Multidisciplinary management of Parkinson's disease

By Dr C Ruth Butlin on the 30 November 2012

The GP's role is to co-ordinate holistic care, writes Dr C Ruth Butlin.

Parkinson’s disease: the GP can monitor multidisciplinary interventions (Photograph: TEK Images/SPL)

Good management of Parkinson's disease (PD) helps to reduce the handicap and distress experienced by the patient. This co-ordinated set of interventions involves professionals from several disciplines.

The GP's responsibility

Patients with PD often experience unrelated disabilities common in older age groups. The median survival after diagnosis is about 15 years, so the newly identified patient faces a long period of growing disability.

The onset is usually insidious and symptoms may be difficult for the patient to describe: recognition of PD may follow reports of 'clumsiness' or tremor, gait problems or frequent falls (related to defective postural reflexes), a non-motor symptom such as constipation, or features suggesting depression or dementia.

When PD is suspected, four cardinal motor symptoms should be sought – tremor, rigidity, akinesia/bradykinesia, and postural instability. Diagnosis is based on detailed history and physical examination.

After preliminary clinical assessment, the GP should arrange an early referral for specialist advice.¹ Investigations such as MRI are primarily to rule out other conditions, such as progressive supranuclear palsy.²

Holistic management can be viewed as four domains: medication, non-pharmaceutical therapy, psychosocial assistance and safe transport, with surgery as a last resort.

Medication

Drugs targeting the underlying biochemical imbalance will be initiated by the specialist only when symptoms are sufficient to justify the risks of adverse effects.

Early aggressive intervention in PD does not improve the prognosis. Delay in starting patients on dopaminergic drugs may postpone onset of dyskinesias.

The aim is to reduce unpleasant symptoms and enhance quality of life, while minimising side-effects. There is inadequate evidence for recommending standard firstand second-line treatment in early PD, so the decision to use levodopa or a dopamine receptor agonist is made on an individual basis, taking into consideration any comorbidity and patient priorities.¹

It is the GP's responsibility to monitor repeat prescription requests to ensure continuity of drug supply, to minimise potentially harmful drug interactions (including any drugs recommended by other specialists for unrelated conditions) and to manage compliance problems when complicated regimens involve large numbers of tablets (particularly if the patient has impaired eyesight or cognition).

The GP can also treat any complications the patient experiences, such as constipation or sleep disturbance, or adverse medication effects. Psychiatric disorders may be detected more easily if reviews are regular.

Non-drug therapy

Although neurological impairments can be partly reduced by medication, other interventions facilitate living with PD. Assessment of the home situation is a priority.

Many patients with PD are supported by elderly spouses who themselves have a disability.

Physiotherapy may help with gait, balance, movement initiation and functional independence.

Occupational therapy can help with employment/leisure activities, self-care and home safety. Provision of walking aids or a wheelchair can be invaluable. A speech and language therapist can assist with intelligibility of speech or alternative modes of communication, and with swallowing difficulties.

In later stages of the disease, involving a palliative care specialist may be appropriate, but the GP is well placed for opportunistic discussion about end-of-life matters and arranging holistic support.¹

Psychosocial assistance

Imparting information clearly, considerately and in a stepwise manner enables the patient to undertake self-care and maintain hope.

An appropriately timed suggestion to the patient or carer to consider the advantages of making a lasting power of attorney or an advance directive may be appreciated, as the patient becomes less physically capable of managing.

A specialist nurse can provide support and information, such as assessing response to treatment and reviewing medication.

Many patients and carers find practical assistance and friendship through organisations such as Parkinson's UK, Carers UK and Age UK. Social services can discuss allowances, residential care for the patient or respite periods for the carer.

Every carer is legally entitled to a carer's assessment. Labelling the carer's medical records with a suitable Read code alerts the GP to consider their health and wellbeing.

Safe transport

Car owners may persist with driving without recognising how hazardous it is. Car modifications might help some patients. A trial drive could be arranged with an authorised assessor. The patient should inform the DVLA about the diagnosis; if not, the GP must do so (informing the patient of this and the reasons for it).

A symptom questionnaire can be completed online.³ Social workers can advise patients on community transport, refunds of costs of attending hospital appointments, or obtaining a Blue Badge for a carer's car.

Conclusion

The GP's role is to co-ordinate holistic management, considering any comorbidity and the patient's domestic situation, and ensuring the patient has the support needed for self-care.