Parkinson's in Secondary care: The Challenges

Introduction

As a final year geriatric registrar, I have aspirations to be a consultant with an interest in movement disorders. The agenda for my project was twofold, understanding the demands of an inpatient liaison movement disorder specialist and identifying the areas that could be improved within the current service.

The Parkinson’s UK dashboard (1) tells me that in Brighton and Hove 0.16% of the population have a diagnosis of Parkinson’s. Total number of annual admissions were 335 with an average length of stay of 2.5 days, 75% of these were non-elective admissions. Interestingly this was higher than neighbouring East Surrey with 325 admissions with a mean LOS of 1.6 days, 71% of which were non-elective.

It is not uncommon for Parkinson patients to have a protracted length of stay and experience excessive morbidity in hospital (2). It seemed logical to audit inpatient admission to understand the demographic and story of these patients. Whilst simultaneously surveying the junior doctors to understand where improvements could be made from their perspective. This process will help me identify the challenges of the service, areas in which could be improved and how the service might develop in the future.

Results

I analysed 25 sequential patients admitted to hospital who were coded with Parkinson’s Disease as one of their top three diagnoses. Interestingly, the results demonstrated a male predominance, M: F 17:8 and an average age of 78.4yrs. The patients had a longer length of stay compared to the dashboard data averaging 11.2 days, 82% of which were non-elective.

The patients alnalysed were multimorbid and complex with an average number of 5 co-morbidities and averaging 7.4 medications finding echoed in other studies (2)(3). The patients were looked after by six different admitting specilities including neurology and care of the elderly. Falls represented the most common theme, alongside a heavy burden of mental health diagnoses including delirium, dementia, anxiety and depression the morbidity of these assocaitions is well deonstrated (4). These cases suggested to me that given the degree of complexity and frailty a comprehensive geriatric assessment would benefit these inpatients, as echoed in other studies (2).

I conducted a junior doctor survey with a range of participants from foundation year doctors to senior registrars. The results weren’t surprising with many doctors reporting a lack of confidence managing medical issues but more so medications related issues in Parkinson patients. There was overwhelming concern, 85%, expressed anxiety managing Parkinson patients who were nil by mouth. Most importantly 71% of respondents felt the current support for managing inpatient Parkinson patients was poor to moderate. The survey highlighted a general feeling that more support and guidance was needed for these patients.

Discussion

From these pieces of work I have been able to devise an intervention action plan. Those that I can action immediately, such as, reviewing the cases with a long length of stay and analysing for common themes. Discussing cohorting with the site managers to ensure patients get directed to the appropriate specialist and finally updating the hospital Parkinson disease guidelines to include medication conversion resources and up to date guidance.

I am in the process of conducting an education programmes for both the multi-disciplinary team and focused junior doctor teaching. Thee aim to address address the issue’s highlighted by the survey and recruit interest in the specialty.

Projects for the near future would include the development of a specialist inpatient physio with an interest in Parkinson's given the heavy burden of falls and associated complexity. Interest to be explored at the MDT teaching. Additional support to be recruited from the mental health team encouraging education in both directions. This collaboration would prevent duplication of work and generate useful discussion. Ideally this partnership could help with the identification, management and even prevention of delirium which we have recognised is a big issue which carries huge implications (4).

Finally, the employment of a Consultant Geriatrician, an expert in complexity and frailty, to perform a bespoke comprehensive geriatric assessment for Parkinson inpatients. With this, encourage the initiation or continuation of advanced care planning using the respect form, an area that my project found to require improvement.

I have identified several interventions which could be explored in the future, virtual consultations to enable in reach to the alternative site. I am also very interested in exploring the idea of a PASU, Parkinson Advanced Symptom Unit, with the aim of admission avoidance and reduction of morbidity (5).

Conclusion

There are many challenges involved in the management of patients with Parkinson’s disease in hospital. The NICE Guidelines (4) state that patients should receive their dopamine medication in a timely manner in order to prevent morbidity. This project demonstrates many barriers to achieving this, however has identified some solutions to bring us closer to achieving this target.

Hospitals provide, delirium inducing environments, poorly timed medication rounds and care from staff who aren't educated in the nuances of Parkinson’s, this will inevitably lead to an increased length of stay. Logically admission avoidance is the key to reducing this morbidity and should be where future work is directed. However, in the mean-time there are many areas in which small changes could lead to great improvements in the holistic care of our patients. I am pleased this project has taken steps to identifying and achieving these.

Service development is much like a comprehensive geriatric assessment there are many factors to consider, many specialties to involve, and a requirement to understand the workings of the system in which we are making the change. Most strikingly the similarity comes in analyzing all the data and designing a realistic and achievable plan that is tailored to the person or the institution. This project has allowed me to understand the current service and the areas in which I can make immediate changes and achievable goals for the future.

References

1. Parkinson’s UK Dashboard: https://www.parkinsons.org.uk/professionals/resources/excellence-network-data-dashboards

2. The clinical frailty scale predicts inpatient mortality in older hospitalised patients with idiopathic Parkinson’s disease, K Torsney, R Romero-Ortuno,, June 201, 103-107,

3. Frailty in Parkinon’s Disease: A Systematic review and meta-analysis, Clinical Parkinsonism and related disorders, 2021 Vol 4 Jacqueline McMilan and Quentin Michalchuk, and Zahara Goodarzi.

4. Defining delirium un idiopathic Parkinson’s disease: A systematic review, Rachael Lawson, Claire McDonald, and David Burn, Parkinson’s related disorders, July 2019 pp 29-39

5. PASU, Parkinson Advanced Symptoms Unit, Dr Neil Archibald, South Tees Hospital, Neurology Academy.

6. NICE Guidelines: Parkinson’s disease in adults NICE guideline Published: 19 July 2017 nice.org.uk/guidance/ng71