Parkinsonism Under-recognized in Assisted Living

Daniel M. Keller, PhD

Nov. 13, 2015

SANTIAGO, Chile — Parkinsonism is common in assisted living facilities and is frequently associated with dementia and depression, but it is typically underdiagnosed and undertreated, a new study suggests.

However, after a comprehensive education program was initiated in 10 facilities, the proportions of correctly diagnosed primary parkinsonism rose, as did the number of patients adequately treated for it.

"The primary diagnosis [of parkinsonism] was increased significantly from 59% to 81%, and the primary treated patients of the cohorts of primary diagnosis patients was also improved from 55% to 90%," said Stanislav Šutovský, MD, PhD, from the Department of Neurology at Comenius University and University Hospital in Bratislava, Slovakia.

He presented his findings here at the XXII World Congress of Neurology (WCN).

Most previous studies of prevalence, recognition, and treatment of parkinsonism in assisted living facilities have been indirect, relying on information from medical charts. This new report used data from the Slovakia Assisted Living Study, which consisted of two cross-sectional studies carried out in 2004 and 2012.

The studies involved comprehensive review of patient history, plus neurologic, psychiatric, cognitive, and motor evaluations. On the basis of these data, a panel of neurologists and psychiatrists revised previous diagnoses and treatments as necessary.

The same 10 assisted living facilities were used at the two time periods. The earlier study evaluated 866 facility residents, and 821 were evaluated at the later period (mean age, 75.9 years).

More Parkinsonism Diagnosed and Treated 

Of the 866 residents studied in 2004, 13% (n = 113) had parkinsonism, 57% dementia, and 54% had depression. The most common forms of dementia were Alzheimer's disease, followed by vascular, mixed, and Parkinson's disease dementia and a variety of other less frequent causes.

Of the 113 parkinsonian patients, 59.2% had Parkinson's disease and 31.6% had vascular parkinsonism, followed by a variety of other causes.

In 2005, Slovakia began a national program to improve mental health among seniors. This program provided information to the public about parkinsonism, dementia, and cognitive disorders in the elderly and offered special courses for nurses and nursing staff in nursing homes. Primary care physicians, neurologists, and psychiatrists received education about diagnosing and treating dementias and parkinsonism.

After implementation of the educational programs, diagnosis and treatment of primary parkinsonism increased, and the prevalence of depression was reduced.

Dr Šutovský pointed out that the study provided a direct estimate of the prevalence of parkinsonism, dementia, and depression in two cohorts of people in assisted living facilities and showed "a significant improvement of [the] primary diagnostic process and therapy after a comprehensive educational program."

However, he also noted that new dopamine agonist drugs became available between the two study periods; this change, as well as others, may also have contributed to better outcomes by 2012.

Table. Parkinsonism Diagnoses and Treatment Before and After Education Program 

Endpoint	2004 (%)	2012 (%)	PValue
Patients diagnosed with primary parkinsonism	51.0	81.0	<.001
Patients treated for primary parkinsonism	55.0	90.5	<.001
Patients with parkinsonism and depression	59.0	45.0	.034
Patients with parkinsonism and dementia	73.5	65.0	NS
NS = not statistically significant.

Session moderator Erik Wolters, MD, PhD, president of the World Federation of Neurology Association of Parkinsonism and Related Disorders and visiting professor of neurology at the University of Zurich in Switzerland, commented to Medscape Medical News that parkinsonism and depression are apparently an under-recognized problem in assisted living "because education did help them enormously with making the proper diagnosis and giving the right treatment to the patients."

He noted that the differences between the 2004 and 2012 cohorts were "really significant" and was impressed that "it's still possible to increase awareness because I thought that everyone knows about all those diseases in Europe," he said. "Apparently not."

Dr Wolters therefore advised that educational programs are helpful and essential. Finally, he said the use of dopamine agonists overall does nothing to improve dementia.

He warned that the percentage of parkinsonian patients who will become demented "is really, really, very high — higher than expected 15 years ago" as people live longer with their disease because of improvements in drugs and deep brain stimulation (DBS) for parkinsonian diseases.

"I think...that every parkinsonian patient will end up with dementia if they live long enough," he predicted. In fact, he said, DBS can exacerbate existing cognitive deficits and lead to dementia earlier compared with the use of drugs.

There was no commercial funding for the study. Dr Šutovský has disclosed no financial relationships. Dr Wolters is an officer of Amarna Stem Cells.

XXII World Congress of Neurology (WCN). Abstract 129. Presented November 1, 2015.

http://www.medscape.com/viewarticle/854487?src=wnl_edit_tpal#vp_2