Increasing recognition of Parkinson disease in Black patients

A recent news story in The Philadelphia Inquirer profiled a Black woman who visited her primary care physician for upper body pain, stiffness, and an unusual gait and was surprised when she was ultimately diagnosed with Parkinson disease. Known by many as an “old White man’s disease,” Parkinson disease affects around 1 million Americans but historically has had low visibility in the Black community, with rare exceptions such as the late boxer Muhammad Ali, who lived with it for 34 years before his death.

Although some studies have suggested that Parkinson disease occurs less often in Black patients than in White patients, a 2020 review found mixed evidence that incidence and prevalence differ significantly by race and pointed to disparities in accessing health care at similar degrees of symptomatology as possible explanations for discordant study findings. A study of 74 patients with newly diagnosed Parkinson disease at a Veterans Affairs medical center concluded that Black patients were less likely than White patients to self-report disability, possibly leading to delays in diagnosis.

According to a 2020 article in American Family Physician, Parkinson disease most commonly presents with “a unilateral resting tremor, often localized to the distal muscles of the hand, causing a pill-rolling motion.” Other key features include cogwheel rigidity and bradykinesia, such as shuffling steps and a freezing gait. Nonmotor symptoms “include rapid eye movement sleep disorder, depression, constipation, fatigue, and olfactory dysfunction” and may precede motor symptoms in many cases. Postural instability and falls occur later in the course of illness. In cases of diagnostic uncertainty, a dopamine transport single-photon emission computed tomography scan (DaTscan) may be used to distinguish Parkinson disease from atypical essential tremor and drug-induced Parkinson-like syndromes.

Recommended therapies for motor symptoms (summarized in a Table and treatment algorithm) include carbidopa/levodopa for significant symptoms, monoamine oxidase-B inhibitors or non-ergot dopamine agonists for milder symptoms, and anticholinergic agents and amantadine for patients younger than 65 years with tremors only. Another Table summarizes pharmacologic management of common nonmotor symptoms. Unfortunately, no therapies have been shown to slow disease progression. On average, patients with Parkinson disease progress from impairment to loss of independence between three and seven years after diagnosis. In patients with Parkinson disease, 40% develop dementia, 20% to 40% develop psychosis, and some eventually have swallowing impairments, aspiration pneumonia, and weight loss due to loss of appetite and difficulty eating.

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This post first appeared on the AFP Community Blog.

To break the UK's National Health Service, roll out prostate cancer screening

The United Kingdom's National Health Service (NHS) is celebrating its 75th anniversary this month. Long hailed as a model health system that provided universal coverage and high-quality care without overly taxing the national budget, the NHS has fallen on hard times. It faces challenges of underfunding, an aging and unhealthy population, an inadequate and increasingly exhausted workforce, and a projected shortage of hospital beds. The headline of a New England Journal of Medicine article asked if the NHS was "at breaking point or already broken?" The widely reported failures of the system to meet patients' basic needs since December 2022 - a time when it should have been recovering from the stresses of the pandemic - has caused public confidence to plummet:

The unspoken agreement between the NHS and U.K. residents was that despite some rationing of care, regional differences in service availability, and the often aging and less-than-sparkling premises, in the event of a medical emergency, an ambulance would arrive promptly and high-quality care would be available at a hospital without anyone requiring an insurance card. That agreement has been broken, and satisfaction with the service is at record lows.

It likely provides little consolation to our neighbors across the pond that the U.S. is in an even sorrier state despite spending twice as much of our gross domestic product per capita on health care services. But the U.K. seems determined to add insult to injury. Despite the resoundingly negative result of the country's only major randomized trial of PSA-based screening, the NHS seems poised to roll out a population-based prostate cancer screening program. (Currently, U.K. men over age 50 can request to have PSA testing, but doctors are not encouraged or incentivized to provide the test routinely to their eligible patients.) They need only look to the U.S. to see that this decision would be a public health disaster that would produce millions of new (mostly overdiagnosed) cancer patients and divert resources away from other primary care preventive care services with a much better likelihood of improving health.

As Dr. Andrew Vickers and colleagues wrote in a recent BMJ article, the prevailing approach to PSA screening in the U.S. and other high-income countries of "informed choice" or "individual shared decision making" drives high rates of testing in older patients who are least likely to benefit and most likely to be harmed, leading to overdiagnosis and inequities:

Approaches to PSA testing that rely on people making an informed choice are likely to reflect and reproduce health inequities in preventive healthcare. Data from Canada, the US, and Switzerland suggest PSA testing is inversely associated with income and education; in Canada and the US, PSA testing is less common in people from ethnic minorities. In the UK and Switzerland, rates of PSA testing are lower in economically deprived areas. Although the effects of disparate rates of PSA testing on health outcomes are still unclear, countries should decide who gets offered screening based on a risk assessment rather than leaving it to individuals.

Vickers and colleagues went on to advise that countries either set up government-sponsored, comprehensive, risk-based programs for prostate cancer detection or, alternatively, make a "clear recommendation against PSA-based screening" - a situation that existed in the United States between 2012 and 2018 when the U.S. Preventive Services Task Force gave this service a "D" (don't do) recommendation grade. The former would presumably maximize benefits by only testing persons at the highest risk of dying from prostate cancer, while the latter would minimize harms by declining to prematurely diagnose prostate cancer in well men. Since 2018, the U.S., and now potentially the U.K., have made the worst choice of all.