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Implications of the latest NICE Parkinson's disease guidance

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VOL: 102, ISSUE: 29, PAGE NO: 26

Jason Beckford-Ball, BA, RMN, is assistant clinical editor, Nursing Times

This month sees the release of NICE best practice guidance for healthcare professionals caring for people with Parkinson's disease, which is a common neurological condition affecting up to 180 people per 100,000 in the UK (NICE, 2006).

This month sees the release of NICE best practice guidance for healthcare professionals caring for people with Parkinson's disease, which is a common neurological condition affecting up to 180 people per 100,000 in the UK (NICE, 2006).

The condition causes a progressive loss of neurons in the basal ganglia, loss of pigmented cells in the substantia nigra and a depletion of dopamine in other areas of the brain (Anderson et al, 2002). This results in motor symptoms including tremor, rigidity, bradykinesia and postural instability (Anderson et al, 2002). Although mostly an idiopathic condition that affects people over the age of 60, it can have an earlier onset due to acute encephalitis, carbon monoxide poisoning or metallic poisoning (Anderson et al, 2002).

As well as the debilitating physical symptoms associated with movement, mental health problems such as depression and dementia can also develop along with pain and autonomic disturbances (NICE, 2006). Combined, this set of symptoms can result in significant disability for the individual with Parkinson's disease and presents a unique set of challenges for their carers and nurses.

Patient-centred care
The document stresses that it should be read in conjunction with the National Service Framework for Long-term (Neurological) Conditions (Department of Health, 2005), which nurses can access via the DH website (www.dh.gov.uk).

Also, following principles governing patient-centred care set out in The NHS Plan (DH, 2000), the guidance states that 'treatment and care should take into account patients' individual needs and preferences'.

The guidance highlights that good communication between healthcare professionals and individuals with Parkinson's is essential and information should be tailored to meet the needs of the individual, taking into account language, culture and any physical or cognitive disabilities. Nurses in secondary care may often be the first point of contact and it is vital that the right information and support is provided. Nurses' knowledge must be up to date and they need to be able to communicate effectively with a person with Parkinson's.

Nurses should also ensure carers and relatives not only have all the information they need but also are included in treatment decisions, unless the patient has asked for them to be excluded (NICE, 2006).

Communication
People with Parkinson's may develop impaired cognitive ability, speech difficulties and depression, and nurses need to offer them both verbal and written information and support.

As Parkinson's results in a gradual deterioration, nurses must liaise with the multidisciplinary team to ensure that the information provided is consistent. This also applies to information supplied to relatives and carers.

Nurses should draw up a plan of care with the individual, her or his carers and any specialists involved, for example dietitians and physiotherapists, to ensure consistency of care (NICE, 2006).

It should also be made easy for individuals to access specialist Parkinson's services. Specialist Parkinson's disease nurses are ideally placed to provide this kind of service and individuals should be provided with their contact details (NICE, 2006).

Diagnosis
The guidance provides some diagnostic pointers. For example, Parkinson's should be suspected in those 'presenting with tremor, stiffness, slowness, balance problems and/or gait disorders' (NICE, 2006).

The guidance also states that a person exhibiting these signs should be referred to a specialist with expertise in differential diagnosis without being treated. Referrals should be expedited quickly - people with suspected mild Parkinson's should be seen within six weeks but those with more advanced symptoms should be seen within two weeks.

Due to the progressive nature of the condition, diagnosis should be regularly reviewed.

Pharmacological therapy
The guidance acknowledges that there is no definitive medicine of choice in early Parkinson's but that appropriate drugs include:

- Levodopa;

- Dopamine agonists;

- Monoamine-oxidase-B inhibitors;

- Antimuscarinics;

- Beta-blockers;

- Amantadine.

Choice of drug should take into account the person's individual clinical and lifestyle characteristics and, after provision of information regarding side-effects and benefits, patient choice (NICE, 2006).

As the condition progresses patients will probably require levodopa therapy to help control motor symptoms. There are a range of adjuvant drugs that can be taken with levodopa therapy, including:

- Dopamine agonists;

- COMT agonists;

- Monoamine-oxidase-B inhibitors;

- Amantadine;

- Apomorphine.

Antiparkinsonian medication should not be withdrawn suddenly or allowed to become ineffective due to problems with absorption (gastrointestinal problems). Sudden withdrawal can result in acute akinesia and neuroleptic malignant syndrome. Drug holidays should also be avoided (NICE, 2006).

People with Parkinson's who are admitted to hospital or nursing homes may not respond well to rigid medication 'rounds' (NICE, 2006). Nurses should ensure that patients have their medication at the right time for them (this may require self-medication) and that any changes in medication should be overseen by a Parkinson's disease specialist.

Mental health problems
As Parkinson's develops, mental health problems can occur, both due to the effect of the condition on self-esteem and quality of life and because of neurological degeneration. One recent study found that up to 80% of those with Parkinson's will experience depression (BBC, 2006) and psychosis, dementia and sleep disorders are also features of the condition.

Depression
Although up to 80% of people with Parkinson's may experience depression, an estimated 40% rarely or never discuss this with healthcare professionals (BBC, 2006). But with their communication skills and high level of patient contact, nurses are in an ideal position to detect symptoms of depression. The guidance makes several recommendations (NICE, 2006):

- There should be a low threshold for diagnosing depression in people with Parkinson's as the guidance notes that mild to moderate depression is most common but is often missed by clinicians;

- Nurses should be aware that mild depression may be masked by some motor features;

- Any therapy programme should be tailored to the individual's Parkinson's treatment programme.

Psychosis
Psychosis is a disabling non-motor complication and is often a result of long-term use of antiparkinsonian medication. Other causes are not fully understood but may include neurochemical imbalances and sleep disturbance. The most common hallucinations are visual and these can affect up to 40% of patients with advanced disease (Poewe, 2003). The guidance recommends that (NICE, 2006):

- Medication thought to be triggering psychosis can be gradually withdrawn;

- Nurses should bear in mind that mild psychotic symptoms can be well tolerated by the individual and her or his carers and may not need treatment;

- Nurses should note that typical antipsychotics exacerbate the motor symptoms of Parkinson's.

Specialist Parkinson's nurses
The guidance highlights the importance of input from specialist Parkinson's disease nurses. People with Parkinson's should have regular access to the following nursing interventions (NICE, 2006):

- Clinical monitoring and needs-led adjustment of medication;

- A consistent point of contact for support, including home visits where appropriate;

- Information on clinical and social issues that may affect people with Parkinson's and their carers.

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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