NICE guidelines Parkinsons disease

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NICE guidelines Parkinsons disease

• Madeleine Purchas

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Aims of talk

• Introduction
• The guideline itself
• Future research /audit
• references

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Parkinsons disease

• James Parkinson 1817
• Essay on shaking palsy
• maladie de Parkinson, Charcot 1888
• Current definition

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Resource implications

• 6-11 people in 6000
• Rising with age, males
• 2 gtage 80
• Cost of 2300 per pt per annum (direct costs)
• Total Cost of 6000 (incl social service
  provision, costs to patient)
• 600m per yr for 100000 pts with PD

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Aim of guideline

• Best available evidence plus expert advice
• Patient choice / patient centred care
• Areas of uncertainty
• Areas for audit / research

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Scope of guideline

• Diagnosis of idiopathic PD and Parkinsonism
• Treatment of idiopathic PD

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Key priorities for implementation

• Referral for expert diagnosis
• Expert review and diagnosis
• Regular access to expert nursing care
• Access to physio, OT, SLT
• Palliative care

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Communication

• Difficulties in communication
• Dementia and depression
• Negative impression of people with PD
• Need for emotional support
• Aim to empower in participating. Written
  information. Points of contact. DVLA

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Diagnosis

• Classical symptoms slowness, shaking, stiffness
• Classical signs bradykinesia, hypokinesia,
  tremor, rigidity
• Post mortem diagnosis
• Incorrect diagnosis in 47, 25, 6-8

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Diagnosis (cont)

• Unilat vs bilat
• Additional signs postural instability,
  orthostatic hypotension, cognitive
• Response to Ldopa
• PET scanning
• DAT scanning
• UK PDS brain bank criteria

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UKPDS brain Bank criteria

• Step 1 Diagnosis of a parkinsonian syndrome
  bradykinesia
• Rest tremor/ Rigidity/ Postural instability
• Step 2 Exclusion criteria for PD
• Hx of strokes, HI, antipsychotic/DA depleting
  drugs, encephalitis, 1 relatives, neg response
  to Ldopa, unilat after 3 yrs, other neuro signs,
  tumour/hydroceph on imaging
• Step 3 supportive criteria for PD 3 of
• Unilat onset, rest tremor, progressive,
  persistent assymetry, excellent response to
  Ldopa, severe Ldopa induced chorea, Ldopa reponse
  over5 yrs, clinical coursegt10 yrs

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Diagnosis (cont)

• Rapid referral
• On no treatment
• Regular review of diagnosis
• SPECT/DAT scanning to exclude essential tremor
• MRI in the diagnosis of parkinsonian syndromes
• PET scanning in clinical trials only
• Acute levodopa / apomorphine challenges no
• Smell testing - ?

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Neuroprotection
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Neuroprotection

• 4 potential neuroprotectors reviewed
• Vit E should not be used
• Co enzyme Q10 only in the context of clinical
  trials
• Dopamine agonists as above
• MAOB inhibitors as above

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Pharmacological therapy in early PD

• Options for initial pharmacotherapy in early PD
• First choice
• Levodopa
• DA agonists
• MAOB inhibitors
• Other
• Anticholinergics
• B Blockers
• Amantadine

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Pharmacotherapy (cont)

• There is no single drug of choice
• Patient preference/clinical characteristics
• Monitoring of ergot derived DA agonists
• Amantadine/anticholinergics

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Pharmacotherapy in later PD

• There is no single drug of choice in later PD
• DA agonists
• COMT inhibitors
• MAOB inhibitors
• Amantadine (not first line)
• Apomorphine (not first line)

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Pharmacotherapy (further considerations)

• Avoid abrupt withdrawal
• In hospital
• Appropriate timing
• Self medication
• Liaison with PD specialist
• DA dysregulation syndrome

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Surgery

• Subthalamic stimulation
• Globus pallidus interna stimulation
• Thalamic stimulation

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Non motor features of PD

• Depression
• Psychotic symptoms
• Dementia
• Sleep disturbance
• Daytime hypersomnolence
• Nocturnal akinesia
• Falls

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Other key interventions

• Specialist nurse
• Physio
• Incl Alexander technique
• OT
• SLT

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Research recommendations

• Neuroprotection NET-PD
• Dementia cholinesterase inhibitors, memantine
• Cost effectiveness of Rx of depression
• Supportive therapies
• Diagnostic investigations

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References

• www.nice.org.uk
• Related guidelines
• Depression
• Alzheimers
• Falls
• Nutrition
• Deep brain stimulation