Rate of Hospitalizations and Underlying Reasons Among People with Parkinson's Disease: Population-Based Cohort Study in UK Primary Care

Predictors of outcomes in people with Parkinson's disease admitted to a large UK teaching hospital

People with Parkinson's disease (PwP) are more commonly admitted to hospital, have higher morbidity and mortality, are more likely to be discharged into 24 hour care and have longer lengths of stay than people without Parkinson's disease (PD). We analysed historic, deidentified data for all PwP admitted to a large UK hospital trust over a 2-year period. We compared outcomes for patients by age, time since PD diagnosis, the presence of dementia, the reason for admission and the admitting speciality, to understand which aspects of care predict outcomes. 712 PwP accounted for 1156 admissions. The median length of stay was 9 days; a diagnosis of dementia, long bone fracture and being admitted under the care of rehabilitation or orthopaedics were associated with longer stays. 9 % of admissions died in hospital, a further 9 % died in the first 90 days post discharge; mortality was higher with increasing age (19 % in those >90 years), comorbid dementia (15 %) and in people whose reason for admission was pneumonia (26 %). 35 % of admissions were readmitted in the 30 days post discharge. Being admitted due to falls or being admitted under accident and emergency almost doubled this rate. 21 % of people did not return home to the same accommodation they left; this was more than doubled (48 %) in those admitted for long bone fractures. By understanding of which aspects of the hospital admission influence outcomes for PwP, we can improve hospital care in the future, learning lessons from areas of the hospital with better and worse outcomes alike.

Net Health System Costs of Parkinson Disease: A Propensity Score-Matched Health Administrative Data Cohort Study in Ontario, Canada

Background and Objectives

Few estimates of the long-term health system costs of Parkinson disease by phase of disease are available. We estimated 10-year and phase-based net health system costs of Parkinson disease before and after case ascertainment.

Methods

Using population-based linked administrative databases from Ontario, Canada, we identified 43,149 community-dwelling persons with incident Parkinson disease aged 40 years and older between 2009 and 2018 using a validated algorithm. These individuals were matched 1:1 to controls without Parkinson disease based on demographics and a propensity score. We calculated phase-based, net health system costs from the provincial government perspective during the preascertainment (3 years before index), initial (1 year after index), early continuing (>1-6 years after index), later continuing (>6-10 years after index), and terminal (1 year before death, if applicable) phases (standardized to 2020 $CAD and calculated on an annual basis). By applying survival probabilities to monthly cost estimates, we also determined 10-year net health system costs, stratified by sex and age.

Results

Annual mean net costs of Parkinson disease were lowest in the preascertainment phase ($212 CAD, 95% CI [$20-$404]), intermediate in the initial phase ($4,576 (95% CI [$4,217-$4,935]), and higher in the early continuing phase ($7,078, 95% CI [$6,717-$7,438]). The later continuing phase ($12,500, 95% CI [$12,060-$12,940]) and the terminal phase ($13,933, 95% CI [$13,123-$14,743]) showed the highest costs. The 10-year net cost of Parkinson disease was $82,153 (95% CI [$77,965-$86,341]) and was significantly higher in women ($89,773, 95% CI [$83,306-$96,240]) than in men ($76,469, 95% CI [$70,983-$81,953]) and older individuals ($92,197, 95% CI [$87,087-$97,307]), compared with younger individuals ($62,580, 95% CI [$55,346-$69,814]). Over the 10-year period, hospital, nursing home, and home care were the largest contributors to costs of Parkinson disease.

Discussion

Health system costs of Parkinson disease are substantial, particularly in the later phases. Interventions to reduce avoidable use of hospital and nursing home services by persons living with Parkinson disease may provide better quality of life and be cost saving from the health system perspective.

Identifying and Predicting Risk for Hospital Admission among Patients with Parkinsonism

BACKGROUND

Patients with parkinsonism are more likely than age-matched controls to be admitted to hospital. It may be possible to reduce the cost and negative impact by identifying patients at highest risk and intervening to reduce hospital-related costs. Predictive models have been developed in nonparkinsonism populations.

OBJECTIVES

The aims were to (1) describe the reasons for admission, (2) describe the rates of hospital admission/emergency department attendance over time, and (3) use routine data to risk stratify unplanned hospital attendance in people with parkinsonism.

METHODS

This retrospective cohort study used Clinical Practice Research Datalink GOLD, a large UK primary care database, linked to hospital admission and emergency department attendance data. The primary diagnoses for nonelective admissions were categorized, and the frequencies were compared between parkinsonism cases and matched controls. Multilevel logistic and negative binomial regression models were used to estimate the risk of any and multiple admissions, respectively, for patients with parkinsonism.

RESULTS

There were 9189 patients with parkinsonism and 45,390 controls. The odds of emergency admission more than doubled from 2010 to 2019 (odds ratio [OR] 2.33; 95% confidence interval [CI] 1.96, 2.76; P-value for trend <0.001). Pneumonia was the most common reason for admission among cases, followed by urinary tract infection. Increasing age, multimorbidity, parkinsonism duration, deprivation, and care home residence increased the odds of admission. Rural location was associated with reduced OR for admission (OR 0.79; 95% CI 0.70, 0.89).

CONCLUSIONS

Our risk stratification tool may enable empirical targeting of interventions to reduce admission risk for parkinsonism patients.

Improving Medication Management for Inpatients with a Secondary Diagnosis of Parkinson Disease

ABSTRACT

Patients who have Parkinson disease require individualized medication regimens to optimize care. A review of the medication management of patients admitted to a tertiary care hospital with a secondary diagnosis of Parkinson disease found significant departures from the patients' home regimen. Medication regimens are often altered by health care teams unfamiliar with Parkinson disease-specific care in order to conform to standard hospital medication orders and administration times, potentially resulting in increased patient falls, delirium, and mortality.A nurse-led multidisciplinary team consisting of pharmacy, nursing, informatics, neurology, and quality personnel implemented a quality improvement (QI) project between July 2020 and July 2022 to identify patients with Parkinson disease, including those with a secondary diagnosis and those undergoing deep brain stimulation, and customize medication management in order to reduce length of stay, mortality, falls, falls with harm, and 30-day readmissions. The QI project team also evaluated patient satisfaction with medication management.Among patients with a secondary diagnosis of Parkinson disease, the proportion who had medication histories conducted by a pharmacy staff member increased from a baseline of 53% to more than 75% per month. For all patients with Parkinson disease, those whose medication history was taken by a pharmacy staff member had orders matching their home regimen 89% of the time, whereas those who did not had orders matching the home regimen only 40% of the time. Among patients with a secondary diagnosis of Parkinson disease, the length-of-stay index decreased from a baseline of 1 to 0.94 and observed-to-expected mortality decreased from 1.03 to 0.78. The proportion of patients experiencing a fall decreased from an average of 5% to 4.08% per quarter, while the proportion of patients experiencing a fall with harm decreased from an average of 1% to 0.75% per quarter. The rate of 30-day readmissions decreased from 10.81% to 4.53% per quarter. Patient satisfaction scores were 1.95 points higher for patients who had medication histories taken by pharmacy than for those who did not (5 versus 3.05).

Association between Parkinson's disease and the risk of adverse cardiovascular events: a systematic review and meta-analysis

Background

This review aims to examine the association of Parkinson's disease (PD) with the increased risk of cardiovascular events.

Methods

PubMed, Embase, CENTRAL, and Scopus databases were electronically searched for papers published up to 5 May 2023. Studies reporting the association between PD and the subsequent risks of stroke, myocardial infarction (MI), and cardiovascular mortality were included.

Results

Sixteen studies were included in this review. The clinical data of 101,712 PD patients were compared with that of the control group of 204,901 patients without PD in the included studies. Meta-analysis showed that PD patients had an increased risk of stroke compared with patients without PD (odds ratio (OR): 1.49; 95% confidence interval (CI): 1.30, 1.72; I2 = 76%). The pooled analysis demonstrated no significant increase in the risk of MI (OR: 1.16; 95% CI: 0.85, 1.59; I2 = 82%) and cardiovascular mortality (OR: 1.20; 95% CI: 0.93, 1.54; I2 = 65%) in PD patients. However, data from cohort studies indicated a possibility of higher risk of MI (OR: 1.36; 95% CI: 1.01, 1.84; I2 = 80%) and cardiovascular mortality (OR: 1.22; 95% CI: 1.00, 1.60; I2 = 62%) in patients with PD.

Conclusion

Patients with PD may have an increased risk of stroke as compared with the age- and gender-matched general population. While our results show that PD does not increase the overall risk of MI and cardiovascular mortality, analysis of cohort studies alone demonstrated that these risks may be higher in patients with PD. The current evidence is of very low quality. Further prospective cohort studies from different countries that would account for important cardiovascular risk factors are needed to improve the current evidence.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, PROSPERO (CRD42023421924).

Risk of hospitalization in synucleinopathies and impact of psychosis

Background

Few studies have investigated the risk of hospitalization among patients with synucleinopathies (Parkinson disease, Dementia with Lewy Bodies, Parkinson disease dementia, Multiple System Atrophy) with associated psychosis and the impact of antipsychotic treatments on hospital admissions and duration of the stay.

Objective

To determine the risk of hospitalization among patients with synucleinopathies and in patients with associated psychosis. To evaluate the impact of antipsychotic treatments on hospital admission of patients with synucleinopathies and psychosis in an incident cohort study in Olmsted County, Minnesota (MN).

Methods

We used the Rochester Epidemiology Project (REP) to define an incident cohort of patients with clinically diagnosed synucleinopathies (1991-2010) in Olmsted County, MN. A movement disorder specialist reviewed all medical records to confirm the clinical diagnosis of synucleinopathies using the NINDS/NIMH unified diagnostic criteria.

Results

We included 416 incident cases of clinically diagnosed synucleinopathies from 2,669 hospitalizations. 409 patients (98.3%) were admitted to the hospital at least once for any cause after the onset of parkinsonism. The median number of hospitalizations for a single patient was 5. In total, 195 (46.9%) patients met the criteria for psychosis: patients with psychosis had a 49% (HR = 1.49, p < 0.01) increased risk of hospitalization compared to patients without psychosis. Among patients with psychosis, 76 (39%) received antipsychotic medication. Treatment with antipsychotic medications did not affect the risk of hospitalization (HR = 0.93, p = 0.65). The median length of hospitalization among the entire cohort was 1 (IQR 0-4) day. There was no difference between hospitalization length for patients with no psychosis and patients with active psychosis (RR = 1.08, p = 0.43) or patients with resolved psychosis (RR = 0.79, p = 0.24).

Conclusion

Psychosis increases the risk of hospitalization in patients with clinically defined synucleinopathies; however, it does not affect the length of hospital stays in our cohort. Antipsychotic treatment does not affect the risk of hospitalization in our study.

Importance of timely administration of dopaminergic medications to improve Parkinson's patients' clinical outcomes

This article explores the challenges posed when ensuring the effective management of patients with Parkinson's in the secondary care setting. The evidence base around the appropriate timing and administration of medications is explored and highlights key themes in the literature to support best practice and raise clinical awareness. Failure to follow prescribed treatments for patients with Parkinson's can have significant implications for both patients and nursing care.

Analyses of hospitalization in Alzheimer's disease and Parkinson's disease in a tertiary hospital

Background

To characterize the pattern of hospitalization in patients with Alzheimer's disease (AD) or Parkinson's disease (PD), and compare the differences to see whether AD patients and PD patients have a different picture of hospitalization.

Methods

The clinical features of all consecutive patients from January 2017 to December 2020 were reviewed. We identified AD patients and PD patients from an electronic database in a tertiary medical center.

Results

The study group comprised 995 AD patients and 2,298 PD patients who were admitted to the hospital for the first time, and re-hospitalized 231 AD patients and 371 PD patients were also included. AD patients were older than PD patients when they were hospitalized (p < 0.001). AD patients had longer lengths of stay, higher re-hospitalization rates, and higher intrahospital mortality rates than PD patients during hospitalization even after adjusting age and gender. PD patients had higher levels of total cost than AD patients due to the cost of the deep brain stimulation (DBS) insertion. Hospitalizations for AD patients occurred most often in the department of geriatrics, while most PD patients were admitted to the department of neurology. Hospitalization due to the presence of comorbid conditions was much higher in AD patients, but a larger proportion of PD patients were hospitalized due to PD disease itself.

Conclusions

The present study found that AD patients and PD patients have a significantly different picture of hospitalization. It is important to implement different management for hospitalized AD and PD, and different emphasis should be given when establishing primary prevention strategies, informing care needs, and guiding healthcare resource planning.

Recent hospitalization and risk of antidepressant initiation in people with Parkinson's disease

BACKGROUND

People with Parkinson's disease (PD) are more likely to be hospitalized and initiate antidepressant use compared to people without PD. It is not known if hospitalization increases the risk of antidepressant initiation. We studied whether a recent hospitalization associates with antidepressant initiation in people with PD.

METHODS

A nested case-control study within the nationwide register-based FINPARK cohort which includes community-dwelling Finnish residents diagnosed with PD between years 1996 and 2015 (N = 22,189) was conducted. Initiation of antidepressant use after PD diagnosis was identified from Prescription Register with 1-year washout period (cases). One matched non-initiator control for each case was identified (N = 5492 age, sex, and time since PD diagnosis-matched case-control pairs). Hospitalizations within the 14 day-period preceding the antidepressant initiation were identified from the Care Register for Health Care.

RESULTS

The mean age at antidepressant initiation was 73.5 years with median time since PD diagnosis 2.9 years. Selective serotonin reuptake inhibitors (48.1%) and mirtazapine (35.7%) were the most commonly initiated antidepressants. Recent hospitalization was more common among antidepressant initiators than non-initiators (48.3 and 14.3%, respectively) and was associated with antidepressant initiation also after adjusting for comorbidities and use of medications during the washout (adjusted OR, 95% CI 5.85, 5.20-6.59). The initiators also had longer hospitalizations than non-initiators. PD was the most common main discharge diagnosis among both initiators (54.6%) and non-initiators (28.8%). Discharge diagnoses of mental and behavioral disorders and dementia were more common among initiators.

CONCLUSIONS

Hospitalisation is an opportunity to identify and assess depressive symptoms, sleep disorders and pain, which may partially explain the association. Alternatively, the indication for antidepressant initiation may have led to hospitalisation, or hospitalisation to aggravation of, e.g., neuropsychiatric symptoms leading to antidepressant initiation.

Personalized Care in Late-Stage Parkinson’s Disease: Challenges and Opportunities

Late-stage Parkinson’s disease (LSPD) patients are highly dependent on activities of daily living and require significant medical needs. In LSPD, there is a significant caregiver burden and greater health economic impact compared to earlier PD stages. The clinical presentation in LSPD is dominated by motor and non-motor symptoms (NMS) that most of the time have a sub-optimal to no response to dopaminergic treatment, especially when dementia is present. Non-pharmacological interventions, including physiotherapy, cognitive stimulation, speech, occupational therapy, and a specialized PD nurse, assume a key role in LSPD to mitigate the impact of disease milestones or prevent acute clinical worsening and optimize the management of troublesome NMS. However, the feasibility of these approaches is limited by patients’ cognitive impairment and the difficulty in delivering care at home. The present care challenge for LSPD is the ability to offer a person-centered, home-delivered palliative care model based on Advanced Care Planning. An ongoing European multicentric project, PD_Pal, aims to address this challenge.

Hallucinations and delusions associated with Parkinson's disease psychosis: safety of current treatments and future directions

INTRODUCTION

: Over half of Parkinson's disease (PD) patients develop psychotic symptoms, and PD psychosis (PDP) is associated with significant distress to patients, caregiver burden, and impairs quality of life. Pharmacological therapy is limited to atypical antipsychotics.

AREAS COVERED

: This review will summarize efficacy but will focus on the safety of antipsychotics for treating PDP, and in particular the off-target safety issues including cognitive impairment, sleep disturbance, cardiovascular effects, and motor function.

EXPERT OPINION

: Pimavanserin is the only medication approved in the US for treating PDP, however clozapine is also considered efficacious. Despite lack of substantial evidence for efficacy, quetiapine is commonly used to treat PDP. Despite the effectiveness of pimavanserin and clozapine for treating PDP, a need exists for additional pharmacological agents that are effective for PDP while providing an acceptable safety and tolerability profile. Medications to treat PDP should avoid worsening motor function, and also minimize sleep disturbances, cognitive impairment, cardiovascular effects, and other non-motor safety concerns. A neutral effect or reduction in mortality risk associated with PD and PDP would be ideal, and low rate of discontinuation due to AEs is desirable. Lastly, medications that can be used safely in combination with other pharmacological agents is essential.