Reimagining Management of Behavioral Disturbances in Patients with End-Stage Parkinson's Disease in Outpatient Community Hospice Settings

Document Type

Conference Proceeding

Publication Date

2-19-2024

Publication Title

Am J Geriatr Psychiatry

Abstract

Introduction: Parkinson's disease (PD) is the fastest growing cause of death and disability among neurologic disorders. As the global population ages and individuals with neurodegenerative disorders survive longer, demand for neurologic care and other healthcare resources will continue to rise. Parkinson's disease and related disorders (PDRD) are the second most common neurodegenerative disease and a leading cause of death. However, patients with PDRD receive less end-of-life care (hospice) than other illnesses, including other neurologic illnesses. Health care resources are disproportionately expended as the end of life approaches. In the United States (US), care for 6% of Medicare beneficiaries who die each year accounts for nearly 30% of Medicare expenditures. PD is associated with high rates of health care utilization compared with matched controls. How health care resources are used at the end of life in PD and other neurodegenerative movement disorders is unknown. Behavioral disturbances complicate clinical management of individuals with PD in outpatient hospice settings, however, outpatient hospice physicians often feel uncomfortable prescribing medications to manage behavioral disturbances of PD patients given (1) unfamiliarity with antipsychotic medications (2) sensitivity of PD patients to centrally acting agents. After conducting our own literature and textbook reviews, we found there exists little consensus and large gaps in how to systematically approach clinical management of behavioral disturbances in patients with end-stage PD. In our poster, we will share themes we observed while conducting our literature review. We also propose next steps for a pilot project to help develop a clinical algorithm for management of behavioral disturbances in patients with end-stage Parkinson's disease in community hospice settings. Methods: We employed a comprehensive search strategy using three main databases: PubMed, Clinical Key, and Cochrane. The following search parameters were used in PubMed: palliative + hospice + parkinson's + 1 year; palliative + hospice + parkinson's + 5 years; palliative + hospice + parkinson's + 10 years; palliative + hospice + parkinson's (with no year filter). A separate search was conducted using the keyword "neuropalliative care," filtered specifically for systematic reviews. In Clinical Key, notable references were retrieved from "Parkinsonism and Other Movement Disorders" and "Palliative Care to Neurological and Neurosurgical Patients". No relevant results were identified in Cochrane using our search criteria. Inclusion and Exclusion Criteria: Studies, reviews, and book chapters were eligible for inclusion if they were written in English and focused on palliative or hospice care for Parkinson's disease patients, specifically addressing behavioral disturbances. The types of literature eligible for inclusion were meta-analyses, systematic reviews, randomized controlled trials (RCTs), and relevant textbook chapters. Papers or chapters that did not discuss behavioral disturbances, solely focused on other neurodegenerative diseases without relevance to Parkinson's disease, focused on inpatient treatment, or lacked depth on the subject were excluded from our review. Screening and Selection: Titles and abstracts of all retrieved records from the searches were initially screened for potential relevance. Full texts of potentially eligible studies were obtained and assessed for eligibility based on the inclusion and exclusion criteria. Any discrepancies regarding study eligibility were resolved through discussion and consensus. Data Extraction: From each included study or book chapter, we extracted data on the study design, population characteristics, interventions, outcomes, and key findings related to the management of behavioral disturbances in end-stage Parkinson's disease. Findings were synthesized and categorized based on themes and gaps identified. Data analysis: Major themes were identified from our literature review and summarized to identify gaps in knowledge and guide our proposal f next steps for research. Results: The comprehensive search yielded a total of 195 articles across all search parameters and databases. The distribution of findings per database is as follows: 1. Pubmed Using the search term "palliative + hospice + parkinson's + 1 year," we retrieved 8 hits. Extending the search to "palliative + hospice + parkinson's + 5 years" resulted in 43 hits. "palliative + hospice + parkinson's + 10 years" produced 66 hits. Using "palliative + hospice + parkinson's" with no year filter gave us 78 hits. 2. Clinical Key Relevant references were obtained from two key sources: "Parkinsonism and Other Movement Disorders" and "Palliative Care to Neurological and Neurosurgical Patients." 3.Cochrane Our search on Cochrane with relevant parameters yielded no results. After the removal of duplicates and initial title and abstract screening, 153 articles remained for full-text evaluation. Of these, 125 articles were excluded as they did not meet our inclusion criteria, leaving a total of 28 articles for in-depth review. Based upon our analysis of the 28 articles remaining, we identified the following themes in existing literature: 1. Underutilization of Hospice Care: Many patients with Parkinson's Disease and Related Disorders (PDRD) receive less end-of-life care compared to patients with other illnesses, even within the neurologic spectrum. 2. Resource Allocation: Studies highlighted that healthcare resources, especially in the US, are disproportionately spent as the end of life (EOL) approaches. Proper EOL care maximization has shown to lead to a 50% reduction in admissions and a 35% reduction in emergency room visits [https://www.capc.org/about/palliative-care/]. This is also evident in PD patients, who see high rates of healthcare utilization compared to matched controls. 3. Challenges in Behavioral Disturbances Management: Behavioral disturbances in Parkinson's patients in outpatient hospice settings pose a significant challenge for care providers. There exists a hesitancy in prescribing medications due to unfamiliarity with antipsychotic medications and concerns over the sensitivity of PD patients to centrally acting agents. Conclusions: Our review underscored a significant gap in the literature regarding a consensus or systematic approach to managing behavioral disturbances in end-stage Parkinson's disease patients, especially in the outpatient hospice setting. The absence of well-established clinical guidelines further complicates the management of these patients.

Volume

32

Issue

4

First Page

S69

Last Page

S70

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