Transcript Presenter slides

Parkinson’s disease
June 2006
changing clinical practice
NICE guidelines are based on the best available
evidence
the Department of Health asks NHS organisations to
work towards implementing guidelines
compliance will be monitored by the Healthcare
Commission
Parkinson’s disease
Parkinson’s disease (PD) is a progressive
neurodegenerative condition
diagnosis is primarily clinical, based on history and
examination
symptoms
classically include
• slow movements (bradykinesia)
• rigid or stiff muscles
• tremor
other symptoms can include
• psychiatric problems
• autonomic disturbances and pain
• progression to significant disability and handicap
need for this guideline
PD is a common, chronic, progressive neurological
condition
significant impact on patients and carers
prompt, accurate clinical diagnosis is important
incidence and prevalence
PD is estimated to affect 100–180 in 100,000 people
annual incidence of 4–20 per 100,000
rising prevalence with age
higher prevalence and incidence of PD in males
depression affects around 40% of PD patients
key priorities referral, diagnosis and review
people with suspected PD should be referred quickly
and untreated to a specialist
diagnosis of PD should be reviewed regularly and
reconsidered if atypical clinical features develop
acute levodopa and apomorphine challenge tests should
not be used in differential diagnosis
suggested actions
review and update services
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•
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care pathways and collaboration between sectors
local commissioning arrangements and service
capacity
current practices around referrals and need to refer
untreated
review provision of service capacity around followup appointments
review current protocols around diagnostics,
medication protocols, shared care protocols and formularies
to ensure they are in line with guideline
diagnostic techniques
SPECT should be considered for people with tremor and
should be available to specialists with expertise
PET should not be used in differential diagnosis of PD
syndromes except in context of clinical trials
MRI should not be used in differential diagnosis of PD
but may be considered for differential diagnosis of PD
syndromes
diagnostic techniques
Magnetic resonance volumetry should not be used in the
differential diagnosis of PD syndromes except in context
of clinical trials
Magnetic resonance spectroscopy should not be used in
the differential diagnosis of parkinsonian syndromes
Objective smell testing should not be used in the
differential diagnosis of parkinsonian syndromes except
in context of clinical trials
key priorities - provide access
to services
PD patients should have regular access to
• monitoring and alteration of medication
• a continuing point of contact
• a reliable source of information
which may all be provided by a PD Nurse Specialist
physiotherapy, speech and language therapy, and
occupational therapy should be available
suggested actions
make sure there are enough trained staff to provide
specialist nursing care and to prescribe and monitor
patients medications
make sure there are enough
• physiotherapists
• occupational therapists
• speech and language therapists
review skill mix of physiotherapists, speech and
language therapists, and occupational therapists
key priorities - palliative care
palliative care should be considered during all phases
people with PD and carers should be given opportunity
to discuss end-of-life issues with appropriate healthcare
professionals
suggested actions
review service capacity and provide training to ensure
that palliative care needs are considered
review patient information and make sure it is useful
pharmacological therapy
no universal first choice drug therapy
choice of adjuvant drug should take into account
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clinical and lifestyle characteristics
patient preference
early disease
Initial therapy
for early PD
Firstchoice
option
Symptom
control
Levodopa

Dopamine
agonists

MAOB inhibitors 
Risk of side effects
Motor
complications
Other
adverse
events
+++


++
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+
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
Anticholinergics

Lack of
evidence
Lack of
evidence
Lack of
evidence
Beta-blockers

Lack of
evidence
Lack of
evidence
Lack of
evidence
Amantadine

Lack of
evidence
Lack of
evidence
Lack of
evidence
pharmacological therapy
most people with PD will develop motor complications
eventually will require Levodopa therapy
prescribed adjuvant drugs alongside Levodopa to
reduce motor complications and improve quality of life
late disease
Adjuvant
therapy for
late PD
Firstchoice
option
Symptom
control
Dopamine
agonists

COMT
inhibitors
Risk of side effects
Motor
complications
Other
adverse
events
++



++


MAOB
inhibitors

++


Amantadine

NS


Apomorphine

+


drug administration
considerations
antiparkinsonian medication should not be withdrawn
abruptly or allowed to fail suddenly
practice of withdrawing patients to reduce motor
complications should not be undertaken
medication should be given at appropriate times and
adjusted after discussion with a specialist
clinicians should be aware of dopamine dysregulation
syndrome and management difficulties
non-motor features of PD
can include
• mental health problems
• depression
• psychotic symptoms
• dementia
• sleep disturbance
• falls
• autonomic disturbance
costs and savings
recommendations considered to have greatest impact
on resources
• savings
– reduced admissions and outpatient
attendances
• costs
– referrals to rehabilitative therapy services
and regular specialist nursing care
access tools online
costing tools
• costing report
• costing template
implementation advice
available from: www.nice.org.uk/CG035
access the guideline online
quick reference guide – a summary
www.nice.org.uk/CG035quickrefguide
NICE guideline – all of the recommendations
www.nice.org.uk/CG035niceguideline
full guideline – all of the evidence and rationale
www.nice.org.uk/CG035fullguideline
information for patients and carers – a plain English
version www.nice.org.uk/CG035publicinfo