Updated Canadian Guideline Reflects Latest Advances and Adds Palliative Care Section

Updated recommendations on Parkinson’s disease have been published in the Canadian Guideline for Parkinson Disease, which includes a new section about palliative care.

Focused on issues relevant to the Canadian healthcare system, the update reflects the latest evidence and advances — particularly regarding diagnostic criteria and treatment options — and draws on recommendations from the United States, Scotland, the United Kingdom, and the European Union.

The Parkinson Canada-funded publication, which was published in the Canadian Medical Association Journal, offers fundamental guidance to healthcare professionals, patients, and families, and was developed with help from experts in Canada from various disciplines.

“This guideline provides evidence-based recommendations to improve the overall standard of care of individuals with Parkinson disease in Canada, not only for healthcare professionals, but also for policy makers, patients themselves, and their caregivers,” Veronica Bruno, MD, a neurologist with a subspecialty in movement disorders at the University of Calgary, said in a news release. “Managing the complexity of Parkinson disease requires clear, standardized procedures that can be used by all actors involved.”

The new guideline has five sections: communication, diagnosis and progression, treatment, non-motor features, and palliative care, which was added in this update. Palliative care, including an option of medically assisted death, should be considered throughout the course of the disease, the publication states.

“End-of-life choices, including advanced care planning with an open and frank discussion with the patient and the person designated as decision-maker, should be initiated early in the disease process,” the guideline says. “Conversations occurring in the ambulatory setting are likely to be more productive and less crises-driven than leaving such conversations until an acute stay in hospital.”

Other highlights include:

• discussion on impulse control disorders, which can develop at any disease stage in patients who are on dopaminergic therapy, particularly dopamine agonists.
• information on advanced therapies, such as deep brain stimulation and intrajejunal levodopa-carbidopa gel infusion, which are now routinely used to manage Parkinson’s motor symptoms and fluctuations.
• evidence showing that exercise interventions should be started early, and that even those with well-established disease can benefit from exercise.
• recommendation that magnetic resonance imaging or other brain scanning should not be used in routine diagnostics, due to overall ineffectiveness.
• evidence that botulinum toxin A (sold with the brand name Botox, among others) helps control the drooling often experienced by Parkinson’s patients.
• recognition that rapid eye movement sleep behavior disorder can be linked to Parkinson’s development.
• evidence that people suspected of having Parkinson’s may benefit from dopamine replacement therapy to help diagnosis.
• guidance on rehabilitation therapy and its benefits for Parkinson’s patients, including those newly diagnosed.

“A limitation to implementing the guideline is the lack of access to health care providers experienced in caring for people with Parkinson disease,” David Grimes, a neurologist at The Ottawa Hospital, said.

“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,” he added.