Multidisciplinary management of Parkinson’s

Parkinson's Academy webinar

In this webinar Dr Rob Skelly, Clare Johnson and Fiona Lindop will give an overview of multidisciplinary team (MDT) working in Parkinson’s. They will describe a biopsychosocial model of Parkinson's and consider the roles of some of the therapy disciplines in supporting people with Parkinson's. They will describe some different models of multidisciplinary working in Parkinson's and make a case for integrated MDTs. The webinar will include practical “Top Tips” that delegates can consider using in their practice.

Webinar objectives

Delegates will get a fuller understanding of what constitutes an integrated multidisciplinary team for the care of a person with Parkinson’s. The roles of the team members will also be highlighted and delegates will be offered guidance on how an optimal multidisciplinary team can be built.

Summary

The complex nature of Parkinson’s disease (PD) makes multidisciplinary management vital to effective care.

Dr Rob Skelly, consultant geriatrician at the University Hospitals of Derby & Burton NHS Foundation Trust, said: “When I speak to someone who is newly diagnosed with PD, I often say that Parkinson’s is due to damaged dopamine neurons. I tell them that levadopa will top up the brain’s dopamine levels and make them feel better.

“While that is true, it is not the whole story. A lot of symptoms do not respond to levadopa, and all medications can be limited by side effects. Offering a range of drug and non-drug treatments to address both the biological and the psychosocial symptoms may be the way forward.”

The Derby service

A multidisciplinary approach provides people with PD access to holistic care, and contributes to ensuring patients and caregivers are educated and informed.

Effective MDTs have an understanding of PD, and use that knowledge to set shared goals with the patient. They are closely integrated, with good, ideally face-to-face, communication, and they “respect and learn from each other”, said Rob.

“It is important that we treat the patient as a whole person, bear in mind their social support, and make sure the person with Parkinson's is always at the centre of care,” he added. “Psychosocial factors are as important, if not more important, than some of the biological factors.”

Derby’s PD service runs a weekly MDT clinic. The team includes geriatricians, PD nurses,physiotherapists, an occupational therapist (OT), a speech and language therapist (SLT), and a mental health consultant. A palliative care consultant joins once of month, and the team also has access to psychology services and dietitians.

During the clinic, patients undergo a range of standardised assessments, including postural blood pressures, heart rate, bone health assessments, and objective and subjective questionnaires. Clinics are followed by a face-to-face MDT meeting, where information on the individual patients is shared, and treatment plans adjusted accordingly.

In most MDTs, a specialist PD nurse or allied healthcare professional will be the primary point of contact for the patient and their care giver. They will co-ordinate the person’s care needs, aiming to make sure they get the right support from the right person at the right time.

Non-motor symptoms

While there is usually some blurring between disciplines, each member of the MDT has theknowledge and skills to tackle specific symptoms.

OTs, for example, have an important role to play in helping people to manage the non-motor and psychological symptoms that can have a huge impact the daily lives of people living with PD, said Clare Johnson, specialist OT at the University Hospitals of Derby & Burton NHS Foundation Trust.

“There will a biological reason for a change in cognition, emotion, and physical abilities,” she said, adding people were often unaware their non-motor symptoms were part of their condition.

Explaining how the symptom related to the biology, and suggesting solutions can help. Apathy, for example, is caused by low dopamine. “If the internal motivation is not there, we need to think about external motivation. That might be looking at things like routine and what they do on a day to day basis, support networks and setting goals and rewards.”

Sleep and fatigue are common problem areas, and OTs will often work with patients to look at sleep routines, quality, and patterns. OTs will also look at a person’s home situation, and if there are any environmental issues that are having an impact on their symptoms, quality of life, and ability to carry out activities of daily living.

Motor symptoms

Physiotherapists place a particular focus on motor symptoms, said Fiona Lindop, specialist physiotherapist with the Derby service, adding it was important that every member of an MDT should understand the role of the basal ganglia in PD.

“Basal ganglia dysfunction leads to the impaired performance of well-learned motor skills and movement sequences. This can lead to difficulties in multi-tasking and shifting motor sets,” she said.

“If somebody changes the subject when talking, for example, someone with Parkinson's might have trouble following where the conversation has gone, or they might have trouble changing their walking direction when the telephone rings.”

They also will have difficulty with processing questions and information, and need a little bit longer to respond. “It is really important for all members of the team to understand this. If they ask a question and see a blank face staring back at them, they need to wait a few extra seconds for the reply.”

As it is the automatic processes that are particularly effected, engaging conscious attention, or “getting them to pay attention to what they're doing”, is the key. However, teams also need to remember that the person may find it difficult to concentrate. Training dual tasking, or advising people to avoid it in high risk situations, is another important strategy.

Physiotherapists educate the person and their care partner around physical activity, and how it is beneficial to PD symptoms. They also look at gait and balance, to try to reduce falls, posture and transfer, and maintaining mobility and strength, as well as teaching strategies for managing freeing and pain.

When to refer

Fiona also explained when it might be appropriate to enlist the support of the wider team.

SLTs, for example, can offer support for multiple common, impactful symptoms. These include communication issues, such as hearing, comprehension, and expression and fluency, timing and melody, as well as how communication impacts on relationships, interactions, and identity. They can help with salvia management, if people are having difficulties swallowing their tablets, or if they are experiencing reduced vocal cord closure.

For people with PD experiencing malnutrition, constipation, or obesity, a referral to a dietitian may be useful. Dietitians can talk to patients about protein redistribution diets, for motor fluctuations in early onset Parkinson’s, and reinforce advice around healthy eating, as well as help manage co-morbidities lie diabetes or irritable bowel syndrome.

Other MDT members may include pharmacists, psychologists, psychiatrists, and continence advisors.

Building an MDT

To those considering establishing or expanding a PD MDT, Rob’s advice was to “start from where you are” and “build on what you already have”, focusing on the key principles of effective MDT working: providing education, person-centred, holistic care, good communication, and respect.