Dr John Hindle discusses the PD guidance from NICE, which promotes quick referral to a specialist for diagnosis and management of non-motor symptoms

In a survey of GPs undertaken to monitor the implementation of NICE guidelines, 94% felt that they had no specialist knowledge of Parkinson's disease (PD). Only 50% of GPs questioned had access to a local PD nurse specialist; sixty-eight percent referred patients once the diagnosis was suspected, but one in five people with PD were never referred to a specialist.1 The pattern of referral and service provision is variable across the country.The recommendations in the new NICE PD guideline have considerable implications for GPs.2

Why is the guideline important?

Parkinson's disease is a common progressive neurological disorder estimated to affect between 100–180 people per 100,000 of the population. It has an annual incidence of up to 20 per 100,000.2 There is an increasing prevalence with age, and a higher prevalence in men. Most GPs will have at least three patients with PD under their care. The condition can lead to extensive disability, which affects the quality of life of the individual, family and carers, and produces a considerable economic impact. The assessment and management of PD is increasingly complex.

For these reasons, the NICE guideline is designed to improve the healthcare of people with PD. The guideline reviews the diagnosis, drug and surgical treatments, the more complex non-motor features and palliative care of PD, and includes information for both primary and secondary care.2

Developing the evidence

The guideline, produced by the Royal College of Physicians National Collaborating Centre for Chronic Conditions, is available at www.nice.org.uk as a quick reference guide and a full guideline. The latter explains the guideline development and the processes of rigorous analysis of the evidence.3

The evidence was graded (Table 1) and used as a basis for recommendations, which were prioritized.3 Where there were no high-quality trials recommendations were based on expert consensus. The evidence grades are not specified in the quick reference guide but are present in other versions of the guideline. The guideline was subjected to two periods of public consultation. A summary algorithm is provided in the guidance (Figure 1).

Table 1: Grading the evidence statements and recommendations

Reproduced by kind permission of the Royal College of Physicians and the National Collaborating Centre for Chronic Conditions

Figure 1: Parkinson's disease algorithm

Reproduced by kind permission of the Royal College of Physicians and the National Collaborating Centre for Chronic Conditions

Diagnosis

Good communication is important, as is the requirement to take into account the patients' individual needs and preferences, so that they can make informed decisions about their care and treatment. The GP is likely to be the first healthcare professional to communicate the possible diagnosis of PD. It is, therefore, important to be aware of recommended good practice in the communication of this diagnosis.

The diagnosis is clinical (Grade B), and when made by GPs is likely to be less accurate than when made by a specialist.

People with suspected PD should, therefore, be referred quickly and untreated to a specialist with expertise in the differential diagnosis of this condition (Grade B), and patients should be seen within 6 weeks.

The diagnosis of PD should be reviewed regularly by specialists and reconsidered if atypical features develop (Grade D).

Multidisciplinary care

Management of PD is multidisciplinary, and patients should have access to:

  • a PD nurse specialist (Grade C)
  • physiotherapy (Grade B)
  • occupational therapy (Grade D-GPP)
  • speech and language therapy (Grade D-GPP).

People with PD and their carers should be given the opportunity to discuss end of life issues with the appropriate healthcare professionals, including GPs (Grade D-GPP).

Pharmacological therapy

In the guideline, 'early disease' refers to people who have developed some functional disability and require symptomatic treatment, and 'later disease' refers to people taking levodopa who have developed motor complications with fluctuations in response and abnormal involuntary movements (dyskinesia).

GPs should be aware of the different drug classes in order to understand the choice of treatments advised by the specialist, and to aid prescribing under shared care agreements. No treatments slow the progression of the disease. There is no drug of first choice in early or late disease. The choice should take into account clinical and lifestyle characteristics, and patient preference after they have been informed of the short- and long-term benefits and drawbacks of different drug classes (Grade D-GPP).

Early disease

The main choices are levodopa (Grade A), the monoamine oxidase type B (MAO-B) inhibitors selegiline or rasagiline (Grade A), or dopamine agonists (DAs) (Grade A). Owing to the side-effects of ergot-derived DAs (bromocriptine, lisuride, pergolide, cabergoline), non-ergot-derived DAs (pramipexole, ropinirole, rotigotine) are preferred in most cases (Grade D-GPP).

Previous clinical guidelines attempted to define patients who may benefit from early introduction of levodopa-sparing drugs, such as DAs,4,5 but little evidence was found to support these decisions. Specialists may opt for levodopa-sparing drugs in biologically younger patients where the disease is likely to have a longer course in order to avoid late motor complications.

All patients will ultimately require levodopa. A key principle of treatment is to maintain good function using the lowest possible dose of levodopa. Anticholinergics should not be drugs of first choice due to neuropsychiatric side-effects (Grade B).

Later disease

The drug choices in later disease include DAs (Grade A), MAO-B inhibitors (Grade A), or cathechol-O-methyl transferase (COMT) inhibitors (entacapone or second line tolcapone) (Grade A) to reduce motor fluctuations. Modified-release levodopa should not be used as a first choice drug (Grade B).

Amantadine can be used to treat dyskinesia (Grade C), and apomorphine can be used to treat severe motor complications, and in a continuous infusion may also reduce fluctuations (Grade B) and improve dyskinesia (Grade D).

Anti-parkinsonian medications should not be withdrawn abruptly or allowed to fail suddenly due to poor absorption, as this may lead to severe physical deterioration (Grade D-GPP).

Surgery is reserved for patients who have severe motor complications and who are refractory to the best medical treatment (Grade D).6

Non-motor features

GPs should be aware that depression, psychosis and dementia are all common. 7 NICE previously produced general guidelines for the management of depression,8 but there is no evidence to support their use in PD.

The choice of antidepressant in PD is down to the risk of interactions or side-effects, patient preference, and clinician experience (Grade D-GPP). Antidepressants should not be used together with MAO-B inhibitors. All anti-parkinsonian medications can precipitate psychosis. A gradual withdrawal of medication may be appropriate under specialist supervision, leaving patients just on levodopa therapy (Grade D-GPP).

Typical anti-psychotic drugs should be avoided. Evidence supports the use of clozapine for psychosis in PD (Grade B), which requires mandatory registration and monitoring. Cholinesterase inhibitors can be used in patients with PD-associated dementia (Grade D-GPP), although further studies are needed.

Sleep problems, including restless leg syndrome and sleep behaviour disorder, are common in PD. It is important to take a sleep history, and recommend simple measures to improve sleep hygiene and reduce sleep disturbance. Daytime hyper-somnolence can be a problem requiring specialist advice (Grade D-GPP). Night-time immobility can be helped by using modified-release levodopa (Grade D-GPP).

All patients are ultimately at risk of falling, and the NICE clinical guideline 21 is a useful guide to the multidisciplinary assessment of falls in PD.9

Autonomic problems can occur in PD, including:

  • urinary dysfunction
  • weight loss
  • dysphagia
  • constipation
  • sexual dysfunction
  • orthostatic hypotension
  • sweating
  • dribbling.

These need individual assessment and management (Grade D-GPP).

Practical implementation advice

The guideline identified a number of key priorities for implementation. These include:

  • referral to an expert for accurate diagnosis and expert review
  • regular access to specialist nursing care, physiotherapy, occupational therapy, and speech and language therapy
  • discussing palliative care.

The guideline covers both primary and secondary care, making its implementation particularly complex. It is useful to identify a local implementation group, which includes GPs, specialists and representatives from the PCT (Local Health Boards in Wales), to review the cost and service implications of applying the guideline using the implementation advice document and the costing template provided (Box).10

NICE considered the cost of implementing the key priorities that were judged to have significant cost implications. The average PCT with an adult population of 145,000 could expect to incur additional costs of £29,000, with estimated savings of £19,000, leading to an estimated annual net cost of £10,000.

Although referrals to specialists would increase, it was thought that improving regular access to specialist nurses for day-to-day care could reduce routine follow-up, and free more time for initial specialist assessment and appropriate follow-up.10

'Payment by Results' for England 2006/07 (not Wales or Scotland) covers inpatient and outpatient activity commissioned from acute providers. Neurology outpatient attendance is not currently included in the 'Payment by Results' tariff so prices would be negotiated locally. Geriatric medicine is in the mandatory tariff and prices reflect the cost of multidisciplinary assessment. Savings will arise only if the recommendations on access to nurse specialists and therapy services are fully implemented.

Implementation tools
NICE has developed the following tools to support implementation of its guideline on Parkinson's disease in primary and secondary care.They are now available to download from the NICE website: www.nice.org.uk.
Implementation advice
The implementation advice document contains suggested actions for implementing the guideline. It aims to help implementers identify recommendations in the guideline that are not part of current practice and should be used alongside the costing report and template.
Slide set
The slides are aimed at supporting organizations to help implement the guideline recommendations at a local level. They do not try to cover all the recommendations from the guideline but contain key messages and should be used in conjunction with the quick reference guide.
Costing tools

National cost reports and local cost templates for the guideline have also been produced.
Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Costing templates are spreadsheets that allow individual NHS organizations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates and quickly assess the impact the guideline may have on local budgets.

Summary

The role of the GP is crucial in the diagnosis, referral and shared care of patients with suspected PD. GPs should ensure that services, which comply with the NICE guidance are commissioned. The most important recommendations in the guideline stress the major role of non-pharmacological aspects of care in this disabling chronic condition.

Guidelines in Practice, September 2006, Volume 9(9)
© 2006 MGP Ltd
further information | subscribe

  1. Parkinson's Disease Society. Treatment of people with Parkinson's disease. PDS research survey on file.www.parkinsons.org.uk/
  2. National Institute for Health and Care Excellence. Clinical guideline CG035. Parkinson's disease. National clinical guideline for diagnosis and management in primary and secondary care. NICE: London, 2006.
  3. Royal College of Physicians.Parkinson's disease. Diagnosis and management in primary and secondary care. RCP: London, 2006.
  4. Bhatia K, Brooks D, Burn D et al. Updated guidelines for the management of Parkinson's disease. Hosp Med 2001; 62 (8): 456–470.
  5. Olanow C, Watts R, Koller W. An algorithm (decision tree) for the management of Parkinson's disease (2001): treatment guidelines. Neurology 2001; 56 (11 suppl 5): S1–S88.
  6. National Institute for Clinical Excellence. Interventional procedures guidance IPG019. Deep brain stimulation for Parkinson's disease. London: NICE, 2003.
  7. Hindle J. Neuropsychiatry. In: Playfer J, Hindle J (Eds). Parkinson's disease in the older patient. London: Arnold, 2001.
  8. National Institute for Clinical Excellence. Clinical guideline CG023. Depression: management of depression in primary and secondary care – NICE guidance. London: NICE, 2004.
  9. National Institute for Clinical Excellence. Clinical guideline CG021. The assessment and prevention of falls in older people. London: NICE, 2004.
  10. Cost impact report.www.nice.org.uk/