Parkinson's disease management

Incorporating NICE Guidance CG35 Parkinson's disease: diagnosis and management in primary and secondary care (June 2006)

Parkinson's Disease (PD) should be diagnosed clinically and based on the UK Parkinson's Disease Society Brain Bank Criteria. Parkinson's Disease is classically determined by the triad or rest tremor (usually starting in one arm) with bradykinesia (slowing of movement) and rigidity (which may manifest as cogwheel rigidity particularly in the arms). Patients often display a generalised lack of movement both in terms of facial expression and general body movement. They often have reduced arm swing (usually asymmetrical at the beginning) with festinate gait. They may have impaired ability to correct their balance.

Treatment is symptomatic. There is currently no treatment that has definitely been proven to slow down the progression of the disease. However, there is on-going evidence that patients perform better if treatment is started earlier rather than later. There is generally no harm done in delaying treatment if the diagnosis is in doubt. A trial of medication does not confirm the diagnosis.

Current drug therapy aims simply to correct the chemical imbalance, it greatly improves the quality and expectancy of life of most patients. Although about 10-20% of patients are unresponsive to treatment.

It is important to eliminate the possibility of anti-dopaminergic drugs causing parkinsonian symptoms, for example prochlorperazine, metoclopramide, chlorpromazine, trifluoperazine, haloperidol and thioridazine. Less commonly, the newer atypical antipsychotics (e.g. risperidone)

If PD is suspected all patients regardless of age should be referred to a specialist untreated, for confirmation of the diagnosis. The diagnosis should be reviewed by the specialist at regular intervals (6-12 months) (NICE CG35 June 06)

Elderly: Antiparkinsonism drugs carry a special risk of inducing confusion in the elderly. It is particularly important to initiate treatment with low doses and to use small increments.

Treatment options

It is not possible to identify a universal first choice drug therapy for people with early PD or first choice drug for adjuvant therapy for people with later PD. The choice of drug should take into account clinical and lifestyle characteristics, and patient preference after the patient has been informed of the short and long term benefits and drawbacks of the drug classes. (NICE CG35 June 2006)

Options for initial pharmacotherapy in early PD

First choice options

Levodopa

  • Good degree of symptom control
  • Evidence of increased motor complications and other adverse events

Dopamine agonists

  • Moderate degree of symptom control
  • Evidence of reduced motor complications
  • Evidence of increased other adverse events

MAOB inhibitors

  • Limited degree of symptom control
  • Evidence of reduced motor complications
  • Evidence of increased other adverse events

Antimuscarinics, beta blockers and amantadine are not considered suitable as first choice treatment options

Options for adjuvant pharmacotherapy in later PD

First choice options

Dopamine agonists

  • Moderate degree of symptom control
  • Evidence of reduced motor complications
  • Evidence of increased other adverse events

COMT inhibitors

  • Limited degree of symptom control
  • Evidence of reduced motor complications
  • Evidence of increased other adverse events

MAOB inhibitors

  • Limited degree of symptom control
  • Evidence of reduced motor complications
  • Evidence of increased other adverse events

Amantadine and apomorphine are not considered suitable as first choice adjuvant treatment options

Anxiety

Benzodiazepines may be useful in the management of anxiety but large doses may affect skeletal muscle function and may worsen falls.

Depression

Depression is common in people with Parkinson's disease. No single class of antidepressant has been proven to be superior. Antidepressant therapies may exaggerate parkinsonian symptoms, as they can have extrapyramidal side effects. They are difficult to predict as they depend on dose, drug and individual susceptibility.

In general the selective serotonin re-uptake inhibitors (SSRI's) are better tolerated than the tricyclic antidepressants. Local specialist opinion is that there is some evidence that mirtazepine may be helpful if the patient has marked tremor, dyskinesia or sleeping problems.

Psychosis

Occurs in 20% of patients with Parkinson's disease and is usually due to medical treatments. Psychosis management requires careful step-wise adjustment of drug treatment and there is a trade-off between control of psychosis and reduced motor control. Atypical antipsychotic drugs at low dosage maybe used. Avoid the older conventional anti-psychotic drugs.

Severe dementia

Occurs in at least 10-30% of patients with advanced disease. Patients should be referred to a psychogeriatrician at a memory clinic for assessment.

Nausea

Many patients are poorly tolerant of levodopa and/or dopamine agonist medicines even when started in lower dosages and titrated slowly upwards. Do not use metoclopramide or prochlorperazine but consider domperidone.

Postural hypotension

May result from the disease and/or the treatment. If antiparkinsonism drugs cannot be reduced then fludrocortisone is a first line treatment.

 

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