Good practice in commencing and changing Parkinson's medication regimes

Presentation slides

• Viv Horton presentation slides
• Dr Neil Archibald presentation slides

Summary

Starting therapy

“The prescription of Parkinson’s medication is a lot less formulaic than in other areas, like cardiology There is a lot of bespoke prescribing to the individual,” said Viv Horton.

It means that treatment decisions should be guided by the person’s situation and priorities, Viv said. She added that it was important to set realistic expectations of what to expect from medication, and explain that the drugs alone will not be enough to manage the condition.

Getting started

In terms of starting medication, clinicians should work with people to consider:

What are you trying to treat?

• Tremor
• Gait
• General motor function
• Nocturnal symptoms

What are you trying to avoid?

• Impulse control issues
• Dyskinesia
• Hallucinations

• Balance
  
• Cognition
• Sleep
• Driving

Person-centered care

Other factors that will influence a treatment plan will be comorbidities and the person’s individual beliefs about medication.

To explore a person’s beliefs around treatment options and side effects, Viv said clinicians can ask questions such as:

• Do you have any preferences regarding medication?
• What are you expecting this medication to provide?
• Do you have any previous experience with this medication?

Clinicians will also need to consider drug-drug interactions and contraindications, said Viv, pointing delegates to useful resources such as the British National Formulary app.

“Then we need to think about asking the patient what their day looks like, and what will suit them best. Is it a once-a-day medication or a three-times-a-day medication? How will it fit into their everyday life?”, said Viv.

Communication

Said Viv: “It is fantastic that we are copying letters to patients, but I do wonder what they might understand from seeing, for example, a prescription for Madapar 62.5mg tds.”

Even if they know what “tds” means, it does not give any useful information on important factors such as what time of day to take the medicine, she added.

“It’s worth thinking ‘am I being explicit in my communication?’ I like to give patients as much information as possible – some verbal information in addition to some written information,” said Viv.

Her tips on patient information included:

• Parkinson’s UK have a fanatic range of trusted information
• Provide clear information on medication benefits
• Provide clear information on possible side effects
• Provide information on what to do if they experience side effects

Communicating with the person’s GP is extremely important. Viv’s team often use a treatment recommendation forms which are filled out in clinic and handed to the patient. They either request the GP prescribe the treatment or they inform the GP of the treatment decision.

Information to be included in the more detailed clinic letter includes the details of any supply made, and recommended parameters such as the titration plan.

It can also be helpful to contact the person’s community pharmacy to let them know about any changes to medications.

Signposting

“I think it’s important to realise that when we’re starting medications, it’s just the beginning of the journey,” said Viv.

Her signposting checklist included:

• Do the Parkinson’s nurses know about this patient and vice versa?
• Is the patient aware of the neurotherapy team, physiotherapists, occupational therapists etc?
• Is the patient aware of Parkinson’s UK?

“Our patients are telling us that it’s quite difficult to get in touch with GPs at the moment. I think it is particularly important that they’re feeling supported and have somewhere to turn if they’ve got any questions or concerns,” concluded Viv.

Changing therapy

Dr Neil Archibald gave a step-by-step guide to the process of changing Parkinson’s therapy while working under the constraints of COVID infection control measures.

1. Know your limits

Just 30 to 40% of consultations at Neil’s centre are currently being carried out at the “gold standard” of face to face. The majority, he said, are being conducted via the phone or by video link.

“Remote consulting is fine if the clinical need is fairly straightforward, you have access to the notes, the patient has capacity, you really don’t need to examine them, and if you have a way of giving them the information they need.

“If you know the patient and already have a good working relationship with them, that helps. I think face to face should be your default if you’re struggling to meet those requirements,” he said.

2. Have a system

“Whatever way you do it, it is useful to have a system,” said Neil. “I always start with the medication.”

He will ask:

• What drugs they are on
• What drugs they are taking
• What time they take their drugs
• How they tend to feel at different times of the day
• Whether there have been any changes in medications – for Parkinson’s or other conditions – since the last consultation

The answers should give the clinician a good idea of how the person responds to medication, when they are dyskinetic and how that relates to their dose, as well as information on their mobility and balance.

It’s also important to think about non-motor symptoms, which can be less dopamine responsive he said.

“I tend to do a top to bottom tour of the body, starting with mood, sleep, cognition, visual problems, speech swallowing, any problems with sleep etc,” said Neil, adding that fatigue and pain also fit into this category.

3. Get the facts

Summary Care Records are a good way of remotely accessing accurate information on a patient’s medication.

“They are really helpful and can avoid some pitfalls, particularly when prescribing a new medication that might have an interaction with something that the patient hasn’t mentioned to you,” said Neil.

4. Document it

“If you want the patient’s medication changed, but don’t document it and communicate it properly to the GP, it isn’t going to happen,” said Neil, adding that if it doesn’t happen, the centre does not get remunerated

Current advice is for clinic letters to be written directly to the patient with the GP copied in, he added.

Our Parkinson’s COVID-19 webinars are available on SoundCloud:
soundcloud.com/neurologyacademy

Watch our previous webinars here: parkinsonsacademy.co/covid-19