Dr Nick Lance
Q What first inspired you to become involved in this clinical area?
The practice where I work was also involved in the work of the rehabilitation department at the local hospital.
I looked after one of the wards and the consultant who oversaw it suggested that I take the Diploma in Geriatric Medicine, which I did. He was looking for a GP to help with his Parkinson’s clinic.
I could see the relevance to primary care and I continued to build up my expertise there for 10 years, before general practice workload took over.
The team was excellent, there were two Parkinson’s disease specialist nurses and we worked closely with physiotherapists, occupational therapists and speech and language therapists.
Q What does your current role in movement disorders involve?
I work solely in general practice, where I see all of the patients on our list with Parkinson’s disease.
I feel happy managing them and I often refer back to the local hospital clinic where I worked.
My general practice colleagues also tend to send patients who have any movement disorders to me for a diagnosis.
Q What do you enjoy most about working in this area?
You can make a real difference for these patients. One older patient I saw was bedbound and had been referred for palliative care. He did not have a formal diagnosis of Parkinson’s disease, but I decided to try him on some medication and it was really successful for him – he’s now mobile. Very few GPs in this country have a specific interest in movement disorders, but it is certainly something that lends itself to primary care, particularly if your practice looks after any local nursing homes.
This area is rewarding, but also frustrating, because fundamentally Parkinson’s is a progressive disease.
Q How could clinicians pursue an interest in this area?
There are diplomas in neurology that clinicians could consider. But the Diploma in Geriatric Medicine is probably best because it is more primary care focused. I would also recommend gaining some experience at a hospital clinic if you have a local neurology consultant or local specialist nurses, who are invaluable.
Q Do you have any tips on diagnosing patients with Parkinson’s disease?
GPs will likely identify a patient with tremor, rigidity and bradykinesia. But it is useful to remember that patients do not have to have all three symptoms to have a diagnosis of Parkinson’s disease, and tremor is not always a presenting feature.
GPs should also be alert to other symptoms, such as drooling, micrographia and constipation.
Patients and health professionals often consider these symptoms to be a natural part of ageing, but in some patients, medication can make a big difference.
Q Which other movement disorders should GPs look out for?
Patients with dystonia or essential tremor will often present in primary care and it can be tricky to distinguish these.
Essential tremor usually affects the arms, hands or fingers symmetrically with a regular oscillation. Dystonic tremor can affect other parts of the body, such as the head, and is usually irregular.
Multiple system atrophy is similar to Parkinson’s disease, but the presence of truncal rigidity in Parkinson’s disease can help to distinguish them.
Drug-induced Parkinson’s disease is something that GPs should look out for, as it can be dealt with effectively in primary care. Many drugs can cause Parkinson’s-like symptoms, including prochlorperazine and antidepressants. Once the medicine is stopped, symptoms can resolve in days or months.
Q What changes to clinical practice would help patients?
More awareness of Parkinson’s disease would be beneficial, particularly among patients in residential homes.
A high percentage of these patients have dementia, but it is always worth considering Parkinson’s disease as a diagnosis.
Locally, we have developed a system where consultants visit nursing homes to see mostly elderly patients with possible Parkinson’s disease, and this is very useful.
In general, GPs should always refer a patient diagnosed with Parkinson’s disease.
But if you have an interest in the area and you talk to a consultant, they are usually happy for you to start treatment and manage medication in the community.