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Parkinson’s disease - top tips on diagnosis and management

Geriatricians Dr Jeremy Playfer and Dr John Hindle give GPs 10 hints on managing this relatively rare but difficult-to-tackle condition.

Geriatricians Dr Jeremy Playfer and Dr John Hindle give GPs 10 hints on managing this relatively rare but difficult-to-tackle condition.

1 Diagnosing Parkinson's Disease (PD) can be straightforward but always seek confirmation from a geriatrician or neurologist who specialises in the condition.

Diagnosis is often based on the observation of rest tremor in the hands and slowness of movement including loss of facial expression and muscular rigidity. But there are other closely related conditions that need to be considered.

Labelling a patient incorrectly as having PD commits them to a lifetime of drug treatment and the diagnosis is difficult to revise once a patient is established on treatment. All that shakes is not PD, with essential tremor being the commonest movement disorder.

A shuffling gait can be due to vascular disease rather than neuro-degeneration. Parkinson's plus syndromes including multi-system atrophy and progressive supra-nuclear palsy are difficult to distinguish from idiopathic PD in the early stages but have a different prognosis and management.

2 Choosing a starting medication is one of the most important decisions. A geriatrician or neurologist with a special interest in PD should also always be asked for advice.

The commonest initial treatment is levodopa (Madopar or Sinemet). After nearly 40 years in use, these drugs are still the most effective at relieving symptoms.

In longer-term use they are associated with motor complications with fluctuation of response and abnormal involuntary movements.

This type of complication can be reduced by using the alternative dopamine agonists – pramipexole, ropinirole, rotigotine – but there is an increased risk of psychiatric complications.

When the patient has only minor problems, treatment may be delayed or an MAOI such as selegiline or rasagiline can be started with the hope of delaying the requirement for levodopa.

Anticholinergic drugs should be avoided because they have unpleasant side-effects and impair cognition. When making these decisions it is helpful to use the specialist's up-to-date knowledge and experience.

3 Review other medications the patient may be taking, especially repeat prescriptions.

This is important to exclude the possibility of drug-induced parkinsonism. As many as one in 10 patients who present with parkinsonism have their symptoms caused by drugs that block dopamine D2 receptors or interfere with the synthesis, storage or release of dopamine.

Examples of neuroleptics often overlooked include prochlorperazine, which is used commonly for dizziness, metoclopramide used for nausea and promethazine combined with amitriptyline used for non-specific symptoms such as pain and sleep disorders.

The list of causes of drug-induced PD is always extending; even calcium antagonists have recently been added.

4 PD is more than just a disorder of movement.

Non-motor features cause much disability. Patients need positive management of constipation, bladder dysfunction and swallowing difficulties, which result from autonomic dysfunction.

Postural hypotension can increase the risk of falls and is exacerbated by co-morbidity and use of diuretics and anti-hypertensive drugs. Sleep disturbance is almost universal and often needs specialist help.

Mental health problems are very common. Be alert to depression, dementia and hallucinations. Psychotic episodes are a major emergency and can be secondary to drugs or infection.

5 Interdisciplinary working is key to best management.

Patients with PD have a wide range of needs. Ideally management needs to be specialised and co-ordinated. Physiotherapy, occupational therapy, clinical psychology, speech therapy and podiatry are all likely to be needed.

6 PD specialist nurses are worth their weight in gold.

There are now more than 200, many of whom are community based. They are invaluable in managing the patient through the stages of the disease. NICE guidelines state that patients with PD should have access to a PD nurse specialist.

7 Carers, as well as the patient, need support.

The diagnosis always affects the family profoundly.

Studies show the main carer is stressed and that carers have an increased risk of ill-health, with twice the risk of depression compared with the general population. Support of the carer also supports the patient.

PD has a long palliative phase and the GP is particularly vital in mobilising support.

8 Communication with PD patients requires special attention.

Patients need time to assimilate information and respond. There are a variety of problems including cognitive and speech impairment, and loss of body language.

Effective communication of the diagnosis and involvement of the patients in choices improves outcomes and reduces stress all round.

9 Encourage patients to join the Parkinson's Disease Society of the UK (PDS).

The PDS is a major charity with the aim of improving care of patients and supporting research. Local branches and support groups can be a valuable social outlet for patients and carers.

The newsletter, website and other publications provide useful information and there is a helpline (0808 800 0303).The PDS can be contacted at enquiries@parkinsons.org.uk.

10 NICE guidelines provide a sound evidence-based guide to the management of PD patients.

The guidelines are available on the NICE website: www.nice.org.uk.

Dr Jeremy Playfer is emeritus consultant geriatrician at the Royal London Hospital.

Competing interests: Dr Playfer has received payments for lectures and/or consultancy work from Orion Pharma, Solvay and Boehringer Ingelheim in the past 12 months

Dr John Hindle is consultant physician in the care of the elderly at Llandudno Hospital

Competing interests: Dr Hindle has received honoraria for lectures and unrestricted educational grants from UCB Pharma, GSK, Orion, Boehringer and Britannia

Dr Hindle and Dr Playfer are authors of Parkinson's Disease in the Older Patient, and its third edition has just been published by Radcliffe Publishing, ISBN 9781846191145 www.radcliffe-oxford.com

Parkinson's is more than just a disorder of movement - patients need management of other symptoms such as constipation. Parkinson's

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