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Hot Topics Blog

Parkinson's Disease

Simon Curtis - 12 Apr, 2018

You see one of your elderly patients with Parkinson’s. They have recently had a fall and you discover they have postural hypotension. Or maybe they have problems with temperature regulation and sweating…or excessive daytime sleepiness, or swallowing, or visual hallucinations, or restless dreams with agitation and abnormal behaviour (rapid eye movement sleep behaviour disorder), depression, or insomnia due to restless legs or nocturnal akinesia. The list goes on.

With our ageing population Parkinson’s disease is becoming increasingly prevalent. The way that we think about it is also changing. Historically considered as a neurological movement disorder, it is now increasingly recognised as a more generalised neurodegenerative condition with a multisystem phenotype with up to 30 non-motor symptoms and complications.

One of the interesting things about the recent NICE Parkinson’s Disease Guideline 2017 was a much greater emphasis on these non-motor symptoms. The first step is recognition by the GP that these are part of the Parkinson’s disease process. As with everything, for the patient explanation and reassurance may be all that is required along with sign posting to self help resources (such as Parkinson’s UK resources). But in addition to that, the NICE guidance suggests a range of potentially useful interventions, which we may want to consider together with our specialist colleagues.

For example, consider your patient with orthostatic hypotension. Are there other drugs which could be contributing? And not just antihypertensives, but also dopaminergics, anticholinergics or antidepressants? If not, then midodrine or fludrocortisone could be considered. For the patient with excessive daytime sleepiness (which is often associated with dopamine agonists) then modafanil is suggested as an option to try. For rapid eye movement sleep disorder, melatonin or clonazepam may be helpful.

As far as treatment of motor symptoms goes, it sadly remains the case we have no neuro-protective treatment for this disabling and progressive disease. All drug treatments are symptomatic and do not reduce long-term progression. Physical exercise, physiotherapy and OT may reduce progression and are vital interventions.

Treatment of Parkinson’s should be specialist guided but with a huge shortage of neurologists GPs are having to take on a greater role. Understanding the protean non-motor symptoms is a crucial part of that, and the NICE Parkinson’s Disease Guideline 2017 is a very useful summary of what they are and how we may help. We have an updated summary in our new Spring 2018 Hot Topics book which we hope will help you to help your patients.

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Lyme Disease - Balancing Under and Over Diagnosis

Simon Curtis - 19 Apr, 2018

Last week NICE produced their long awaited new guideline on Lyme disease NICE 2018, NG95 usefully summarised in the BMJ 2018;361:k1261. An increased awareness of risk will see many more patients seeking advice from their GPs regarding tick bites and possible Lyme disease this summer. These new guidelines lay out very useful pathways for diagnosis and testing. They stress that asking about possible exposure and clinical judgement are key in diagnosis of possible cases.

It is fascinating to see how our view of Lyme disease is changing. No longer a rare, esoteric diagnosis Lyme is now endemic throughout the UK with 2,000 to 3,000 confirmed cases each year, which is likely to be a significant under-estimate. It is also no longer just a summer or a rural disease. Although the ticks are present predominantly from April to October the disease can present at any time of the year and throughout the whole of the UK including urban areas. Globally, the incidence is increasing and a fascinating sounding new book (not read it yet!) describes Lyme as ‘the first epidemic of climate change’ as ticks and Lyme are now commonly seen in areas where it was once too cold for them to live.

How we understand the clinical picture of Lyme, and how we test for it, is also changing. We previously thought that erythema migrans had to be present or that there had to be a clear history of a tick bite before considering the diagnosis. Now we know that Lyme disease can present without erythema migrans and neither is a clear recollection of a tick bite essential (they can be tiny!) before considering the diagnosis. There are multiple different clinical presentations. Furthermore the phenotype varies with different strains causing different patterns of disease. Recent research in the BJGP 2017 highlights that the European strain for example is associated particularly with neurological manifestations, such as facial palsy. The guideline encourages a two-tier approach to serological testing of suspected cases with an initial ELISA test and a more specific confirmatory (immunoblot) test if positive or equivocal but the guideline acknowledges that testing is imperfect, with both false negatives and positives, and clinical judgement is key.

If identified early and receiving appropriate treatment then 95% of people with Lyme disease can expect a cure with antibiotics. We as GPs need to balance this information with a need to remind patients that most ticks do NOT cause Lyme disease and are harmless, to avoid prescription of unnecessary antibiotics, to encourage patients to get outside and exercise but to be ‘tick aware’ and on correct tick removal. Antibiotic prophylaxis after bites is not routinely recommended, and these guidelines have a clear pathway on who should be treated and/or tested.

It strikes me that as with so many things, with Lyme disease we GPs shall have to tread the delicate path between over and under diagnosis. Hoping of course, that on this path we don’t get bitten by a tick…

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