The NICE PD guideline recommends that GPs leave diagnosis and treatment to specialists, explains Dr Chris Taggart
Parkinson's disease (PD) is a condition seen infrequently by GPs and so can be difficult to manage in primary care. It is, therefore, a relief that we now have a sensible and practical guideline from NICE1 that details what we can do as a GP when working with our hospital colleagues or PD specialist nurse. I plan to keep a copy of the quick reference guide on my computer.2
The guideline emphasises that a patient with suspected PD should be referred quickly and untreated to an expert. This referral should be within 6 weeks, but if the presentation is severe or complex, referral should be within 2 weeks.
Who the expert is will depend on local services. It could be a neurologist with a special interest in PD (which is ideal), a general neurologist, a PD specialist nurse, or a GP with a special interest in PD someone who is able to make a definite diagnosis, which can be difficult.
Once diagnosed, the patient will need to be reviewed every 6–12 months. As with all chronic conditions, the diagnosis needs reviewing because it may turn out that the patient does not have PD and the treatment is incorrect.
A GP could carry out this review, but a PD specialist nurse who works closely with an expert neurologist is most suitable. The two excellent PD specialist nurses in Coventry have revolutionised the care of PD patients by bringing care into the community and have acted as a bridge between primary and secondary care.3
Treatment for PD is complex and is best left to the experts; the prescribing of anti-cholinergics should be avoided and patients referred untreated. Neuroprotective agents are unproven and may be unsafe so patients should not be started on them unless in a clinical trial.
The role of GPs is to prescribe the medications that have been initiated by the expert, but only if good shared-care protocols are in place. Support from a PD specialist nurse or a phone call from the neurologist will confirm that the correct treatment is signed off.
The guideline states that, ideally, the patient should have access to physiotherapy, occupational therapy and speech and language therapy.1 Sadly these services are often not available.
The concept of non-motor features of PD may be new to many GPs but they are often more troublesome to patients than the motor features (bradykinesia, rigidity and resting tremor) that doctors tend to concentrate on. The guideline recommends looking out for depression, dementia, sleep disturbance, urinary dysfunction, dysphagia, constipation, hypotension and sweating.1
Patients will be grateful if these issues are discussed with them as previous doctors may well have ignored such symptoms. I have experience of this as my mother-in-law, who died from PD, had all the non-motor symptoms but her doctors were more comfortable treating her motor symptoms.
Patients and carers are central to the new guideline as management is only as good as they judge it to be. Openness, explanation and honesty make a big difference. Palliative care needs to be organised to ensure that a patient's dignity is maintained to the end of their lives.
Hopefully this guideline will be a major step forward in PD management, and GPs and experts can ensure that patients get all the care and services that are available.
- National Institute for Health and Care Excellence. Parkinson's disease – diagnosis and management in primary and secondary care. NICE Clinical Guideline 35. London: NICE, 2006.
- National Institute for Health and Care Excellence. Parkinson's disease – diagnosis and management in primary and secondary care. Quick Reference Guide. NICE Clinical Guideline 35. London: NICE, 2006.