New guideline on Parkinson's disease aimed at physicians and people with Parkinson's

A comprehensive new Canadian guideline provides practical guidance for physicians, allied health professionals, patients and families on managing Parkinson disease, based on the latest evidence. The guideline is published in CMAJ (Canadian Medical Association Journal), accompanied by an easy-to-reference infographic and podcast.

Parkinson disease is a debilitating, progressive neurological condition that affects quality of life for patients and their caregivers.

Since publication of the first Canadian guideline in 2012, there have been substantial advancements in the literature for Parkinson disease. The new guideline, funded by Parkinson Canada, is based on the latest evidence and advances in diagnosis, treatment and symptom management, and contains a new section on palliative care. Experts from various health disciplines from across Canada helped develop the guideline.

"We hope this guideline will help physicians and other health care professionals improve the care of people with Parkinson disease," says Dr. David Grimes, a neurologist at The Ottawa Hospital and the University of Ottawa Brain and Mind Research Institute, Ottawa, Ontario.

The guideline is divided into 5 sections for ease of use. Highlights:

Communication

• People with Parkinson disease should be encouraged to participate in choices about their own care.
• Communication should be both verbal and written.
• Discussions should aim for balance between providing realistic information about prognosis and promoting optimism.
• Families and caregivers should be informed about the condition and available support services.

Diagnosis and progression

• Suspect Parkinson disease in anyone with tremor, stiffness, slowness, balance problems or gait disorders.
• CT or MRI brain scanning should not be routinely used to diagnose Parkinson disease.
• No therapies are effective for slowing or stopping brain degeneration in Parkinson disease.

Treatment

• A regular exercise regimen begun early has proven benefit.
• Patients with possible diagnosis of Parkinson disease may benefit from a trial of dopamine replacement therapy to help with diagnosis.
• Deep brain stimulation and gel infusion are now routinely used to manage motor symptoms.
• Rehabilitation therapists experienced with Parkinson disease can help newly diagnosed patients, and others through all stages.

Nonmotor features

• Botulinum toxin A helps control drooling.
• Management of depression should be tailored to the individual and their current therapy.
• Dementia should not exclude a diagnosis of Parkinson disease, even if present early.
• Rapid eye movement sleep behaviour disorder can predate the diagnosis of Parkinson disease.

Palliative care

• The palliative care needs of people with Parkinson disease should be considered throughout all phases of the disease.
• If the patient asks, the option of medical assistance in dying should be discussed.

In addition to its usefulness to health care professionals, the guideline may be used by policy-makers, charities and funders as well as people with Parkinson disease and their families.

"A limitation to implementing the guideline is the lack of access to health care providers experienced in caring for people with Parkinson disease," says Dr. Grimes. "In addition to specialist physicians, we need more nurses, and speech, occupational and physical therapists with training in this area, as well as adequate palliative care for Parkinson patients."

The guideline, which draws upon recommendations from Scotland, the United Kingdom, the European Union and the United States, is focused on recommendations relevant to the Canadian health care system.

"The guideline provides evidence-based recommendations to improve the overall standard of care of individuals with Parkinson disease in Canada, not only for health care professionals, but also for policy-makers, patients themselves and their caregivers," writes Dr. Veronica Bruno, Department of Clinical Neurosciences, Movement Disorders Program and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, and coauthor in a related commentary. "Managing the complexity of Parkinson disease requires clear, standardized procedures that can be used by all actors involved."

The guideline "represents a great effort to streamline the management of Parkinson disease across Canada," they write.