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Parkinson's Disease: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care

Parkinson's Disease: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care

NICE Clinical Guidelines - National Collaborating Centre for Chronic Conditions (UK)

Version: 2006

Preface

It is almost 200 years since James Parkinson described the major symptoms of the disease that came to bear his name. Slowly but surely our understanding of the disease has improved and effective treatment has been developed, but Parkinson’s disease remains a huge challenge to those who suffer from it and to those involved in its management. In addition to the difficulties common to other disabling neurological conditions, the management of Parkinson’s disease must take into account the fact that the mainstay of pharmacological treatment, levodopa, can eventually produce dyskinesia and motor fluctuation. Furthermore, there are a number of agents besides levodopa that can help parkinsonian symptoms, and there is the enticing but unconfirmed prospect that other treatments might protect against worsening neurological disability. Thus, a considerable degree of judgement is required in tailoring individual therapy and in timing treatment initiation.

Symptomatic pharmacological therapy in Parkinson’s disease

Early disease has been used to refer to people with PD who have developed functional disability and require symptomatic therapy.

Neuroprotection

Neuroprotection is a process in which a treatment beneficially affects the underlying pathophysiology of PD (Figure 6.1). This definition is preferred to ‘disease-modifying therapy’ since the latter may encompass processes, which lead to modification of clinical outcomes without any effect on the underlying pathophysiology of the condition. Good examples of this are drugs that delay the onset of motor complications in PD, such as dopamine agonists. This outcome is not necessarily due to a neuroprotective effect; it may arise from a variety of pharmacokinetic and pharmacodynamic mechanisms.,

Diagnosing Parkinson’s disease

‘It knocked me for six . . . I became very low . . . I thought it can’t be me . . . it’s just elderly people who got it.’

Surgery for Parkinson’s disease

Recognition of the limitations of dopaminergic therapy and the need to treat motor complications were the prime movers in the revival of functional stereotactic surgery for PD. This was aided by technological advances in the fields of imaging and computing. The introduction of CT and MRI scanning allowed surgeons to visualise and directly target deep brain structures without the need for indirect calculations from atlases based on cadaveric dissections. Modern engineering methods and computer technology resulted in easily used and reliable stereotactic hardware. Further advances came with the development of technology for deep brain stimulation (DBS), which has become the mainstay of movement disorder surgery.

Key messages

Recommendations for implementation consist of recommendations selected by the GDG that highlight the main areas likely to have the most significant impact on patient care and patient outcomes in the NHS as a whole.,

Non-motor features of Parkinson’s disease

‘I feel trapped inside my body . . . as if I’m not in control . . . almost as if someone or something else is running my life.’

Research recommendations

The questions below are not in order of priority.

Other key interventions

‘Never has anybody said to us, “Do you think you need a physiotherapist, a speech therapist, or an occupational therapist –do you need these services?” That’s something we have gone out to find ourselves and I think too late.’

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