Long term medical management of patients with Parkinson’s disease falls between Neurologists, Physicians, Care of the Elderly Physicians, and General Practitioners. The following gives an indication of how care might be managed and is in keeping with NICE at each stage (Diagnostic, Maintenance, Complicated).
Patients with suspected Parkinson's disease should be referred to a specialist with expertise in the condition. This is likely to be a Neurology or Care of the Elderly physician, and the aim is to see them within six weeks of referral. Here the diagnosis will be confirmed and discussed with the patient, any investigations arranged, and initial management discussed. Diagnosis is usually made clinically, but occasionally blood tests and imaging are required. They will be offered referral to the Parkinson's disease specialist nurse. They will be given information about the illness and the contact details for the Parkinson's disease society. If appropriate, patients will be referred to physiotherapy, occupational therapy, neuropsychology and speech and language therapy.
NICE suggests regular expert review of diagnosis, at six monthly intervals. During the maintenance stage symptom control is usually managed by a gradual increase in the first line medication, or by starting medication if the patient has previously chosen not to take any. 10% of patients develop complications each year after diagnosis. This review will aim to identify complications and take appropriate action. If appropriate, patients will be referred to physiotherapy, occupational therapy, neuropsychology and speech and language therapy.
The following complications are common. It is not essential to await secondary care review to consider and begin management of complications.
a) Failure of therapy
Therapy fails for many reasons. The patient may not be compliant, because they have difficulty taking medication or because they don't want to. The patient may not respond well to the specific therapy. The diagnosis may be incorrect ( lack of response to dopaminergic therapy is more common in atypical parkinsonian syndromes). If the patient is compliant then a change in medication may be appropriate.
Dyskinesia, involuntary movement, can occur at any time from diagnosis. It may be exacerbated by medication and by other illness (eg thyrotoxicosis). Management relies on adjusting medication to help the patient attain their optimum balance between mobility and dyskinesia. Frequently patients prefer to tolerate dyskinesia than to risk immobility. Strategies to improve dyskinesia include changes in timing, dose and type of medication. Occasionally neurosurgery is offered to help control severe dyskinesia.
Dementia can occur, in the longer term, in up to 70% of patients. Cognitive decline however is not inevitably due to Parkinson's disease and other causes (eg drug therapy, B12 deficiency, depression, and hypothyroidism) must be considered. A cognitive assessment either formally through neuropsychology or informally using a bedside assessment (eg 100 point score -see useful links page) is helpful. Acetylcholinesterase inhibitors such as galantamine can help.
There are a great many causes of falls in the PD patient. These include postural hypotension, episodes of akinesia, and impairment of postural reflexes. Sometimes it is a consequence of the combination of the illness and obstacles in the home. A useful start in investigation is to check Erect & Supine blood pressure.
e) Swallowing/Speech problems
In the early stages of the illness it is unusual for patients to suffer significant swallowing difficulties though reduced speech volume is common. In later illness swallowing difficulties can lead to malnutrition. Consider direct referral to Speech and Language Therapy. On occasion patients can benefit from gastrostomy feeding. This is requested and arranged through the GRH neurology service and PD nurse.
Depression is a very common component of the illness. The best treatment approach is not known, but almost certainly lies in maximising physical function and psychological care. SSRI's are often used. Selegiline has mild antidepressant properties but the combination of selegiline and tricyclic antidepressants is contraindicated (causing serotonin syndrome).
g) Postural hypotension
This is a component of the illness but is often exacerbated by medication. The following treatments are sometimes used:
1. Fludrocortisone 1mg daily. 2. TED stockings 3. Blocking head of bed
Confusion and hallucination are common in PD and do not necessarily indicate dementia. Like cognitive impairment it is important to consider other causes, for example urinary tract infection, constipation and medication. Sometimes hallucination is a side effect of dopaminergic medication, and some patients would rather live with hallucination (which are often relatively benign) than suffer immobility. The newer atypical antipsychotics (eg olanzapine, risperidone, clozapine) may have a place but can still exacerbate parkinsonism.
i) Sleep disturbance/Hypersomnolence
Both are common effects of Parkinson's disease and the medication used to treat it. Consider sleep quality and hygiene as well as medication effects.
Providing medical assessment confirms that driving performance is not impaired, the patient can be licensed. A short period licence may be required. Should the driver require a restriction to certain controls, the law requires this to be specified on the licence.
PDUK tel: 0207 9318080. Website: http://www.parkinsons.org.uk/
There are now four Parkinson's specialist nurses serving the needs of Gloucestershire's PD patients. One (Claire Pollock) is based full time within Cheltenham General and Gloucestershire Royal Hospitals, whilst three are community based. The direct phone line for the community service is 08456 598 109.