Based on NICE 2019, NG127 & NICE July 2017 and BMJ 2017;358;j1951
- Exercise - physical activity has been shown to be very important in reducing motor and non-motor symptoms; consider referring to physio especially if balance or motor problems.
- Consider referral to Occupational Therapy if difficulty with activities of daily living & to Speech & Language therapy if problems with communication, swallowing or saliva.
- Patient information and support: lots of good information from Parkinson’s UK.
Drug treatment of motor symptoms:
- All drugs are for symptomatic benefit and none influence the long-term progression.
- Initiation and alteration of all drugs should be done under specialist supervision.
- First-line drugs:
- Levodopa - better for motor symptoms with fewer adverse effects but higher long-term motor complications.
- Dopamine agonists (non-ergot derived e.g. pramipexole, ropinirole) - less good for motor symptoms but fewer motor complications, but higher adverse effects.
- MAO-B inhibitors - less good for motor symptoms but fewer motor complications, but higher adverse effects).
- Adjuvant therapy: consider adding dopamine agonist, MAO-B inhibitor or COMT inhibitor to levodopa if dyskinesia or motor fluctuations despite optimal levodopa therapy.
- Impulse control disorders (e.g. hypersexuality, gambling, binge eating) can occur with any dopamineric therapy, but particularly dopamine agonists; warn patients and family about this potential complication as can be distressing.
- If it occurs seek specialist advice, but we should not alter/stop medications without advice - medications usually need to be slowly reduced due to risk of dopamine withdrawal.
Non-motor symptom treatment (review potential causative/contributory drugs in all cases):
- Day time sleepiness, particularly associated with dopamine agonists; consider modafinil.
- Rapid eye movement sleep disorder - consider clonazepam or melatonin.
- Orthostatic hypotension: meds review important; consider midodrine or fludrocortisone.
- Depression (CKS 2018) - can be difficult to diagnose as features may be wrongly attributed to the PD; consider CBT; best evidence for TCAs but use may be limited by side effects (cognitive impairment and falls) so SSRIs may be more appropriate.
- Psychosis: don’t treat if well tolerated; consider quetiapine or clozapine (specialist only).
- Dementia: consider cholinesterase inhibitor or memantine.
- Drooling: refer to speech & language therapy or consider glycopyrronium bromide.
Palliative care - consider referring at any stage to consider end of life care.