Who should look after people with Parkinson's disease?
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7431.62 (Published 09 January 2004) Cite this as: BMJ 2004;328:62All rapid responses
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Multi disciplinary care not multidisciplinary teams for Parkinsonism
The editorial on ‘Who should care for patients with Parkinsonism ?’
is very thought provoking, and multidisciplinary care (rather than
multidisciplinary team) is the need of the moment. Imagine, if
multidisciplinary care implied, involvement of multiple professionals from
different disciplines being involved in the care of the patient with
Parkinsonism, the patient and their carers may end up going from pillar to
post to get adequate attention.
The multidisciplinary care should consist of the multidimensional care
without involving too many professionals. This in effect would mean that
one professional should be able to provide the care the multidisciplinary
team of a general practitioner, a neurologist, a geriatrician,
pharmacists, specialist nurses, neuropsychiatrist, and physiotherapists or
any other professional, will provide. Depending on the clinical needs and
priorities, any one professional could be the key person to manage the
patient. This would enhance the quality of care in a cost effective way.
Professor S.K. CHATURVEDI, M.D.
Consultant Psychiatrist,
North Staffordshire Combined Healthcare NHS Trust,
Stoke on Trent.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
We welcome the conclusions of Kale & Menken that
multidisciplinary teams comprising a general practitioner, a neurologist,
a geriatrician, pharmacists, specialist nurses and physiotherapists are
needed to meet the needs of patients with Parkinson's disease(1).
Unfortunately however, their editorial was notable by its failure to
include a neuropsychiatrist as part of this team.
Parkinson's disease is a complex disorder comprising both motor and
neuropsychiatric features. Indeed, the neuropsychiatric complications can
often be the most distressing aspects of the disease. Several studies have
reported high rates of depression (40-50%)(2), dementia (20-61%)(3), drug
induced psychosis (30%)(3), anxiety, panic and social phobia (40%)(4),
and apathy (40-45%)(5) in affected individuals
In our institution, we provide a neuropsychiatry service to patients
with Parkinson’s disease and other neurological or neuropsychiatric
disorders within the framework of a multidisciplinary team. In our
experience, such an model is the best approach for accurate diagnosis and
facilitates a co-ordinated approach to treatment . In addition feedback
from patients suggests this is also the approach favoured by patients
and their relatives
While the motor features of Parkinson's disease clearly pose a
significant clinical challenge, it must be remembered that affected
individuals also have high rates of neuropsychiatric disorder and the
composition of multidisciplinary teams should reflect the complex needs of
this patients group.
Dr Ciaran Corcoran,
Professor Kieran C Murphy, Department of Psychiatry, Royal College of
Surgeons in Ireland and Beaumont Hospital, Dublin 9, Ireland .
References
1.Kale R, Menken M. Who should look after patients with Parkinson’s
disease? BMJ 2004; 328:62-63
2.McDonald WM, Richard IH, DeLong MR. Prevalence, etiology, and
treatment of depression in Parkinson's disease. Biol Psychiatry 2003;
54:363-75.
3.Bogousslavsky J, Cummings JL. Behaviour and mood disorders in focal
brain lesions. Cambridge University Press 2000; Chapter 6, p159.
4.Richard IH, Schiffer RB, Kurlan R. Anxiety and Parkinson's disease.
J Neuropsychiatry Clin Neurosci 1996; 8:383-92.
5.Starkstein SE, Mayberg HS, Preziosi TJ, Andrezejewski P, Leiguarda
R, Robinson RG. Reliability, validity, and clinical correlates of apathy
in Parkinson's disease. J Neuropsychiatry Clin Neurosci 1992; 4:134-9.
Competing interests:
None declared
Competing interests: No competing interests
Kale and Menken fail to acknowledge the very important emotional and
cognitive aspects of Parkinson's disease (PD) (and other movement
disorders, as a matter of fact). This is surprising given that depression,
for example, has an alleged frequency of up to 70% in patients with PD
(1), and other psychopathological states such as anxiety/panic, psychotic
phenomena (frequently medication-induced), obsessive-compulsive and
addictive behaviours, and cognitive impairment, are equally troublesome to
PD sufferers and those who care for them (2). The management of these
problems requires a great deal of experience, and often, of expertise.
Psychiatrists, and neuropsychiatrists in particular, have an important
role in the multidisciplinary management of PD.
(1)Cummings JL. Depression and Parkinson's disease: a review. Am J
Psychiatry 1992; 149: 443-454.
(2) Ring HA, Serra-Mestres J. Neuropsychiatry of the basal ganglia.
JNNP 2002; 72: 12-21.
Competing interests:
psychiatrist
Competing interests: No competing interests
We would very much support the views about the importance of
multidisciplinary care for patients with Parkinson’s disease (PD) and
would like to emphasize the fundamental importance of Parkinson’s disease
nurse specialists within the team. In addition to the team members that
were listed, we have found that psychiatrists, speech and language
therapists and occupational therapists have an important role to play.
In the UK, PD patients in secondary care are usually looked after by
neurologists or geriatricians, both bringing their own particular
expertise. However, we do not believe that both specialties together are
required for the day to day management of the majority of PD patients. The
key is that the doctor responsible for the care of the Parkinson’s disease
patient has an interest and expertise in PD, and is backed by the
multidisciplinary team.
This article is timely in that PD appears to be falling between “two
stools”. It was not mentioned in the National Service Framework for the
Elderly even though the vast majority of patients suffering from PD are
over the age of 65. Even more surprisingly, in the National Service
Framework for Chronic Neurological Conditions, currently under
development, there is a suggestion that they will be concentrating on only
those patients of working age (i.e. under the age of 65) and so yet again
most people with PD will “miss out”.
Finally we do not agree with your statement saying that the
prevalence of Parkinson’s disease in the UK is 200-300 per 100,000 of the
population. Schrag et al reported age adjusted rates for Parkinson’s
disease as 168 cases per 100,000 of the population (1) while Sutcliffe et
al reported an estimate of 121 cases per 100,000 of the population (2).
1. 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.
2. Sutcliffe RL, .Meara JR. Parkinson's disease epidemiology in the
Northampton District, England, 1992. Acta Neurologica Scandinavica 1995;
92:443-50.
Competing interests:
None declared
Competing interests: No competing interests
Dr Kale and Dr Menken fail to mention once the mental health needs of
these unfortunate patients. Psychiatric co-morbidity is extremely common
in Parkinson's and I am frequently asked for advice on management. Yet Dr
Kale and Dr Menken don't seem to feel that psychiatrists should be
included in the 'multidisciplinary team' caring for these patients.
Competing interests:
A psychiatrist
Competing interests: No competing interests
Kale and Menken's editorial makes an interesting reading.
Unfortunately not many neurologists in India would discuss the management
strategies with the refering GP. If the latter is made a part of the
management team it would certainly benefit the patient
Competing interests:
None declared
Competing interests: No competing interests
Editor,
I was extremely interested in your recent editorial about providing
care for people with Parkinsons Disease. The article refers to a
'neurophobia' of GPs that arises from deficiencies in undergraduate
medical education.
We carried out a study last year into referrals from primary care to
specialist out patient clinics in a number of specialties including
neurology, orthopaedics, gastroenterolgy, cardiology and paediatrics. We
recorded the frequency with which a diagnosis was offered in the referral
letter, and if so, whether it was correct. We found that by far the
fewest correct diagnoses were offered in neurolgy (28%). This compares
with more than 60% correct diagnoses in orthopaedics and paediatrics.
We wonder whether this is due to lack of confidence GPs have in this
specialty, stemming from medical school, where only a tiny proportion of
time is allocated to neurology. Perhaps further studies like these would
enable university tutors to prioritise when drawing up undergradute
medical curricula.
Competing interests:
None declared
Competing interests: No competing interests
I enjoyed this very thoughtful article about the need for health care
professionals in the United Kingdom in the care of the Parkinson afflicted
patient. I would like to respectfully ask the authors if there has been
any consideration for the implementation of the Physician Assistant in the
UK for the care of such a patient? The concept of the Physician Assistant
is currently being explored by several health trust organizations and the
NHS in Britain in the family practice settings. I would like to propose
further discussion in this regard among the physician and other health
care readers of this journal. Thank You.
Competing interests:
None declared
Competing interests: No competing interests
Authors' reply
We welcome comments made by our colleagues in psychiatry about
including psychiatrists in multidisciplinary teams to look after people
with Parkinson’s disease. The main criteria for inclusion in the team
should be that the person has an interest in the condition and the
necessary expertise. Including a neurologist who has no interest in
Parkinson’s disease (usually because of a singular interest in another
neurological subspecialty) or excluding a psychiatrist who has an interest
in Parkinson’s disease are both undesirable. Team members would vary
depending on local factors. We have previously argued for better
cooperation between neurologists and psychiatrists.[1]
We clarify that the prevalence of Parkinson’s disease quoted (200-300
per 100 000) is from reference 3 (Calne) in the editorial. Reference 4
(Schrag et al) is about London and states the following: “The crude and
adjusted rates for idiopathic Parkinson's disease (probable and possible
combined) were 128 (95% confidence interval 109 to 150) per 100 000 and
168 (142 to 195) per 100 000 respectively. The corresponding rates for all
types of parkinsonism were 193 (95% confidence interval 169 to 220) and
254 (95% confidence interval 222 to 287).”
1. Baker MG, Kale R, Menken M. The wall between neurology and
psychiatry. BMJ 2002;324:1468-9.
Competing interests:
None declared
Competing interests: No competing interests