Beyond the neurologist: the importance of a multidisciplinary approach in SSA

Catherine DotchinConsultant Geriatrician

Northumbria Healthcare NHS Foundation Trust

Overview

• Lack of specialist doctors evidence

• Rurality in Africa

• Nurse specialist training

• Access to drug treatment

• Physiotherapy

• OT and SALT

Neurologists worldwide• Ratio in Africa 0.03 neurologists/100,000 people (cf

4.84/100,000 in Europe)

• India: 1 Neurologist per 1.2 million inhabitants (850 neurolgists/1000 million people)

• All African and SE Asian countries had <1 neurologist /100,000 people

• Postgraduate training available in a few countries only (Nigeria, Ethiopia, northern African countries, South Africa)

World Neurology Atlas 2004

Geriatricians in Africa

• Replies from 40/54 countries (74%)

• Data were obtained via an internet search for a further three countries

• Out of 43, 25 countries had no geriatricians

• 35/40 countries had no formal undergraduate training for medical students on geriatrics

• 33/40 countries reported no national postgraduate training scheme for geriatrics

Dotchin et al Age and Ageing 2012

Making a diagnosis - difficulties

• Lack of neurologists/geriatricians/neurosurgeons/psychiatrists

• Lack of imaging –CT if lucky, no MRI, no DAT available

• Lack of PM studies to confirm clinical diagnosis

• Public awareness/stigma/health seeking behaviours

Access to treatment

• WHO Neurology atlas (2004): estimated availability of anti-PD drugs through primary healthcare system ranged from 12.5% in Africa to 79% in Europe

• However this doesn’t really tell us about the treatment gap in PD as so many undiagnosed

• Also treatment available may have only been anticholinergics

WHO Essential drugs list

• WHO Essential Drugs list, revised in March 2007.

• biperiden 2 mg (hydrochloride) and levodopa + carbidopa 100 mg/10 mg or 250 mg /25 mg

• Levodopa:carbidopa - nausea and other intolerable side effects, leading to non-adherence.

• Anticholinergic not a first line treatment, especially in non-tremor predominant or more elderly patients

• Some hospitals in Africa can only access drugs on this list

Rurality in SSA

• One option for filling the gap in medical services for older persons in Africa would be non-physician clinicians or assistant medical officers

• In many SSA countries they already perform many of the roles a doctor would, but require significantly shorter, and less expensive, training.

• They are also more likely to remain working in their own country and to work in rural areas

Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet 2007; 370: 2158–63

MDT involvement

• Traditional healers – may be first port of call ??train to identify and refer on, certainly need to work with them in many areas

• Raising awareness in the general public ?role of faith organisations

• Lack of OT/ SALT/ Social services/ walking aids and equipment/ PDNS

• Physiotherapy

Rochester et al Movement Disorders 2010, Miller et al South African Journal of Communication 2012

Partnerships in PD

Voluntary Bodies

Service Users

Health VisitorCarers

Person withPD

Friends

Family

ConsultantAge Concern

Social Worker

PsychiatristPsychologist

Dietician

District Nurse

GP

PDS

SALT

OT

Physiotherapy

PD Nurse

Physiotherapy

• RESCUE trial carried out in European centres shows that cueing is effective in treated patients with PD

• No previous data on effectiveness in untreated PD

• Easy to deliver in the patient’s home, relatively low cost, no side effects

• Would it be possible to deliver in Tanzania?

• Would it be effective if the patient has never had drug treatment?

Nieuwboer et al. 2007

Methods

Cueing training•3 weeks •At home (therapy & assessment)•19 participants•Age 76.4 (12.9)•H&Y 2.4 (.7)

Results: Effect of therapeutic cueing

Outcome Change P value

Step length 0.7 m <.0001

Speed 0.17 m/s <.0001

Step frequency

7.8 steps/min 0.046

UPDRS III 6 0.004

Therapeutic cueing improved• Walking• Motor severity• ADL • Similar results for dual task gait

Physio footage

Communication Challenges in Parkinson’s1

People with Parkinson’s find that their ability to communicate with other people is often limited by the effects of their Parkinson’s upon:

• Speech

• Writing

• Non-verbal communication skills

Caregiver strain in SSA

• PD carers in Hai asked ZBI

• 25 patients – 5 independent, therefore no main carer, 20 had carers, 3 patients had PDD

• Mean age of patients 77 years

• Mean ZBI 30 (high)

• Only predictor of strain was disease severity

• Compared to dementia patients and carers –mean age of patients 86 years, mean ZBI 15

Dotchin et al - submitted Int Psychgeriatrics

Carers’ quotes from Hai

• ‘Caring for the sufferer has made my life very difficult’

• ‘Caring for the sufferer is a big burden to me’

• ‘This illness has made us become very poor’

Speech and language therapy

• Communication

• Swallowing

• Advice on diet/liquids

Conclusions• Lack of specialist doctors in SSA from several specialties

• ?use AMOs or clinical officers in their place

• Specialist nurses used with good effect in UK

• Access to drugs is difficult – education (patient and caregiver) and follow up so important, ideally suited to PDNS role

• A lot of older frailer PD patients live rurally in SSA –Mohammed may need to go to the mountain! Role of nurses especially in rural areas to visit at home

• Role of physiotherpy (even if drug treatment not available)

• Role of SALT – often not available but a precious resource if you have one