Parkinson's- How to remote consult during COVID-19

Remote consulting:

• Motor symptoms and signs
• Cognitive and psychiatric assessment
• Non-motor features

Summary

Introduction

Dr Richard Davenport (0.33) introduced the webinar, explaining that we chose to address remote working because it has been a common question raised in previous webinars.

• Motor symptoms and signs (Richard)
• Cognitive and psychiatric assessment (Ross)
• Non-motor features (Ed)

Richard explained that the content of this webinar has come from experiences in holding remote clinics and acknowledged that many clinicians who have remained in their usual roles will probably have found their own way forward. He noted that those who had been redirected to frontline services and are now resuming some of their core roles with Parkinson’s patients again will likely benefit most. However, sharing examples of good practice across peers is often useful to all.

Some caveats for this webinar content included:

• This discussion is grounded in the context of COVID-19 and that these ideas are not a replacement for personal consultations but a means of meeting a need in the current pandemic. There may be learning from this which affects how we consult in the future, but there will always be a place for face to face clinics.
• ‘Remote consulting’ has quite negative connotations, so perhaps ‘virtual consulting’ is a better term.
• Rather than telephone consultations which many have done previously, this is addressing the video-link element of the virtual consultation.
• We are not discussing hospital to hospital video consultations, but clinical to patient consultations.

Motor symptoms and signs (4.02)

Personal forms of virtual technology used included ‘AttendAnywhere’ (also called ‘NearMe’) which has begun to be used in some Trusts. Richard has used a combination of Skype, Facetime and the telephone, predominantly from home, and has tailored his choice of technology depending on the appointment.

Those with movement disorders, motor neurone disease patients, as well as new patients, have required the videolink format most.

Some general challenges can be:

• Internet quality, not only at the end of the consultant, but also the patient.
• Appropriate settings, including adequate lighting, background sound, dress code (as usual for a clinic), checking your camera angle. The settings at the other end are harder to control and we may need to give patients information about how to set up their technology for an optimal consultation.
• IT issues – impossible to Skype or Facetime someone who is not expecting the call, so we are having to telephone people first to prime them to accept the video call.
• Those with Parkinson’s often are older, and whilst many are au fait with technology, many are not, and this can cause problems.
• Patients with cognitive, speech or other difficulties are the same as in a face to face clinic but these difficulties feel magnified when in a virtual consultation.
• Rules with one person talking at a time where spouses or family members are in attendance.
• Non-verbal communication is often lost and a lot of the consultations are shorter because there is a limited amount of being able to establish rapport with patients.
• Patients are called in advance so that they expect the appointment, but a number of people have felt that the consultation could be a lot more relaxed (patients in the bath, or out shopping!) so ensuring patients know that they need to be somewhere they can concentrate and be uninterrupted.

The examination itself:

• Good connection for good video
• Helpful to have a partner who can be the camera operative
• Having some space around themselves to walk safely etc.
• Abnormal movements, see their face,
• Cranial nerves – look at the face to get an idea of speech and drooling
• Bradykinesia can be tested with finger or feet taps, piano testing and such so long as you ensure people can put their fingers in front of the camera
• ‘Get up and go’ test and walking test are reliant on having a partner or carer there to assist
• Testing tremor can be done through drinking a glass of water, doing some handwriting
• Tone is difficult to assess.
• Ending a consultation: include talking about the diagnosis and a plan for moving forward, following up with a letter and documenting the form of consultation, and such.

Richard followed up with three case studies to expand on these comments (19.25-23.08).

Richard answered a question around how we measure mobility speed virtually (24.08).

Cognitive psychiatric assessment (23.26)

There have been some challenges in using virtual assessments, specifically:

• Usually a consultation involves visiting a patient at home, experiencing their living environment and relationships, and building a bigger picture from that
• Neuropsychiatry has had some reservations about making decisions and diagnoses based on virtual assessments. This is primarily because using this sort of technology can require more cognitively than a face to face conversation, taking up processing space in the brain, meaning you may get lower performance from someone.
• Only 20-25% of people in the 70+ age bracket have chosen to use a smartphone or similar device whereas other age categories have a much higher take-up. This has been studied and this research can be helpful to arm yourselves with.
• Ross outlined a number of different neuropsychological assessments and associated research available which demonstrates that they can be useful when carried out virtually (27.09)
• One study Ross cited (28.36) outlined that teleneuropsychiatry can work and administration of the tests can work virtually. However, assessment is often therapeutic and you reflect back to the patient, and this is quite difficult to do virtually.
• Ross went through the telephone MoCA (31.41) and noted its possible use in primary care to decide on possible referrals, and noted a few other assessment tools that could be of use in virtual settings (all outlined on the slides).
• Ross talked through some very simple tests that are easy to do over the phone to assess different elements, from a ‘listing 10 words’ exercise that can rule out Alzheimer’s disease, to ‘tapping the phone 5 times’, giving the opposites of words, and so on.
• Ross highlighted that the need for virtual consultations has highlighted a big gap in understanding and knowledge. He noted new research using MindCheck that he and colleagues hope to use to undertake some research in this area (36.27).

Ross responded to a few questions on the assessments, how accessible they are and whether Parkinson’s nurses should feel confident in using the MoCA. Another question asked about using the MoCA blind, for those with visual impairments was encouraged as a good alternative to use at this time (37.22-44.21)

Non-motor features (44.44)

• Ed noted that this can be a more challenging area of clinical practice, made more difficult during the COVID-19 pandemic.
• Eed noted that he has a cohort of patients in the Western Isles and so has been used to using telemedicine to support them, but that uses as hospital to hospital setting.
• In terms of non-motor symptoms, Ed discussed:
  • what they are,
  • why they are important,
  • how we can assess them,
  • what sort of medications might be available to treat them.
• Ed noted the wide variety and broad range of non-motor symptoms and highlighted that most patients will have at least two or three of these symptoms, although it is common to think of Parkinson’s as a predominantly movement disorder-based condition.
  • There are several non-motor symptoms commonly reported pre-diagnosis
  • There are a number of non-motor symptoms that are likely to affect the person as their Parkinson’s progresses
  • The non-motor symptoms appear to be unrelated to the dopamine changes in the body and so are usually unaffected by Parkinson’s medication
  • Some of these can be triggered or worsened by drug therapies such as hallucinations or impulsivity.
• The more non-motor symptoms a person has, the worse the quality of life for both the person and their carer.
• Ed noted that there is not a great deal of recent data on non-motor symptoms (48.45) but high levels of reported concentration, anxiety, insomnia,constipation, urinary disturbance are common with up to 50% and more reporting these.
• For identification of non-motor symptoms it can be useful to use the Parkinson’s UK questionnaire (50.36), sending them out in advance of a consultation or asking your Parkinson’s nurse to do this with them.
• Treatment options for non-motor symptoms are various and Ed discussed some recent studies into possible options both pharmacological and non-medicinal (51.52).
• The challenge with diagnosing non-motor symptoms is that there is only a short consultation and a predilection for focusing on the motor symptoms (55.36).
• With the telemedicine service to the Western Isles, I have found that addressing cognitive and mood disorders and the like via video consultation can be a difficult conversation to have.
• This is why filling out the questionnaire ahead of time helps remove that potential awkwardness and helps with time constraints.

Presentation slides