Audience

  • Highland HSCP
  • Primary and/or Secondary Care.

Key points

Key Points

  • Refer suspected Parkinson’s disease (PD) patients early, before beginning treatment, to a clinician with relevant expertise, who should be involved in both initiation and ongoing monitoring of drug therapy.
  • Therapy for PD should be multi-disciplinary; drug treatment is only one aspect
  • 'Is this person at risk of developing delirium, and how will I reduce that risk?"

Drug treatment of PD aims to alleviate the symptoms whilst seeking to reduce the potential to develop dopaminergic complications.

Tremor generally responds poorly to most drugs. Expectations need to be created at the outset.

A clinician with expertise in PD should be involved in drug treatment decisions on the initiation and ongoing monitoring of therapy as the disease progresses. Drugs used in the treatment of PD are detailed in the Highland Formulary (see resources). 

Common drug-related problems

Nausea and vomiting  Domperidone* is now no longer recommended for long-term use however in some patients with PD the benefits may outweigh the risks. Other antiemetics may cause worsening of PD symptoms, including metoclopramide and prochlorperazine.
Dizziness and instability  Balance disturbances are common in PD and unlikely to respond to treatment; consider hypotension, avoid drug treatment, in particular avoid prochlorperazine. Referral to physiotherapy should be considered.
Depression  For patients on monoamine-oxidase-B inhibitors (eg selegeline) consider mirtazapine as first-line therapy. Monitor as per guidance (see resources)
Correct formulations  Ensure accurate prescribing of all modified-release (m/r), immediate release (IR), dispersible and combination preparations (Stanek /Stalevo). Doses of m/r and immediate-release preparations are not interchangeable.
Confusion and hallucinations 

Patients with Parkinsonian syndromes have a lower threshold for confusion and hallucinations; if these symptoms develop consider drug-related causes, the standard medical causes of delirium and the need for specialist referral. If patients have significantly disturbed or distressing behaviour, antipsychotics such as haloperidol should be avoided. If necessary, lorazepam may be used- see SIGN annex 4 (see resources)

Dementia is common in PD; see treatment guidance in Shared care guidelines for prescribing cholinesterase inhibitors and memantine for dementia (see resources).
Anti-cholinergics There is a particular risk of confusion with anticholinergics see cholinergic burden (see resources). In Overactive bladder symptoms use of drugs that have the least anticholinergic properties should be used, with regular review for efficacy.
Orthostatic hypotension

Measure postural blood pressures in patients presenting with light-headedness or dizziness. Advise simple measures as first-line treatment:

  • 2 litres fluid daily
  • compression stockings
  • raise head of the bed by 15 degrees.
  • Avoid large meals and alcohol
  • Increase salt intake

Review medications which may lower blood pressure: often in PD BP levels reduce over time and medication may not be required.

Medicines to consider - Midodrine, fludrocortisone (or domperidone, can be considered under specialist advice [off-label].)
Excess salivation Speech and language therapy can help as there tends to be an associated swallowing problem. Oral application of atropine sulfate drops 1% may be helpful [off-label]. See also saliva management: sialorrhoea guidance on TAM (see resources).

*Domperidone is associated with a small increased risk of serious side-effects and is now contra-indicated in those with underlying cardiac conditions and other risk factors – see Gov Drug safety update (see resources) In patients with PD it is useful as an antiemetic and to treat orthostatic hypotension – please discuss with a specialist before discontinuing treatment and for further information see Association of British Neurologists (ABN) advice (see resources). 

Administration of Parkison's disease medication in hospital

It is vitally important that patients in hospital receive their PD medication at the correct time, even if this is outwith normal drug times; sudden changes in PD medication can lead to sudden, severe deterioration.

Symptom control in hospital relies on patients receiving medication at specific times to ensure:

  • improvement in the patient’s quality of life
  • prevention of deterioration in a patient’s condition which can result in slowness, stiffness, immobility, tremor and rigidity
  • prevention of acute withdrawal of medication (which can result in acute adverse reactions)
  • prevention of unnecessary extension in a patient’s hospital stay.

When patients with PD are admitted to hospital:

  • refer to guidance Inpatient management of Parkinson’s including nil by mouth guidance (see resources) 
  • the local Parkinson’s team should be informed by telephone
  • where possible patients should self-administer their PD medication.

Patient journey

  1. GP suspects PD and refers patient to Consultant.
  2. Parkinson’s disease clinics held at Caithness General Hospital, Wick, Raigmore Hospital, Inverness and County Hospital, Invergordon and Fort William and in peripheral clinics, eg Skye. The PD service for patients from Argyll & Bute H&SCP is now delivered from GG&C. Patients under the age of 65 years with suspicion of PD should be referred to Neurology Outpatients Clinic, Raigmore Hospital.
  3. Consultant discusses differential diagnosis, treatment options such as physiotherapy, speech and language therapy, occupational therapy and medication, and gives information on PD.

Editorial Information

Next review date: 01/01/2024

Author(s): Neurology Department .

Approved By: TAMSG of the ADTC

Reviewer name(s): Dr D Gray, Associate Specialist .

Document Id: TAM281

Related resources

Further information for Health Care Professionals

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References

Further information for Patients

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Self-management information