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Parkinson's disease - Management
What is the role of primary care in the management of people with confirmed Parkinson's disease?
- To be aware of local services for people with Parkinson's disease and to enable appropriate access to them. Services may include:
- A Parkinson's disease physician specialist.
- A Parkinson's disease nurse specialist (PDNS), if available.
- Speech and language therapy, physiotherapy, occupational therapy, social services, community nursing, continence and urology specialists, palliative care specialists, and psychology and mental health services.
- The Parkinson's Disease Society local branch, regional support, and free UK helpline (0808 800 0303).
- To liaise with the person's Parkinson's disease physician specialist and PDNS (if available), particularly in relation to changes in medication.
- Only start or alter anti-parkinsonian medication on the advice of a specialist.
- Ensure that changes to repeat medication are made promptly.
- Titrate therapy between specialist review appointments according to recommendations from secondary care.
- Do not suddenly stop any anti-parkinsonian medication as this can precipitate acute akinesia or neuroleptic malignant syndrome.
- To identify worsening motor symptoms and motor complications (which may be caused by the disease itself or by anti-parkinsonian medication), and manage these appropriately.
- This will usually require the advice of a specialist or an interim referral.
- To identify and appropriately manage non-motor symptoms and complications, which may be caused by the disease itself or by anti-parkinsonian medication.
- Advice or referral to a specialist may be needed.
- To manage comorbidities: avoid or use with caution any drugs that could exacerbate parkinsonism or interact with anti-parkinsonian medication — see Drugs to avoid.
- To advise care staff in nursing or residential homes of the need for the correct timing of anti-parkinsonian medication.
- To offer a regular medication review, including adherence and adverse effects.
- To offer support to family and carers.
- To ensure that palliative care requirements are met throughout all phases of the disease, particularly at the end of life.
Basis for recommendation
The recommendations regarding the role of primary care in the ongoing management of people with confirmed Parkinson's disease are generally based on expert opinion.
Access to local services
- This recommendation is derived from the National Institute for Health and Clinical Excellence (NICE) guideline on Parkinson's disease and from a Scottish Patient Pathway for Parkinson's disease.
- NICE stresses the importance of access to allied healthcare services, in particular nurse specialists, occupational therapy, physiotherapy, and speech and language therapy [NICE, 2006].
- The Patient Pathway highlights the importance of awareness by primary care practitioners of all the services that could be used by people with Parkinson's disease and of appropriate referral to these services when necessary [Centre for Change and Innovation, 2005].
Liaison with specialists
- The importance of effective multidisciplinary team working is broadly expressed [Parkinson's Disease Society, 2003; Kale and Menken, 2004; Centre for Change and Innovation, 2005].
- The recommendation to only start or alter anti-parkinsonian medication on the advice of a specialist is pragmatic, on the basis that drug management becomes increasingly complex as the disease advances, and an average GP's list will have only 2–4 people with Parkinson's disease, making it difficult to acquire sufficient experience of the condition [Dodel et al, 1998; Playfer, 2000]. However, the Parkinson's Disease Society suggests that, if a GP has a special interest, a local shared-care protocol could be used [Parkinson's Disease Society, 2007].
- The recommendation to ensure that changes to repeat medication are made promptly is based on a retrospective survey (published as a research letter) which found that 29% of medication changes recommended at specialist outpatient clinic appointments were not completed [Ng et al, 2007]. The authors acknowledged that there may be abundant reasons for this level of non-completion.
- A Scottish Patient Pathway recommends that GPs should titrate therapy between specialist visits according to recommendations from secondary care [Centre for Change and Innovation, 2005].
- Suddenly stopping anti-parkinsonian medication can precipitate acute akinesia or neuroleptic malignant syndrome, which can be serious [NICE, 2006; Parkinson's Disease Society, 2007].
Management of worsening motor symptoms and motor complications
Management of non-motor symptoms
Management of comorbidities
- Whilst it is self-evident that comorbidities will be managed by primary care, this is specifically stated in an editorial, Who should look after people with Parkinson's disease? [Kale and Menken, 2004].
- The recommendation to take care to avoid using any drugs that could exacerbate parkinsonism or that interact with anti-parkinsonian medication is derived from a Parkinson's Disease Society publication, The professional's guide to Parkinson's disease [Parkinson's Disease Society, 2007].
Advising care home staff of the need for correct timing of anti-parkinsonian medication
Medication reviews
Supporting family and carers
Palliative care
- The recommendation to ensure that palliative care requirements are met throughout all phases of the disease, particularly at the end of life, is based on the NICE guideline [NICE, 2006].
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