Frailty and Parkinson's

Join Julie Jones & Janice Murtagh as they discuss Frailty and Parkinson’s. What do we mean by frailty and how does this impact on someone living with Parkinson’s? What are the interventions and treatments available to help? Find out the answers to these questions by joining this webinar.

Objectives of the webinar

To have a greater understanding of what frailty is, how this relates to people living with Parkinson’s and what can be done to help those who are frail and live with Parkinson’s.

Summary

Frailty has a complex aetiology, and it can often be difficult to understand “where it ends, and the Parkinson’s begins”.

The World Health Organization (WHO) describes frailty as a “progressive, age-related decline in physiological systems that results in decreased reserved of intrinsic capacity which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcomes.” In simple terms, said Dr Janice Murtagh, it is a reduced ability to withstand illness without loss of function.

“It is when a patient comes in with what seems like a relatively minor insult, but it has a really significant affect on them, either physically or cognitively,” she explained, adding that there are significant associations with cognitive impairment, depression, and multi-morbidity.

Frailty is associated with immune and neuroendocrine dysregulation, nutritional deficits, and musculoskeletal and neurological system deterioration. An elevated allostatic load, which Janice described as the burden of chronic stress on wellbeing, is another important factor.

Presentation and assessment

“The central problem with frailty is the potential for serious adverse outcomes after a seemingly minor stressor event or change,” Janice said, adding that treatment responses may be quite different in the frail and non-frail population. “It should be identified with a view to improving outcomes and avoiding unnecessary harm.”

However, this is easier said than done, said Janice, adding both frailty and Parkinson’s are highly complex, making assessment challenging.

Frail patients will often present with non-specific symptoms, such as increased confusion, falls, or reduced mobility, for example. Cognitive problems can hinder effective history taking, and there may be a range of invisible and interconnected issues. Taking time to unpick these is “really important”, but impossible in the time A&E and urgent care settings have for assessment.

It isn’t usually possible to identity frailty with an “end of the bed test”, said Janice. Multiple tools are available, many of which aim to either identify or stratify frailty. The best approach will very much depend on the setting and the objective. “In a community setting, for example, you might want the know the degree of frailty so you can measure change over time…If you are at front-of-hospital, you may just need to know if a person is frail or not, so you can refer them onto the right service.”

There is no universal agreement on the best tool to use in people with Parkinson’s, but the two most utilised are the Frailty Phenotype tool and the Clinical Frailty Scale.

Frailty and Parkinson’s

A 2021 systematic review and meta analysis found a frailty rate of 38% among people with Parkinson’s. Longer disease duration, motor impairment, non-tremor dominant Parkinson’s, and total daily levodopa dose were all associated with frailty.¹

“The review identified that being frail with Parkinson's is definitely associated with him adverse outcomes,” Janice said. These patients are much more likely to recurrently fall, to have a cognitive impairment or dementia diagnosis, or have troublesome fatigue or hallucinations, for example.¹

However, the evidence on how to manage frailty in Parkinson’s “really isn’t there yet”, said Janice. “We have to approach them in much that same way as we approach other people with frailty.”

MDT approach

Multi-disciplinary team (MDT) management is associated with better outcomes in this complex area, said Julie Jones. “That really reflects the diversity of the symptoms you see, the diversity of the problems people have, and the complexity of managing Parkinson's. With each member of the MDT coming in, you're able to address all those different angles and put a targeted treatment approach together.”

Explaining the differing roles of the MDT, Julie said that Parkinson’s nurses were the key “gate keepers” and case managers, responsible for assessment, screening, care planning, and medication management. From their perspective of regular contact with patients, nurses are able to secure timely access to other members of the MDT when needed.

Physiotherapy is extremely important for maintaining joint range of movement, muscle strength and muscle power, said Julie. Adding that physical activity could also help with fatigue, she introduced the concept of “exercise snacking”. “Rather than people feeling they have to do half an hour of exercise, which may be not possible, it's thinking about gradual increase, from a little and often starting place,” she said.

Where it is available, occupational health is a “wonderful resource” that can “enable people to optimise their function, and remain independent withing the home environment”. They're also very skilled at “looking beyond the Parkinson's,” said Julie, saying occupational therapists were key to making decisions regarding home adaptations, adaptive devices, and technologies.

Dietetics are another important ally in caring for people with Parkinson’s, which can impact nutritional intake, and frailty, which is associated with nutritional deficit. They can help with balancing protein and medication intakes, and look at bone health and GI function, for example said Julie.

References

McMillan, J. M., Michalchuk, Q., & Goodarzi, Z. (2021). Frailty in Parkinson’s disease: a systematic review and meta-analysis. Clinical parkinsonism & related disorders, 4, 100095.

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