• 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.
• 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.

In depth

• At the time of diagnosis, all people with Parkinson's disease who drive should be advised to inform the Driver and Vehicle Licensing Agency (DVLA) and their car insurer of their condition.
• Sudden onset of sleep without awareness or warning signs has been reported rarely during treatment with levodopa or dopamine agonists (including apomorphine).
• People taking these drugs should be informed of this and advised not to drive, and also to consider any other occupational hazards if sudden onset of sleep occurs.
• However, in relation to people with Parkinson's disease, the Driver and Vehicle Licensing Agency (DVLA) states that:
• For Group 1 entitlement (to drive cars and motorcycles), 'Providing medical assessment confirms that driving performance is not impaired, can be licensed. A 1-, 2-, or 3-year licence may be required. Should the driver require a restriction to certain controls, the law requires this to be specified on the licence'.
• For Group 2 entitlement (to drive large lorries and buses), 'Licence refused or revoked if condition is progressive or disabling. If driving would not be impaired and condition stable, can be considered for licensing subject to satisfactory reports and annual review (individual basis)'.
• The latest information from the DVLA regarding medical fitness to drive can be obtained at www.dvla.gov.uk/medical/ataglance.

In depth

• Look for and treat any acute illness (such as an infection or constipation) that could be exacerbating motor symptoms.
• Check adherence with anti-parkinsonian medication, including the correct doses and timings.
• If symptoms or complications persist, contact the person's Parkinson's disease specialist team for advice (on changes to treatment), or make an interim referral.

In depth

• Consider a stepped approach to the management of constipation due to colonic dysmotility in Parkinson's disease:
• Increase dietary fibre and fluid intake (advise at least eight glasses of water per day).
• Increase exercise.
• Use fibre supplements (such as ispaghula husk).
• Use a stool softener (such as docusate).
• Use an osmotic laxative, such as lactulose or macrogols (Movicol^® or Laxido^®).
• Enemas may occasionally be required.
• See the CKS topic on Constipation.

In depth

• Advise people who have sudden onset of sleep without awareness or warning signs not to drive and to consider any occupational hazards.
• Initial management of daytime hypersomnolence depends on its likely cause:
• Anti-parkinsonian medication (such as dopamine agonists):
• Seek specialist advice.
• Sedating medication (such as antihistamines, antipsychotics, and some antidepressants):
• Reduce, stop, or use an alternative medication; seek specialist advice if necessary.
• Inadequate rest at night:
• See Sleep disturbance.
• Dementia.
• Consider requesting advice from, or an interim referral to, the person's Parkinson's disease specialist team, so that:
• Medication that could be causing or contributing to daytime hypersomnolence can be reduced or stopped.
• Modafinil can be considered for daytime hypersomnolence (off-licence use). However:
• Modafinil is contraindicated in people with uncontrolled moderate to severe hypertension, and in people with arrhythmias.
• Modafinil is associated with skin and subcutaneous tissue reactions, and with the development of neuropsychiatric disorders.

In depth

• 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.

In depth

• Consider referral to a speech and language therapist for:
• Full assessment of swallowing ability.
• Advice, and a trial of behavioural management techniques to encourage regular saliva swallows.
• Use of a portable metronomic brooch as a reminder for saliva swallows.
• Lip-seal and swallow exercises.
• Consider referral to the person's Parkinson's disease specialist team.

In depth

• Severe sweating may occur as an end-of-dose 'off' phenomenon. It may also occur during the 'on' motor state, when it is usually associated with dyskinesia.
• Exclude other causes of excessive sweating. See the section on Initial assessment in the CKS topic on Hyperhidrosis.
• Consider referral to the person's Parkinson's disease specialist team for a review of medication — sweating may respond to adjustments in anti-parkinsonian treatment.

In depth

• If falls occur soon after the onset of parkinsonism, suspect an alternative diagnosis, such as progressive supranuclear palsy.
• Refer to the person's Parkinson's disease specialist for review of the diagnosis.
• Assess and treat Postural (orthostatic) hypotension.
• Consider referral for multifactorial and multidisciplinary assessment and interventions to prevent falls.
• This is likely to be delivered by a specialist falls service and, ideally, will include a professional with understanding of Parkinson's disease.
• For more information, see the CKS topic on Falls - risk assessment.

In depth

• Refer promptly to a speech and language therapist for:
• Assessment and swallowing advice.
• Further investigations such as videofluoroscopy or fibre-optic endoscopic examination of swallow safety (particularly if silent aspiration is suspected).
• Liaison with the person's Parkinson's disease specialist team is also recommended as symptoms may respond to alterations to anti-parkinsonian medication.

In depth

• If an impulse control disorder (such as hypersexuality, pathological gambling, or compulsive buying) or dopamine dysregulation syndrome is suspected, contact the person's Parkinson's disease specialist team.
• Explanation may be beneficial, and non-pharmaceutical measures, such as restriction of spending and internet access (for example to gambling sites), could be advised.

In depth

For nausea or vomiting after starting or increasing the dose of a dopaminergic drug

• Initially, if nausea is mild:
• Reassure that nausea often settles over time as tolerance occurs.
• Advise the person to take their medication with food.
• If nausea persists or is more severe:
• Prescribe domperidone, reducing or stopping it when the nausea or vomiting settles.
• Do not use metoclopramide or prochlorperazine.
• Consider seeking the advice of a specialist, who may recommend one or more of the following:
• An increase in the proportion of decarboxylase inhibitor to levodopa (only feasible for co-careldopa).
• A slower titration of the anti-parkinsonian drug.
• A switch to an alternative.

For nausea or vomiting unrelated to medication

• If an anti-emetic is required, use domperidone, reducing or stopping it when the nausea settles. Avoid metoclopramide or prochlorperazine.

In depth

• Liaise with, or refer to, the person's Parkinson's disease specialist team for the following types of pain, as they may require an alteration to anti-parkinsonian medication:
• Dystonic pain.
• Primary or central neuropathic pain.
• Akathisia-related pain.
• The following types of pain can initially be managed in primary care, but liaise with, or refer to, the person's Parkinson's disease specialist team if pain cannot be controlled with these measures:
• Musculoskeletal pain:
• Treat with simple analgesics and regular exercise; consider physiotherapy.
• If appropriate, see the CKS topics on Shoulder pain and Back pain - low (without radiculopathy).
• Radicular neuropathic pain:
• Treat with simple analgesics, drugs specifically for neuropathic pain such as gabapentin, and gentle exercise.
• If appropriate, see the CKS topics on Neck pain - cervical radiculopathy, Neuropathic pain - drug treatment and Sciatica (lumbar radiculopathy).

In depth

• Consider a stepped approach to the management of postural (orthostatic) hypotension in Parkinson's disease:
• Stop or reduce the dose of antihypertensive medications.
• Reduce or change anti-parkinsonian drugs after discussion with specialist services.
• Advise the person to increase their dietary salt and fluid intake, to avoid caffeine at night, to eat frequent, small meals, and to avoid alcohol.
• Advise the person to elevate the head of their bed by 30–40 degrees.
• Consider prescribing compression stockings after excluding arterial insufficiency (see the CKS topic on Compression stockings).
• Consider referring people with persistent or troublesome symptoms to a unit with expertise in falls and syncope.
• A salt-retaining steroid (such as fludrocortisone) may be recommended.
• Occasionally, midodrine (a direct-acting sympathomimetic) may be prescribed, but this is only available on a named-patient basis.

In depth

• Have a low threshold for suspecting psychotic symptoms in people with Parkinson's disease.
• Consider excluding causes besides Parkinson's disease itself, anti-parkinsonian drugs, and dementia, including:
• Delirium caused by other physical illness or drug treatments.
• Other comorbid mental illness, such as depression.
• Liaise with, and promptly refer to, specialist services all people with Parkinson's disease who develop psychotic symptoms:
• Mild psychotic symptoms may not need to be actively treated if they are well tolerated by the person and carer.
• More severe psychotic symptoms may require gradual withdrawal of precipitating anti-parkinsonian medication or the use of an atypical antipsychotic (such as clozapine, under the care of a mental health specialist).

In depth

• If hypersexuality is reported:
• Suspect that it may be caused by dopaminergic therapy (even when there is erectile dysfunction) and contact the person's Parkinson's disease specialist team.
• If erectile dysfunction or anorgasmia is reported:
• Exclude comorbid endocrine abnormalities (such as hypothyroidism or hyperprolactinaemia).
• Consider the possibility of underlying depression.
• Consider discontinuing drugs associated with erectile dysfunction (such as alpha-blockers) or anorgasmia (such as selective serotonin reuptake inhibitors [SSRIs]).
• Consider prescribing a phosphodiesterase type-5 inhibitor for erectile dysfunction (sildenafil, tadalafil, or vardenafil), which are available on the NHS for men with Parkinson's disease. The prescription must be endorsed 'SLS' by the prescriber.
• Avoid these drugs in people with hypotension (systolic blood pressure less than 90 mmHg), and use with caution in people with postural (orthostatic) hypotension.
• For more information, see the CKS topic on Erectile dysfunction.
• Consider referral to a urological specialist or specialist services for erectile dysfunction.

In depth

• Take a full sleep history and advise good sleep hygiene.
• Identify whether any of the following may be present and manage them appropriately, usually by requesting an interim referral or advice from the person's Parkinson's disease specialist team:
• Conditions related to Parkinson's disease:
• Restless legs syndrome.
• Periodic leg movements of sleep.
• Rapid eye movement (REM) sleep behaviour disorder.
• Nocturnal akinesia (inability to turn over in bed).
• Nocturia (see Urinary dysfunction).
• Conditions that may be caused by anti-parkinsonian medication (such as selegiline and dopamine agonists):
• Vivid dreams or nightmares.
• Hallucinations.
• See the CKS topic on Insomnia.

In depth

• If the person presents with an abrupt change in voiding pattern, exclude urinary tract infection.
• If frequency or polyuria are present, consider testing for diabetes.
• Consider discussing the use of an antimuscarinic drug (such oxybutynin or tolterodine) with the person's Parkinson's disease specialist team:
• Such treatment can induce a toxic confusional state and may worsen symptoms of dementia.
• Drugs that do not cross the blood–brain barrier (such as trospium chloride) may be less likely to induce confusion.
• Consider referral to a urological specialist if there are refractory or persistent bladder problems.

In depth

• Although unintended weight loss occurs in over 50% of people with Parkinson's disease, other medical causes for weight loss (such as malignancy and endocrine diseases) should also be considered.
• If other medical causes of weight loss can be safely excluded, consider:
• Liaising with the person's Parkinson's disease specialist team to arrange:
• Investigations of swallowing — see Impaired swallowing (dysphagia).
• Review of anti-parkinsonian medications, as weight loss appears to correlate with severity of dyskinesia.
• Referring to a dietitian, and the provision of dietary supplements on the advice of the dietitian.

In depth

In general terms, depression in people with Parkinson's disease should be diagnosed and treated in the same way as for people without Parkinson's disease — see the CKS topic on Depression.

• However, there are specific considerations in relation to diagnosis and assessment, and the choice of drug treatment in people with Parkinson's disease.

• Have a low threshold for diagnosing depression in people with Parkinson's disease.
• Consider using a depression rating scale to screen for and assess the severity of depression.

In depth

• In addition to individual preference, the choice of antidepressant medication should depend on evidence of efficacy, the likely impact of potential adverse effects, and the person's current medication:
• Selective serotonin reuptake inhibitors (SSRIs) are most commonly used.
• SSRIs can worsen motor symptoms, but this occurs rarely.
• SSRIs should not be used by people taking selegiline or rasagiline.
• Use SSRIs with caution in people taking entacapone or tolcapone.
• Tricyclic antidepressants may be more effective than SSRIs in people with Parkinson's disease but their use is limited by the risk of adverse effects. They should only be used with caution.
• Avoid tricyclic antidepressants in people with postural (orthostatic) hypotension, falls, or dementia.
• Tricyclic antidepressants should not be used without specialist advice by people taking selegiline or rasagiline.
• Use tricyclic antidepressants with caution in people taking entacapone or tolcapone.
• People taking selegiline or rasagiline may cautiously use trazodone or mirtazapine (off-label use for selegiline).
• There are no known contraindications to the use of any type of antidepressant in people taking amantadine, apomorphine, or oral dopamine agonists.
• Other antidepressants:
• Irreversible monamine oxidase-A inhibitors (phenelzine, isocarboxazid, tranylcypromine) should not be used with levodopa, selegiline, rasagiline, entacapone, or tolcapone.
• Moclobemide should not be used with selegiline or rasagiline, and should be used with caution in people taking entacapone, tolcapone, and levodopa.
• Venlafaxine and duloxetine should not be used by people taking selegiline or rasagiline, and used with caution in those taking entacapone, or tolcapone (risk of serotonin syndrome).
• Consider contacting the person's Parkinson's disease specialist to ensure that their anti-parkinsonian medication regimen is optimal.
• Seek specialist advice if:
• There is doubt about whether an antidepressant can be safely prescribed.
• There is suspicion that the antidepressant prescribed may be affecting motor control or causing adverse effects.

In depth

• Psychological treatments, such as cognitive-behavioural therapy, may be considered for depression in people with Parkinson's disease.
• The use of psychological treatment should depend on the individual's preference and needs, and on other factors, such as cognitive impairment.
• See the section on Psychological interventions in the CKS topic on Depression for more detailed information.

In depth

• Ensure that any requested changes to repeat medication have been made since the last specialist visit, and check that doses and timings are correct.
• Check that any relevant drug monitoring has been undertaken if there is a local agreement for monitoring to take place in primary care.
• Ask about and monitor adherence to treatment and explore any barriers to taking medication.
• If the person is over-using dopaminergic medication, consider whether they may have dopamine dysregulation syndrome (compulsive overuse of dopaminergic drugs) — see Impulse control and related disorders.
• The National Institute for Health and Clinical Excellence has issued guidance on Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence that can be found at www.nice.org.uk.
• Ask about possible adverse effects of anti-parkinsonian medication.
• Ensure that no other medication is exacerbating the Parkinson's disease — see Drugs to avoid.
• Do not stop anti-parkinsonian medication abruptly because of the risk of causing neuroleptic malignant syndrome (which can be serious).
• Respond to any concerns about motor and non-motor symptoms of Parkinson's disease.
• Check that the person has appropriate access to support services — see Role of primary care.

In depth

Contact the person's Parkinson's disease specialist team if the following adverse effects of anti-parkinsonian medication occur, as alterations to the medication may be needed:

• Fibrotic reactions (such as cardiac valvulopathy and retroperitoneal fibrosis) related to ergot-derived dopamine agonists (bromocriptine, cabergoline, or pergolide).
• Nausea and vomiting related to anti-parkinsonian medication.
• Motor complications, including motor fluctuations and dyskinesias.
• Dystonic or akathisia-related pain.
• Neuropsychiatric symptoms, including:
• Cognitive impairment.
• Daytime hypersomnolence or excessive drowsiness.
• Impulse control and related disorders, such as hypersexuality, pathological gambling, or compulsive buying.
• Psychotic symptoms, confusion, and vivid dreaming.
• Sleep disturbance.
• Autonomic disturbances.
• Diarrhoea:
• May be caused by entacapone and tolcapone (catechol-O-methyltransferase inhibitors).
• Dose reduction or, if severe, discontinuation may be considered.
• Excessive saliva (sialorrhoea).
• Excessive sweating (hyperhidrosis).
• Hypotension and Postural (orthostatic) hypotension.
• Peripheral oedema:
• May occur with amantadine and dopamine agonists, but is not dose dependent.
• Diuretics or discontinuation of the offending medication may be considered.
• Weight loss.

The following adverse effects can initially be managed in primary care, but liaison with or referral to the person's Parkinson's disease specialist team may be needed if initial measures fail:

• Constipation.
• Nausea and vomiting unrelated to anti-parkinsonian medication.

In depth

• If possible, avoid the following drugs because they can worsen parkinsonism:
• The anti-emetics, metoclopramide and prochlorperazine.
• Anti-psychotics:
• On specialist advice only, clozapine may be used to treat psychosis in people with Parkinson's disease. Quetiapine appears to be well-tolerated with a good safety profile, but may not be effective for psychosis in people with Parkinson's disease.
• Some other drugs can also, less commonly, cause parkinsonism — see Differential diagnosis.
• If possible, also avoid the following drug combinations:
• Erythromycin and clarithromycin significantly increase the bioavailability of bromocriptine and cabergoline. Azithromycin would not be expected to interact.
• Ciprofloxacin significantly increases the bioavailability of ropinirole. Use an alternative antibiotic, or seek specialist advice about dose adjustment.
• Cough and cold preparations containing sympathomimetics (pseudoephedrine, ephedrine) should not be used with rasagiline or selegiline (risk of hypertension). Preparations containing dextromethorphan (a cough suppressant) should also not be used (risk of serotonin syndrome). People taking bromocriptine should also avoid sympathomimetics (increased risk of hypertension).
• Advise people to check with the pharmacist before purchasing over-the-counter cough and cold remedies.
• Pethidine should not be given with selegiline or rasagiline, or for 2 weeks after stopping these drugs.
• Some antidepressant drugs should not be used with some drugs for Parkinson's disease:
• People taking rasagiline or selegiline should not use selective serotonin reuptake inhibitors, venlafaxine, duloxetine, sor tricyclic antidepressants. Trazodone or mirtazapine may be cautiously used (off-label use for selegiline).
• See Drug treatment of depression for details.

In depth

• The palliative care requirements of people with Parkinson's disease should be considered throughout all phases of their disease.
• See the recommendations for the management of pain in people with Parkinson's disease.
• However, identification of the palliative phase may indicate that a more comprehensive range of palliative care services will be needed to control symptoms (including pain) and to meet the needs for personal, social, psychological, and spiritual support:
• People with Parkinson's disease are in the palliative phase when:
• They are unable to tolerate adequate dopaminergic therapy and they are unsuitable for surgery, or
• They have advanced comorbidity (such as severe dementia).
• Palliative care must address:
• Physical problems, including pain, breathlessness, anorexia, immobility, and constipation.
• When the person becomes immobile, high priority should be placed on assessing the risk for pressure ulcers, and managing any ulcers that do develop.
• When the benefits of dopaminergic drugs have been lost or adverse effects such as hallucinations become intolerable, it may be necessary to withdraw drugs; this should be done by (or on the advice of) a specialist, with the consent of the person and their carers.
• Social problems, including loss of employment, role change, and fear for dependants.
• Psychological problems, including depression, fear and anxiety, uncertainty, and guilt.
• Existential problems: religious, non-religious, the meaning of life, and 'why me?'.
• Stress on carers:
• Timely respite care can support carers and delay admission to a care home.
• End-of-life issues:
• People receiving palliative care should be supported so that they can live in, and die in, the place of their choice.

In depth