Parkinson’s disease

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Parkinsons disease
June 2006
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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

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

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need for this guideline

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

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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

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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

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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
  follow-
• up appointments
• review current protocols around diagnostics,
• medication protocols, shared care protocols and
  formularies
• to ensure they are in line with guideline

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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

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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

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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

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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

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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

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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

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pharmacological therapy

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

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early disease
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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

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late disease
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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

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non-motor features of PD

• can include
• mental health problems
• depression
• psychotic symptoms
• dementia
• sleep disturbance
• falls
• autonomic disturbance

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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

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access tools online

• costing tools
• costing report
• costing template
• implementation advice
• available from www.nice.org.uk/CG035

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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