• American Medical Directors Association (AMDA). Parkinson's disease in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2002. 34 p. [16 references]

This is the current release of the guideline.

According to the guideline developer, this guideline was reviewed by the original Steering Committee and is still considered to be current as of Jan 2007. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

• Parkinson's Disease
• Parkinsonism

Diagnosis
Evaluation
Management
Treatment

Family Practice
Geriatrics
Internal Medicine
Neurology

Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Patients
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Social Workers
Speech-Language Pathologists

• To improve the quality of care delivered to patients with Parkinson's disease (PD) in long-term care settings
• To guide care decisions and to define roles and responsibilities of appropriate care staff

Elderly residents of long-term care facilities with Parkinson's disease

Diagnosis/Assessment

1. Relevant history, physical examination, assessment of physical function, and mental, emotional, and cognitive status (e.g., mini-mental state examination)
2. Assessment for signs of dysphagia and altered nutritional and functional status
3. Assessment of medication use
4. Assessment of the risk of developing comorbidities and complications and the need for specialty consultation

Management/Treatment

1. Individualized care plan
2. Nonpharmacologic interventions such as physical/occupational therapy, speech therapy, dietary therapy, recreational therapy
3. Pharmacologic interventions:
   • Dopaminergic precursor--carbidopa/levodopa (Sinemet, Sinemet CR)
   • Dopamine agonists -- bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip)
   • Catechol-O-methyl transferase (COMT) inhibitors -- entacapone (Comtan, Comtess), tolcapone (Tasmar)
   • Anticholinergics -- benztropine (Cogentin), trihexyphenidyl (Artane)
   • Antiviral -- amantadine (Symadine, Symmetrel)
   • Monoamine oxidase (MAO) inhibitors -- selegiline (Eldepryl)
   • Tricyclic antidepressants -- nortriptyline, desipramine
   • Selective serotonin re-uptake inhibitors -- citalopram (Celexa), venlafaxine (Effexor), paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft)
   • Other antidepressants -- mirtazepine (Remeron), bupropion (Wellbutrin)
   • Antipsychotics -- clozapine (Clozaril), quetiapine (Seroquel)

Note: Surgical interventions to treat Parkinson's disease are in development but currently are not practical treatment options for patients in the long-term care setting.

4. Nutritional interventions as necessary
5. Management of complications and comorbidities associated with PD
6. Referral to community resources or palliative care as needed
7. Monitoring of patient's response to interventions and subsequent adjustments of interventions as needed
8. Monitoring the status and the need for a change in patient's level of care, and review of relevant medications

• Symptoms of Parkinson's disease
• Functional status/activities of daily living
• Adverse effects of treatment
• Quality of life

Searches of Electronic Databases

Not stated

Not stated

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking. The groups were composed of practitioners involved in patient care in the institutional setting. Using pertinent articles and information and a draft outline, the group worked to make a simple, user-friendly guideline that focused on application in the long-term care institutional setting.

Not applicable

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

External Peer Review
Internal Peer Review

All American Medical Director Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include American Medical Director Association physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long-term care setting.

The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.

Potential benefits associated with the implementation of this guideline include the following:

• Earlier identification of Parkinson's disease (PD) and its complications
• Better management of PD, allowing patients to maintain their highest practicable physical, mental, and psychosocial function
• Greater individualization of care
• Enhanced quality of life
• Better documentation of, and rationale for, patients’ personal goals and decision-making processes regarding their disease and its treatment
• More appropriate pharmacologic therapy for PD
• More appropriate physician participation in the care of the patient with PD
• Improved patient and family satisfaction with care
• More appropriate resource utilization
• Improved treatment and monitoring protocols
• Improved staff education and awareness of this complex progressive disease

Side Effects of Drugs Used to Treat Parkinson's Disease

• Long-term use of levodopa is associated with motor complications. Involuntary movements (dyskinesias) are among the most disabling of these complications.
• Side effects from dopamine agonists include confusion, hallucinations, hypotension, nausea and vomiting, and daytime sedation. Patients over age 70, especially those with dementia, are at higher risk for side effects from dopamine agonists.
• Anticholinergic medications may provoke acute confusional states or cause or contribute to cognitive dysfunction. Anticholinergic medications should be used with caution in patients with dementia and the very old.

Refer to Table 13 in the original guideline document for adverse effects of specific medications used to treat Parkinson's disease.

This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association, its heirs, executors, administrators, successors, and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use, negligent or otherwise, of this clinical practice guideline.

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps, which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

1. Recognition
   • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
2. Assessment
   • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
3. Implementation
   • Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
   • Identify individual responsible for each step of the CPG.
   • Identify support systems that impact the direct care.
   • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
4. Monitoring
   • Evaluate performance based on relevant indicators and identify areas for improvement.
   • Evaluate the predefined performance measures and obtain and provide feedback.

Implementation of guidelines will be affected by resources available in the facility, including staffing, and will require the involvement of all those in the facility who have a role in patient care. In addition, those responsible for implementation should identify operational areas within the facility that would be affected by the guideline's implementation and should seek input from staff and managers in those areas on the development of other relevant facility-specific protocols, policies, and procedures.

The Appendix of the original guideline document offers suggestions for general process indicators as well as clinical process and outcome indicators specific to measuring facility performance in the management of Parkinson's disease.

End of Life Care
Living with Illness

Effectiveness
Patient-centeredness
Safety

• American Medical Directors Association (AMDA). Parkinson's disease in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2002. 34 p. [16 references]

Not applicable: Guideline was not adapted from another source.

2002 (reviewed 2007)

American Medical Directors Association - Professional Association

Organizational participants included:

• American Association of Homes and Services for the Aging
• American College of Health Care Administrators
• American Health Care Association
• American Society of Consultant Pharmacists
• National Association of Directors of Nursing Administration in Long-Term Care
• National Association of Geriatric Nursing Assistants
• National Conference of Gerontological Nurse Practitioners

Corporate supporters of this guideline include Aventis Pharmaceuticals, Forest Laboratories, Inc, GlaxoSmithKline, Janssen Eldercare, LifeScan, Novartis Pharmaceuticals, Pfizer, Inc, Pharmacia Corporation, and Organon, Inc.

Steering Committee

Larry W. Lawhorne, MD, CMD, Project Chair

Steven Levenson, MD, CMD, Chair Clinical Practice Committee

Committee Members: Charles Cefalu, MD, MS, Chair; Lisa Cantrell, RNC, Co-Chair; Sandra Brownstein, Pharm D. FASCP, CGP; Annette Carron, D.O.; Linda L. Cook, RNC, LSW; Vincent DeLuzio, Rec. Therapist; Danielle Dodman, MS,CCC-SLP; Dianne Fiore, OT,R.; Ira Leroi, MD; Jill Marjama-Lyons, MD; Lu Anne Reed, BSN, RNC, CRRN; Cynthia Ross, CNA; Anne Skalmoski, PT; Teresa Tempkin, RNC, MSN, ANP

Not stated

This is the current release of the guideline.

According to the guideline developer, this guideline was reviewed by the original Steering Committee and is still considered to be current as of Jan 2007. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

None available

This NGC summary was completed by ECRI on September 3, 2003. The information was verified by the guideline developer on April 8, 2004. This summary was updated by ECRI on January 18, 2006, following the U.S. Food and Drug Administration advisory on Clozaril (clozapine). This summary was updated by ECRI on May 31, 2006 following the U.S. Food and Drug Administration advisory on Paxil (paroxetine hydrochloride). This summary was updated by ECRI on November 22, 2006, following the FDA advisory on Effexor (venlafaxine HCl). This summary was updated by ECRI Institute on April 17, 2007 following the withdrawal from the market of Permax (pergolide). This summary was updated by ECRI Institute on November 2, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on July 25, 2008, following the U.S. Food and Drug Administration advisory on Antipsychotics.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please contact the American Medical Directors Association (AMDA) at (800) 876-2632.