Clinical dilemmas in parkinson 's
Consultant neurologist Dr Andrea Lindahl offers a guide for GPs on best practice in the clinical management of patients with Parkinson's disease
The GP plays a pivotal role in the management of Parkinson's disease (PD), and will often be the first to face the clinical dilemmas that require fundamental changes in management.
Management becomes more complex as the disease progresses and NICE's recommended best practice is for the GP to be part of a team that includes Parkinson's specialists, specialist nurses, and allied health professionals1. Recognition and management of non-motor symptoms in primary care can have a great impact on quality of life for both patient and carer. GPs and specialist nurses usually manage most non-motor features such as constipation (which responds well to macrogols such as Movicol), recognition of neuropsychiatric problems and appropriate referral, falls prevention and the management of postural hypotension.The GP faced with a Parkinson's patient attending a busy surgery will face a number of dilemmas. Most of us can spot obvious PD reasonably accurately, but it is still surprisingly easy to be caught out.In more subtle cases where the patient presents with 'clumsiness' or 'heaviness' in the arm, possibly without tremor, or if the symptoms and signs are bilateral, the diagnosis may not be so straightforward and alternative diagnoses need considering2. You might think 'well if I'm right then a little Sinemet or Madopar will help' and start treatment. But then what happens if the patient fails to respond? Are you happy with what dose to start and how to titrate the drug? Can you discuss the timing of when to start treatment, outline all the treatment options, consider short-term and long-term side-effects and allow the patient to choose the strategy that best fits in with their individual lifestyle? It would be completely unreasonable to expect this, as most GPs perhaps look after four or five patients with PD, and individuals vary, so NICE recommends that all cases of suspected PD should be referred untreated to a specialist with expertise in the differential diagnosis – usually a neurologist or geriatrician.
Specialist referral means the diagnosis can be confirmed (or refuted) and so treatment options can be discussed. The nurse specialist offers a valuable source of education for patient and carer, ongoing support and the ability to monitor the effects and side-effects of medications.
Patients are usually also put in touch with the Parkinson's Disease Society as a further source of information and, if they wish, the opportunity of meeting other patients in their local area. A wide range of resources can also be found for professionals at www.parkinsons.org.ukPatients with a confirmed diagnosis of PD are also advised to inform the DVLA and their car insurance company, although if they do not suffer with excessive daytime sleepiness there are usually no problems with continuing to drive at the time of diagnosis.GPs may also be the first port of call for PD patients suffering from side-effects. Nausea may be a side-effect of dopamine agonist treatment. However, it is usually self-limiting and not a reason to stop the agonist immediately.Liaison with a nurse or consultant specialist would be appropriate. Alternatively you could start domperidone (10-20mg three times per day) and advise the patient to take the medication with food. Metoclopramide and prochlorperazine block dopamine and exacerbate the motor features of PD and should not be used. If symptoms persist or the patient develops any other adverse events, then liaise with the PD team. In some cases (particularly when the patient has been on long-term higher doses of treatment) abrupt withdrawal of dopaminergic treatment can be dangerous, resulting in a syndrome similar to neuroleptic malignant syndrome. This causes hyperpyrexia, rigidity and raised creatine kinase and can lead to death. Because of these risks PD drugs should not be stopped or altered without speaking to the PD specialist.Patients are often well controlled on dopamine agonists for several years, but then symptoms may recur and their condition deteriorate. They are often then switched to treatments combining levodopa and a dopa carboxylase inhibitor (DCI).Treatment may begin to work less well and 'wear off', the medication not lasting through to the next dose. New symptoms may include a deterioration in walking, a more severe tremor, embarrassment about the condition and a reluctance to go out. Carers may report a change in personality, social withdrawal, poor sleep and daytime drowsiness.At this stage review by the PD specialist is required to consider whether treatment can be changed to improve motor function. The patient may also be developing non-motor symptoms (see box right)3. It may be that embarrassment about physical condition is leading to social withdrawal, but it is also important to consider whether or not the patient is depressed. Depression is common in PD, affecting up to 50% of patients and has been largely under-recognised and undertreated in the past4.The evidence base for treatment of depression in PD is scant and in practice most specialists use a selective serotonin reuptake inhibitor if treatment is indicated. The PD patient who is depressed may well be identified in primary care, and the GP can begin treatment.
The other issue to consider is whether the patient is sleeping well. Although excessive daytime sleepiness can be a side-effect of medication (which you may ask the PD specialist to review), sleep disorders at night can exacerbate daytime drowsiness.In addition to general advice on sleep hygiene (avoiding tea and coffee before bed, ensuring that bedrooms are a comfortable temperature, avoiding long daytime naps and the like) it is worthwhile taking a good sleep history. Ask about how quickly the patient falls asleep, how long they remain asleep and what wakes them up. Inquire about vivid or disturbing dreams, uncomfortable sensations in the legs – that might indicate restless legs syndrome (RLS) – and ease of getting comfortable in bed (a simple bed rail may assist the patient turning over at night). Ask the bed partner if possible about leg movements in sleep (periodic limb movements of sleep can be associated with RLS) and whether the patient acts out violent dreams, which may indicate rapid eye movement sleep behaviour disorder (RBD) – see below. This takes a few minutes and identifying an easily treatable sleep disorder can have a huge impact on quality of life for the patient, and importantly the carer. Common sleep disorders in PD are listed in the box above. RBD deserves special mention as it is not only common but eminently treatable. Normally REM sleep is when we dream and during REM sleep muscles become paralysed and therefore we do not move. In RBD this normal muscle paralysis is lost and patients act out their dreams, which often have a violent or threatening nature. One patient described a recurring dream where his wife was being attacked by intruders. While acting out his dream and defending his wife by striking out at the attackers, he broke her nose. Understandably, you may find that the bed partner has moved into another room. Other patients have injured themselves by leaping out of bed while dreaming and hitting the furniture. RBD responds extremely well to a small dose of clonazepam at bedtime (0.5-1mg). This simple measure can therefore alleviate patient and carer fatigue, improve patients' mood in the daytime and prevent injury to patient or spouse.RLS is also common and easily treated. Further information can be obtained from www.restlesslegs.org.uk.