HHE Neurology supplement 2018 - Page 7

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 7 HHE 2018 | hospitalhealthcare.com