January2017-1

CALGARY AND AREA

Specialist LINKLinking Physicians

PatientName: DateofReferral:

DateofBirth: ReferringMD:

CalgaryRHRN: Fax:

PHN/ULI: Today’sDate:

CONFIRMATION: ReferralReceived

TRIAGECATEGORY: EnhancedPrimaryCarePathway:Parkinson’sDisease

REFERRALSTATUS: ACCEPTEDconsideractionsinthemedicalhomeasoutlinedbelowDearColleague,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithParkinson’sDisease.TheDivisionofNeurologyhaschangedthetriagemanagementofcertainmovementdisorderstoshortenwaittimesandyourpatientwillbeseenmorerapidlybyaGENERALNEUROLOGIST.ConsultationswiththeSUBSPECIALITYMOVEMENTDISORDERNEUROLOGISTwilloccurifandwhenthecasebecomesmorecomplex.Ifyoufeelthereissufficientfunctionalimpairmentindailyactivities,PLEASEstartlevodopa(Sinemet)priortothispatientbeingassessed.Themedicationiswelltoleratedandapositiveresponsetomedicationwillnothinderconfirmationofthediagnosis–infact,improvementofsymptomsandsignswiththismedicationmaysupportyourclinicaldiagnosis.Resourcesforpatientsaswellasguidelinesforinitiatinglevodopaareattached.PLEASEalsoconsiderareferraltocommunityphysiotherapyorCommunityAccessibleRehab(CAR)ortheFALLSclinicnotingParkinson’sDiseaseasthediagnosisifthereissufficientfunctionalimpairment.ThisclinicalpathwayandcareadvicehasbeendevelopedbytheCalgaryZonePrimaryCareNetworksinpartnershipwiththeSectionofNeurologyandAlbertaHealthServices.Theselocalguidelinesarebasedonbestavailableevidence,currentlocalresourcesandarepracticalintheprimarycaresettingThisreferralisACCEPTEDandanappointmenttimeispendingwithaGeneralNeurologist.Thepatientwillbecontacteddirectlywithappointmentinformationonceavailable.ForgeneraladviceonpatientcarefromaNeurologistinthiscaseorothers,callSpecialistLINK,aneurologyphoneconsultationservice,available08:00-17:00weekdaysat403.910.2551ortoll-freeat1.844.962.5465.Thankyou,CentralAccessandTriageSectionofNeurologyDepartmentofClinicalNeurosciences

January2017-2

EnhancedPrimaryCarePathway:Parkinson’sDisease

1.FocusedsummaryofPDrelevanttoprimarycare

Parkinson’sDisease(PD)andEssentialtremor(ET)aretwoofthemostcommonmovementdisordersencounteredbyfamilydoctors;bothpresentwithtremorbutthetwodisordersaretreateddifferently.ThediagnosisofPDisclinical.Wherethereisfunctionalimpairment,treatmentcanproducesignificantbenefitandmaybeinitiatedwithoutaneurologyreferral.Parkinson’sDiseaseischaracterizedbytremorATREST(notwhileholdingobjects),cogwheelrigidity,bradykinesia(slowness)andbalancedifficulty(posturalinstability).Patientscomplainofunilateralonsetoftremorwhiletheirhandisatrest,smallhandwritingincomparisontothepast(micrographia),decreasedfacialexpression,softvoice(hypophonia),andstiffnessresultinginslowmovement(bradykinesia).Overyears,thesesignsandsymptomsspreadtobecomebilateral.ThemnemonicTRAPisoftenusedasareminderofthecardinalfeaturesofidiopathicPD,consistingof:restingTremor,cogwheelRigidity,Akinesiaorbradykinesia,andPosturalinstability.Other“non-motor”symptoms,presentatearlystagesofthediseaseincludedecreasedolfaction,depressionandanxiety,balancedifficulty,constipation,bladderdysfunctionandseeming“actingoutofdreams”whileinbedatnight(REMsleepbehaviordisorder).Druginducedparkinsonismshouldbeexcluded.Commonculpritdrugsincludemetoclopramide(usedtotreatnausea)aswellasavarietyofantipsychoticmedications(haloperidol,olanzapine,aripiprazole,pimozideandrisperidone).Assistancefrompsychiatrywillbeneededinchangingantipsychoticmedicationstomedicationssuchasquetiapineorclozapine.IfthereissufficientfunctionalimpairmentofdailyactivitiesinidiopathicParkinson’sDisease,medicaltreatmentisindicated.OfallthedrugsavailabletotreatPD,levodopahasthegreatestefficacywiththefewestsideeffectssoisthedrugofchoice.LevodopacomesinmultipleformulationsbutSinemetregular100/25(levodopa/carbidopa),yellowincolour,(notSinemetCR)shouldbeused.PatientswithPDshowdramaticbenefittoadequatedosesoflevodopa,whichimprovestremorandbradykinesia,gaitandfacialexpression.Section4describesanexampletitrationscheduleforthismedication.ThereareanumberofsimilarneurodegenerativesyndromestoPDwhichintheinitialstagescanappearasPD;however,astheyearspass,certainsignsandsymptomsemergethatalertthecliniciantoanalternatediagnosis.Intheearlystages,itisdifficulttodistinguishPDfromtheseothersyndromes.However,thepresenceofearlydementia,fallingandhallucinations,aswellaslackofasignificantbenefittolevodopa,shouldwarntheclinicianthatanotherdiagnosis(LewyBodydementia,progressivesupranuclearpalsy,multiplesystemsatrophy)maybeentertained.Patientswiththeseotherconditionsoftenbenefitfromlevodopa,butnotasmuchasthosewithPD;atrialoflevodoparemainsworthwhileinthesepatients.

January2017-3

COMPARISONOFTREMORINETANDPD

EssentialTremor Parkinson’sDisease• Tremorpresentwithholdingobjectsor

performingtasks• Head/voicetremor• Bilateralonsetoftremor,usuallyhands• ETOHresponsive(1-2drinkswine/beer)• Nocogwheelrigidity• Writinglargeandshaky• Tremorbetterwithwalking• Positivefamilyhistory

• Tremorpresentatrest• Chintremor• Unilateralonsetoftremor/bradykinesia• ETOHunresponsive• Cogwheelrigidity• Smallhandwriting(micrographia)• Tremoremergeswithwalkingwithreduced

armswig;stooped,shufflinggait• Often,noclearfamilyhistory

January2017-4

2.Checklisttoguideyourin-clinicreviewofthispatientwithPDsymptoms

o SignsofPD

o NosignsofEssentialTremor

o Ruleoutdruginducedparkinsonism:metoclopramidefornausea;antipsychotics:haloperidol,pimozide,risperidone,olanzapine,aripiprazole

o NoredflagssuggestiveofanotherparkinsonianconditionotherthanParkinson’sDisease(rapidprogressionofdisability;earlydementia,falls,hallucinations,nobenefitfromlevodopa)

o Ifthereissignificantfunctionalimpairment,startlevodopa(Sinemet)(seeSection4)3.Linkstoadditionalresources

Forphysicians:

www.parkinson.org

REFERRALFORMFORCOMMUNITYACCESSIBLEREHABPROGRAM:http://www.albertahealthservices.ca/frm-104014.pdf

UniversityofCalgaryDepartmentofClinicalNeurosciencesMovementDisordersClinicwebsite:www.dcns.ca/programs/movementdisorders

http://www.parkinsonalberta.ca

http://www.uptodate.com

http://www.parkinsonclinicalguidelines.ca/sites/default/files/PhysicianGuide_Non-motor_EN.pdf

Forpatients:

UpToDate®-BeyondtheBasicsPatientInformation(freelyaccessible)

Parkinson’sAlberta:http://www.parkinsonalberta.ca/

Parkinson’sDiseaseFoundation:http://www.pdf.org/

www.michaeljfox.org4.SuspectedPDPathway

ThisAHSCalgaryZonepathwayhasbeendevelopedwithconsiderationoftheseguidelines.Thefollowingisbest-practiceclinicalpathwaysformanagementofPDintheprimarycaremedicalhome:

CALGARY AND AREA

Specialist LINK

SUSPECTED PARKINSON’S DISEASE

Drug-induced Parkinsonism:

• Psychiatric drugs (see text)• Anti-emetic drugs (example: Metoclopramide)

CHANGE IF POSSIBLETo reverse drug induced

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Red Flags • Rapid progression• Early dementia• Early falls and hallucinations• No benefit from levodopa• Dystonia• Aphasia• Trunk/limb ataxia

• T - Resting tremor• R - Cogwheel rigidity• A - Akinesia/bradykinesia• P - Postural instability

If functional disability, start Sinemet regular 100/25; consider further increase after evaluation.

January2017-6

IfapatientwithsuspectedParkinson’sDiseaseneedsandwishesmedicaltreatment(andtherearenoredflagsorevidenceofdruginducedparkinsonism),thenlevodopashouldbeinitiated.TheformulationofchoiceisSinemetregular100/25(yellowtablet).Initiatetreatmentint.i.d.dosingwithmealsstartingwith½tablett.i.d.andincreasingoverto1tablett.i.d..Atthispoint,evaluatethepatientagain-ifthepatientisbetter,itmaybebesttoleavethemedicationatthisdose.Otherpatientswillbenefitfromafurtherincreaseto2tabletst.i.d.,whichremainsamodestdose.StartingSinemet100/25

Week Breakfast Lunch Supper1 0.5 0.5 0.52 1 1 1EVALUATE3 1.5 1.5 1.54 2 2 2

Potentialsideeffectsoflevodopaareprimarilylimitedtonausea(usualmildandtransient),andmildposturalhypotension.Persistentnauseamaybetreatedbytakingthelevodopawithmealsorasmallsnackorstartingdomperidone10mg1/2hourpriortoeachdoseoflevodopaandnotexceeding10mgt.i.d..DomperidonemayprolongtheQTinterval,arisktoconsider,butcanprovidesignificantbenefittorefractorynausea. Commonerrorsinstartinglevodopaincludeschedulingthemedicationdosestoofarapart(i.e.,6a.m.and6p.m.)orstayingatalowdoseofmedication(1tablett.i.d.)despiteprogressionofsymptomsandsigns.PDisaprogressiveneurodegenerativeconditionandmedicationswillneedtobeincreasedovertime,dependingonindividualpatientneeds.