Diagnosis

• PD should be diagnosed clinically and based on the UK Parkinson’s Disease Society Brain Bank Criteria (discuss tissue donation for diagnostic confirmation)
• PD symptoms: Tremor (5 Hz); Rigidity; Bradykinesia; Loss postural reflexes (balance, gait disorder)
• Motor Problems:
  • End of dose effect, benefit wearing off earlier and earlier
  • ON-OFF effect unpredictable fluctuation
  • Dyskinesia (Athetoid or Choreiform)

Investigation

• SPECT (single photon emission CT): where essential tremor cannot be distinguished from PD
• Other means of imaging should not be used: e.g. PET, MRI, MR volumetry etc
• DO NOT offer Levodopa challenge test

Management

• DO NOT offer following for neuroprotection: Co-enzyme Q10, Vit E, DA agonist, MAO-B inhibitors

Conservative

• Specialist Parkinson Nurse
• Physiotherapy: gait re-education
• Occupational Therapy: improve transferring and mobility
• SALT

Pharmacological Therapy in Early PD

• The following are all first line, no universal first choice:
  • Levodopa (Sinemet - Incl decarboxylase inhibitor, reduces conversion to DA before BBB, as decarb can’t cross) Good symptom control, increased motor complications, low a dose possible to maintain function w/o motor effects
  • DA Agonist (Pramipexole - Non-Ergot derived preferred as Ergot derived Bromocriptine has fibrotic reaction S/E and monitor U+Es, ESR, Chest X-ray) Moderate symptom control, reduced motor complications
  • MAO-B inhibitor (Selegeline) Limited symptom control, reduced motor complications
• No evidence: Anti-cholinergics, Beta-Blockers & Amantadine, may help severe tremor in young pts

Pharmacological Therapy in Later PD

• The following Adjuvant therapies are first line and offer moderate symptom control with reduced motor complications:
  • DA Agonist
  • MAO-B Inhibitor (Selegeline) inhibits DA breakdown synaptically
  • COMT Inhibitor (Entcarpone) Inhibits DA breakdown peripherally
• Modified release Levodopa should be used to reduce motor complications but not be first choice
• Anti-Parkinsonian drugs should not be withdrawn rapidly or allowed to fail due to poor absorption, or ‘drug holiday’ and may cause acute akinesia or Neuroleptic Malignant Syndrome
• Given risk of sudden change, patient should be allowed to self-medicate during periods of transition

Surgery

Bilateral subthalamic nucleus (STN) stimulation OR Bilateral globus pallidus interna (GPi) stim if:

• Have motor complications that are refractory to best medical treatment
• Biologically fit with no clinically significant active comorbidity
• Levodopa responsive
• No clinically significant active mental health problems, e.g. depression or dementia

Non Motor Symptoms Treatment:

• Depression: low threshold
• Psychotic symptoms: Atypical antipsychotics only e.g. Clozapine
• Dementia: Further research required for Anti-Cholinesterase inhibitors
• Sleep disturbance: encourage good sleep hygiene, manage RLS
• Autonomic disturbance: treat urinary disturbance, ED, constipation, dysphagia

NICE Source: CG35 Parkinson’s disease in over 20s: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.