Parkinson’s disease: a multidisciplinary approach

Parkinson’s disease is an important cause of disability. Even though its incidence is relatively small (20 per 100 000 a year), it has a high prevalence (200-300 per 100 000 in the United Kingdom) and poses a sizeable burden.^{w1 w2} Chronic conditions, such as Parkinson’s disease, are best managed by a multidisciplinary team.

What is Parkinson’s disease?

Parkinson’s disease is a progressive degenerative neurological disorder of the central nervous system that impairs motor function, speech, and cognition (box 1). In time its symptoms and signs become worse. This leads to progressive stages of impairment and subsequent degrees of disability. Parkinson’s disease results primarily as a result of insufficient action or formation of dopamine in the substantia nigra, resulting in decreased stimulation of the motor cortex by the basal ganglia. This lack of dopaminergic stimulation results in impaired motor cortex activation, which manifests clinically as the motor symptoms of Parkinson’s disease (see box 1). Non-motor symptoms may also result in addition to problems with drug side effects.

Various drugs can be used to manage the motor symptoms of Parkinson’s disease, including levodopa, dopamine agonists, monoamine oxidase B inhibitors, anticholinergics, and catechol-O-methyl transferase inhibitors. Patients with Parkinson’s disease may show a good response to treatment in early disease, but side effects and tolerance to drugs can be challenging and time consuming to treat and manage in moderate to severe disease. Because of the progressive nature of the disease, the multidisciplinary approach aims for early and continued intervention to improve the quality of life of these patients.

The multidisciplinary team

Rehabilitation in a patient with a progressive disease such as Parkinson’s disease is best approached by a multidisciplinary team, which comprises several different professionals and services (box 2). The centre of the team is the patient. Treatment should always be relevant to the patient’s goals. The patient should be encouraged if possible to take a lead in decisions about drugs and treatment. Patients will differ in the extent to which they wish or are able to take on such responsibilities. However, patients will be better able to understand and reach these goals if they receive education about their disease. Such teaching could improve self management and self efficacy.^w3

As well as helping the patient, physiotherapists also give advice to the carer

Doctors

The doctor forms an important part of the multidisciplinary team, whether it is the geriatrician or the neurologist. It is his or her role to ensure that the patient receives appropriate treatment. The doctor weighs the risk of drug related complications against the benefits of starting, for example, levodopa.

However, the doctor’s job is not only to provide the patient with drugs. They must gear their advice to a whole range of other avoidable physical and social problems as well—for example, contractures of limbs; psychiatric manifestations, such as mental confusion and depression; unemployment; or carers’ stress. The doctor must respond to physical or functional changes in the patient to target and coordinate optimal care.

Neurologists play a crucial role in the early stages of the disease and in patients who have diagnostic dilemmas. Consultants in geriatric and rehabilitation medicine work in multidisciplinary teams, providing inpatient and outpatient services for patients with complex and changing disabilities. These services are important in the management of Parkinson’s disease because of the complexity of the physical or motor manifestations and cognitive impairments and also because of the need to coordinate multidisciplinary interventions and to work between the hospital and the community.

Psychiatrists have an important part to play in the management of patients with Parkinson’s disease. Many of the non-motor symptoms (box 1) of Parkinson’s disease (dementia, depression, hallucinations, and so on) are caused by the disease itself, or side effects of drugs used. Management of these symptoms may be challenging and therefore require specialist input. Additionally, in certain cases, psychiatrists may contribute to discharge planning by helping with capacity assessments, if the patient has cognitive impairment.

Nurses

Specialist nurses have been trained to look after people with Parkinson’s disease. Typically, a specialist nurse will have a hospital base and will be in direct contact with individual patients and their families both in the clinic and at home. In a randomised controlled trial no notable differences in health outcome were found between patients receiving care from a nurse specialist and patients receiving standard care from their general practitioner.^w4 An improvement in the subjective wellbeing of patients cared for by a nurse was seen without any increase in cost.

Specialist nurses have several important roles. They provide advice about all aspects of the disease, including options for drug treatment. They provide a vital link between community and hospital services. They are also involved in education and training of other healthcare professionals about Parkinson’s disease and its management. Alternatives to specialist nurses in Parkinson’s disease include specialist rehabilitation outreach nurses and social services or joint funded staff with special responsibilities for people with neurological disabilities.

Physiotherapists and occupational therapists

Physiotherapists assess and treat problems with mobility in patients with Parkinson’s disease. They provide individually tailored plans for patients to improve and maintain motor function. They may teach the patient techniques to make automatic movements easier; give them advice on aids and adaptations to facilitate independent living; or provide exercises to help maintain muscle strength and prevent falls. As well as helping the patient, physiotherapists also give advice to the carer about the best techniques for moving a person with Parkinson’s disease. This ensures that the carer can avoid injury and prevents harm to the person to whom they are providing care.

Parkinson’s disease may make it more difficult to carry out self care (dressing, washing, eating, bathing, toileting) and can cause difficulties with everyday activities around and outside the house (housework, shopping) and at work and leisure. Occupational therapy helps people with Parkinson’s disease to maintain as high a level of independence for as long as possible. Occupational therapists can recommend to patients and their families how best to approach and carry out daily activities in a safe and efficient way. They can advise on adaptations to the home environment to make it as safe and convenient as possible.

People with Parkinson’s disease may benefit from simple modifications to everyday items—for example, Velcro instead of buttons and zips in clothes, satin sheets or nightclothes to help movement in bed, elastic shoelaces, bath seats, non-slip mats, and so on. Occupational therapists also provide specialist equipment and adaptations that may help with everyday tasks and with getting around.

Speech and nutrition

The rehabilitation of people with Parkinson’s disease is also supported by specialist teams, such as those that advise on continence, nutrition and feeding, tissue viability, and pain. Speech and language therapists improve vocal loudness and pitch range, and they review the safety and efficiency of swallowing to minimise the risk of aspiration.

They work alongside dieticians to ensure adequate nutrition. In advanced disease some patients may also require input from palliative medicine teams, which provide support and control of symptoms for patients and their families, in hospital and in the community.

Community services

Social services, acting on the basis of assessments by hospital and community multidisciplinary care teams, coordinate the provision of equipment; home adaptations, with occupational therapists; and home services. They can also assess and advise on the availability of benefits, transport, respite, and housing and on the needs of carers. Social services managers provide a system of ongoing review for severely disabled people with complex needs. They organise regular multidisciplinary reviews using a standardised format that takes into account health as well as social needs, and they are involved in decisions about placement at a residential or nursing home if this is appropriate.

Several other services are provided specifically for disabled people—for example, housing, leisure, education, and new supporting people schemes. In addition, voluntary agencies, for example, the Parkinson’s Disease Society, provide education and support to patients, their carers, and healthcare professionals alike so that the patient can receive the best possible care.

Care givers

Parkinson’s disease causes cognitive and motor deficits, so patients may find it difficult to navigate these various services. The care giver is central in ensuring that the patient can fully benefit. The care giver may be the spouse, partner, sibling, child, or anyone who looks after the patient on a regular basis.

Education of the care giver about the condition and the different management and service options is important to ensure that the patient receives optimum care. Additionally, support for the care giver is important, in terms of respite care for the patient and so on, to ensure that care for the patient does not falter. A study on the effects of Parkinson’s disease on the quality of life of patients’ spouses concluded that spouses often feel lonely, frustrated, helpless, and socially isolated when confronted with their partner’s disease.^w5 The study also concluded that educational support programmes often alleviate these fears.

Provision of multidisciplinary care

The multidisciplinary approach to treating people with Parkinson’s disease is the holistic step towards improving the quality of life of these patients. Carne et al studied the efficacy of a multidisciplinary treatment programme on one year outcomes of individuals with Parkinson’s disease.^w6 They examined the records of 41 patients with Parkinson’s disease. In this cohort 30 patients (70%) benefited from the intervention.

A study by Wade et al examined whether patients with Parkinson’s disease have a sustained benefit after a multidisciplinary rehabilitation programme for outpatients.^w7 Their study concluded that patients with Parkinson’s disease decline significantly in six months, but a short spell of multidisciplinary rehabilitation may improve mobility. They also concluded that follow-up treatments may be needed to maintain any benefit achieved from the multidisciplinary rehabilitation.

Multidisciplinary teams, however, do not exist in several countries because of financial or logistical constraints. In some areas specific services, such as physiotherapy, SALT (Southern area learning as teams), and so on, may be available, but the approach to patient management may not be as coordinated as occurs in a multidisciplinary team. As a result, patients in these areas may not receive all the services needed to manage their condition optimally.

Parkinson’s disease might benefit from a vast range of services, and a multidisciplinary approach to the management of Parkinson’s disease helps to deliver well rounded care. This, together with more funding, could result in a more efficient approach to Parkinson’s disease.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

See Education http://student.bmj.com/issues/08/07/education/278.php.

From the archive: See the Clinical Review in the BMJ (2007;335:441-5; www.bmj.com/cgi/content/full/335/7617/441).

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2. Schrag A, Ben-Shlomo Y, Quinn NP. Cross sectional prevalence survey of idiopathic Parkinson’s disease and parkinsonism in London. BMJ 2000. 321: 21-2.
3. Jarman B, Hurwitz B, Cook A, Bajekal M, Lee A. Effects of community based nurses specialising in Parkinson’s disease on health outcome and costs: randomised controlled trial. BMJ 2002. 324: 1072.
4. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. JAMA 2002. 288: 2469-75.
5. Dressen C, Brandel JP, Schneider A, Magar Y, Renon D, Ziégler M. Effects of Parkinson’s disease on quality-of-life patients’ spouses: a qualitative survey. Rev Neurol 2007. 163(8-9): 801-7
6. Carne W, Cifu D, Marcinko P, Pickett T, Baron M, Qutubbudin A et al. Efficacy of a multidisciplinary treatment program on one-year outcomes of individuals with Parkinson’s disease. Neurorehab 2005. 20 (3): 161-167
7. Wade DT, Gage H, Owen C, et al. Multidisciplinary rehabilitation for people with Parkinson’s disease: a randomised controlled study J Neurol Neurosurg Psychiatry 2003. 74: 158–62.

      

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