Transcript The Team Approach: Caring for Elders with Parkinson`s Disease

The Team
Approach:
Caring for Elders
with Parkinson's
Disease
Pamela Willson, PhD, RN, FNP, BC, CNE
Wednesday, October 10, 2012 Prairie View A&M
University College of Nursing
1-2 p.m. 12th floor Board Room
Objectives
 Review PD clinical features
 Describe PD implications of managing
healthcare within federal healthcare system
 Integrate recent clinical data & evidence-based
strategies into treatment strategies
 Describe telehealth methods for improving PD
patients access to care
 Discuss a chronic disease self-management
educational intervention
Parkinson Disease (PD)
 PD is the 2nd most common neurodegerative
disease
 40,000 – 59,000 new cases annually in the US
 More common in older individuals; increases
after age 60
 1.5 million Americans
 About 80,000 are Veterans
PD Classical Clinical Features
 Resting Tremor
 Cogwheel Rigidity
 Bradykinesia
 Postural Instability
PD Associated Clinical Features
 Micrographia
 Dysphagia
 Hypophonia
 Depression
 Shuffling gait/festination
 Autonomic
dysfunction
 Drooling
 Dementia
Progressive Chronic Disease
 Loss of dopaminergic neurons
 Classic movement abnormalities and tremor
 Rigidity and muscle stiffness – back & neck pain,
cramping, soreness and heaviness feelings of the
muscles, inflexibility
 Freezing or motor block – start hesitation, midmotion, worsens with stress
 Motor fluctuation – sudden wearing-off, dyskinesia,
or no response to meds, dysarthria
 Rigidity & incoordination of muscles – dysphagia,
aspiration
Progressive Chronic Disease
 Progresses to a multicentric disorder affecting
many systems
 Neuropsychiatric changes – depression, hallucination,
delirium, anxiety, panic attack, & agitation
 Cognitive impairment – PD dementia
 Sleep disturbances – insomnia, REM behavior disorder,
sleep apnea, excessive daytime sleepiness, & sleep
attack
 Autonomic dysfunction – constipation, urinary
problems, incontinence, orthostatic hypotension, &
sexual dysfunction
Etiologies & Risk Factors
 Genetic defects – 10% of cases
 First-degree relative with PD – RR is 1.6 to 10.4
 Environmental factors
 Pesticides, herbicides, & heavy metals
 Rodent model
 Twin study – exposure to cleaning solvent
trichloroethylene; 6-fold increased risk
 Agent Orange – exposure to about 2.6 million
soldiers
 Living in a rural area
 Drinking well water
Department of Veterans
Affairs (VA)
 PD added to list of presumed to be
service-related illness for veterans who
served in combat in Vietnam
 IOM evidence suggesting that exposure
to Agent Orange & other herbicides may
be a risk factor for PD
 The policy provides treatment & disability
assistance
Six PADRECCs
 Parkinson’s Disease Research Education
and Clinical Centers (PADRECCs)
 Established in 2001
 Expanded to include 51 consortium
community care facilities
 Goal to improve the long term functional
outcome of veterans through innovative
research, clinical care and educational
programs
 Modeled after the GRECC and MIRECC
PADRECC Resources
 http://www.parkinsons.va.gov
 PADRECC/Consortium Hotline at 1-800949-1001 x 5769
 Resources & educational materials
 Patients
 Providers
Who’s on the Team?
Team Members
 Patient & Caregiver
 Speech Pathologist
 Primary Care Provider
 Psychiatrist
 Neurologist
 Psychologist
 Neurosurgeon
 Social Worker
 Physical Medicine &
Rehabilitation
 Pharmacist
 Physical Therapist
 Occupational Therapist
 Neuroscience Nurse
 Educator
MEDVAMC Team
MEDVAMC Team
 Aliya I. Sarwar, MD - Interim Director
 J. Gabriel Hou, MD,PhD - Associate Director of Research & Interim CoDirector
 Linda Fincher, BSN, RN - Assistant Clinical Director
 Pamela Willson, PhD, RN, FNP-BC, CNE - Associate Director of Education
 Shawna Johnson, BSN, RN - Clinical Care Coordinator
 Michele York, PhD - Clinical Neuropsychologist
 Arnold (Herb) Love - Administrative Officer
 Farah Atassi, MD, MPH - Research Health Science Specialist
 Suzanne Moore, MS - Research Health Science Specialist
Managing the Complexities of
Parkinson Disease: Practical
Strategies for the Federal
Healthcare Professional (U.S. Medicine,
2012)
1.0 CME – management of PD
Treatment Guidelines
 VA Algorithm for Treatment of Early PD
 www.parkinsons.va.gov/cfiles/PocketCardFront.pdf
 American Academy of Neurology (2006)
 Early & late-stage PD treatment
 European Federation of Neurological Sciences &
the United Kingdom’s National Institute for Health
and Clinical Excellence (2006)
 Canadian Neurological Sciences Federation
(2012)
PADRECC Outcomes
 Does a multidisciplinary treatment approach
improve PD patients functional outcomes?
 N= 43; No DBS or thalamotomy patients
 Average age 71.5; 31 white 12 African-American
 Unified Parkinson’s Disease Rating Scale (UPDRS)
on one year follow-up
 Overall, mean improvement of -5.4
 30 patients (68.8%) improved by -11.28 points
 2 unchanged; 11 (25.6%) worsened by 9.82 points
Diaz & Bronstein (2005) NeuroRehabilitation 20, 161-167
PADRECC Outcomes
 Team members seen and visit types:
Neurology physician – 2.84 visits (100%)
Neurology nurse – 1.74 (88.4%)
Medication change – 26 (60.5%)
Referrals
 Rehabilitation therapy were most common – 62.8%
 Neuropsychological testing – 41.9%
 Functional diagnostic testing – 16.3%
 Support group – 9.3%
 Education
 Home exercise programs – 86%
 Health wellness – 83.7%
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PD Assessment Measures
 Unified Parkinson’s Disease Rating Scale (UPDRS)
 Measures clinical course of PD over time
 Subscales: mentation, behavior & mood; ADLs, &
motor skills
 Hoehn and Yahr
 Scale classifies PD’s six stages – severity of disease
 0= no involvement; 1=unilateral involvement only
through 5=confinement to bed or wheelchair
 PDQ-39
 Quality of Life; 39 items & 8 subscales
 Mobility, ADL, emotional well-being, stigma, social
support, cognitions, communication & bodily
discomfort
Karon Cook, PhD, 2003
Physical Therapy
 Patients with a Hoehn & Yahr disability scale
score of 3 or higher (0-5 scale)
 Compromised postural righting reflexes
 Unable to recover balance on a pull test
 Falls are a recurring problem; patient’s have
difficulty walking sideways or backwards; gait is
slow & shuffling
 Safety training; rearrange furniture; flexibility exercise
to improve axial mobility; cueing strategies
Elizabeth J. Protas, PT, PhD, FACSM, 2003
Model of Care for Physical &
Occupational Therapy
 Task specific training regimes
 Taught to do one thing at a time; avoid dual
activities
 Long movement sequences should be broken into
steps; focus on learning one at a time
 Exercise and activity training should be undertaken
at peak medication dose
 Begin therapies early in disease process:
 Preserve flexibility
 Prevent deconditioning
 Minimalize mental decline
 Find solutions to functional problems
Trail & Warkentin, 2003
Depression
 50% of PD patients suffer from depression
 Decreased energy & motivation; feelings of sadness,
helplessness, hopelessness; changes in weight, sleep
& appetite; irritability, & thoughts of suicide
 May co-exist with cognitive decline symptoms
 Nonpharmacological strategies:
 Walking, tai chi, yoga and water therapy
 Community education/support groups
 Behavioral/cognitive counseling of individuals or
families
Naomi Nelson, PhD, 2003
Communicative Needs
 Most eventually exhibit hypokinetic dysarthria
with associated respiratory, laryngeal, and
articulatory dysfunction
 Aim is to strengthen muscles involved with
volume production & articulation
 Augmentative communication devices –
amplification systems for reduced loudness
 Nonelectronic communication boards or
notebooks or computers
 Reevaluate with changing patient needs
Jean Whitehead, MA, CCC/SLP, 2003
Access to Care
 Telemedicine/Telehealth
 Is there a difference between office-based vs
home web-based clinical assessments for PD?
 Random crossover design; 42 PD patients were
evaluated at baseline and 6- & 12-weeks
 Correlation coefficient between web and office
were:
 0.67 (first visit) to 0.75 (last visit)
 Doctor vs patient scores of 0.81 & 0.82
 No difference in responsiveness and data precision
 Fewer missing values for web-based assessments
Cubo, et al., 2012, Movement Disorder, 27(2),308-311.
Telehealth Education
 Usefulness & usability of follow-up telehealth
medication counseling of community-based PD
patients
 RCT for in-person, videophone, or telephone
standardized medication educational session – 20-30
minutes (N=75)
 Patients were more satisfied with videophone
equipment & counseling than telephone or inperson sessions Nurses found visualization via
videophone significantly more useful for medication
and self-management interactions
 Telehealth has the potential to facilitate patientprovider communication and partnerships in chronic
disease preventive health care
Fincher, Ward, Dawkins, Magee, & Willson, 2009, Jl of Gerontological Nursing, 35(2), 16-24.
Telehealth Increased
Access
 Pilot RCT of telemedicine for PD patients
in a community setting
 Telemedicine vs usual care; 3 telemedicine
visits over 6-months (N=10)
 UPDRS motor subscale was improved (p = 0.03)
relative to baseline for telehealth nursing home
patients vs usual care patients
 QOL PDQ-39 and patient satisfaction were
higher for telemedicine patients
 Implementation cost was low; about $250 per
site
Dorsey, et al, 2010
Telehealth Access
Telehealth Access
Dorsey, et al, 2010
Telehealth Access
Dorsey, et al, 2010
Chronic Disease Self-Management
Counseling (CDSM) Program
 CDSM trainers (faculty & students) delivered
workshops:
 Techniques to deal with problems such as frustration,
fatigue, pain and isolation
 Exercise for maintaining and improving strength,
flexibility, and endurance
 Medications
 Nutrition
 Communicating effectively with family, friends, and
health professionals
CDSM Program
Course Products
 Students participated in CDSM patient
counseling in 6-week (2.5 hours per
session) course
 Students developed theory-based
patient educational handouts for
multiple chronic conditions (e.g.,
Parkinson’s Disease, Stroke, Diabetes,
Heart Failure, Kidney Disease)
Theory Assignments
 Social Cognitive Theory
 Theory of Reasoned Action & Belief
Model
 Transtheoretical Model of Behavior
Change
 Health Promotion Model
 Literature search for Theoretical
underpinnings of CDSM
Evidence Based Practice
Strategies
 Evaluated an EB SM research article
 Determining the evidence for patient SM
support programs
 Journal Club format for presentation
 Summative evaluation paper
 Impact of SM intervention on Pt outcomes
 Apply to Pt education & SM
 Experience as a facilitator & future practice
 Students were highly motivated & engaged
 Met course objectives
 Demonstrated SM and clinical competencies
Student Reflective Evaluations
 “It [CDSM Program] took the mystery out
of action planning for me”
 [Implementation of SM classes & clinical]
“actually seeing the program in action
cemented this skill in my brain…I will feel
confident in using this skill in my practice”
Students Reflective Evaluations
 [I got to] “witnessed SM in action”
 “This experience [CDSM Program] helped
me see the big picture of holistic care”
 [I] “appreciate the importance of
formulating an action plan to motivate
our patients to change behavior”
Patient Evaluation CDSM Program
My overall satisfacion with…
I direct my self management…
Establish self-management at…
Support my self-management
Appreciate relaxation exercises
Complete my action plan
Increase my physical activity
Stay on track managing risk…
Understand stroke
Identify personal risk factors
0
4.7
4.5
4.3
4.5
4.5
4.3
4.5
4.2
4.5
4.5
1
2
3
4
5
Conclusions
 Linking two courses facilitated a higher
level demonstration of independent
student skills and the use of National
Guidelines in the management of
complex patients
 The Chronic Disease Self-Management
course added to the students skill sets,
demonstrating theoretical based (selfefficacy, health prevention) patient
education methods & materials
Future ???
 CDSM program for patients with PD
 Videoconference delivery mode
 Pilot study:
 The Chronic Disease Self-Management
course for patients at Beaumont and
Richmond Community Based Outreach
Clinics (CBOCs)
 Feasible, acceptable, improved patient
QOL indices
Anderson, et al., 2012
Summary
 Most patients with PD are older than 60 years
 Access to specialty care improves patient
outcomes and quality of life
 The specialty skills of a multidisciplinary team
improves patient care
 PD is a progressive chronic disease that needs
frequent monitoring as symptoms progress and
fluctuate
 Telemedicine/telehealth provides increased
patient access and high patient satisfaction
Questions ?