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

TLDR

There is no global consensus on defining advanced Parkinson’s disease or timing of device‑aided therapies, leading to heterogeneous care. The study aimed to reach consensus among movement disorder specialists on key patient characteristics indicating transition to advanced Parkinson’s disease and guiding appropriate use of device‑aided therapies. A Delphi‑panel approach involving specialists from 10 European countries was used to synthesize opinions and build consensus on indicators of suspected advanced Parkinson’s disease and eligibility for device‑aided therapies based on motor, non‑motor, and functional impairments. Consensus identified key advanced Parkinson’s disease indicators—moderate motor fluctuations, ≥1 h of dyskinesia, ≥2 h off time, ≥5 levodopa doses, mild dementia, hallucinations, falls, and ADL difficulty—and defined eligibility for device‑aided therapies, with good levodopa responders, cognitively intact patients under 70, and those with dyskinesia or levodopa‑resistant tremor considered suitable candidates.

Abstract

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.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.A Delphi-panel approach was utilized to synthesize opinions of movement disorder specialists and build consensus.A panel was comprised of movement disorder specialists from 10 European countries with extensive experience of treating PD patients (mean =24.8 ± 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.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.