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Parkinson’s disease

About

What is covered

This pathway covers the diagnosis and management of Parkinson's disease in adults in primary and secondary care.
Parkinson's disease is a progressive neurodegenerative condition resulting from the death of the dopamine-containing cells of the substantia nigra. It is estimated to affect 100–180 people per 100,000 of the population (between 6 and 11 people per 6000 of the general population in the UK [the size of the average general practice list]) and has an annual incidence of 4–20 per 100,000. There is a rising prevalence with age and a higher prevalence and incidence in males. There is no consistently reliable test that can distinguish Parkinson's disease from other conditions that have similar clinical presentations. The diagnosis is primarily clinical, based on a history and examination.
People with Parkinson's disease classically present with the symptoms and signs associated with parkinsonism, namely bradykinesia, rigidity and rest tremor.
Parkinsonism can also be caused by drugs, and conditions that are less common than Parkinson's disease. These include multiple cerebral infarction and degenerative conditions such as progressive supra-nuclear palsy and multiple system atrophy.
Although Parkinson's disease is predominantly a movement disorder, other impairments frequently develop including psychiatric problems such as depression and dementia. Autonomic disturbances and pain (which is rarely a presenting feature of Parkinson's disease) may later ensue, and the condition progresses to cause significant disability and handicap with impaired quality of life for the affected person. Family and carers may also be affected indirectly.
The NICE clinical guideline on Parkinson's disease will be updated to take account of clinical trial data on the pharmacological and surgical treatment of Parkinson's disease (see the NICE review decision and guidance in development webpage for information). Prescribers should refer to a drug's summary of product characteristics for up-to-date information and to inform decisions made with individual patients.

Updates

Updates to this pathway

15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.
26 March 2015 Minor maintenance update.
28 August 2014 Minor maintenance update.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Parkinson's disease: diagnosis and management in primary and secondary care

What is covered

This pathway covers the diagnosis and management of Parkinson's disease in adults in primary and secondary care.
Parkinson's disease is a progressive neurodegenerative condition resulting from the death of the dopamine-containing cells of the substantia nigra. It is estimated to affect 100–180 people per 100,000 of the population (between 6 and 11 people per 6000 of the general population in the UK [the size of the average general practice list]) and has an annual incidence of 4–20 per 100,000. There is a rising prevalence with age and a higher prevalence and incidence in males. There is no consistently reliable test that can distinguish Parkinson's disease from other conditions that have similar clinical presentations. The diagnosis is primarily clinical, based on a history and examination.
People with Parkinson's disease classically present with the symptoms and signs associated with parkinsonism, namely bradykinesia, rigidity and rest tremor.
Parkinsonism can also be caused by drugs, and conditions that are less common than Parkinson's disease. These include multiple cerebral infarction and degenerative conditions such as progressive supra-nuclear palsy and multiple system atrophy.
Although Parkinson's disease is predominantly a movement disorder, other impairments frequently develop including psychiatric problems such as depression and dementia. Autonomic disturbances and pain (which is rarely a presenting feature of Parkinson's disease) may later ensue, and the condition progresses to cause significant disability and handicap with impaired quality of life for the affected person. Family and carers may also be affected indirectly.
The NICE clinical guideline on Parkinson's disease will be updated to take account of clinical trial data on the pharmacological and surgical treatment of Parkinson's disease (see the NICE review decision and guidance in development webpage for information). Prescribers should refer to a drug's summary of product characteristics for up-to-date information and to inform decisions made with individual patients.

Updates

Updates to this pathway

15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.
26 March 2015 Minor maintenance update.
28 August 2014 Minor maintenance update.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Parkinson's disease (2006) NICE clinical guideline 35
Subthalamotomy for Parkinson's disease (2004) NICE interventional procedure guidance 65
Deep brain stimulation for Parkinson's disease (2003) NICE interventional procedure guidance 19

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Options for initial pharmacotherapy in early Parkinson's disease

Patients should be regularly monitored for the development of impulse control disorders. Patients and carers should be made aware that behavioural symptoms of impulse control disorders including pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists and/or other dopaminergic treatments containing levodopa. Review of treatment is recommended if such symptoms develop.
Initial therapy for early Parkinson's disease
First-choice option
Symptom control
Risk of side effects
Notes
Motor complications
Other adverse events
Levodopa
Yes
+++
  • Use lowest dose possible to maintain good function in order to reduce development of motor complications.
  • Do not use modified-release levodopa to delay onset of motor complications.
Dopamine agonists
Yes
++
  • If side effects prevent titration to clinically efficacious dose, replace with another dopamine agonist or another drug class.
  • In view of the risk of fibrotic reactions with ergot-derived dopamine agonists, a non-ergot-derived agonist should be preferred in most cases.
  • If an ergot-derived dopamine agonist is used, the patient should have a minimum of renal function tests, erythrocyte sedimentation rate (ESR) and chest radiograph performed before starting treatment, and annually thereafter.
  • Do not use the ergot-derived dopamine agonists (bromocriptine, cabergoline and pergolide) as initial pharmacotherapy because of serious potential adverse effects. (See the MHRA drug safety update on ergot-derived dopamine agonists, the BNF and the summaries of characteristics for individual drugs.)
Monoamine oxidase B (MAO-B) inhibitors
Yes
+
+++ Good degree symptom control; ++ moderate degree symptom control; + limited degree symptom control; ↑ evidence of increased motor complications/other adverse events; ↓ evidence of reduced motor complications/other adverse events.

Adjuvant pharmacotherapy options in later Parkinson's disease

Patients should be regularly monitored for the development of impulse control disorders. Patients and carers should be made aware that behavioural symptoms of impulse control disorders including pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists and/or other dopaminergic treatments containing levodopa. Review of treatment is recommended if such symptoms develop.
Adjuvant therapy for later Parkinson's disease
First-choice option
Symptom control
Risk of side effects
Notes
Motor complications
Other adverse events
Dopamine agonists
Yes
++
  • If side effects prevent titration to clinically efficacious dose, replace with another dopamine agonist or another drug class.
  • In view of the risk of fibrotic reactions with ergot-derived dopamine agonists, non-ergot-derived agonists should be preferred in most cases.
  • If using an ergot-derived agonist, exclude cardiac valvulopathy with echocardiography before starting treatment. Also ensure a minimum of renal function tests, erythrocyte sedimentation rate and chest radiograph are performed before starting treatment, and annually thereafter. Patients taking cabergoline or pergolide should be regularly monitored for cardiac fibrosis by echocardiography (within 3–6 months of initiating treatment and subsequently at 6–12 month intervals). (See the MHRA drug safety update on ergot-derived dopamine agonists, the BNF and the summaries of characteristics for individual drugs.)
Monoamine oxidase B (MAO-B) inhibitors
Yes
++
Catechol-O-methyl transferase (COMT) inhibitors
Yes
++
  • Entacapone: due to poor concordance, if using entacapone, offer triple combination preparation (levodopa, carbidopa and entacapone; trade name Stalevo [Orion]).
  • Tolcapone: only use if entacapone fails due to lack of efficacy or side effects. Perform liver function tests every 2 weeks during first year of therapy, and according to the 'Summary of product characteristics' thereafter.
Amantadine
No
Non-significant result
  • May be used for reducing dyskinesia.
Apomorphine
No
+
  • Intermittent injections may be used to reduce off time in patients with severe motor complications.
  • Continuous subcutaneous infusions may be used to reduce off time and dyskinesia in patients with severe motor complications. Initiation should be restricted to expert units with appropriate monitoring facilities.
Modified-release levodopa
No
++
+++ Good degree symptom control; ++ moderate degree symptom control; + limited degree symptom control; ↑ evidence of increased motor complications/other adverse events; ↓ evidence of reduced motor complications/other adverse events.

Glossary

Paths in this pathway

Pathway created: March 2014 Last updated: December 2015

© NICE 2017

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