Parkinson's DiseaseSimon 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.