Annals of Long Term Care

Parkinson’s disease (PD) was originally described in 1817 by English surgeon James Parkinson, who referred to the condition as “shaking palsy.”¹ PD is the second most common neurodegenerative disease in adults, following Alzheimer’s disease.² PD is estimated to afflict approximately 1 million Americans, or about 1% of the US population older than 60 years.^3,4 This number is likely to double in the next 15 to 20 years as baby boomers continue to age.⁵

PD is uncommon before the age of 40, and its prevalence and incidence increases steadily thereafter.^5,6 The incidence is higher among men than women,⁷ but all races and ethnic groups are affected.⁴ Although therapy can ameliorate the symptoms of PD and improve both the quality of life and life expectancy, PD continues to be associated with progressive disability and increased mortality.^8,9 FDA-approved medications to treat PD are summarized in Table 1 [click thumbnail for full view].

The cardinal signs of PD are resting tremor, rigidity, bradykinesia, and postural instability. Other common signs include micrographia (small handwriting), mask-like facial expressions, shuffling gait, and muffled speech. Motor complications of PD are outlined and defined in Table 2 [click thumbnail for full view]. Neuropsychiatric complications and autonomic disturbances are also commonly seen.

Although PD cannot yet be cured, early diagnosis and treatment can extend patients’ lives, improve their mobility and function, and enhance their quality of life. Clinical guidelines can help clinicians effectively manage PD in their patients. Numerous clinical guidelines for the management of PD exist, including by AMDA–Dedicated to Long Term Care Medicine, the American Academy of Neurology, the National Institute for Health and Clinical Excellence, and other organizations; thus, determining which guidelines to follow may be challenging for clinicians. We review one of the most recently published PD guidelines, which was released by the Movement Disorder Society’s Task Force on Evidence-Based Medicine in Movement Disorders and appeared in the European Handbook of Neurological Management.^10,11 These guidelines are unique because they were composed following a comprehensive review of the existing literature, including other guidelines, and outline level of evidence for most recommendations. While these guidelines may have some degree of bias, which we will discuss later in this article, they nevertheless provide solid recommendations that can help guide clinical practice. We also provide a case scenario that demonstrates how the guidelines can be applied in the long-term care setting.

Case Scenario

The patient is a 75-year-old white man who has been a nursing home resident for 3 years. The patient’s medical history includes PD, which was diagnosed 10 years earlier, and mild hypertension. The patient’s current medications include selegiline 5 mg twice daily and carbidopa-levodopa every 6 hours to control his PD symptoms, and hydrochlorothiazide 25 mg daily to treat his hypertension.

The nursing staff report that the resident sustained multiple falls and has demonstrated increasing disorientation in the previous few months. He has also required more redirection and has worsening memory. During the day, the patient has increased tremors and stiffness in his upper extremities, but these symptoms are relieved by his next dose of carbidopa-levodopa.

On physical examination, the patient’s supine blood pressure is 120/80 mm Hg. When moved to a sitting position, he reports severe vertigo, and a decline in systolic blood pressure of 40 mm Hg is noted. He has bilateral resting hand tremors, mild rigidity in his upper extremities, and a slow, shuffling, unsteady gait. His Mini-Mental State Examination score is 20. What treatment options are available to manage this patient’s illness? Following a review of the guidelines, we outline potential treatment options for this case scenario.

Guideline Methods and Potential Limitations

Guidelines for the therapeutic management of PD were initially published by the Movement Disorder Society’s Task Force on Evidence-Based Medicine in Movement Disorders in two chapters of the European Handbook of Neurological Management in 2006 and were updated in late 2010.^10,11 In one chapter, Oertel and colleagues¹⁰ address the pharmacologic, neurosurgical, and nonpharmacologic/non-neurosurgical management of early-stage PD.In the other chapter, the authors¹¹ provide guidelines for the symptomatic control of motor and nonmotor problems in late-stage PD, outlining pharmacologic and nonpharmacologic treatments, as well as preventive and symptomatic therapies.While important potential outcomes are considered, a formal cost analysis for various options was not conducted. Because of the large volume of evidence and the detailed, comprehensive nature of the recommendations, this article will be limited to the updated guidelines related to patients with late-stage (complicated) PD, which have practical value for busy, practicing long-term care professionals treating residents who have this disease.

The guideline authors searched Medline, the full database of the Cochrane Library, and the International Network of Agencies for Health Technology Assessment for articles published up to September 2009 to gather evidence. Databases were searched for existing guidelines and management reports, requests were made to the European Federation of Neurological Societies (EFNS) for its guidelines, and reference lists from selected articles were checked. The search resulted in more than 100 recommendations and 530 references. The authors failed to define explicit inclusion and exclusion criteria for collected evidence, which may have introduced selection bias into the recommendations. Although the resulting guidelines are comprehensive, too many recommendations were made and there was a lack of focus on tackling individual symptoms of the disease. Both of these factors may diminish the usefulness of these guidelines in clinical practice.

The guidelines were authored by the Movement Disorder Society’s 20-member Task Force on Evidence-Based Medicine in Movement Disorders. The original author group members met in June 2008 and May 2009 to develop a strategy for revising the original guidelines, and additional members were asked to join the author group. Two authors reviewed publications relating to each section of the original document, graded the evidence, and made necessary revisions. The authors stated their departmental affiliations, country of origin, and potential conflicts of interest, but failed to divulge their academic titles, educational affiliations, or clinical areas of expertise. A task force dominated by specialty group members could add significant bias to the recommendations. Author groups that have a balance of practicing generalists, specialists, and researchers are more likely to produce objective guidelines. The absence of a formal process of deliberation may have produced additional guideline bias, and consideration of patient preferences in guideline development was not apparent.

The authors gathered pertinent articles published up to September 2009, and the guidelines were published in late 2010; thus, the evidence was current. Although some evidence was gathered from the 1970s, most references were dated within 5 to 10 years of guideline publication. The guidelines were not subjected to an external review by an objective group of professionals, and their applicability in clinical practice was not determined.

More than 100 recommendations were included in the final guidelines. Individual recommendations were preceded by a comprehensive review of evidence, which we do not discuss in this article. The strength of evidence and rating of recommendations were classified according to EFNS guidance.¹²