Parkinson's in older patients: A ‘motion-emotion’ conundrum

Parkinson’s disease (PD) is the second most common neurodegenerative disorder after Alzheimer’s disease. Its aetiology remains elusive despite huge strides in our understanding of its pathogenesis. Successful ageing is the dominant risk factor, as is demonstrated by a prevalence of approximately one in 1,000 in the adult population under 65 years, rising to one in 50 in people aged over 80. This article describes some of the common challenges in managing the majority of people with Parkinson’s disease while also focusing on some aspects of care particular to more frail patients. Motor treatments, strategies for tailoring treatment to individual patients, the psychiatry of PD and the valuable role of PD clinical nurse specialists have been covered in a previous Clinical Focus.

Hence, I have endeavoured to align with, rather than duplicate that content here. The fundamental principle to keep in mind when managing patients is that it is best considered a neuropsychiatric disorder, where different symptoms can undermine a patient’s quality of life at different times and that the best solution for the patient should focus on rapidly identifying what is driving the decline and also who in primary and/or secondary care is best placed to intervene. Clearly, this throws up challenges to our healthcare service and current practices remain outside of a national guiding strategy.  

Diagnosing PD

Much has been written of different healthcare professional groups’ diagnostic accuracy in determining the presence of clinical parkinsonism. When present, rest tremor is obvious, as is the cardinal sign of bradykinesia and the third of the triad, rigidity, is generally easily elicited.

NICE encourages early onward referral if GPs are suspicious of the presence of parkinsonism, but in practice few public service specialists can see new PD referrals within the six week timeframe recommended by NICE. The differential in younger and older patients is somewhat ‘different’. Common mimics in the older patients include drug-induced, particularly neuroleptic-induced parkinsonism, cerebrovascular disease and dementia with Lewy bodies (reflecting part of the same clinical spectrum), in addition to the classical Parkinson’s plus disorders of progressive supranuclear palsy (PSP), multiple systems atrophy (MSA) and corticobasal degeneration (CBD). If symptoms are minor, then not commencing treatments before referral has the benefit of the specialist seeing the patient in the ‘de novo’ state, increasing diagnostic accuracy. Neuroleptic-induced parkinsonism can creep up on one and present in a clinically identical fashion to degenerative PD. So unless a clear correlation exists between neuroleptic commencement (or dose escalation) and parkinsonism onset, then the prudent step is to perform a DaTscan, which is readily available in many Irish centres. This carries clear benefits over commencing an indefinite treatment course of PD medications that in themselves can have psychiatric side effects. Structural brain imaging by way of CT, or MRI if readily available, is also beneficial in picking up unexpected vascular disease in a patient who one might think has a clean vascular risk profile.

Motor pharmacological treatments

As with many other illness syndromes which dominantly affect older people, the published literature for pharmacological treatments in PD has a strong age bias. Playfer identified that in RCTs in PD between 1999 and 2007, of 19,156 patients, the mean age in all trial participants was 63.7 years and that 94% of patients were younger than 80 years. 

A ‘motion-emotion’ conundrum exists more commonly for older patients whereby the pursuit of preserving motor function aggravates the psychiatric manifestations of their disorder while the reverse also holds true, as antipsychotics including the most commonly and appropriately prescribed ‘atypical’ agents, quetiapine and olanzapine, can exert an anti-D2 receptor effect thus impairing motor function. The best option in this instance is often to first de-escalate the dopamine replacement treatment and negotiate with the patient and family around optimising both physical and mental health.

Anticholinergic agents are poorly tolerated and rarely prescribed, whilst amantadine and dopamine agonists (ropinirole, pramipexole, rotigotine) are less well tolerated in older people at the higher doses required to manage patients in the complex stage of their illness. This in the main leaves oral treatment strategies for the older person centring on levodopa-based therapies. As the disease progresses through the complex stage, advancing age becomes an exclusion criterion for referral for surgery (cut-off for deep brain stimulation is early 70s) and a general reluctance exists in commencing apomorphine infusion treatment, unless the PwP has a relatively clean psychiatric profile. Duodopa, levodopa intestinal gel infusion delivered via PE-J tube is effective, but the most expensive treatment option. Both infusion treatment options generally require good family support for the patient in order to be successful. 

The nursing home setting and PD

Moving from one’s own home into a place of care is in many instances a milestone that may not be avoided The literature supports the psychiatric manifestations of PD, particularly psychosis and dementia, being the strongest predictors for loss of home living.

Accelerated decline in this setting is often due to injury from falls, aspiration pneumonia secondary to progressive dysphagia, greater prominence of cognitive and psychotic symptoms and profound fluctuations in levels of arousal with dominant somnolence. 

Patients should continue to receive good access to all disciplines previously engaged in their care: physician groups should include their PD specialist, psychiatry of later life and palliative care, in addition to their GP. Medications can often be simplified as patients are now less physically active, often are of lower weight and are experiencing clear side-effects of dopamine-replacement treatment. 

Swallow care by therapists who can also educate nursing staff on safe oral intake is hugely beneficial, as is access to physiotherapy services to help maintain physical performance if possible, help modify safety risks from falls and facilitate rehabilitation following return from acute hospital transfers. Lastly, advanced care planning with engagement with the person if still possible, or their family, is a central pillar in managing their care.

Hospitalisations

People with PD are more likely than their age-matched controls to attend emergency departments and have acute admissions. Most common presentations include fall-related injury, sepsis, psychiatric disturbances including delirium, dementia and psychosis and motor complications of their Parkinson’s disease; all of which occur more commonly in older patients in the complex and palliative stages of their illness. 

International evidence supports poor hospital care – poor staff knowledge of the condition, poor adherence to medication schedules, poor awareness and management of common co-presentations such as delirium, dysphagia and constipation which results in poorly joined up care with subsequent extended lengths of stay and increased service consumption. Negative patient outcomes include high discharge rates to care facilities and high inpatient mortality. Service modelling in this area is deficient, reflecting the challenge imposed by a multiple of potential acute presentations and different international healthcare systems; increasingly, the focus is in applying comprehensive geriatric care principles and although intuitive for older patients, the evidence base is awaited. 

End of life care

PD is a chronic non-curative disorder and generally patients will have many years in which they can be engaged to discuss their end of life care. The Irish Hospice Foundation and End of Life Forum have been especially proactive in promoting self-awareness and autonomy for people with non-cancer illnesses including PD. Vehicles such as their ‘Think Ahead’ document are readily available to physicians for a small cost and can be used in primary and secondary settings to facilitate engagement between patients and their family. 

Our own experience is similar to UK publications in this area – with many patients not dying in their own home or even nursing home, but instead dying in hospital following what can be a predictable complication of their advanced PD, such as a sepsis episode. 

A 2012 Dutch GP publication in Age & Ageing highlighted this predictability by demonstrating that a quarter of all GP contact time was generated by patient proximity to death; median contacts increased from 5 to 11.7 and contact time increased from 90 to 300 minutes. 

Final thoughts

Today, most patients with Parkinson’s disease can be described as ‘older’ and this will increasingly be the norm. The majority of older people should be managed just as younger patients are – with a fair degree of confidence and success, particularly in the early and middle years of their condition. 

The priorities for managing their healthcare should include early accurate diagnosis, ongoing focus on health promotion and fitness, patient autonomy and education of their condition, so that patients are empowered to be more greatly involved in maximising the quality of their lives. 

There are well-recognised and to-be-anticipated challenges in providing care to older patients around the high burden of chronic illness, with its associated impact on function; competing medications for multiple chronic conditions in the face of poorer medication tolerance; threat to living and independence from acute illnesses; and a requirement to engage in preparation for the advanced stages of the illness so that PwP can be self-determined in their decision-making around fundamental issues such as place of living and place of dying. 

An interdisciplinary approach across primary and secondary services is required to best optimise their care. In Ireland as in the UK, movement disorder/PD clinical nurse specialists seem to be a cost-effective and acceptable link between patient and primary and secondary care. 

PD remains a late or missing entrant at the national healthcare table. The recent and ongoing economic challenges should not be used as reason to delay the development of a national PD strategy similar to those developed successfully during the times of greater resource for cancer, heart disease and stroke disease. 

The Alzheimer’s Society of Ireland published its National Dementia Strategy in 2012, engaging with people with dementia illnesses and their family members, and primary and secondary services. The strategy remains in the political long grass awaiting sufficient opportunity and momentum to get over the line as health policy. 

A similar approach for PD management would give direction to healthcare services and enable effective use of resources so that in each patient-physician interaction we can have confidence that our own patients are accessing that component of the healthcare service that best meets their need at a given time.