Optimizing Treatment in Undertreated Late-Stage Parkinsonism: A Pragmatic Randomized Trial

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Abstract

Background: Treatment of patients with late-stage parkinsonism is often sub-optimal. Objective: To test the effectiveness of recommendations by a movement disorder specialist with expertise in late-stage parkinsonism. Methods: Ninety-one patients with late-stage parkinsonism considered undertreated were included in apragmatic a pragmatic multi-center randomized-controlled trial with six-month follow-up. The intervention group received a letter with treatment recommendations to their primary clinician based on an extensive clinical assessment. Controls received care as usual. The primary outcome was the Unified Parkinson Disease Rating Scale (UPDRS)part-II (Activities of Daily Living). Other outcomes included quality-of-life (PDQ-8), mental health (UPDRS-I), motor function (UPDRS-III), treatment complications (UPDRS-IV), cognition (Mini-mental-state-examination), non-motor symptoms (Non-Motor-Symptoms-scale), health status (EQ-5D-5L) and levodopa-equivalent-daily-dose (LEDD). We also assessed adherence to recommendations. In addition to intention-to-treat analyses, a per-protocol analysis was conducted. Results: Sample size calculation required 288 patients, but only 91 patients could be included. Treating physicians followed recommendations fully in 16 (28%) and partially in 21 (36%) patients. The intention-to-treat analysis showed no difference in primary outcome (between-group difference=-1.2, p=0.45), but there was greater improvement for PDQ-8 in the intervention group (between-group difference=-3.7, p=0.02). The per-protocol analysis confirmed these findings, and showed less deterioration in UPDRS-part I, greater improvement on UPDRS-total score and greater increase in LEDD in the intervention group. Conclusions: The findings suggest that therapeutic gains may be reached even in this vulnerable group of patients with late-stage parkinsonism, but also emphasize that specialist recommendations need to be accompanied by better strategies to implement these to further improve outcomes.

Detaljer

Författare
  • Adrianus L.A.J. Hommel
  • Marjan J. Meinders
  • Nico J. Weerkamp
  • Carmen Richinger
  • Christian Schmotz
  • Stefan Lorenzl
  • Richard Dodel
  • Miguel Coelho
  • Joaquim J. Ferreira
  • Francois Tison
  • Thomas Boraud
  • Wassilios G. Meissner
  • Kristina Rosqvist
  • Jonathan Timpka
  • Per Odin
  • Michael Wittenberg
  • Bas R. Bloem
  • Raymond T. Koopmans
  • Anette Schragand
  • Care of Late Stage Parkinsonism (CLaSP) Consortium
Enheter & grupper
Externa organisationer
  • Radboud University Medical Center
  • University Hospital Essen
  • University of Lisbon
  • Centre Hospitalier Universitaire de Bordeaux
  • University of Otago
  • Philipp University of Marburg
  • University College London
  • HMC Bronovo
  • University Hospital Munich
  • Paracelsus Private Medical University of Salzburg
  • University of Bordeaux
  • New Zealand Brain Research Institute
Forskningsområden

Ämnesklassifikation (UKÄ) – OBLIGATORISK

  • Neurologi

Nyckelord

Originalspråkengelska
Sidor (från-till)1171-1184
Antal sidor14
TidskriftJournal of Parkinson's Disease
Volym10
Utgåva nummer3
StatusPublished - 2020
PublikationskategoriForskning
Peer review utfördJa