Association of specialist involvement and quality of care for Parkinson's disease.

Because Parkinson's disease (PD) has multiple neurological symptoms and often complex treatments, the quality of PD care may be higher when a specialist is involved. We examined the medical records, from 1998 to 2004, of 401 Los Angeles veterans with Parkinson's disease to determine whether care met key indicators of PD care quality. All care following a visit to a movement-disorder specialist or general neurologist was classified as specialty care. We compared adherence to each indicator by level of specialist involvement through logistic regression models. Over the study period, 10 indicators of PD care quality were triggered 2,227 times. Overall, movement disorder specialist involvement (78%) was associated with higher adherence to indicators than did general neurologist involvement (70%, P = 0.006) and nonneurologist involvement (52%, P < 0.001). The differences between movement disorder specialist and nonneurologist involvement were especially large for four indicators: treatment of wearing-off, assessments of falls, depression, and hallucinations. There is significant room for improving aspects of PD care quality among patients who do not have the involvement of a specialist. Quality of care interventions should involve specialists in management of motor symptoms and incorporate methods for routine assessment of nonmotor PD symptoms.

Benefits and risks of pharmacological treatments for essential tremor.

Essential tremor can cause significant functional disability in some patients. The arms are the most common body part affected and cause the most functional disability. The treatment of essential tremor includes medications, surgical options and other forms of therapy. Presently there is no cure for essential tremor nor are there any medications that can slow the progression of tremor. Treatment for essential tremor is recommended if the tremor causes functional disability. If the tremor is disabling only during periods of stress and anxiety, propranolol and benzodiazepines can be used during those periods when the tremor causes functional disability. The currently available medications can improve tremor in approximately 50% of the patients. If the tremor is disabling, treatment should be initiated with either primidone or propranolol. If either primidone or propranolol do not provide adequate control of the tremor, then the medications can be used in combination. If patients experience adverse effects with propranolol, occasionally other beta-adrenoceptor antagonists (such as atenolol or metoprolol) can be used. If primidone and propranolol do not provide adequate control of tremor, occasionally the use of benzodiazepines (such as clonazepam) can provide benefit. Other medications that may be helpful include gabapentin or topiramate. If a patient has disabling head or voice tremor, botulinum toxin injections into the muscles may provide relief from the tremor. Botulinum toxin in the hand muscles for hand tremor can result in bothersome hand weakness and is not widely used. There are other medications that have been tried in essential tremor and have questionable efficacy. These drugs include carbonic anhydrase inhibitors (e.g. methazolamide), phenobarbital, calcium channel antagonists (e.g. nimodipine), isoniazid, clonidine, clozapine and mirtazapine. If the patient still has disabling tremor after medication trials, surgical options are usually considered. Surgical options include thalamotomy and deep brain stimulation of the thalamus. These surgical options provide adequate tremor control in approximately 90% of the patients. Surgical morbidity and mortality for these procedures is low. Deep brain stimulation and thalamotomy have been shown to have comparable efficacy but fewer complications have been reported with deep brain stimulation. In patients undergoing bilateral procedures deep brain stimulation of the thalamus is the procedure of choice to avoid adverse effects seen with bilateral ablative procedures. The use of medication and/or surgery can provide adequate tremor control in the majority of the patients.