Palliative care in Parkinson's disease : developing a needs assessment tool

Background: Parkinson’s disease (PD) is a common, life-limiting, neurodegenerative condition. Despite calls for improved access to palliative care, provision is lacking, due in part to poor understanding and recognition of palliative care needs. Where services exist, negotiating the chronic-palliative interface is challenging. Aims: 1) To establish the palliative needs of people living with PD. 2) To adapt and clinimetrically test a palliative assessment tool for PD. Method: A sequential mixed method design was adopted: Aim 1: Systematic review and synthesis of qualitative evidence and primary qualitative study (focus groups and semi-structured interviews). Combined findings used to adapt a palliative care assessment tool for Parkinson’s disease. Aim 2: Face and content validity tested by expert panel. Construct validity examined in 50 people with PD and their carers. Inter-rater reliability examined in broad range of clinicians using video consultations. Results: Aim 1 – Four lines of argument were identified: i) Information tension, ii) care tension, iii) interpersonal negotiations, iv) intra-personal negotiations. The response to diagnosis, carer vigilance and presence of disease milestones were highlighted. Aim 2 - Construct validity was good (tau B > 0.6) for two constructs, moderate (>0.4) for five and fair (>0.2) for the remainder. Reliability as measured by kappa was moderate (kappa >0.4) for four, fair (>0.2) for five and poor for four constructs. Two constructs with poor kappa are explained by extremely high percentage agreement. Conclusions: Adaptation of the NAT:Parkinson’s disease has been successful, with clinimetric properties supporting use by a range of clinicians. Future studies should examine utility within integrated services

Palliative care in Parkinson's disease: Review of needs assessment tools

Palliative care in Parkinson’s disease (PD) has developed significantly in the past five years. The presence of unmet palliative care need, similar to that in malignant conditions, is well established, but may not always be identified by clinicians in everyday practice. To address this, clinicians must be able to rapidly identify, triage, assess and address unmet needs and monitor response to intervention. This is also central to establishing integrated models of care for PD. Systematic evaluation of need can be facilitated by structured assessment tools, and several such tools have now been described for PD. This article reviews the palliative care assessment tools which have been developed for PD, both for patients and also for caregivers. It sets out the psychometric properties of these tools and describes the way in which they may be applied within an overall, systematic assessment of unmet need

Palliative care and Parkinson's disease : meeting summary and recommendations for clinical research

Introduction: Palliative care is an approach to caring for patients and families affected by serious illnesses that focuses on the relief of suffering through the management of medical symptoms, psychosocial issues, advance care planning and spiritual wellbeing. Over the past decade there has been an emerging clinical and research interest in the application of palliative care approaches to Parkinson’s disease (PD) and outpatient palliative care services are now offered by several movement disorders centers. Methods: An International Working Group Meeting on PD and Palliative Care supported by the Parkinson’s Disease Foundation was held in October 2015 to review the current state of the evidence and to make recommendations for clinical research and practice. Results: Topics included: 1) Defining palliative care for PD; 2) Lessons from palliative care for heart failure and other chronic illnesses; 3) Patient and caregiver Needs; 4) Needs assessment tools; 5) Intervention strategies; 6) Predicting prognosis and hospice referrals; 7) Choice of appropriate outcome measures; 8) Implementation, dissemination and education research; and 9) Need for research collaborations. We provide an overview of these discussions, summarize current evidence and practices, highlight gaps in our knowledge and make recommendations for future research. Conclusions: Palliative Care for PD is a rapidly growing area which holds great promise for improving outcomes for PD patients and their caregivers. While clinical research in this area can build from lessons learned in other diseases, there is a need for observational, methodological and interventional research to address the unique needs of PD patients and caregivers

Mutant huntingtin causes defective actin remodeling during stress: defining a new role for transglutaminase 2 in neurodegenerative disease

Huntington's disease (HD) is caused by an expanded CAG tract in the Interesting transcript 15 (IT15) gene encoding the 350 kDa huntingtin protein. Cellular stresses can trigger the release of huntingtin from the endoplasmic reticulum, allowing huntingtin nuclear entry. Here, we show that endogenous, full-length huntingtin localizes to nuclear cofilin–actin rods during stress and is required for the proper stress response involving actin remodeling. Mutant huntingtin induces a dominant, persistent nuclear rod phenotype similar to that described in Alzheimer's disease for cytoplasmic cofilin–actin rods. Using live cell temporal studies, we show that this stress response is similarly impaired when mutant huntingtin is present, or when normal huntingtin levels are reduced. In clinical lymphocyte samples from HD patients, we have quantitatively detected cross-linked complexes of actin and cofilin with complex formation varying in correlation with disease progression. By live cell fluorescence lifetime imaging measurement–Förster resonant energy transfer studies and western blot assays, we quantitatively observed that stress-activated tissue transglutaminase 2 (TG2) is responsible for the actin–cofilin covalent cross-linking observed in HD. These data support a direct role for huntingtin in nuclear actin re-organization, and describe a new pathogenic mechanism for aberrant TG2 enzymatic hyperactivity in neurodegenerative diseases

The terminal phase in Parkinson's disease: a mixed methods systematic review

Background: Extending specialist palliative care to people with Parkinson's disease (PD) has been a priority over the past two decades. Despite improvements in advance care planning and early integration of palliative services, little is known about the dying phase of PD. Aims: To systematically review and synthesise the literature describing the occurrence and management of symptoms in the terminal phase of PD. Methods: Searches of MEDLINE, Embase, CINAHL, PsycInfo and Web of Science from 1990 to 2020 were conducted. Thematic synthesis of qualitative articles and narrative synthesis of quantitative articles were integrated to produce the final analysis. Findings: 285 articles were reviewed and 18 met the inclusion criteria. Professionals found recognition of the terminal phase challenging, and palliative care services are underused. Difficulties include titration of dopaminergic medication, leading to premature termination, or incorrect dosing, of medication. Conclusion: More research is needed to capture the terminal phase of PD, in both the hospital and community setting, in order to increase the evidence base for symptom management

Terminal Care in Parkinson’s Disease: Real-Life Use of Continuous Subcutaneous Apomorphine Infusion to Improve Patient Comfort

International audienceBackground - There are currently no recommendations on the therapeutic management of Parkinson's disease (PD) patients at the end of life. Objective - To describe a cohort of patients with PD who benefited from continuous subcutaneous apomorphine infusion (CSAI) initiation at the end of their life as comfort care. Methods - This real-life cohort includes 14 PD patients, who benefited from 24-h, low-dose CSAI (0.5-3 mg/h) in the context of terminal care. Patient's comfort (pain, rigidity, and/or ability to communicate) and occurrence of CSAI-related side-effects (nausea/vomiting, cutaneous and behavioral manifestations) were evaluated based on medical records. Results - All patients (age 62-94 years, disease duration 2-32 years) presented with late-stage PD and a compromised oral route. Treatment lasted from a few hours to 39 days. CSAI led to substantial functional improvement, with a good safety profile. Overall clinical comfort was deemed improved by the medical team, the patient, and/or caregivers. Conclusions - CSAI might be a promising approach in PD terminal care, as it reduces motor symptoms and overall discomfort, with an apparent good safety profile. Use of the apomorphine pen, sublingual film or a classic syringe pump might be considered when apomorphine pumps are not available. Larger observational cohorts and randomized controlled trials are needed to establish the efficacy and tolerability of apomorphine in the context of terminal care and more broadly, in an advance care planning perspective

Access and attitudes toward palliative care among movement disorders clinicians

© 2021 International Parkinson and Movement Disorder SocietyBackground: Neuropalliative care is an emerging field for those with neurodegenerative illnesses, but access to neuropalliative care remains limited. Objective: We sought to determine Movement Disorder Society (MDS) members' attitudes and access to palliative care. Methods: A quantitative and qualitative survey instrument was developed by the MDS Palliative Care Task Force and e-mailed to all members for completion. Descriptive statistics and qualitative analysis were triangulated. Results: Of 6442 members contacted, 652 completed the survey. Completed surveys indicating country of the respondent overwhelmingly represented middle- and high-income countries. Government-funded homecare was available to 54% of respondents based on patient need, 25% limited access, and 21% during hospitalization or an acute defined event. Eighty-nine percent worked in multidisciplinary teams. The majority endorsed trigger-based referrals to palliative care (75.5%), while 24.5% indicated any time after diagnosis was appropriate. Although 66% referred patients to palliative care, 34% did not refer patients. Barriers were identified by 68% of respondents, the most significant being available workforce, financial support for palliative care, and perceived knowledge of palliative care physicians specific to movement disorders. Of 499 respondents indicating their training in palliative care or desire to learn these skills, 55% indicated a desire to gain more skills. Conclusions: The majority of MDS member respondents endorsed a role for palliative care in movement disorders. Many members have palliative training or collaborate with palliative care physicians. Although significant barriers exist to access palliative care, the desire to gain more skills and education on palliative care is an opportunity for professional development within the MDS. © 2021 International Parkinson and Movement Disorder Society.info:eu-repo/semantics/publishedVersio

The impact of COVID-19 on palliative care for people with Parkinson’s and response to future pandemics

© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.Introduction: Although in some countries, palliative care (PC) still remains poorly implemented, its importance throughout the course of Parkinson's disease (PD) is increasingly being acknowledged. With an emergence of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pandemic, growing emphasis has been placed on the palliative needs of people with Parkinson's (PwP), particularly elderly, frail, and with comorbidities.Areas covered: The ongoing COVID-19 pandemic poses an enormous challenge on aspects of daily living in PwP and might interact negatively with a range of motor and non-motor symptoms (NMS), both directly and indirectly - as a consequence of pandemic-related social and health care restrictions. Here, the authors outline some of the motor and NMS relevant to PC, and propose a pragmatic and rapidly deployable, consensus-based PC approach for PwP during the ongoing COVID-19 pandemic, potentially relevant also for future pandemics.Expert opinion: The ongoing COVID-19 pandemic poses a considerable impact on PwP and their caregivers, ranging from mental health issues to worsening of physical symptoms - both in the short- and long-term, (Long-COVID) and calls for specific, personalized PC strategies relevant in a lockdown setting globally. Validated assessment tools should be applied remotely to flag up particular motor or NMS that require special attention, both in short- and long-term.info:eu-repo/semantics/publishedVersio