Parkinsonism and Related Disorders 20 (2014) 360e369 Contents lists available at ScienceDirect Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis Editor’s comment: In this thoughtful and provocative Point-of-View contribution, van der Eijk and colleagues address the shortcomings of the classical model of “professional physician-centered care” and describe an alternative “collaborative patient-centered care” approach that involves, among many other things, shared decision making with patients in the context of a multidisciplinary care setting. They propose that this alternative approach may improve quality of care and produce better outcomes for individuals with disorders such as Parkinson’s disease, while also being cost-effective. The authors discuss their experience with such an approach and describe both the benefits and barriers they have encountered. Whether one agrees or disagrees with the authors’ proposals, this article will provide much food for thought and reflection. Ronald F. Pfeiffer, Editor-in-Chief Department of Neurology, University of Tennessee HSC, 855 Monroe Avenue, Memphis, TN 38163, USA Point of view Consensus-based clinical practice recommendations for the examination and management of falls in patients with Parkinson’s diseaseq Marjolein A. van der Marck a, Margit Ph.C. Klok a, Michael S. Okun b, Nir Giladi c, Marten Munneke a,d, Bastiaan R. Bloem e,*, on behalf of the NPF Falls Task Force1 a Radboud university medical center, Nijmegen Centre for Evidence Based Practice, Department of Neurology, Nijmegen, The Netherlands b University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA c Movement Disorders Unit, Department of Neurology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel d Radboud university medical center, Nijmegen Centre for Evidence Based Practice, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands e Radboud university medical center, Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Nijmegen, The Netherlands article info abstract Article history: Falls in Parkinson’s disease (PD) are common and frequently devastating. Falls prevention is an urgent Received 28 December 2012 priority, but there is no accepted program that specifically addresses the risk profile in PD. Therefore, we Received in revised form aimed to provide consensus-based clinical practice recommendations that systematically address po- 13 September 2013 tential fall risk factors in PD. We developed an overview of both generic (age-related) and PD-specific Accepted 2 October 2013 factors. For each factor, we specified: best method of ascertainment; disciplines that should be involved in assessment and treatment; and which interventions could be engaged. Using a web-based Keywords: tool, we asked 27 clinically active professionals from multiple relevant disciplines to evaluate this Parkinson’s disease Accidental falls overview. The revised version was subsequently reviewed by 12 experts. Risk factors and their associated fi Prevention interventions were included in the nal set of recommendations when at least 66% of reviewing experts Clinical protocol agreed. These recommendations included 31 risk factors. Nearly all required a multidisciplinary team approach, usually involving a neurologist and PD-nurse specialist. Finally, the expert panel proposed to first identify the specific fall type and to tailor screening and treatment accordingly. A routine evaluation of all risk factors remains reserved for high-risk patients without prior falls, or for patients with seem- ingly unexplained falls. In conclusion, this project produced a set of consensus-based clinical practice recommendations for the examination and management of falls in PD. These may be used in two ways: for pragmatic use in current clinical practice, pending further evidence; and as the active intervention in clinical trials, aiming to evaluate the effectiveness and cost-effectiveness of large scale implementation. Ó 2014 The Authors. Published by Elsevier Ltd. All rights reserved. DOI of original article: http://dx.doi.org/10.1016/j.parkreldis.2013.10.028. q This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). * Corresponding author. Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud university medical center PO Box 9101, 6500 HB, Nij- megen, The Netherlands. E-mail address: [email protected] (B.R. Bloem). 1 Listed at the end of the manuscript. 1353-8020/$ e see front matter Ó 2014 The Authors. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.parkreldis.2013.10.030 M.A. van der Marck et al. / Parkinsonism and Related Disorders 20 (2014) 360e369 361 1. Introduction severity of each risk factor); which disciplines should be involved in the assessment and treatment; the primarily responsible disci- Falls in patients with Parkinson’s disease (PD) are common and pline; and suggestions for therapeutic interventions to reduce or often devastating. Prospective surveys have revealed high rates of eliminate the risk factor. falls that exceed those of the community-dwelling elderly. A meta- analysis concluded that the risk of sustaining a fall was consider- 2.2. Multidisciplinary evaluation of the concept recommendations ably increased in moderately affected patients with PD as compared with healthy age-matched peers. Almost 50% of patients fell during The concept recommendations were presented via a web-based a brief follow-up of only 3 months [1]. tool to a group of 27 professionals from multiple disciplines that Falls in PD are associated with a poor prognosis. Injuries are were recruited from National Parkinson Foundation (NPF) centers common, and patients with PD with hip fractures face high (Fig. 1). These professionals evaluated the recommendations, gave morbidity and mortality [2]. Minor injuries such as bruises or lac- additional suggestions, and rated their level of expertise with each erations are even more common [3]. Moreover, the disease appears risk factor. If they rated their expertise as ‘none’ in any category, to become more severe and difficult to treat once falls are present, their scores were not considered. Subsequently, the revised rec- usually because of fall-related injuries and cognitive dysfunction, ommendations were reviewed by 12 international experts from and overall survival of fallers is reduced [4]. Falls also commonly multiple relevant disciplines (Falls Task Force group; Fig. 1). These induce a fear of renewed falls [3], which can lead to secondary experts were selected for their specialization and research experi- immobilization and a reduction in general fitness, thereby ence in balance, gait and falls in PD. For each item, agreement be- increasing the risk of cardiovascular disease [5]. Lack of physical tween at least two-thirds of these experts was considered as activity is also associated with constipation, pressure sores, consensus. Therapeutic interventions were scored on a 6-point insomnia and osteoporosis (which further increases fracture risk) scale, ranging from 0 (totally unimportant) to 5 (extremely [6]. Immobility also deprives patients of their independence and important). Interventions with a mean evaluation score of >2were social interactions. Not surprisingly, falls and mobility problems included as final recommendations. have been associated with poorer quality of life. [7e9] In addition, the economic burden of falls in PD is substantial, due to the rela- 2.3. Implementation of the protocol in clinical practice tively high cost of treatment of injuries and nursing home admis- sions [10]. Two possible ways to implement the recommendations in These potentially serious implications, make the prevention of clinical practice were offered to the panel of 12 experts. Option A falls a high priority in the management of patients with PD. How- was a ‘One size fits all approach’ where all patients should be ever, there is no accepted falls prevention program tailored spe- reviewed for all risk factors, and be treated accordingly. This cifically to the problems encountered in individual patients with approach is comprehensive and ascertains that all risk factors will PD. We therefore developed falls prevention recommendations be addressed, but might lead to “over-care” in a subset of patients. specifically for PD, based on consensus among various health pro- Option B was the ‘Fall type approach’ where the first diagnostic step fessionals and a smaller panel of experts on falls in PD. The starting is to identify the specific fall type for each patient (e.g., falls that are point was based on the premise that falls in PD are typically always caused by freezing of gait, or falls that are consistently multifactorial, resulting not only from various disease-specific preceded by syncope). For those patients with a clear and identi- mechanisms (e.g. freezing of gait) [11], but also from generic age- fiable fall pattern, the diagnostic and therapeutic approach could be related risk factors [12]. Indeed, older patients with PD are not limited to those specific risk factors and no unnecessary disciplines exempt from age-related processes or problems common to any will be addressed. This provides a specialized approach, but carries geriatric population, such as complex co-morbidity or poly- the risk of under-treatment and missing of unidentified additional pharmacy.