Dr Jim George - Parkinson's Disease Service in Cumbria

PARKINSON’S DISEASE

Dr J George

Parkinson’s Disease and NICE Guidance

Context Main messages NICE Guidelines Local implications Summary

AN ESSAY ON THE SHAKING PALSY James Parkinson 1817

‘ Involuntary tremulous motion, with

lessened muscular power, in parts not in

action and even when supported; with a

propensity to bend the trunk forward, and

to pass from a walking to a running pace:

the senses and intellects being uninjured ’

Demographics

UK Population projectionsIndexed on 1995 (Royal Commission 1999)

0

50

100

150

200

250

300

1995 2001 2011 2021 2031 2041 2051

under 65

65-74

75-84

85+

10/03/2004

PREVALENCE OF PARKINSON'S DISEASEper 100,000

0

500

1000

1500

2000

2500

0-39 40-49 50-59 60-69 70-79 >80

AGES

Carlisle UK

Iceland

Aberdeen, UK

Northampton, UK

PD IS COMMON-RISING TO ~ 2%OF ELDERLYPOPULATION

1:7 DIAGNOSED < 60 YEARS

Twice the population at risk

Ten-fold increase in prevalence

13/04/23

4 stage clinical management scale

MacMahon DG Thomas S J Neurology (1998) [suppl1]:S19-22

Diagnosis

Maintenance therapy

Complex

Palliative care

13/04/23

How Long do PwPD Live?Duration of Disease

Stage PD yrs Atypical yrs (n=59) (n= 14)

Diagnosis 1.6 ± 1.5 1.8 ± 1.8

Maintenance therapy 5.9 ± 4.8 3.0 ± 2.0

Complex 4.9 ± 4.4 3.5 ± 3.5

Palliative care 2.2 ± 2.2 1.5 ± 1.2

Total 14.6 9.8

Mean Age at onset 64

So, a long term strategy is required even for ‘older’ patients

Lewy Bodies

UK Parkinson’s disease society survey, 2004Main symptoms listed by patients ahead of motor problems

Is the Diagnosis Easy?

50% error rate in primary care 25% error in secondary care Reduced to <10% with use of UKPDS BB

criteria(plus retrospectoscope!)

Meara

Hughes, Lees

NICE GUIDELINES

Full Guidance Quick Reference guide Patient version Levels of Evidence ABCD/GPP Audit Criteria www.nice.org.uk

Diagnosis

Tremor Rigidity Akinesia Postural Instability

Red Flags / Exclusions

Repeated head injury Encephalitis Supranuclear gaze palsy Severe early autonomic involvement Cerebellar signs L dopa unresponsive Early severe dementia Neuroleptic treatment History repeated strokes

Supportive positive criteria (3)

Unilateral onset Rest tremor Progresssive disorder Persistent asymmetry Good response to Ldopa Ldopa reponse 10 years Clinical course 10 years +

Essential tremor Drugs Vascular Atypical Parkinsonism syndromes

Differential Diagnosis

History and examination

Writing,swallowing,drooling,tremor, Falls,slowness,freezing,turning over Getting up from a chair Smell, memory, driving,eyes,voice Tremor,bradykinesia,rigidity, Pull test,spiral, handwriting, gait Carer concerns

National Collaborating Centre for Chronic Conditions

Referral to expert for accurate diagnosis

People with suspected PD should be referred quickly* and untreated to a specialist with expertise in the differential diagnosis of this condition.

* The GDG considered that people with suspected mild PD should be seen within 6 weeks but new referrals in later disease with more complex problems require an appointment within 2 weeks

National Collaborating Centre for Chronic Conditions

Diagnosis and expert review

The 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 the differential diagnosis of parkinsonian syndromes.

* The Guideline Development Group considered that people diagnosed with PD should be seen at regular intervals of 6–12 months to review their diagnosis.

Treatment of PD –1969

Brain’s diseases of the nervous system OUP 1969

‘The sufferer should be encouraged to lead an active life as long as possible but should avoid fatigue. A ‘zip’ fastener on the trousers is a convenience.’

‘L-dopa in doses up to 5 grams looks promising’

Drug Treatment

L dopa (A) Dopamine agonists - ergot

- non ergot (A) COMT Inhibitors (A) (not for early disease) MAOB Inhibitors (A)

Drug Treatment (continued)

It is not possible to identify a drug of first choice for early or later disease. The choice should take into account clinical lifestyle characteristics and patient preference.

Non-motor symptoms are important and should be considered in all phases of the disease

NICE PD Guidelines 2006

Dementia

‘The dark secret of Parkinson’s Disease’ 30% cross sectional studies 80% cumulative incidence Subtle cognitive impairment is the norm

Cholinesterase Inhibitors (D)

DLB & PD Dementia: A Disease Spectrum

TimeArbitrary 12 months

DLBDLB PD DementiaPD Dementia

Fluctuating cognition & hallucinations Parkinsonian features

Education from healthcare providers & support groups avoid misinformation & incomplete information Realistic goals

Support professional & peer support emotional & financial counseling

Exercise keep active & avoid deconditioning regular stretching exercises physical therapy

Nutrition balanced diet & suitable consistency nutritional counseling

NON-PHARMACOLOGIC INTERVENTIONS IN PDNON-PHARMACOLOGIC INTERVENTIONS IN PD

Parkinson’s Disease Nurse (C) Physiotherapy (B) Occupational Therapy (D - GPP) Speech Therapy (D - GPP)

Multidisciplinary Care

National Collaborating Centre for Chronic Conditions

Disease progression

Interventions

Communication

Interventions for people with PD

Diagnosis & early disease

Throughout disease

Later disease

Refer untreated to a specialist who makes and reviews diagnosis:

· use UK PDS Brain Bank Criteria

· consider 123 I-FP-CIT SPECT

· specialist should review diagnosis at regular intervals (6-12 months)

It is not possible to identify a universal first choice drug therapy for people with early PD. The choice of drug first prescribed should take into account:

· clinical and lifestyle characteristics

· patient preference

Provide regular access to specialist care particularly for:

· clinical monitoring and medication adjustment

· a continuing point of contact for support, including home visits when appropriate,

which may be provided by a Parkinson’s disease nurse specialist

Consider access to rehabilitation therapies, particularly to:

· maintain independence, including activities of daily living and ensure home safety

· help balance, flexibility, gait, movement initiation

· enhance aerobic activity

· assess and manage communication and swallowing

Consider management of non-motor symptoms in particular:

· depression

· psychosis

· dementia

· sleep disturbance

It is not possible to identify a universal first choice adjuvant drug therapy for people with later PD. The choice of drug prescribed should take into account:

· clinical and lifestyle characteristics

· patient preference

Consider apomorphine in people with severe motor complications unresponsive to oral medication:

· intermittent injections to reduce off time

· continuous subcutaneous infusion to reduce off time and dyskinesia

Consider surgery:

· bilateral STN stimulation for suitable people refractory to best medical therapy

· thalamic stimulation for people with severe tremor for whom STN stimulation is unsuitable

Reach collaborative care decisions by taking into account:

· patient preference and choice after provision of information

· clinical characteristics, patient lifestyle and interventions available

Provide communication and information about:

· PD services and entitlements

· falls, palliative care and end-of-life issues

Local Implications

Parkinson’s disease clinics Parkinson’s disease specialist nurses * Education * Multidisciplinary Team * Drug costs

THE FUTURE ????

Summary

Parkinson’s disease is a dementia with a long motor prodrome

Management is multidisciplinary Referral to a specialist Service should be patient centred

Case 1

School bus driver Tremor only Ethical issue

DATscan images

Case 2

55 year old man Classical bradykinesia and rigidity Good response to L dopa-very active Visual problems 2nd opinion

Case 3

Retired geography teacher lives alone Classical PD-good response L dopa 7 years on/off symptoms Start ropinirole –good response 2013 admission increased confusion,

delusions and hallucinations