotor symptoms, (2) PWPs' emotional and spiritual needs, (3) care partners' needs, (4) the completion of annual advance care planning, and (5) timely referrals to specialist palliative care and hospice when appropriate.

Results

A total 1,882 individuals (1,266 PWP and 616 care partners) responded to the survey (response rate 14.5%). Few PWP (22%) reported that their neurologists never asked regarding bothersome nonmotor symptoms or did so or only if they brought it up. Fifty percent of PWP reported that pain as a specific nonmotor symptom was never managed or managed only if they brought it up. Similarly, PWPs' emotional and spiritual needs (55%), care partners' well-being (57%), and completion of advance care planning documentation (79%) were never addressed or only addressed if PWP brought it up. The quality of clinical communication was generally rated as open and honest (64% PWP). Fewer PWP (30%) reported that doctors helped them deal with the uncertainties of Parkinson disease. Most PWP (85%) reported being knowledgeable regarding PC, and 68% reported that the goal of PC was to help friends and family cope with the illness.

Discussion

Although some elements of PC are currently being addressed in routine care for PWP, there are many gaps and opportunities for improvement. These data may facilitate focused attention and development of resources to improve the quality and availability of PC for Parkinson disease.

Effects of Exercise-Based Interventions on Physical Activity Levels in Persons With Parkinson's Disease: A Systematic Review With Meta-analysis

BACKGROUND AND PURPOSE

Parkinson's disease (PD) is the most common neurodegenerative movement disorder. Symptom severity leads to devastating consequences such as falls, immobility, impaired quality of life, and reduced general activity. Adopting a sedentary lifestyle creates a vicious circle, as physical inactivity can negatively affect the clinical domains of PD. Despite the recognition of the disease-modifying potential of physical activity (PA), achieving adequate exercise levels can be challenging for individuals with PD. This study aimed to investigate the repercussions of exercise-based interventions to improve PA levels in persons with PD through a systematic review with meta-analysis.

METHODS

A search was conducted from database inception to February 2021 across 3 databases: PubMed, Web of Science, and Scopus. Randomized controlled trials were included if they involved persons with PD, outcome measures associated with PA levels, and an exercise-based intervention. Two reviewers performed independent data extraction and methodologic quality assessment of the studies using the Downs and Black quality checklist.

RESULTS

A total of 6 studies were included in the study (1251 persons with PD). Four intervention types were identified: balance, strength, aerobic, and multimodal exercise (combination of several types of exercise programs). The meta-analysis showed that exercise interventions have a positive effect on PA (standard mean difference = 0.50, 95% CI =-0.02, 1.00; P = .06). The risk of bias was generally low.

CONCLUSIONS

The findings support the use of exercise-based interventions (aerobic exercise, balance exercise, strength exercise, and/or multimodal exercise) to improve PA levels. However, the limited number of studies and the heterogeneity of the interventions do not allow us to draw a definitive conclusion.

Comparative Efficacy, Safety, and Acceptability of Pimavanserin and Other Atypical Antipsychotics for Parkinson's Disease Psychosis: Systematic Review and Network Meta-Analysis

BACKGROUND

The current comparative efficacy, safety, and acceptability of atypical antipsychotics (AAPs) in treating Parkinson's Disease Psychosis (PDP) are not entirely understood.

OBJECTIVE

To evaluate comparative efficacy, safety, and acceptability of AAPs in patients with PDP.

METHODS

We conducted a systematic review and a network meta-analysis to compare the efficacy, safety, and acceptability of pimavanserin, quetiapine, olanzapine, clozapine, ziprasidone, and risperidone. We estimated relative standardized mean differences (SMDs) for continuous outcomes and odds ratios (OR) for binary outcomes, with their respective 95% confidence intervals (CIs).

RESULTS

We included 19 unique studies evaluating AAPs in a total of 1,242 persons with PDP. Based on Clinical Global Impression Scale for Severity, pimavanserin (SMD, -4.81; 95% CI, -5.39, -4.24) and clozapine (SMD, -4.25; 95% CI, -5.24, -3.26) significantly improved symptoms compared with placebo. Also, compared to placebo, pimavanserin (OR, 1.16; 95% CI, 1.07, 1.24) significantly improved psychotic symptoms based on Scale for Assessment of Positive Symptoms for Parkinson's Disease Psychosis/Hallucinations and Delusions scores. In comparison to placebo, clozapine (SMD, -0.69; 95% CI, -1.35, -0.02), pimavanserin (SMD, -0.01; 95% CI, -0.56, 0.53), and quetiapine (SMD, 0.00; 95% CI, -0.68, 0.69) did not impair motor function per Unified Parkinson's Disease Rating scale. Based on Mini-Mental State Examination scale, quetiapine (SMD, 0.60; 95% CI, 0.07, 1.14) significantly impaired cognition compared to placebo.

CONCLUSIONS

In patients with PDP, pimavanserin and clozapine demonstrated significant improvement in psychosis without affecting motor function. With quetiapine being associated with a significant decline in cognition and despite not impairing motor function, our findings suggest that it should be avoided in patients with PDP and reduced cognitive abilities.

Hospitalization and the Risk of Initiation of Antipsychotics in Persons With Parkinson's Disease

OBJECTIVES

The use of antipsychotics in persons with Parkinson's disease (PD) is common, although their use may aggravate the symptoms of PD. Clozapine and quetiapine are the only antipsychotics recommended in PD treatment guidelines. Information on factors associated with initiation of antipsychotics is needed. We investigated whether recent hospitalization is associated with initiation of antipsychotics in persons with PD, and whether discharge diagnoses differ between those who had antipsychotics initiated and those who did not.

DESIGN

Nested case-control study in the nationwide register-based Finnish Study on Parkinson's disease (FINPARK).

SETTING AND PARTICIPANTS

The FINPARK study includes 22,189 persons who received an incident, clinically verified PD diagnosed during 1996-2015 and were community-dwelling at the time of diagnosis. The cases were 5088 persons who had antipsychotics initiated after PD diagnosis, identified with 1-year washout. The controls were 5088 age-, sex-, and time from PD diagnosis-matched persons who did not use antipsychotics on the matching date (antipsychotic purchase date). Recent hospitalization was defined as discharge in the 2-week period preceding the matching date.

METHODS

Associations were investigated with conditional logistic regression.

RESULTS

Quetiapine was the most commonly initiated antipsychotic (72.0% of cases), followed by risperidone (15.0%). Clozapine was initiated rarely (1.1%). Recent hospitalization associated strongly with antipsychotic initiation [61.2% of cases and 14.9% of controls, odds ratio (OR) 9.42, 95% CI 8.33-10.65], and longer hospitalizations were more common among cases. PD was the most common discharge diagnosis category (51.2% of hospitalized cases and 33.0% controls), followed by mental and behavioral disorders (9.3%) and dementia (9.0%) among cases. Antidementia and other psychotropic medication use were more common among cases.

CONCLUSIONS AND IMPLICATIONS

These results suggest that antipsychotics were initiated because of neuropsychiatric symptoms or aggravation of those symptoms. Antipsychotics should be prescribed after careful consideration to avoid adverse effects in persons with Parkinson's disease.

Parallel development of Parkinson's-specific competencies for exercise professionals and criteria for exercise education programs

INTRODUCTION

The Parkinson's Foundation sought to develop Parkinson's specific competencies for exercise professionals who work with people with Parkinson's (PwP). These competencies built upon exercise guidelines and professional competencies for healthy populations. The purpose of this article is to describe the development of the professional competencies, continuing education criteria, and a pilot accreditation process.

METHODS

Competency development included: (1) an expert panel conducting an environmental scan, within the USA, related to exercise professional education in Parkinson's and synthesizing Parkinson's-specific exercise guidelines, (2) surveying people with Parkinson's in the USA, and (3) developing the competencies and curriculum criteria with psychometricians. A pilot accreditation process for Parkinson's exercise educational programs and continuing education courses includes an application, baseline, 6- and 12-month assessments. Activities reported here did not require ethical review. The survey was approved by NORC at the University of Chicago's Institutional Review Board (IRB).

RESULTS

The environmental scan, exercise guidelines, and survey (n = 627) informed competency development. The five key condition-specific domains were: (1) foundational information on the disease and role of exercise, (2) exercise screening, (3) group and individual exercise design, (4) behavior and counseling for exercise, and (5) interprofessional communication and program development. Seven applicants were accredited as certification programs (n = 3) or continuing education courses (n = 4).

DISCUSSION

The competencies, curriculum criteria, and accreditation processes support exercise professionals working with PwP. Reducing variation in the knowledge and skills of exercise professionals can improve the safe implementation and effectiveness of exercise programs, which are a critical part of integrated plan for people with Parkinson's disease (PD).

Neurological update: the palliative care landscape for atypical parkinsonian syndromes

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.

COVID-19 and Integrated Multidisciplinary Care Model in Parkinson's Disease: Literature Review & Future Perspectives

Clinical diversity and multi-systemic manifestations of Parkinson's disease (PD) necessitate the involvement of several healthcare professionals from different disciplines for optimal care. Clinical guidelines recommend that all persons with PD should have access to a broad range of medical and allied health professionals to implement an efficient and effective multidisciplinary care model. This is well supported by growing evidence showing the benefits of multidisciplinary interventions on improving quality of life and disease progression in PD. However, a "multidisciplinary" approach requires gathering healthcare professionals from different disciplines into an integrative platform for collaborative teamwork. With the Coronavirus Disease 2019 (COVID-19) pandemic, implementation of such a multidisciplinary care model has become increasingly challenging due to social distancing mandates, isolation and quarantine, clinics cancellation, among others. To address this problem, multidisciplinary teams are developing innovate virtual platforms to maintain care of people with PD. In the present review, we cover aspects on how SARS-CoV-2 has affected people with PD, their caregivers, and care team members. We also review current evidence on the importance of maintaining patient-centered care in the era of social distancing, and how can we utilize telehealth and innovative virtual platforms for multidisciplinary care in PD.

A long-term community gym program for people with Parkinson's disease: a feasibility study of the Monash Health "Health and Fitness" model

PURPOSE

To investigate the feasibility and acceptability of the Health and Fitness Program (HFP), a long-term community gym program for people with mild to moderate Parkinson's disease (PD).

METHODS

Physiotherapists, with PD expertise, developed individualised exercise programs for new HFP members in consultation with them. Gym instructors, with PD training, supervised the HFP sessions. Exercises included progressive strength training, aerobic, balance, and stretching. Participants who had been enrolled in the HFP for 12 months, were recruited to a single group pre/post design study to test the program's feasibility and acceptability. Feasibility included safety, retention, attendance, and compliance data and acceptability measured using a customised questionnaire.

RESULTS

17 of the 20 HFP members enrolled maintained membership for 12 months and participated in this study. The program was shown to be feasible with no falls reported during sessions, only one participant reported pain from exercising lasting more than 48 h, retention was high (85%) and most members complied with their program. Overall satisfaction with the program was high, with seven somewhat satisfied and 10 very satisfied.

CONCLUSION

The HFP demonstrated that a PD community gym program is feasible and acceptable when physiotherapists and PD-trained instructors collaborate to provide individualized exercise programs.IMPLICATIONS FOR REHABILITATIONPeople with Parkinson's disease need support to maintain long-term adherence to regular exercise which can be achieved with supervised community-based gym programs.A community-based PD-specific exercise program can be safe and acceptable to people with PD when PD specialist physiotherapists are involved in planning participants' exercise programs and PD-trained gym instructors supervise the exercise sessions.Members are satisfied with programs that have strategies in place to minimise barriers to participation, such as keeping costs to members low, providing a quality service, having supportive trained staff, and creating opportunities for social interaction between members.Evidence-based community exercise programs may result in improved strength and aerobic fitness and maintain quality of life in people with mild to moderate PD however further research using an RCT study is needed.

Parkinson's Disease: Risk Factor Modification and Prevention

The global burden of Parkinson's disease (PD) has increased from 2.5 to 6.1 million since the 1990s. This is expected to rise as the world population ages and lives longer. With the current consensus on the existence of a prediagnostic phase of PD, which can be divided into a preclinical stage and a prodromal stage, we can better define the risk markers and prodromal markers of PD in the broader context of PD pathogenesis. Here, we review this pathogenetic process, and discuss the evidence behind various heritability factors, exposure to pesticides and farming, high dairy consumption, and traumatic brain injuries that have been known to raise PD risk. Physical activity, early active lifestyle, high serum uric acid, caffeine consumption, exposure to tobacco, nonsteroidal anti-inflammatory drugs, and calcium channel blockers, as well as the Mediterranean and the MIND diets are observed to lower PD risk. This knowledge, when combined with ways to identify at-risk populations and early prodromal PD patients, can help the clinician make practical recommendations. Most importantly, it helps us set the parameters for epidemiological studies and create the paradigms for clinical trials.

Research on depression in Parkinson disease: A bibliometric and visual analysis of studies published during 2012-2021

BACKGROUND

The diagnosis and treatment rate of Parkinson disease (PD) with depression has a low diagnostic rate, and there is no consensus on the choice of treatment mode. This study evaluates the global research trends of scientific outputs related to depression in PD from multiple perspectives, using a bibliometric analysis and visualization tool to scientifically analyze the knowledge from the literature.

METHODS

Literature related to depression in PD published from 2012 to 2021 was included and selected from the Web of Science Core Collection database in October 2021. CiteSpace software was used to visualize and analyze co-occurrence analyses for countries, institutions, authors, and keywords.

RESULTS

A total of 4533 articles from the Web of Science database were included. The United States made the largest contribution with the majority of publications (1215; 29.40%). Toronto University was the most productive institution. PD, depression, quality of life, dementia, nonmotor symptom, prevalence, anxiety, Alzheimer disease, symptom, and disorder would be significantly correlated with depression in PD. The current hot spots in this field focus on the following: risk factors for depression in PD, assessment scale of depression in PD, and rehabilitation of depression in PD.

CONCLUSIONS

This analysis not only reveals the current research trends and hotspots but also provides some instructive suggestions on the development of depression in PD.

Confirming Parkinson Disease Diagnosis: Patterns of Diagnostic Changes by Movement Disorder Specialists

Background

The American Academy of Neurology Parkinson Disease (PD) quality measures include an annual diagnostic review.

Objective

To investigate the frequency and pattern of changes in diagnoses between PD and other causes of parkinsonism.

Methods

This prospective longitudinal cohort study included consented patients diagnosed with PD at least once and a minimum of two times at the Movement Disorders Center between 2002 and 2017. Movement disorder specialists confirmed and documented diagnoses at every visit. Longitudinal changes in diagnoses were identified across visits.

Results

Of 1567 patients with parkinsonism, 174 had non-PD parkinsonism with no change over time. Of 1393 patients diagnosed with PD at least once, 94% (N = 1308) had no change of diagnosis over time and 6% (N = 85) had a change of diagnosis including PD ⟷ drug-induced parkinsonism (DIP) (27.1%), PD ⟷ multiple system atrophy (MSA) (20.0%), PD ⟷ progressive supranuclear palsy (PSP) (18.8%), PD ⟷ Lewy body dementia (DLB) (16.5%), PD⟷ vascular parkinsonism (9.4%), more than two diagnoses (4.7%), and PD ⟷ corticobasal syndrome (CBS) (3.5%). The direction of diagnostic switches was as follows: PD ⟶ other parkinsonism diseases (36.5%), other parkinsonism diseases ⟶ PD (31.8%), and 31.8% of multiple switches. There were no significant differences in duration of follow-up, age at first visit, gender, race, marital status, education, income, cognition, or employment between the stable and unstable groups. Diagnostic change was associated with greater PD severity and greater medical comorbidity.

Conclusion

Over a 15-year period, movement disorder specialists changed their clinical diagnosis of PD in 6% of patients. The most common diagnostic switches, to or from PD, were DIP, MSA, PSP, and DLB. This study describes routine clinical diagnostic patterns in the absence of pathologic confirmation. The presence of diverse diagnostic changes over time underscores the value of confirming PD diagnosis.

Long-term Effect of Regular Physical Activity and Exercise Habits in Patients With Early Parkinson Disease

Background and Objectives

Owing to the lack of long-term observations or comprehensive adjustment for confounding factors, reliable conclusions regarding long-term effects of exercise and regular physical activity in Parkinson disease (PD) have yet to be drawn. Here, using data from the Parkinson's Progression Markers Initiative study that includes longitudinal and comprehensive evaluations of many clinical parameters, we examined the long-term effects of regular physical activity and exercise habits on the course of PD.

Methods

In this retrospective, observational cohort study, we primarily used the multivariate linear mixed-effects models to analyze the interaction effects of their regular physical activity and moderate to vigorous exercise levels, measured with the Physical Activity Scale for the Elderly questionnaire, on the progression of clinical parameters, after adjusting for age, sex, levodopa equivalent dose, and disease duration. We also calculated bootstrapping 95% confidence intervals (CIs) and conducted sensitivity analyses using the multiple imputation method and subgroup analyses using propensity score matching to match for all baseline background factors.

Results

Two hundred thirty-seven patients with early PD (median [interquartile range] age, 63.0 [56.0–70.0] years, male 69.2%, follow-up duration 5.0 [4.0–6.0] years) were included. Regular physical activity and moderate to vigorous exercise levels at baseline did not significantly affect the subsequent clinical progression of PD. However, average regular overall physical activity levels over time were significantly associated with slower deterioration of postural and gait stability (standardized fixed-effects coefficients of the interaction term [β_interaction] = −0.10 [95% CI −0.14 to −0.06]), activities of daily living (β_interaction = 0.08 [95% CI 0.04–0.12]), and processing speed (β_interaction = 0.05 [95% CI 0.03–0.08]) in patients with PD. Moderate to vigorous exercise levels were preferentially associated with slower decline of postural and gait stability (β_interaction = −0.09 [95% CI −0.13 to −0.05]), and work-related activity levels were primarily associated with slower deterioration of processing speed (β_interaction = 0.07 [95% CI 0.04–0.09]). Multiple imputation and propensity score matching confirmed the robustness of our results.

Discussion

In the long term, the maintenance of high regular physical activity levels and exercise habits was robustly associated with better clinical course of PD, with each type of physical activity having different effects.

Trial Registration Information

ClinicalTrials.gov Identifier: NCT01176565.

Classification of Evidence

This study provides Class II evidence that sustained increase in overall regular physical activity levels in patients with early PD was associated with slower decline of several clinical parameters.

Delivery models of neuropalliative care

Drawing its beginnings from end-of-life care, palliative care has developed into a specialized interdisciplinary effort aiming to alleviate distress in all its form, and spanning the whole serious illness trajectory. With this evolution came the inevitable expansion to different sites and modes of care delivery. This section discusses the various models of bringing palliative care to patients with neurologic illness. It begins by distinguishing primary from specialist palliative care, then examines various models of inpatient and outpatient care. Hospital-based models include consultation service and dedicated inpatient units, while outpatient care mainly consists of palliative care specialists embedded in disease-specific clinics. Home-based palliative care and services provided through telemedicine are discussed. Hospice, a model of care often associated with end-of-life palliative care is detailed, together with suggestions on when to consider transitioning to hospice care. It is worth noting that there is not a single best model of palliative care delivery for persons living with neurologic illness. The models discussed in this chapter are complementary not competing and should be adopted by clinicians to fit the needs of patients and caregivers, the resources available in the healthcare system, and based on where patients are in the spectrum of their illness.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

The Impact of COVID-19 on Community-Based Exercise Classes for People With Parkinson Disease

OBJECTIVE

he purpose of the study was to determine the impact of novel coronavirus 2019 (COVID-19) restrictions on community-based exercise classes for people with Parkinson disease (PD) and their instructors.

METHODS

Data were collected via custom-designed electronic surveys for people with PD and class instructors who reported attending or teaching PD-specific exercise class ≥1 time/week for ≥3 months prior to pandemic restrictions (March 2020). The PD group also completed the Godin Leisure-Time Questionnaire, Self-Efficacy for Exercise scale, Schwab-England scale, and Parkinson's Disease Questionnaire 8.

RESULTS

Eighty-seven people with PD (mean = 70 [7.3] years old) and 43 instructors (51 [12.1] years old) from the United States completed surveys (October 2020 to February 2021). Mean Schwab-England (84 [16]) and Parkinson's Disease Questionnaire 8 (21 [15]) scores indicated low-to-moderate disability in the PD group. Ninety-five percent of the PD group had COVID-19 exposure concerns, and 54% reported leaving home ≤1 time/week. Although 77% of the PD group scored "active" on the Godin Leisure-Time Questionnaire, the mean Self-Efficacy for Exercise Scale score (55 [24]) indicated only moderate exercise self-efficacy, and >50% reported decreased exercise quantity/intensity compared with pre-COVID. There was decreased in-person and increased virtual class participation for both groups. The top in-person class barrier for the PD (63%) and instructor (51%) groups was fear of participant COVID-19 exposure. The top virtual class barriers were lack of socialization (20% of PD group) and technology problems (74% of instructor group).

CONCLUSION

During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and decreased exercise quantity and intensity. Virtual classes may not fully meet the needs of people with PD, and primary barriers include technology and lack of socialization.

IMPACT

As COVID-19 restrictions wane, it is imperative to help people with PD increase exercise and activity. The barriers, needs, and facilitators identified in this study might help inform approaches to increase participation in exercise and activity for people with PD.

LAY SUMMARY

During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and a decrease in exercise quantity and intensity. If you have PD, virtual classes might not fully meet your needs. Primary barriers may include technology problems and lack of social interaction.

Age and Life-Sustaining Treatment Preferences in Parkinson Disease

Objective

Advance Care Planning (ACP) is one of 10 key elements in the American Academy of Neurology Parkinson disease (PD) clinical practice quality measures. We know little about how aging influences ACP views in people with PD.

Methods

We conducted a cross-sectional survey of 39 participants (mean age 70.3 years; range: 52-81) with PD to explore correlations between older age and life-sustaining treatment preferences while controlling for confounders including years of education, Montreal Cognitive Assessment score and Movement Disorders Society Unified Parkinson's disease Rating Scale motor score. Scenarios asked participants to choose their level of interest in pursuing life-sustaining measures in the setting of specific medical illnesses including stroke, metastatic cancer, severe heart attack, and dementia. All participants were men and were recruited from the Veterans Affairs Ann Arbor Healthcare System.

Results

In the hypothetical stroke, metastatic colon cancer, and dementia scenarios, older age correlated with more aggressive care goals related to the use cardiopulmonary resuscitation to treat cardiopulmonary arrest.

Conclusions

Advancing age in PD may correlate with paradoxically more aggressive goals as it relates to life-sustaining treatment preferences including cardiopulmonary resuscitation. This may reflect a response to heightened concern among older adults with PD about the potential for compromised autonomy in the setting of aging.

Individuals With Parkinson Disease Are Adherent to a High-Intensity Community-Based Cycling Exercise Program

BACKGROUND AND PURPOSE

Parkinson disease is a progressive neurological disorder with no known cure or proven method of slowing progression. High-intensity, laboratory-based aerobic exercise interventions are currently being pursued as candidates for altering disease progression. The aim of this project was to evaluate the translation of a laboratory-based intervention to the community by monitoring exercise adherence (eg, attendance) and intensity (eg, heart rate [HR] and cadence) in 5 established Pedaling for Parkinson's exercise classes. A secondary aim was to determine the impact of disease severity and demographics variables on exercise adherence.

METHODS

A 12-month pragmatic design was utilized to monitor attendance, HR, and cadence during each Pedaling for Parkinson's class session. Over the course of 1 year, approximately 130 sessions were offered. Forty-nine (n = 30 males) persons with mild to moderate Parkinson disease from 5 community fitness facilities participated.

RESULTS

Out of the approximately 130 cycling sessions offered at each site over 12 months, 37% of the participants attended greater than 2 classes per week (80-130 total sessions), 47% attended 1 to 1.9 classes per week (40-79 total sessions), and less than 17% attended less than 1 class per week (<40 total sessions). Average pedaling cadence was 74.1 ± 9.6 rpms while average percentage of HR maximum was 68.9 ± 12.0%. There were no significant differences between cycling adherence and intensity variables based on disease severity, age, or sex.

DISCUSSION AND CONCLUSIONS

Consistent attendance and exercise performance at moderate to high intensities are feasible in the context of a community-based Pedaling for Parkinson's class. Consistency and intensity of aerobic exercise have been proposed as critical features to elicit potential disease modification benefits associated with exercise. Community-based fitness programs that bring laboratory protocols to the "real world" are a feasible intervention to augment current Parkinson disease treatment approaches. See the Supplementary Video, available at: http://links.lww.com/JNPT/A357.

Comparison of Mini-Mental State Examination and Montreal Cognitive Assessment Ratings Across Levels of Parkinson's Disease Severity

BACKGROUND

Cognitive impairment (CI) is common in Parkinson's disease (PD) and an important cause of disability. Screening facilitates early detection of CI and has implications for management. Preclinical disability is when patients have functional limitations but maintain independence through compensatory measures.

OBJECTIVE

The objective of this study was to investigate the relationship between scores on the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) with levels of PD severity and disability.

METHODS

PD patients (n = 2,234) in a large observational study were stratified by disease severity, based on Total Unified Parkinson's Disease Rating Scale (Total UPDRS) and Hoehn and Yahr (HY) stage. Using MMSE (n = 1,184) or MoCA (n = 1,050) and basic (ADL) and instrumental activities of daily living (IADL) scales for disability, linear regression analysis examined associations between cognitive status and disability.

RESULTS

Cognition and disability were highly correlated, with the strongest correlation between IADL and MoCA. Only 16.0% of mean MMSE scores were below threshold for CI (28) and only in advanced PD (Total UPDRS 60+, HY≥3). MoCA scores fell below CI threshold (26) in 66.2% of the sample and earlier in disease (Total UPDRS 30+, HY≥2), corresponding with impairments in ADLs.

CONCLUSION

In a large clinical dataset, a small fraction of MMSE scores fell below cutoff for CI, reinforcing that MMSE is an insensitive screening tool in PD. MoCA scores indicated CI earlier in disease and coincided with disability. This study shows that MoCA, but not MMSE is sensitive to the emergence of early cognitive impairment in PD and correlates with the concomitant onset of disability.

Psychological Impact of Parkinson Disease Delusions on Spouse Caregivers: A Qualitative Study

There is growing research on carers of people with Parkinson's disease (PD) experiences. However, the impact on carers by PD delusions is not specifically examined. We conducted a qualitative study using semi-structured interviews of spouse carers of PD patients with delusions. Thematic analysis was employed using MAXQDA 2018. Twelve spouse participants (SPs) were interviewed. Four themes emerged: Managing incredulity: trying to make sense of delusion content; Hypervigilance: constant alertness to bizarre and threatening discourse and behavior; Defensive strategizing: anticipating delusions and potential consequences; Concealing and exposing: ambivalence about disclosing the effect of delusions yet wanting support. SPs reported effects on their emotional well-being and marital relationship and challenges to an orderly, predictable life. SPs were reluctant to share their experiences due to delusion content (often infidelity and sexual in nature) and a desire to protect their spouses' image. SPs' awareness of the potential for delusional thought was low prior to their occurrence. Conclusions: education surrounding potential neurobehavioral changes should occur for patients and carers. Clinicians should be aware that the impact of delusions on carers is often greater than disclosed in clinical interviews. Interdisciplinary teams speaking separately to spousal carers may improve disclosure and delivery of appropriate psychological support.

Health Care Resource Utilization Associated With Parkinson Disease Among Medicare Beneficiaries

OBJECTIVE

To compare differences in health care resource utilization (HcRU) over time between Medicare beneficiaries with and without Parkinson disease (PD).

METHODS

This retrospective observational study used the Chronic Conditions Data Warehouse (5% Medicare sample) between 2005 and 2015. In a propensity score-matched (age, sex, race, and comorbidity adjusted) sample of beneficiaries with and without PD, we examined all-cause HcRU due to inpatient admissions, emergency department (ED) admissions, skilled nursing facility (SNF) admissions, health care provider encounters, neurologist visits, rehabilitation service visits, and non-PD medication fills. Relative to beneficiaries without PD, we reported adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for beneficiaries with PD using generalized linear models with log link and negative binomial variance functions.

RESULTS

A total of 467,064 Medicare enrollees (unmatched sample) met the inclusion criteria. Of these, 3.3% had PD. In the matched sample and relative to beneficiaries without PD, beneficiaries with PD displayed higher rates of inpatient admissions (IRR 1.29, 95% CI 1.24-1.34), ED admissions (IRR 1.31, 95% CI 1.27-1.34), SNF admissions (IRR 2.00, 95% CI 1.92-2.09), health care provider encounters (IRR 1.18, 95% CI 1.16-1.20), neurologist visits (IRR 5.57, 95% CI 5.35-5.78), rehabilitation service visits (IRR 1.47, 95% CI 1.41-1.53), and non-PD medication fills (IRR 1.10, 95% CI 1.08-1.11) over time.

CONCLUSION

These results reflect patterns of medical care among Medicare beneficiaries with PD. The findings can help clinicians, payers, and policy makers make evidence-based decisions for the allocation of scarce health care resources for PD management.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that Medicare beneficiaries with PD use more health care resources than matched controls without PD.

Somatic symptoms have negligible impact on Patient Health Questionnaire-9 depression scale scores in neurological patients

BACKGROUND AND PURPOSE

There is concern that the Patient Health Questionnaire-9 (PHQ-9) depression scale may be impacted by the presence of somatic symptoms (differential item functioning [DIF]) in patients with neurological conditions. We evaluated the PHQ-9 for the presence and impact of DIF in large clinical samples of neurological patients.

METHODS

We conducted a cross-sectional study of patients seen at the Cleveland Clinic Cerebrovascular, Headache, Movement Disorder, and Neuromuscular clinics who completed the PHQ-9 and patient-reported disease severity measures as part of standard care between 29 July 2008 and 21 February 2013. We evaluated PHQ-9 items for DIF with respect to disease-specific severity for each condition. Salient DIF impact was characterized as a difference between DIF-adjusted and unadjusted PHQ-9 scores.

RESULTS

Included in the study were 2112 patients with stroke, 8221 with migraine, 440 with amyotrophic lateral sclerosis (ALS), and 5022 with Parkinson disease (PD). Several PHQ-9 items demonstrated DIF with respect to disease-specific severity, although salient DIF was present in very few patients (stroke, n = 0; migraine, n = 1; ALS, n = 13; PD, n = 1).

CONCLUSIONS

PHQ-9 items function consistently across disease severity, with salient levels of DIF impact found only for a very small proportion of people. These results suggest that the PHQ-9 provides a consistent measure of depression severity among people with neurological conditions associated with somatic symptoms that overlap with depression.

The experience of care partners of patients with Parkinson's disease psychosis

Background

Parkinson’s disease psychosis (PDP) has a major impact on quality of life and care partner burden; however, little is known about the lived experiences of care partners in managing PDP.

Objective

To understand how care partners of individuals with PDP experience their role and articulate their needs related to psychosis.

Methods

This was a qualitative study of semi-structured telephone interviews. Recruitment was conducted online via the clinical study matching tool, Fox Trial Finder; study activities took place remotely via telephone interviews. Transcripts of the phone interviews were analyzed by grounded theory methods, and a codebook of key themes that emerged from the analysis was developed.

Results

Nine care partners (all female) were interviewed. Discussion topics in the codebook included (1) care partner burden and guilt; (2) communication with medical professionals; (3) coping strategies; (4) emotional reactions of the care partner to psychosis; (5) sources of knowledge about PD psychosis; (6) attitudes towards medications for PDP; (7) strategies to care for loved ones with psychosis; (8) psychosis triggers.

Conclusions

This qualitative analysis uncovers important aspects of the care partner experience, including challenges in navigating the medical system and communicating with professionals. Providers treating patients with PDP should be aware of these constraints and provide added support for strained care partners.

Designing a screening battery for exercisers with Parkinson's disease

PURPOSE

Develop a screening battery for persons with Parkinson's Disease (PD) that is easily administered in a short amount of time by community exercise professionals and measures changes in function.

METHODS

An integrated, stakeholder-engaged, mixed methods approach included interviews and meetings with community exercise professionals on the development of a screening battery. Persons with PD (n = 57, age = 72.1 ± 8.1 years) who were already enrolled in fitness classes or individualized training at three locations participated in the screening battery twice over 8-16 weeks and provided feedback. Trends from interviews and meeting notes were identified using summative content analysis. Quantitative changes in performance were compared with paired t-tests. Cohen's d effect sizes were calculated for all significant differences.

RESULTS

Current barriers for functional screenings included time and space. Using this feedback, we developed a screening battery that took under 20 min, required little equipment, had been previously validated, could be performed in individual and group settings, and provided objective feedback that was motivating for persons with PD to continue exercising. Persons with PD demonstrated improved functional performance on sit-to-stand (d = -0.71), two-minute walk test (d = -3.83), and arm curls (d = -0.78).

CONCLUSION

Test results can be a motivator for persons with PD and lead to increased exercise adherence. Easily administered tests can show improvements in this population. Community exercise professionals are able to safely screen persons with PD to detect functional deficits and assist with programming.Implications for RehabilitationRegular exercise can slow declines in physical function and quality of life in people with Parkinson's disease.Use of physical assessments in community exercise programs can improve motivation to exercise for this population.Physical assessments such as sit-to-stand and arm curls can be used to demonstrate improvements in people with Parkinson's disease.

Frameworks for Parkinson's Disease Rehabilitation Addressing When, What, and How

PURPOSE OF REVIEW

This review summarizes the evidence on rehabilitation for people with Parkinson's disease, including when to refer, what rehabilitation professionals should address, and how to deliver rehabilitation care.

RECENT FINDINGS

Clinical practice guidelines support physical therapy, occupational therapy, and speech-language pathology for Parkinson's disease. However, integrating guidelines into practice may be difficult. Implementation studies take into account patient and clinician perspectives. Synthesizing guidelines with implementation research can improve local delivery. There is moderate to strong evidence supporting physical therapy, occupational therapy, and speech-language pathology soon after diagnosis and in response to functional deficits. We propose a framework of three pathways for rehabilitation care: (1) consultative proactive rehabilitation soon after diagnosis for assessment, treatment of early deficits, and promotion meaningful activities; (2) restorative rehabilitation to promote functional improvements; and (3) skilled maintenance rehabilitation for long-term monitoring of exercise, meaningful activities, safety, contractures, skin integrity, positioning, swallowing, and communication.

Triggers and alleviating factors for fatigue in Parkinson's disease

BACKGROUND

Fatigue is common in Parkinson's Disease, but few effective treatments are available for it. Exploring triggers and alleviating factors, including effects of exercise, could inform development of management strategies for Parkinson's Disease fatigue.

OBJECTIVES

To examine triggers and alleviating factors for fatigue reported by individuals with Parkinson's Disease, including perceived effect of exercise.

METHODS

A sample of individuals with self-reported Parkinson's Disease participating in the study Fox Insight were administered an online survey. The survey included the Parkinson's Fatigue Scale, the Physical Activity Scale for the Elderly, and multiple-choice questions about triggers and alleviating factors for fatigue.

RESULTS

Among the sample of 1,029 individuals with Parkinson's disease, mean (standard deviation (SD)) age was 67.4 (9.3) years, 44.0% were female. Parkinson's Fatigue Scale score ranged from 16-80, mean (SD) 48.8 (16.2). Poor sleep (62.1%) and physical exertion (45.1%) were frequently reported triggers for fatigue. Coping strategies including sitting quietly (58.1%), laying down with or without napping, and exercise (20%). Physical Activity Scale for the Elderly scores were higher in those who reported that exercise alleviated their fatigue (49.7%) compared to those who reported it worsened their fatigue (18.9%) (mean (SD) score 158.5 (88.8) vs 119.8 (66.6) respectively; p<0.001).

CONCLUSIONS

Several behavioral and environmental triggers and alleviating strategies for fatigue are reported by individuals with Parkinson's disease. Many feel that exercise alleviates fatigue, though the relationship between exercise and fatigue in Parkinson's Disease appears complex. This exploratory study may inform future development of treatments or coping strategies for Parkinson's disease fatigue.

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.

Palliative Care in Movement Disorders: an Evolving Field

PURPOSE OF REVIEW

This review summarizes the current state of evidence for palliative care (PC) in movement disorders, describes the application of PC to clinical practice, and suggests future research directions.

RECENT FINDINGS

PC needs are common in persons living with movement disorders and their families from the time of diagnosis through end-of-life and contribute to quality of life. Early advance care planning is preferred by patients, impacts outcomes and is promoted by PC frameworks. Systematic assessment of non-motor symptoms, psychosocial needs and spiritual/existential distress may address gaps in current models of care. Several complementary and emerging models of PC may be utilized to meet the needs of this population. A PC approach may identify and improve important patient and caregiver-centered outcomes. As a relatively new application of PC, there is a need for research to adapt, develop and implement approaches to meet the unique needs of this population.

Would people living with epilepsy benefit from palliative care?

Palliative care (PC) is an approach to the care of persons living with serious illness and their families that focuses on improving quality of life and reducing suffering by addressing complex medical symptoms, psychosocial needs, spiritual well-being, and advance care planning. While PC has traditionally been associated with hospice care for persons with cancer, there is now recognition that PC is relevant to many noncancer diagnoses, including neurologic illness, and at multiple points along the illness journey, not just end of life. Despite the recent growth of the field of neuropalliative care there has been scant attention paid to the relevance of PC principles in epilepsy or the potential for PC approaches to improve outcomes for persons living with epilepsy and their families. We believe this has been a significant oversight and that PC may provide a useful framework for addressing the many sources of suffering facing persons living with epilepsy, for engaging patients and families in challenging conversations, and to focus efforts to improve models of care for this population. In this manuscript we review areas of significant unmet needs where a PC approach may improve patient and family-centered outcomes, including complex symptom management, goals of care, advance care planning, psychosocial support for patient and family and spiritual well-being. When relevant we highlight areas where epilepsy patients may have unique PC needs compared to other patient populations and conclude with suggestions for future research, clinical, and educational efforts.

Palliative Care for Parkinson's Spectrum Disorders: an Emerging Approach

Parkinson's spectrum disorders (PSD) are neurodegenerative parkinsonian conditions that carry a tremendous symptom burden. Palliative care is an interdisciplinary medical specialty that focuses on improving quality of life for patients and caregivers affected by serious life-limiting illnesses, at any stage of disease. Research and clinical programs into this emerging therapeutic approach remain limited. This review focuses on the role of palliative care in the treatment of patients with PSD. Gaps in knowledge and recommendations for future research are discussed.

Therapy of Parkinson's Disease Subtypes

Early descriptions of subtypes of Parkinson's disease (PD) are dominated by the approach of predetermined groups. Experts defined, from clinical observation, groups based on clinical or demographic features that appeared to divide PD into clinically distinct subsets. Common bases on which to define subtypes have been motor phenotype (tremor dominant vs akinetic-rigid or postural instability gait disorder types), age, nonmotor dominant symptoms, and genetic forms. Recently, data-driven approaches have been used to define PD subtypes, taking an unbiased statistical approach to the identification of PD subgroups. The vast majority of data-driven subtyping has been done based on clinical features. Biomarker-based subtyping is an emerging but still quite undeveloped field. Not all of the subtyping methods have established therapeutic implications. This may not be surprising given that they were born largely from clinical observations of phenotype and not in observations regarding treatment response or biological hypotheses. The next frontier for subtypes research as it applies to personalized medicine in PD is the development of genotype-specific therapies. Therapies for GBA-PD and LRRK2-PD are already under development. This review discusses each of the major subtyping systems/methods in terms of its applicability to therapy in PD, and the opportunities and challenges designing clinical trials to develop the evidence base for personalized medicine based on subtypes.

Chasing Protection in Parkinson's Disease: Does Exercise Reduce Risk and Progression?

Exercise may be the most commonly offered yet least consistently followed therapeutic advice for people with Parkinson's disease (PD). Epidemiological studies of prospectively followed cohorts have shown a lower risk for later developing PD in healthy people who report moderate to high levels of physical activity, and slower rates of motor and non-motor symptom progression in people with PD who report higher baseline physical activity. In animal models of PD, exercise can reduce inflammation, decrease α-synuclein expression, reduce mitochondrial dysfunction, and increase neurotrophic growth factor expression. Randomized controlled trials of exercise in PD have provided clear evidence for short-term benefits on many PD measurements scales, ranging from disease severity to quality of life. In this review, we present these convergent epidemiological and laboratory data with particular attention to translationally relevant features of exercise (e.g., intensity requirements, gender differences, and associated biomarkers). In the context of these findings we will discuss clinical trial experience, design challenges, and emerging opportunities for determining whether exercise can prevent PD or slow its long-term progression.

Trends of inpatient palliative care use among hospitalized patients with Parkinson's disease

INTRODUCTION

Palliative care in Parkinson's Disease (PD) is an effective intervention to improve quality of life, although historically, access and availability have been very restricted.

METHODS

We performed a retrospective cohort study using the National Inpatient Sample (NIS) data from 2007 to 2014. Diagnostic codes were used to identify patients with PD and palliative care referral. Trends were calculated and logistic analysis performed to identify predictors of palliative care use.

RESULTS

We identified 397,963 hospitalizations from 2007 to 2014 for patients with PD. Of these, 10,639 (2.67%) were referred to palliative care. The rate of consultation increased from 0.85% in 2007 to 4.49% in 2014. For 1 unit in year increase, there was 1.23 time the odds of receiving palliative consultation (OR 1.23, CI 1.21-1.25, p < 0.0001). Hispanics (OR 0.90, CI 0.81-1.01, p = 0.0550), Black (OR 0.90, CI 0.81-1.01, p = 0.0747) and White patients had similar rates of referral after adjustment. Women were less likely to be referred to palliative care (OR 0.90, CI 0.87-0.94, p < 0.0001). Other factors strongly associated with a higher rate of referrals included private insurance when compared to Medicare (OR 2.14, CI 1.89-2.41, p < 0.0001) and higher income (OR 1.41, CI 1.30-1.53, p < 0.0001).

CONCLUSION

There has been a significant increase in palliative care referrals among hospitalized patients with PD in the US, although the overall rate remains low. After controlling for confounders, racial and ethnic disparities were not found. Women, patients with Medicare/Medicaid, and those with lower income were less likely to be referred to palliative care.

Patient-Centric Care for Parkinson's Disease: From Hospital to the Community

Parkinson's disease (PD) is a chronic neurodegenerative disease with complex motor and non-motor symptoms often leading to significant caregiver burden. An integrated, multidisciplinary care setup involving different healthcare professionals is the mainstay in the holistic management of PD. Many challenges in delivering multidisciplinary team (MDT) care exist, such as insufficient expertise among different healthcare professionals, poor interdisciplinary collaboration, and communication. The need to attend different clinics, incurring additional traveling and waiting time for allied health therapies can also make MDT care more burdensome. By shifting MDT care to local community settings and into patients' homes, patient-centered care can be achieved. In Singapore, the National Neuroscience Institute created the Community Care Partners Programme in 2007 to bring the allied MDT team to the community and nurse-led Integrated Community Care Programme for Parkinson's Disease in 2012 to provide care in community and at patient's home. However, attaining MDT care in the community setting is difficult to achieve where there is a shortage of PD-trained professionals. As such, interdisciplinary and transdisciplinary management would be other best practice options to deliver patient-centric care in PD. Telemedicine could be another viable option to bring the MDT closer to the patient.

An improved sex-specific and age-dependent classification model for Parkinson's diagnosis using handwriting measurement

BACKGROUND AND OBJECTIVES

Diagnosis of Parkinson's with higher accuracy is always desirable to slow down the progression of the disease and improved quality of life. There are evidences of inherent neurological differences between male and females as well as between elderly and adults. However, the potential of such gender and age infomration have not been exploited yet for Parkinson's identification.

METHODS

In this paper, we develop a sex-specific and age-dependent classification method to diagnose the Parkinson's disease using the online handwriting recorded from individuals with Parkinson's (n = 37; m/f-19/18;age-69.3 ± 10.9yrs) and healthy controls (n = 38; m/f-20/18;age-62.4 ± 11.3yrs). A support vector machine ranking method is used to present the features specific to their dominance in sex and age group for Parkinson's diagnosis.

RESULTS

The sex-specific and age-dependent classifier was observed significantly outperforming the generalized classifier. An improved accuracy of 83.75% (SD = 1.63) with the female-specific classifier, and 79.55% (SD = 1.58) with the old-age dependent classifier was observed in comparison to 75.76% (SD = 1.17) accuracy with the generalized classifier.

CONCLUSIONS

Combining the age and sex information proved to be encouraging in classification. A distinct set of features were observed to be dominating for higher classification accuracy in a different category of classification.

From Passive Patient to Engaged Partner: My Journey With Parkinson Disease

This patient narrative by Richard Higgins with Maureen Hennessey describes Richard's journey of learning to live with a chronic and progressive illness. It begins with Richard's diagnosis and shares many of the lessons learned along the way. Richard copes daily with this condition, relying on the support and expertise of his wife and the treatment team he has assembled while also encouragingly drawing on the skills and knowledge gained as a longtime running coach. A clinical commentary is provided at the article's conclusion, drafted by Richard's friend, Maureen Hennessey, PhD, CPCC, CPHQ, offering observations about the relevance of Richard's story to participatory medicine and suggesting pertinent resources for patients and health care professionals.

Self-reported visual dysfunction in Parkinson disease: the Survey of Health, Ageing and Retirement in Europe

BACKGROUND AND PURPOSE

Visual dysfunction is a non-motor symptom of Parkinson disease (PD), but its prevalence is unknown as population-based data on the epidemiology of visual symptoms in PD are lacking. The objective was to determine the prevalence of visual dysfunction in PD.

METHODS

This was a cross-sectional analysis of data from adults ≥50 years old in the Survey of Health, Ageing and Retirement in Europe (SHARE), a multinational population-based health survey of adults living in one of 27 European countries and Israel. PD diagnosis was self-reported. Impairment in overall, distance or near eyesight was defined as a score of 4 or 5 on a 1-5 scale. Adjusted logistic regression was used to determine the association between PD and self-reported vision.

RESULTS

There were 115 240 age-eligible participants in the SHARE study (mean age 64.3 years, 54% female), of whom 1438 (1.25%) reported a diagnosis of PD. In adjusted logistic regression models, PD was associated with increased odds of impaired overall [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.91-3.72], distance (OR 2.55, 95% CI 2.04-3.19) and near (OR 2.07, 95% CI 1.69-2.55) eyesight. Individuals with PD were also less likely to report having an eye examination within the previous 2 years (OR 0.59, 95% CI 0.38-0.92), but this did not remain statistically significant after adjusting for confounders (OR 0.76, 95% CI 0.47-1.24).

CONCLUSIONS

Visual dysfunction is significantly more common in PD than in the general adult population. Visual symptoms are a potentially under-recognized and under-treated source of reduced quality of life in PD patients that require further attention and study.

Diagnosis and Treatment of Parkinson Disease: A Review

IMPORTANCE

Parkinson disease is the most common form of parkinsonism, a group of neurological disorders with Parkinson disease-like movement problems such as rigidity, slowness, and tremor. More than 6 million individuals worldwide have Parkinson disease.

OBSERVATIONS

Diagnosis of Parkinson disease is based on history and examination. History can include prodromal features (eg, rapid eye movement sleep behavior disorder, hyposmia, constipation), characteristic movement difficulty (eg, tremor, stiffness, slowness), and psychological or cognitive problems (eg, cognitive decline, depression, anxiety). Examination typically demonstrates bradykinesia with tremor, rigidity, or both. Dopamine transporter single-photon emission computed tomography can improve the accuracy of diagnosis when the presence of parkinsonism is uncertain. Parkinson disease has multiple disease variants with different prognoses. Individuals with a diffuse malignant subtype (9%-16% of individuals with Parkinson disease) have prominent early motor and nonmotor symptoms, poor response to medication, and faster disease progression. Individuals with mild motor-predominant Parkinson disease (49%-53% of individuals with Parkinson disease) have mild symptoms, a good response to dopaminergic medications (eg, carbidopa-levodopa, dopamine agonists), and slower disease progression. Other individuals have an intermediate subtype. For all patients with Parkinson disease, treatment is symptomatic, focused on improvement in motor (eg, tremor, rigidity, bradykinesia) and nonmotor (eg, constipation, cognition, mood, sleep) signs and symptoms. No disease-modifying pharmacologic treatments are available. Dopamine-based therapies typically help initial motor symptoms. Nonmotor symptoms require nondopaminergic approaches (eg, selective serotonin reuptake inhibitors for psychiatric symptoms, cholinesterase inhibitors for cognition). Rehabilitative therapy and exercise complement pharmacologic treatments. Individuals experiencing complications, such as worsening symptoms and functional impairment when a medication dose wears off ("off periods"), medication-resistant tremor, and dyskinesias, benefit from advanced treatments such as therapy with levodopa-carbidopa enteral suspension or deep brain stimulation. Palliative care is part of Parkinson disease management.

CONCLUSIONS AND RELEVANCE

Parkinson disease is a heterogeneous disease with rapidly and slowly progressive forms. Treatment involves pharmacologic approaches (typically with levodopa preparations prescribed with or without other medications) and nonpharmacologic approaches (such as exercise and physical, occupational, and speech therapies). Approaches such as deep brain stimulation and treatment with levodopa-carbidopa enteral suspension can help individuals with medication-resistant tremor, worsening symptoms when the medication wears off, and dyskinesias.

Palliative Care for Parkinson Disease

Palliative care (PC) is an approach to the care of persons affected by serious illness that focuses on reducing suffering by addressing medical, psychosocial, and spiritual needs. Persons living with Parkinson disease have PC needs that begin at the time of diagnosis and continue throughout the course of the illness including nonmotor symptom burden, caregiver distress, grief, and increased mortality. Primary PC refers to essential PC skills that may be practiced by nonpalliative medicine specialists to improve outcomes for their patients.