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Guideline Summary
Guideline Title
Diagnosis and pharmacological management of Parkinson's disease. A national clinical guideline.
Bibliographic Source(s)
Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and pharmacological management of Parkinson's disease. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Jan. 61 p. (SIGN publication; no. 113).  [189 references]
Guideline Status

This is the current release of the guideline.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

Drug Withdrawal

  • March 29, 2007 – WITHDRAWAL: Permax (Pergolide) External Web Site Policy: Voluntary market withdrawal in the U.S. and worldwide due to safety concerns of an increased risk of cardiovascular events. See the U.S. Food and Drug Administration (FDA) Web site for more information.

Scope

Disease/Condition(s)

Parkinson's disease

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Geriatrics
Medical Genetics
Neurology
Nursing
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Health Care Providers
Managed Care Organizations
Nurses
Patients
Pharmacists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Guideline Objective(s)

To provide recommendations based on current evidence for best practice in the diagnosis and pharmacological management of Parkinson's disease

Target Population

Patients with Parkinson's disease

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Clinical diagnosis
  2. Referral for diagnosis
  3. Pathological confirmation
  4. Diagnostic tools
    • Functional imaging
      • Single photon emission computed tomography
      • Positron emission tomography
    • Structural imaging
      • Transcranial ultrasound
      • Computed tomography or magnetic resonance imaging
    • Acute dopaminergic testing
    • Chronic levodopa response
    • Olfactory testing
  5. Diagnosing depression in patients with Parkinson's disease

Treatment/ Management

  1. Drug efficacy in early disease
    • Levodopa
    • Dopamine agonists (ergot-derived dopamine agonists not recommended as first-line therapy)
    • Monoamine oxidase B inhibitors
    • Anticholinergics (not recommended as first-line therapy)
  2. Pharmacological management of motor complications
    • Monoamine oxidase B inhibitors
    • Oral and transdermal dopamine agonists
    • Apomorphine
    • Catechol-o-methyl transferase inhibitors
  3. Management of daytime sleepiness*
  4. Oral supplements (tocopherol)
  5. Treatment for gait disorders**
  6. Pharmacological treatment of mental health disorders
    • Low-dose clozapine
    • Monitoring psychosis treatment

*Modafinil and melatonin are not recommended for the management of excessive daytime sleepiness.

**Botulinum toxin not recommended for significant gait freezing.

Note: The role of the allied health professionals and the benefits of neurosurgical management of Parkinson's disease, such as deep brain stimulation, have not been covered in this guideline. The management of some non-motor symptoms is not included in this guideline.

Major Outcomes Considered
  • Sensitivity and specificity of diagnostic testing
  • Change in disability rating scores
  • Changes in activities of daily living scores
  • Time to initiation of levodopa
  • Adverse drug effects
  • Incidence of comorbidities

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Quantitative Search Parameters

The literature review for this guideline addressed a set of key questions defined by the guideline development group. Searches were carried out for the period 1998-2008, with some covering the period 1980-2008. Databases used were the Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, CINAHL, Embase, Medline and PsycINFO. A search of key terms and key sites was also carried out on the Internet. A copy of the Medline version of the main strategy will be included in the "supporting materials" section of the Scottish Intercollegiate Guidelines Network (SIGN) website after publication (see the "Availability of Companion Documents" field). Members of the guideline development group contributed additional literature.

The searches identified 2,448 papers of potential interest. Of these 640 were identified as having the potential to form part of the evidence base and were reviewed in detail.

Identifying Qualitative Evidence

A literature search was carried out covering the databases CINAHL, Embase, Medline, and PsycINFO for the period 1998-2008. This search focused on the identification of qualitative literature relevant to the following themes in Parkinson's disease: communication, information needs, family/carer needs, attitudes to drug therapy, non-motor symptoms and multidisciplinary team working. A copy of this search strategy is available on the SIGN website (see the "Availability of Companion Documents" field).

The initial result from this search was 597 references. An initial sift of the results aimed at removing clearly irrelevant papers and focusing on research journals reduced this number to 55 references.

Two pairs of reviewers independently reviewed this list of abstracts to identify relevant papers. At the end of this process, the number of papers considered to be of relevance was reduced to 10.

Each pair of reviewers was then asked to identify themes that emerged from the joint list of selected papers, and to pick out papers that they thought represented the key issues underlying each theme. These papers were reviewed for methodological quality using the Critical Appraisals Skills Programme (CASP) checklist developed by the Public Health Resource Unit, Oxford. At the conclusion of this process the papers included as evidence were split into six themes: communication, information needs, family/carer needs, attitudes to drug therapy, non-motor symptoms and multidisciplinary team working.

Number of Source Documents

10

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort studies

High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies (e.g., case reports, case series)

4: Expert opinion

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Once papers have been selected as potential sources of evidence, the methodology used in each study is assessed to ensure its validity. The result of this assessment will affect the level of evidence allocated to the paper, which will in turn influence the grade of recommendation that it supports.

The methodological assessment is based on a number of key questions that focus on those aspects of the study design that research has shown to have a significant influence on the validity of the results reported and conclusions drawn. These key questions differ between study types, and a range of checklists is used to bring a degree of consistency to the assessment process. The Scottish Intercollegiate Guidelines Network (SIGN) has based its assessments on the MERGE (Method for Evaluating Research and Guideline Evidence) checklists developed by the New South Wales Department of Health, which have been subjected to wide consultation and evaluation. These checklists were subjected to detailed evaluation and adaptation to meet SIGN's requirements for a balance between methodological rigour and practicality of use.

The assessment process inevitably involves a degree of subjective judgment. The extent to which a study meets a particular criterion - e.g., an acceptable level of loss to follow up - and, more importantly, the likely impact of this on the reported results from the study will depend on the clinical context. To minimise any potential bias resulting from this, each study must be evaluated independently by at least two group members. Any differences in assessment should then be discussed by the full group. Where differences cannot be resolved, an independent reviewer or an experienced member of SIGN Executive staff will arbitrate to reach an agreed quality assessment.

Evidence Tables

Evidence tables are compiled by SIGN Executive staff based on the quality assessments of individual studies provided by guideline development group members. The tables summarise all the validated studies identified from the systematic literature review relating to each key question. They are presented in a standard format to make it easier to compare results across studies, and will present separately the evidence for each outcome measure used in the published studies. These evidence tables form an essential part of the guideline development record and ensure that the basis of the guideline development group's recommendations is transparent.

Additional details can be found in the companion document titled "SIGN 50: A Guideline Developers' Handbook." (Edinburgh [UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50]), available from the SIGN Web site External Web Site Policy.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Synthesising the Evidence

Guideline recommendations are graded to differentiate between those based on strong evidence and those based on weak evidence. This judgment is made on the basis of an (objective) assessment of the design and quality of each study and a (perhaps more subjective) judgment on the consistency, clinical relevance and external validity of the whole body of evidence. The aim is to produce a recommendation that is evidence-based, but which is relevant to the way in which health care is delivered in Scotland and is therefore implementable.

It is important to emphasise that the grading does not relate to the importance of the recommendation, but to the strength of the supporting evidence and, in particular, to the predictive power of the study designs from which that data was obtained. Thus, the grading assigned to a recommendation indicates to users the likelihood that, if that recommendation is implemented, the predicted outcome will be achieved.

Considered Judgment

It is rare for the evidence to show clearly and unambiguously what course of action should be recommended for any given question. Consequently, it is not always clear to those who were not involved in the decision making process how guideline developers were able to arrive at their recommendations, given the evidence they had to base them on. In order to address this problem, Scottish Intercollegiate Guideline Network (SIGN) has introduced the concept of considered judgment.

Under the heading of considered judgment, guideline development groups summarise their view of the total body of evidence covered by each evidence table. This summary view is expected to cover the following aspects:

  • Quantity, quality, and consistency of evidence
  • External validity (generalisability) of study findings
  • Directness of application to the target population for the guideline
  • Any evidence of potential harms associated with implementation of a recommendation
  • Clinical impact (i.e., the extent of the impact on the target patient population, and the resources needed to treat them in accordance with the recommendation)
  • Whether, and to what extent, any equality groups may be particularly advantaged or disadvantaged by the recommendations made
  • Implementability (i.e., how practical it would be for the National Health Service [NHS] in Scotland to implement the recommendation.)

The group are finally asked to summarise its view on all of these issues, both the quality of the evidence and its potential impact, before making a graded recommendation. This summary should be succinct, and taken together with its views of the level of evidence represent the first draft of the text that will appear in the guideline immediately before a graded recommendation.

Additional detail about SIGN's process for formulating guideline recommendations is provided in Section 6 of the companion document titled "SIGN 50: A Guideline Developers' Handbook." (Edinburgh [UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50], available from the SIGN Web site External Web Site Policy.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

A national open meeting is the main consultative phase of Scottish Intercollegiate Guidelines Network (SIGN) guideline development, at which the guideline development group presents its draft recommendations for the first time. The national open meeting for this guideline was held on 18 September 2008 and was attended by 131 representatives of all the key specialties relevant to the guideline. The draft guideline was also available on the SIGN website for a limited period at this stage to allow those unable to attend the meeting to contribute to the development of the guideline.

Peer Review

All SIGN guidelines are reviewed in draft form by independent expert referees, who are asked to comment primarily on the comprehensiveness and accuracy of interpretation of the evidence base supporting the recommendations in the guideline. A number of general practitioners (GPs) and other primary care practitioners also provide comments on the guideline from the primary care perspective, concentrating particularly on the clarity of the recommendations and their assessment of the usefulness of the guideline as a working tool for the primary care team. The draft is also sent to at least two lay reviewers in order to obtain comments from the patient's perspective.

It should be noted that all reviewers are invited to comment as individuals, not as representatives of any particular organisation or group. Corporate interests, whether commercial, professional, or societal, have an opportunity to make representations at the national meeting stage where they can send representatives to the meeting or provide comment on the draft produced for that meeting. Peer reviewers are asked to complete a declaration of interests form.

The comments received from peer reviewers and others are carefully tabulated and discussed with the Chair and with the guideline development group. Each point must be addressed and any changes to the guideline as a result noted or, if no change is made, the reasons for this recorded.

As a final quality control check prior to publication, the guideline and the summary of peer reviewers' comments are reviewed by the SIGN Editorial Group for that guideline to ensure that each point has been addressed adequately and that any risk of bias in the guideline development process as a whole has been minimised. Each member of the guideline development group is then asked formally to approve the final guideline for publication.

Recommendations

Major Recommendations

Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC) In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.

The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.

Diagnosis

Clinical Diagnosis Compared with Pathological Confirmation

C - Clinicians should be aware of the poor specificity of a clinical diagnosis of Parkinson's disease in the early stages of the disease, and consider this uncertainty when giving information to the patient and when planning management.

D - Formal research criteria should not be used in isolation for diagnosing Parkinson's disease in a clinical setting but clinicians should take them into account when making a clinical diagnosis.

Who Should Make the Diagnosis?

C - Patients with suspected Parkinson's disease should be referred untreated to a hospital clinician with sufficient expertise in movement disorders to make the diagnosis.

Diagnostic Tools

Functional Imaging

B - Single photon emission computed tomography (SPECT) with (123I-labeled N-omega-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)tropane (123I-FP-CIT SPECT scanning) should be considered as an aid to clinical diagnosis in patients where there is uncertainty between Parkinson's disease and non-degenerative parkinsonism/tremor disorders.

C - Routine use of functional imaging is not recommended for the differential diagnosis of Parkinson's disease and Parkinson's plus disorders such as progressive supranuclear palsy and multiple system atrophy.

Structural Imaging

C - Transcranial ultrasound should not be undertaken in the differential diagnosis of idiopathic Parkinson's disease from other associated conditions, except within defined research protocols.

C - Computed tomography or magnetic resonance imaging brain scanning should not be routinely applied in the diagnosis of idiopathic Parkinson's disease.

D - Magnetic resonance imaging brain scanning is recommended in patients where it would be clinically helpful to identify:

  • The degree and extent of cerebrovascular disease, in particular in subcortical brain areas including the basal ganglia, to differentiate idiopathic Parkinson's disease from vascular parkinsonism.
  • The degree and distribution of brain atrophy, in patients with features suggesting a Parkinson's plus disorder.

C - Computed tomography or magnetic resonance imaging brain scanning is recommended in patients where it would be clinically helpful to identify:

  • The presence of a structural lesion or lesions which may cause or contribute to parkinsonism/gait disorder/tremor.

Acute Dopaminergic Testing and Chronic Levodopa Response

A - Acute challenge testing is not recommended in the diagnosis of Parkinson's disease.

A - Patients with suspected Parkinson's disease should be considered for a trial of chronic levodopa treatment.

Olfactory Testing

B - Objective olfactory testing is not recommended in the diagnosis of Parkinson's disease.

Diagnosing Depression in Patients with Parkinson's Disease

C - Self-rating or clinician-rated scales may be used to screen for depression in patients with Parkinson's disease.

Pharmacological Management

Drug Efficacy in Early Disease

A - Patients with early Parkinson's disease and motor symptoms may be considered for treatment with levodopa in combination with a dopa decarboxylase inhibitor.

A - Patients with early Parkinson's disease and motor symptoms may be considered for treatment with oral/transdermal dopamine agonists.

B - Ergot derived dopamine agonists should not be used as first line treatment for Parkinson's disease.

A - Patients should be warned about the potential for dopamine agonists to cause impulse control disorders and excessive daytime somnolence and be informed of the implications for driving/operating machinery.

A - Patients with early Parkinson's disease and motor symptoms may be considered for treatment with monoamine oxidase B inhibitors.

B - Anticholinergic drugs should not be used as first line treatment in patients with Parkinson's disease.

Pharmacological Management of Motor Complications

A - Monoamine oxidase B inhibitors may be considered for the treatment of motor complications in patients with advanced Parkinson's disease.

A - Dopamine agonists (oral or transdermal) may be considered for the management of complications in patients with advanced Parkinson's disease. The non-ergot agonists (ropinirole, pramipexole, and rotigotine) are preferable to the ergot agonists.

A - Intermittent subcutaneous apomorphine may be considered for the reduction in 'off' time in patients with advanced Parkinson's disease.

D - Subcutaneous apomorphine infusions may be considered for the management of severe motor complications, but should only be provided in units with sufficient experience and resources.

A - Catechol-o-methyl transferase inhibitors may be considered for the reduction in 'off' time in patients with advanced Parkinson's disease who have motor fluctuations.

Management of Daytime Sleepiness

A - Modafinil and melatonin are not recommended for the management of excessive daytime sleepiness associated with Parkinson's disease.

Oral Supplements

A - Tocopherol is not recommended for neuroprotection in patients with early Parkinson's disease.

Gait Disorders

B - Injection of botulinum toxin into the calf muscles of people with Parkinson's disease who have significant gait freezing is not recommended.

Pharmacological Treatment of Mental Health Disorders

A - Patients with psychosis in Parkinson's disease should be considered for treatment with low-dose clozapine and undergo weekly monitoring for the first 18 weeks of treatment followed by fortnightly monitoring for the first year and then monthly thereafter.

B - Where weekly monitoring of blood is not possible on a consistent basis, low-dose quetiapine should be considered as an alternative antipsychotic for the treatment of patients with psychosis in Parkinson's disease.

Definitions:

Grade of Recommendations

A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Level of Evidence

1++: High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort studies

High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies (e.g., case reports, case series)

4: Expert opinion

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and management of patients with Parkinson's disease

Potential Harms

Adverse effects of medications

Qualifying Statements

Qualifying Statements
  • This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgment should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is, however, advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.
  • Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on the Scottish Intercollegiate Guidelines Network web site, www.sign.ac.uk External Web Site Policy.

Prescribing of Licensed Medicines Outwith Their Marketing Authorisation

Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation (product licence). This is known as "off label" use. It is not unusual for medicines to be prescribed outwith their product licence and this can be necessary for a variety of reasons.

Generally the unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience.

Medicines may be prescribed outwith their product licence in the following circumstances:

  • For an indication not specified within the marketing authorisation
  • For administration via a different route
  • For administration of a different dose

Prescribing medicines outside the recommendations of their marketing authorisation alters (and probably increases) the prescribers' professional responsibility and potential liability. The prescriber should be able to justify and feel competent in using such medicines.

Any practitioner following a Scottish Intercollegiate Guidelines Network (SIGN) recommendation and prescribing a licensed medicine outwith the product licence needs to be aware that they are responsible for this decision, and in the event of adverse outcomes, may be required to justify the actions that they have taken.

Prior to prescribing, the licensing status of a medication should be checked in the current version of the British National Formulary.

Implementation of the Guideline

Description of Implementation Strategy

Implementing the Guideline

Implementation of national clinical guidelines is the responsibility of each National Health Service (NHS) Board and is an essential part of clinical governance. Mechanisms should be in place to review care provided against the guideline recommendations. The reasons for any differences should be assessed and addressed where appropriate. Local arrangements should then be made to implement the national guideline in individual hospitals, units and practices.

Auditing Current Practice

A first step in implementing a clinical practice guideline is to gain an understanding of current clinical practice. Audit tools designed around guideline recommendations can assist in this process. Audit tools should be comprehensive but not time consuming to use. Successful implementation and audit of guideline recommendations requires good communication between staff and multidisciplinary team working.

The guideline development group has identified the following as key points to audit to assist with the implementation of this guideline:

Graded Recommendation* Audit Point Options
C - Patients with suspected Parkinson's disease should be referred untreated to a hospital clinician with sufficient expertise in movement disorders to make the diagnosis. Was the patient referred untreated to a hospital clinician with sufficient expertise in movement disorders to make a diagnosis? Record drug class if treatment has already started.
A - Patients with early Parkinson's disease and motor symptoms may be considered for treatment with levodopa in combination with a dopa decarboxylase inhibitor.

A - Patients with early Parkinson's disease and motor symptoms may be considered for treatment with oral/transdermal dopamine agonists.

A - Patients with early Parkinson's disease and motor symptoms may be considered for treatment with monoamine oxidase B inhibitors.

B - Anticholinergic drugs should not be used as first line treatment in patients with Parkinson's disease

B - Ergot derived dopamine agonists should not be used as first line treatment for Parkinson's disease.
What drug classes were used to treat patients with motor symptoms in early disease? Recommended
  • Levodopa (with dopa decarboxylase inhibitor [DDI])
  • Non-ergot dopamine agonists (oral or transdermal)
  • Monoamine oxidase (MAO)-B inhibitors
Not recommended
  • Anticholinergics
  • Amantadine
  • Ergot derived dopamine agonists
A - Patients should be warned about the potential for dopamine agonists to cause impulse control disorders, excessive daytime somnolence and the implications for driving/operating machinery. Was appropriate information provided to patients prescribed dopamine agonists? Record provision of information:
  • Discussion with medical staff
  • Discussion with nursing staff
  • Written material
  • Website
  • Other

*See the "Rating Scheme for the Strength of the Recommendations" field for a definition of the ratings A-D.

Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and pharmacological management of Parkinson's disease. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Jan. 61 p. (SIGN publication; no. 113).  [189 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Jan
Guideline Developer(s)
Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]
Source(s) of Funding

Scottish Executive Health Department

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group: Dr Donald Grosset (Chair), Consultant Neurologist, Southern General Hospital, Glasgow; Dr Graeme Macphee (Secretary), Consultant in Medicine for the Elderly, Southern General Hospital, Glasgow; Ms Juliet Brown, Information Officer, SIGN; Dr Carl Counsell, Consultant Neurologist, University of Aberdeen; Dr Richard Davenport, Consultant Neurologist, Western General Hospital, Edinburgh; Mr Phillip Dry, Patient representative, Greenock; Mr Alan Dunbar, Patient Representative, Edinburgh; Professor Jonathan Evans, Professor of Applied Neuropsychology, Gartnavel Hospital, Glasgow; Ms Alison Foster, Senior Pharmacist, Ayr Hospital; Dr Duncan Gray, Associate Specialist, Care of the Elderly, Raigmore Hospital, Inverness; Dr Conor Maguire, Consultant in Medicine for the Elderly, Royal Victoria and Western General Hospitals, Edinburgh; Dr Moray Nairn, Programme Manager, SIGN; Dr Neil Prentice, Senior Lecturer in Old Age Psychiatry, Murray Royal Hospital, Perth; Dr Edwin Robertson, General Practitioner, Alexandria; Dr Stuart Rochow, Consultant in Medicine for the Elderly, Woodend Hospital, Aberdeen; Ms Shona Scott, Parkinson's Disease Nurse Specialist, Royal Alexandra Hospital, Paisley; Mr Andrew Sim, Scotland Manager, Parkinson's Disease Society; Dr Graeme Simpson, Consultant in Geriatric Medicine, Royal Alexandra Hospital, Paisley; Dr David Stewart, Consultant in Medicine for the Elderly, Victoria Infirmary, Glasgow; Ms Carol Vennard, Parkinson's Disease Nurse Specialist, Southern General Hospital, Glasgow

Financial Disclosures/Conflicts of Interest

Declarations of interests were made by all members of the guideline development group. Further details are available from the Scottish Intercollegiate Guidelines Network (SIGN) Executive.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Quick reference guide: diagnosis and pharmacological management of Parkinson's disease. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2010 Jan. 2 p. Electronic copies: Available in Portable Document Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site External Web Site Policy.
  • Diagnosis and pharmacological management of Parkinson's disease. Summary of recommendations. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2010 Jan. 3 p. Electronic copies: Available from the SIGN Web site External Web Site Policy.
  • Search narrative. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2010 Jan. 1 p. Electronic copies: Available in PDF from the SIGN Web site External Web Site Policy.
  • SIGN 50: A guideline developer's handbook. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2001 Feb. (SIGN publication; no. 50). Electronic copies: Available from the SIGN Web site External Web Site Policy.
  • Appraising the quality of clinical guidelines. The SIGN guide to the AGREE (Appraisal of Guidelines Research & Evaluation) guideline appraisal instrument. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2001. Available from the SIGN Web site External Web Site Policy.

In addition, a non-motor symptoms checklist and key points to audit are available in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on October 20, 2010. This summary was updated by ECRI Institute on May 20, 2011 following the U.S. Food and Drug Administration advisory on antipsychotic drugs.

Copyright Statement

Scottish Intercollegiate Guidelines Network (SIGN) guidelines are subject to copyright; however, SIGN encourages the downloading and use of its guidelines for the purposes of implementation, education, and audit.

Users wishing to use, reproduce, or republish SIGN material for commercial purposes must seek prior approval for reproduction in any medium. To do this, please contact sara.twaddle@nhs.net.

Additional copyright information is available on the SIGN Web site External Web Site Policy.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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