CONy 2024 | The Stepped-care approach to holistic and subtype-driven care for patients with Parkinson’s

Karolina Popławska-Domaszewicz:
Good morning, my name is Karolina Poplawska-Domaszewicz. I work in Poznań University Hospital, and I’m also affiliated with King’s College Hospital in London and I’m a movement disorder specialist.

K. Ray Chaudhuri:
Hi there, Ray Chaudhuri, I’m a professor of movement disorders and director of the King’s Parkinson’s Center at King’s College Hospital and King’s College in London.

There’s a lot of initiatives now which are looking at Parkinson’s as a heterogeneous condition, not just a single disorder. In fact we published this in 2017, that Parkinson’s is a syndrome and not a single disease. And now it’s good to see that several people have taken it up. The Movement Disorder Society has got a group which is looking at staging and definition of Parkinson’s. More recently, Eoin Mulroy and others have followed our recommendation and tried to describe Parkinson’s as various syndromes. Syndrome 1 and Syndrome 2, they call it. So it’s basically based on the fact that there are multiple neurotransmitters are involved, not just dopamine. Acetylcholine, serotonin, noradrenaline. We’ve published on the cholinergic deficiency, noradrenergic dysfunction. And these presents in various different ways. And I think the important thing in clinical practice is for us to recognize this, the different ways these Parkinson patients present in different subtypes, particularly the non-motor subtypes, because that drives then very individual subtype-based personalized medicine. And so one size doesn’t fit all. How you treat a cholinergic subtype of Parkinson’s is very different to a sleep dominant Parkinson, where you probably will not be prescribing drugs such as pramipexole or ropinirole because of sleep events. And it’s quite different to how you will avoid anticholinergic drugs in cholinergic subtype. And it’s quite different to how you treat a noradrenergic subtype, where your focus is on the autonomic function, on pain, on REM behavior disorder, etc. So I think that’s how the concept has changed, and our personalized medicine delivery is now highly based on those concepts.

Karolina Popławska-Domaszewicz:
The Stepped-care toolkit is a modern, holistic pathway of care for all health care professionals who look after people with Parkinson’s. Stepped-care toolkit includes motor assessment as well as non-motor. We focus on cognitive and neuropsychiatric function, sleep, autonomic dysfunction. It also ensures that bone health, gut and oral health, comorbidities, co-medication are not overlooked, and generally it gives a very holistic management for Parkinson’s disease. And now the project has gone global. We have centers from Japan, China, India, Malaysia, South Africa, Egypt, Tunisia, Chile, and many European ones. And I’m very delighted to coordinate this project with Prof, Chaudhuri and his wonderful team, especially with Dr Kumar, Dr Trivedi, Dr Batzu in King’s College Center of Excellence in London.

K. Ray Chaudhuri:
The dashboard incorporates the five vitals of Parkinson’s, which actually Karolina mentioned in Stepped-care, because the Stepped-care is, in a way, practical implementation of the dashboard, if you will. So the dashboard has motor as a vital, nonmotor as a vital, gut, bone, and oral health as another vital, then vision, and finally co-medications and comorbidities. So this is being implemented as part of Stepped-care. We are very much hoping that this will be a prompt that is either available as a printout, or perhaps in the future, as a downloadable app version for all doctors and health care professionals. They will download this before they do a clinic and make sure they check these things in every patient, and not forget things such as bone health or checking for anticholinergic drugs, etc. So I think it’s being widely implemented, and I’m hopeful that once Karolina’s Stepped-care program is completed globally in those centers, then we’ll be able to put it in the framework of the policymakers so it becomes the pathway of care for Parkinson’s all across the world.

I think timeline wise, what we’re currently doing is doing a cognitive pre-testing of the Stepped-care paradigm. So we’ve asked a group of doctors, health care professionals, and patients to give their opinion on the on the toolkit. We are hoping to complete that by end of April. Then we’ll publish that data. And based on the recommendation, the final form of Stepped-care paradigm is available. So we’re very hopeful that the final protocol or the pathway will go out towards probably September, October time, perhaps in time for the Movement Disorders Congress.