Parkinsons disease

June 2006

changing clinical practice

NICE guidelines are based on the best available evidence
the Department of Health asks NHS organisations to work towards implementing guidelines compliance will be monitored by the Healthcare Commission

Parkinsons disease

Parkinsons disease (PD) is a progressive neurodegenerative condition diagnosis is primarily clinical, based on history and examination

symptoms
classically include slow movements (bradykinesia) rigid or stiff muscles tremor

other symptoms can include psychiatric problems autonomic disturbances and pain progression to significant disability and handicap

need for this guideline

PD is a common, chronic, progressive neurological condition
significant impact on patients and carers prompt, accurate clinical diagnosis is important

incidence and prevalence

PD is estimated to affect 100180 in 100,000 people
annual incidence of 420 per 100,000

rising prevalence with age

higher prevalence and incidence of PD in males depression affects around 40% of PD patients

key priorities referral, diagnosis and review

people with suspected PD should be referred quickly and untreated to a specialist diagnosis of PD should be reviewed regularly and reconsidered if atypical clinical features develop

acute levodopa and apomorphine challenge tests should not be used in differential diagnosis

suggested actions
review and update services care pathways and collaboration between sectors local commissioning arrangements and service capacity current practices around referrals and need to refer untreated review provision of service capacity around followup appointments review current protocols around diagnostics, medication protocols, shared care protocols and formularies to ensure they are in line with guideline

diagnostic techniques
SPECT should be considered for people with tremor and should be available to specialists with expertise
PET should not be used in differential diagnosis of PD syndromes except in context of clinical trials MRI should not be used in differential diagnosis of PD but may be considered for differential diagnosis of PD syndromes

diagnostic techniques
Magnetic resonance volumetry should not be used in the differential diagnosis of PD syndromes except in context of clinical trials Magnetic resonance spectroscopy should not be used in the differential diagnosis of parkinsonian syndromes
Objective smell testing should not be used in the differential diagnosis of parkinsonian syndromes except in context of clinical trials

key priorities - provide access to services

PD patients should have regular access to monitoring and alteration of medication a continuing point of contact a reliable source of information which may all be provided by a PD Nurse Specialist physiotherapy, speech and language therapy, and occupational therapy should be available

suggested actions
make sure there are enough trained staff to provide specialist nursing care and to prescribe and monitor patients medications make sure there are enough physiotherapists occupational therapists speech and language therapists review skill mix of physiotherapists, speech and language therapists, and occupational therapists

key priorities - palliative care

palliative care should be considered during all phases

people with PD and carers should be given opportunity to discuss end-of-life issues with appropriate healthcare professionals

suggested actions

review service capacity and provide training to ensure that palliative care needs are considered review patient information and make sure it is useful

pharmacological therapy
no universal first choice drug therapy choice of adjuvant drug should take into account clinical and lifestyle characteristics patient preference

early disease
Initial therapy for early PD Firstchoice option Symptom control Risk of side effects Motor complications Lack of evidence Lack of evidence Lack of evidence
Other adverse events

Levodopa Dopamine agonists

+++ ++ + Lack of evidence Lack of evidence Lack of evidence

Lack of evidence Lack of evidence Lack of evidence

MAOB inhibitors Anticholinergics Beta-blockers Amantadine

pharmacological therapy
most people with PD will develop motor complications
eventually will require Levodopa therapy prescribed adjuvant drugs alongside Levodopa to reduce motor complications and improve quality of life

late disease
Adjuvant therapy for late PD
Dopamine agonists COMT inhibitors MAOB inhibitors

Firstchoice option

Symptom control

Risk of side effects

Motor complications Other adverse events

++ ++ ++

Amantadine
Apomorphine

NS
+

drug administration considerations

antiparkinsonian medication should not be withdrawn abruptly or allowed to fail suddenly
practice of withdrawing patients to reduce motor complications should not be undertaken medication should be given at appropriate times and adjusted after discussion with a specialist clinicians should be aware of dopamine dysregulation syndrome and management difficulties

non-motor features of PD
can include
mental health problems depression psychotic symptoms dementia sleep disturbance falls autonomic disturbance

costs and savings

recommendations considered to have greatest impact on resources
savings reduced admissions and outpatient attendances costs referrals to rehabilitative therapy services and regular specialist nursing care

access tools online

costing tools
costing report costing template implementation advice

available from: www.nice.org.uk/CG035

access the guideline online

quick reference guide a summary www.nice.org.uk/CG035quickrefguide
NICE guideline all of the recommendations www.nice.org.uk/CG035niceguideline full guideline all of the evidence and rationale www.nice.org.uk/CG035fullguideline information for patients and carers a plain English version www.nice.org.uk/CG035publicinfo