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

Abstract

Background: Lack of a global consensus on the definition of advanced Parkinson's disease (APD) and considerations for timing of device-aided therapies may result in heterogeneity in care. Objectives: To reach consensus among movement disorder specialists regarding key patient characteristics indicating transition to APD and guiding appropriate use of device-aided therapies in the management of PD symptoms. Methods: A Delphi-panel approach was utilized to synthesize opinions of movement disorder specialists and build consensus. Results: A panel was comprised of movement disorder specialists from 10 European countries with extensive experience of treating PD patients (mean ¼24.8 ± 7.2 years). Consensus on indicators of suspected APD and eligibility for device-aided therapies were based on motor symptoms, non-motor symptoms, and functional impairments. Key indicators of APD included: (i) motor-moderate troublesome motor fluctuations, 1 h of troublesome dyskinesia/day, 2 h "off" symptoms/day, and 5-times oral levodopa doses/day; (ii) non-motor-mild dementia, and non-transitory troublesome hallucinations; (iii) functional impairment-repeated falls despite optimal treatment, and difficulty with activities of daily living. Patients with good levodopa response, good cognition, and <70 years of age were deemed as good candidates for all three device-aided therapies. Patients with troublesome dyskinesia were considered good candidates for both levodopa-carbidopa intestinal gel and Deep Brain Stimulation (DBS). PD patients with levodopa-resistant tremor were considered good candidates for DBS. Conclusion: Identifying patients progressing to APD and suitable for device-aided therapies will enable general neurologists to assess the need for referral to movement disorder specialists and improve the quality of care and patient outcomes.

5-2-1 Criteria: A Simple Screening Tool for Identifying Advanced PD Patients Who Need an Optimization of Parkinson’s Treatment

“…However, in the absence of a biomarker, a diagnostic test, or a gold standard index to determine the severity of PD (based on the motor and nonmotor symptoms), clinicians often rely on varied clinical evaluation and medical history to determine staging in PD [2]. Recently published systematic reviews and consensus articles acknowledge the growing need to establish guidelines for the different treatment approaches for advanced PD patients [3][4][5][6][7][8]. At this stage, it is important to ensure timely referral of patients to a movement disorder specialist before deterioration of quality of life (QoL) and development of complications of advancing disease [9,10].…”

“…In this context, 5-(5 times oral levodopa tablet taken/ day) 2-(2 hours of OFF time/day) 1 (1 hour/day of troublesome dyskinesia) criteria have recently been proposed by a Delphi expert consensus panel for diagnosing advanced PD [8,13]. However, these criteria have been only applied in one cohort of advanced PD patients under levodopa infusion therapy (ADEQUA Study) [14].…”

Update on the Management of Parkinson’s Disease for General Neurologists

“…As PD is clinically very heterogenous and progressive in nature, it is not an easy task to define the concept of advanced PD. Various efforts in the form of systematic analyses, expert consensuses from national steering committees in Europe [24], and Delphi studies with specialized MD panelists [29,30] have been made to propose criteria. Advanced PD is generally reached when patients develop characteristic complications associated with long-term levodopa treatment, uncontrolled with optimized conventional therapies [29].…”

“…For practical purposes, patients should be using ≥5 effective doses of levodopa daily before considering transition to advanced therapies [30]. If "off" periods persist, adding MAO-B inhibitors and/or COMT-inhibitors should be considered [59].…”

“…e disease duration and the emergence of motor [65] and nonmotor [66] complications are crucial for the diagnosis of advanced PD. Antonini et al [30] published a series of indicators for transition to advanced PD achieved with a Delphi approach that may provide good orientation (Table 4).…”