by Dr Laura Daunt

After attending the Advanced Parkinson’s MasterClass, there were 2 things that struck me;

  1. In order to create a business case for service improvement you require data, data and more data.
  2. The development of a complex Parkinson’s clinic is what our service was evolving, but we hadn’t yet labelled or analysed it.

Background

Historically, our movement disorder service was divided into 2 mutually exclusive streams; patients referred to either a neurology or a geriatrician led clinic, with little patient movement between the two. A year ago, we piloted a geriatrician led liaison clinic – half made up of patients under regular geriatrician follow up and half of ‘on the day access slots’ for neurology patients deemed to require CGA (comprehensive geriatric assessment). Those patients seen on the day from neurology clinic were reviewed as either a one off, or taken over under regular geriatrician led follow up. Moreover, the service was streamlined to encompass a single point of access for referrals, with triage into either a geriatrician or neurology clinic on the basis of need.

Method and results

I presented data of the clinical encounters of patients reviewed in the ‘on the day’ access slots from October 2016 to October 2017. In this time there were 40 clinics, with an average of 3 ‘on the day’ patients seen per clinic – in addition to 4 to 5 patients under routine geriatrician follow up. There were 102 patient encounters, but due to several being seen more than once, this equated to 96 patients. The average age was 75 years old, with 49 male patients  and 47 female patients. Most patients were in the complex phase of Parksinson’s disease; 65% complex, 27% maintenance, 4% diagnosis, 4% palliative. Two thirds of patients had Idiopathic Parkinson’s disease, with the remainder having Parkinson’s plus syndromes, Parkinson’s disease dementia, vascular Parkinsonism or other higher level gait disorders. The average time from diagnosis was 7.5 years. Most, 90%, were living in their own homes, 5% in nursing homes and 5% in residential homes.

Approximately 20% of patients had problems with dementia, falls, hallucinations, postural hypotension and wearing off. Seven patients had impulse control disorders. As a result of the clinic review, 48% had medications increased or commenced, 23% had medications stopped and 15% were referred to community practitioners (matrons or geriatricians). Sixteen patients (17%) were taken over for regular geriatrician led follow up.

I then analysed this subgroup of 16 patients taken under regular geriatrician follow up. The average age for this group was 80 years old – 70% had Idiopathic Parkinson’s disease, 12% Parkinson’s disease dementia, 6% vascular Parkinsonism, 6% Dementia with Lewy Bodies and 6% non-specific weakness. Nearly all (93%) were in the complex phase of Parkinson’s disease with the remaining 7% in the palliative phase. The average time from Parkinson’s diagnosis was 8 years.

In this smaller cohort, nearly two-thirds were falling, and over a third of patients had hallucinations, dementia, postural hypotension, wearing off and/or impulse control disorders. Two-thirds had their medications increased or new ones commenced, and a third had medications stopped. A third were referred to community matrons or community geriatricians. Other referrals were; Mental health (13%), physiotherapy (25%), speech and language therapy (13%), social work (19%), other specialty (19%). There were no documented discussions regarding bone health or advanced care planning. One patient out of the 16 died since review, and 25% had a hospital admission. Only 6% had come from a care home.

What have we learnt?

Those patients seen in the ‘on the day’ slots and taken over to regular geriatrician led follow up are:

  • Older
  • Complex phase
  • Falling
  • Likely to have dementia or hallucinations

Only 6% of patients had come from a care home, reflecting the ‘lost tribe’ of patients unable to get to clinic from these care settings. Advanced care planning was not discussed on first meeting with these patients, but was deferred until more of a rapport was built. Bone health discussions were poor. This has prompted a further audit and plan to instate a yearly bone health review with for each patient.

Patients with Parkinson’s do require regular follow up. Over two-thirds of patients had medications started, increased and the remaining third had medications stopped. A third were referred to community services. This is aided by links to these teams through my community geriatirician role, particularly to continue follow up of patients who cannot make clinic appointments.

The future….

The next steps are:

  • To look into a multidisciplinary clinic for these complex patients
  • To use the data for a business case for a community Parkinson’s nurse for all CCGs in Nottingham. At present only 2 out of 5 areas have this service.
  • To re-audit bone health practice.

 

Dr Laura Daunt, Queen’s Medical Centre, Nottingham