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Parkinson's disease - Management
How do I manage dementia in people with Parkinson's disease?

  • Treat any condition that may be causing or exacerbating cognitive impairment, such as depression or acute infection.
  • Consider safely reducing or discontinuing (on specialist advice if necessary) any drugs that may be causing or exacerbating cognitive impairment, including:
    • Drugs with an antimuscarinic action, including tricyclic antidepressants, tolterodine, and oxybutynin.
    • H2-receptor antagonists such as ranitidine.
    • Benzodiazepines.
    • Amantadine.
    • Dopamine agonists.
  • Refer for specialist assessment for:
    • Optimization of anti-parkinsonian drug regimen, and/or
    • Use of a cholinesterase inhibitor. Currently, only rivastigmine is licensed for use in people with Parkinson's disease dementia in the UK.
Clarification / Additional information
Basis for recommendation

These recommendations are based on: two National Institute for Health and Clinical Excellence publications, Parkinson's disease: national clinical guideline for diagnosis and management in primary and secondary care [National Collaborating Centre for Chronic Conditions, 2006] and Guideline on supporting people with dementia and their carers in health and social care [National Collaborating Centre for Mental Health, 2007]; and an evidence-based review, Report of a joint task force of the European Federation of Neurological Societies (EFNS) and the Movement Disorder Society-European Section (MDS-ES) on late (complicated) Parkinson's disease [Horstink et al, 2006]. In particular:

  • A Cochrane systematic review identified one randomized, double-blind, placebo-controlled trial (n = 541) that compared rivastigmine with placebo in Parkinson's disease dementia. Rivastigmine was associated with statistically significant, though modest, improvements in cognition and function, but it was poorly tolerated due to nausea, tremor, and vomiting [Maidment et al, 2006].
  • NICE identified seven studies, including just two randomized controlled trials (one each of rivastigmine and donepezil), of cholinesterase inhibitors for Parkinson's disease dementia, concluding that they are effective in treating cognitive decline and psychosis, but that not all people respond [National Collaborating Centre for Chronic Conditions, 2006].
  • Optimization of dopaminergic drugs is recommended in an evidence-based review [Leroi et al, 2006] on the basis of a study which randomized 82 people newly-diagnosed with Parkinson's disease to levodopa, bromocriptine (a dopamine agonist), or antimuscarinic drugs. The review reported the study finding that the dopaminergic drugs (levodopa and bromocriptine) improved memory and cognition, whereas antimuscarinic medication worsened registration.

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