DRAFT FOR FIRST CONSULTATION Full version of NICE Guideline No. X Parkinson’s Disease Diagnosis and Management in Primary and Secondary Care. Developed by National Collaborating Centre for Chronic Conditions Royal College of Physicians Parkinson’s disease: full guideline DRAFT (August 2005) Page 1 of 277 DRAFT FOR FIRST CONSULTATION Table of contents Guideline Development Group Membership ................................................5 Acknowledgments: .......................................................................................6 Preface.........................................................................................................7 1. Introduction ..................................................................................................8 Background ..................................................................................................8 Modern Definition .........................................................................................8 Health and resource implications .................................................................8 2. Methodology ..............................................................................................10 Aim .............................................................................................................10 Scope .........................................................................................................10 Methodology...............................................................................................12 3. Key Messages ...........................................................................................20 Recommendations for implementation .......................................................20 Audit criteria ...............................................................................................22 Referral to expert for accurate diagnosis....................................................22 Expert review of diagnosis .........................................................................22 Regular access to Parkinson's disease specialist nursing care..................22 Cholinesterase inhibitors for dementia and/or psychosis ...........................23 Patient views ..............................................................................................23 PD Algorithm ..............................................................................................24 4. Communication with People with Parkinson’s disease and their carers.....25 Introduction ................................................................................................25 5. Diagnosing Parkinson's disease ................................................................33 Introduction ................................................................................................33 Clinical versus post-mortem diagnosis .......................................................37 Expert versus non-expert diagnosis ...........................................................38 Review of Diagnosis...................................................................................40 Single Photon Emission Computed Tomography (SPECT)........................40 Positron Emission Tomography (PET) .......................................................45 Magnetic Resonance Imaging (MRI) ..........................................................46 Magnetic resonance volumetry...................................................................48 Magnetic resonance spectroscopy.............................................................49 Acute levodopa and apomorphine challenge tests.....................................49 Objective smell testing ...............................................................................51 6. Neuroprotection .........................................................................................55 Introduction ................................................................................................55 Vitamin E....................................................................................................59 Co-enzyme Q10 ..........................................................................................60 Dopamine agonists.....................................................................................62 MAO-B Inhibitors........................................................................................65 7. Symptomatic pharmacological therapy in PD ............................................68 Introduction ................................................................................................68 Early Pharmacological Therapy..................................................................69 Levodopa ...................................................................................................70 Modified-release levodopa .........................................................................72 Dopamine Agonists ....................................................................................74 Monoamine oxidase B inhibitors.................................................................77 Beta-adrenergic antagonists (beta-blockers)..............................................79 Parkinson’s disease: full guideline DRAFT (August 2005) Page 2 of 277 DRAFT FOR FIRST CONSULTATION Amantadine ................................................................................................80 Anticholinergics ..........................................................................................82 Comparisons of drug classes .....................................................................83 Dopamine agonists versus levodopa..........................................................83 Monoamine oxidase type B inhibitors versus levodopa..............................88 Monoamine oxidase type B inhibitors versus dopamine agonists ..............90 Choice of initial pharmacological therapy in early PD.................................91 Later Disease .............................................................................................92 Modified-Release Levodopa.......................................................................92 Dopamine agonists.....................................................................................95 Monoamine Oxidase B Inhibitors................................................................98 Rasagiline ................................................................................................100 Catechol-O-Methyl Transferase Inhibitors................................................102 Amantadine ..............................................................................................107 Apomorphine............................................................................................108 Adverse events.........................................................................................110 Outcome...................................................................................................112 Comparisons of Drug Classes..................................................................114 Dopamine agonists versus MAO-B inhibitors ...........................................114 COMT inhibitors versus dopamine agonists.............................................114 Dopamine-agonists versus amantadine ...................................................116 Choice of adjuvant therapy in later PD .....................................................116 8. Surgery for Parkinson's disease ..............................................................117 Introduction ..............................................................................................117 STN stimulation........................................................................................120 GPI stimulation.........................................................................................125 Comparison of different types of deep brain stimulation...........................126 Thalamic stimulation.................................................................................128 9. Non-motor Complications of Parkinson's Disease ...................................129 Introduction ..............................................................................................129 Mental Health Problems ...........................................................................130 Sleep Disturbance....................................................................................141 Falls..........................................................................................................145 Autonomic Disturbance ............................................................................146 Pain ..........................................................................................................150 10. Other key interventions ..........................................................................151 Introduction ..............................................................................................151 Parkinson’s Disease Nurse Specialist Interventions.................................151 Physiotherapy...........................................................................................155 Occupational therapy ...............................................................................159 Speech and language therapy .................................................................161 11. Palliative care in Parkinson’s disease ....................................................165