Advanced stages of PD: interventional therapies and related patient-centered care

Abstract

During the last decades, symptomatic treatment of motor symptoms of Parkinson's disease (PD) improved continuously and is reflected by long-range independency of the patient during the disease course. However, advanced stages of PD still represent an important challenge to patients, caregivers and treating physicians. In patients with advanced PD, interventional therapy strategies are increasingly applied. These device-related treatment strategies using pump-based continuous dopaminergic stimulation (CDS) or deep brain stimulation (DBS) opened new treatment options especially if motor complications predominate. Well-designed clinical studies on these interventional therapeutic approaches provided class 1 evidence for the efficacy of DBS and CDS in advanced PD and opened new perspectives for their use in earlier disease stages also. Therefore, careful selection of patients amenable to the (semi)invasive therapy options becomes more and more important and requires an interdisciplinary setting that accounts for (i) optimal patient information and awareness, (ii) selection of best individual treatment modality, (iii) training of relatives and caregivers, (iv) management of complications, and (v) follow-up care. Here, we address these topics by summarizing current state-of-the-art in patient selection, providing specificities of treatment options and troubleshooting, and defining steps towards an optimized patient-centered care. Interventional therapies pioneer in the area of individualized treatment approaches for PD, and may be complemented in the future by biomarker-based improved stratification and by closed-loop systems for adaptive therapeutic strategies. In the present review, we summarize the proceedings of an Expert Workshop on Parkinson's disease held on November 22, 2014 in Frankfurt, Germany.

Classification of advanced stages of Parkinson’s disease: translation into stratified treatments

“…The practicing neurologists should be involved in rounds for movement disorders as part of the extended therapeutic concept (Krüger et al 2015). Pharmacists and medical associations also serve as an important source of information for patients, less so the peer groups and the health insurances.…”

Understanding the lived experiences of Parkinson's disease and deep brain stimulation (DBS) through occupational changes

“…To date, research on the impact of DBS in PD has centred on individual symptom or performance measurement in the areas of motor function (Deuschl et al ., ; Haahr et al ., ; Krüger et al ., ), health or disease‐related quality of life (QOL) (Deuschl et al .; Perestelo‐Pérez et al ., ), or activities of daily living (Schüpbach et al ., ). The evidence within these areas indicates substantial and profound changes (generally improvements) in symptoms and related function and therefore, the lives of individuals and their caregivers.…”

Developing consensus among movement disorder specialists on clinical indicators for identification and management of advanced Parkinson’s disease: a multi-country Delphi-panel approach

“…Given the lack of instruments linked to treatment management, developing indicators for clinical staging is important for routine clinical practice, especially since many PD patients are not seen by movement disorder specialists until later in the disease. Guidance is also lacking on the timing and use of device-aided therapies and when oral/transdermal medications are no longer effectively controlling symptoms 4,[19][20][21] . Identifying the most appropriate management approach for patients in the advancing stage of PD is critical in providing improved health-related quality-of-life and stabilizing symptoms.…”