Some drugs used
in the condition,
particularly
clozapine,
require the
establishment
of fail-safe
and accessible
monitoring
systems
that usually
require close
collaboration
between multiple
agencies
Allied professional services
Although the guideline falls short of
recommending that nurse specialist services
should be provided, recommendation 1.7.1 states
that people with Parkinson’s should have access
to clinical monitoring, a continuing point of
contact for support, home visits and reliable
information for themselves and carers. In
practice, because of the shortage of Consultant
Neurologists and Geriatricians in England, it is
difficult to imagine how this could be effectively
achieved without a Parkinson’s nursing service.
There are new recommendations on
physiotherapy, occupational therapy and speech
and language therapy that should be offered to
those who require it (that is, those with motor
or balance problems, those with difficulties with
activities of daily living and those with
communication, swallowing or saliva problems
respectively). These services must therefore be
provided. Referral to a dietician is a ‘consider’
recommendation (that is, it is not considered
mandatory to offer such a service).
Impulse control disorder
Compulsive and obsessive disorders are
increasingly recognised as a major challenge
of treating Parkinson’s, especially in advancing
illness. 10 These include pathological gambling,
excessive shopping, eating or hypersexuality.
Mild degrees of impulse control disorder are very
common in people with Parkinson’s but, even
when severe, the condition may remain hidden
from the family and carers as well as from the
clinician involved. Patients with pathological
gambling may lose hundreds of thousands of
pounds, and there is the potential for expensive
litigation if patients are not appropriately warned
and the warnings recorded. Those with
hypersexuality may acquire a forensic record.
Patients may appear indifferent to the problems
impulse control disorder creates around them.
Prevention of problems is better than cure in this
situation. NICE emphasises the importance of
providing information to alert patients, family
and carers about impulse control disorder when
starting and reviewing medication, and
recommends that dopaminergic therapy is
reduced if this develops. The disorder does not
respond readily to drug treatment. NICE
stipulates that cognitive behavioural therapy
should be offered if drug reduction does not help.
Psychosis
Hallucinations, predominantly visual, paranoia
and agitation can be troublesome adverse effects
of medication in Parkinson’s, especially in
advanced disease. These symptoms are driven
predominantly by dopaminergic drug treatment,
that is, by l-dopa and the dopaminergic agonist
drugs (ropinirole, pramipexole, rotigotine and
bromocriptine) that are the mainstay of
Parkinson’s treatment. Dopaminergic drug
reduction does not always facilitate a reasonable
balance between good mobility and psychotic
symptoms, and in some there is an uncomfortable
trade off between mobility and psychotic
symptoms. Some patients require antipsychotic
drugs. Unfortunately most antipsychotic drugs are
contraindicated in Parkinson’s because they
greatly worsen mobility. NICE therefore
recommends only two antipsychotic drugs for
this indication – quetiapine and clozapine. The
former is only modestly effective, but reasonably
well tolerated. 11 The latter, while more effective,
is more difficult for patients to tolerate and
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