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Comment z

A multidisciplinary approach can help

both Parkinson’s and epilepsy patients
We are pleased to introduce a new series of Commentaries from the Primary
Care Neurology Society (P-CNS). These aim to provide a primary care perspective
on the neurology articles featured in each issue of Progress. Here, Dr Alistair
Church provides a commentary on our Review ‘Diagnosis and management of psychosis in
Parkinson’s disease’ (see page 7 of this issue) and Dr Karen Lanyon gives her perspective on
‘Improving quality of care for epilepsy patients using a pharmacist review service’ (page 12).

Be aware of the signs existing dementia with cholin -

Psychosis in
Parkinson’s disease
It is becoming increasingly evident
that Parkinson’s disease is much
more than a deficiency of the neuro-
transmitter dopamine. Serotonergic
and noradrenergic pathways are
strongly implicated, causing diverse
non-motor problems. Patients are
often more disabled by these
non-motor, non-dopaminergic com-
plications. Insomnia, depression,
impaired postural reflexes, auto-
nomic and neuropsychiatric mani-
festations often cause more distress
for both patient and carer than
tremor, bradykinesia and rigidity.
Often the development of
neuropsychiatric complications, in
the form of dementia and psy-
chosis, particularly when insight is
lost, are the most distressing for
patient and carer alike.
The primar y care team has a
vital role in the support of patients
with Parkinson’s disease and their
carers. The neuropsychiatric com-
plications of this condition can be
unexpected and devastating. The
carer, who already has to shoulder
an increasing burden of care,
effectively has to deal with the loss
of a loved one at the same time .
The development of psychosis,
sometimes with loss of insight, can
lead to the breakdown of care in
the home and result in institution-
alisation.
It is vital that signs of psychosis are
actively looked for every time the
patient makes contact with pri-
mary care. Carers should be made
aware of this possible complica-
tion, particularly when medication
is increased or added.
When psychosis presents early,
ie within a year of the motor symp-
tom onset, this may suggest a diag-
nosis of dementia with Lewy bodies.
Most patients with Parkinson’s dis-
ease present with psychosis later, it
becoming more apparent after 10
years or more of disease duration.
Many of the dopaminergic
treatments, particularly dopamine
agonists and amantadine, can pre-
cipitate psychosis. This leads to a
difficult balancing exercise, often
sacrificing control of motor impair-
ment for improvement in psychosis
and diminution of hallucinations.
Once recognised, management
involves two important measures:
excluding reversible causes such as
intercurrent infection or elec-
trolyte imbalance and reviewing
the patient’s medication, looking
particularly at recently added or
increased dopaminergic therapy
and considering any adjustments.
The GP should be alert to the
possibility of agitated depression
presenting with or complicating psy-
chosis. Depression in Parkinson’s
disease is common and can co-exist
with psychosis. The treatment of co-
esterase inhibitors can lead to an
improvement in psychosis.
Antipsychotics should be used
as a last resort in conjunction with
secondary care. The introduction
of typical antipsychotics can lead
to a marked deterioration in
motor function. Use of atypical
antipsychotics such as quetiapine,
aripiprazole or clozapine for a
short period of time at a low dose
and with regular reviews can be
helpful.
As with any chronic neuro -
degenerative condition, the goal
posts are continuously moving,
hence the need for regular review.
Early recognition of neuro -
psychiatric complications of
Parkin son’s disease and their
prompt management is important
in supporting the patient and
carer to maintain as independent a
lifestyle as possible and to control
distressing behaviour.
Multidisciplinary approach
A multidisciplinar y approach
involving primary care, neurology
and psychiatry is of great impor-
tance in fine tuning management
in this complex phase of the dis-
ease, to achieve the best possible
outcome for patient and carer.
Dr Alistair Church,
GP and Associate Specialist in
Neurology, Royal Gwent Hospital

4 Progress in Neurology and Psychiatry September/October 2012 www.progressnp.com

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z Comment

with their GP. Thirty-minute antidepressant medication. If

Pharmacist review
service for epilepsy
Approximately 600 000 people in
the UK have a diagnosis of epilepsy
and take antiepileptic medication.
This is equivalent to 1 in 103 peo-
ple. In the UK, 70 per cent of peo-
ple with epilepsy could be seizure
free with optimal treatment.
Currently only 52 per cent of this
population are seizure free. This
18 per cent treatment gap equates
to 108 000 people having unneces-
sary seizures.1
The 2004 Quality and Out -
comes Framework (QOF) intro -
duced an annual review for
patients with epilepsy. This has
raised the awareness of epilepsy
among primar y care staff.
However, unless it is performed by
someone who takes an interest in
epilepsy it may not improve the
care of patients, since the criteria
are basic and do not necessarily
address issues important to
patients’ wellbeing. The article by
Carole Brown in this issue about
using a pharmacist review service
demonstrates that if the annual
review is performed by someone
with a special interest in epilepsy it
can help improve seizure control,
reduce side-effects of medication
and improve patient care. Also –
and importantly in these times of
economic austerity – it has been
shown to be cost-effective.
The advantage in using a phar-
macist for the annual review is that
patients may be more honest about
non-adherence with them than
appointments with GPs are a rarity
so this allows plenty of time for
patients to discuss any concerns
regarding their condition with the
healthcare provider.
Encouraging a holistic approach
The protocol directs the pharma-
cist towards a holistic approach.
The assessment of fitness to drive
is not mentioned in the protocol
but the author does address this
later in the article. Epilepsy is the
most common cause of collapse
behind the wheel of the car and
many patients are either given no
advice, incorrect advice or choose
to ignore the advice they are given.
All patients should be asked about
ongoing focal seizures or ‘seizure
warnings’. This may highlight the
fact that the patient is not fit to
drive unless these are controlled
for 12 months. The driving regula-
tions regarding focal seizures are
currently being reviewed to bring
the UK into line with other mem-
bers of the European Community.
Practitioners need to be aware that
patients may have been given dif-
ferent driving advice if they have
lived in other European countries.
The protocol does not include
a mental health assessment but
the author states that preliminary
questions are used to screen for
depression. Depression in epilepsy
is more common than in some
other chronic diseases and yet
there is a reluctance to treat men-
tal health disorders in patients with
epilepsy because of the risk of
reducing seizure threshold with
patients are living with depression
or anxiety, these can have as pro-
found an impact on their quality
of life as living with seizures.
The author uses the Cardiff
Health Check to assess patients
with a learning disability. More
than one in five people with
epilepsy have learning or intellec-
tual disabilities. This population is
often overlooked in health screen-
ing and the management of
chronic disease.
A special interest makes a difference
Carole Brown’s article describes one
of the first Practitioner with a
Special Interest (PwSI) epilepsy
review services in the UK. This serv-
ice has proven it can provide cost-
effective epilepsy care that surpasses
the basic QOF indicators and
improves patient care in the com-
munity. It has been well received by
patients and their carers. Good
communication between primary
and secondary care ensures that
patients are directed towards the
appropriate services if problems are
highlighted during the review. This
is an example of how the use of a
primary care PwSI can help improve
quality of life for patients with a
chronic condition such as epilepsy.
Dr Karen Lanyon, GP with a Special
Interest in Epilepsy, Insch Medical
Practice, Aberdeenshire
Reference
1. Joint Epilepsy Council. Epilepsy prevalence,
incidence and other statistics. December 2011.
www.jointepilepsycouncil.org.uk/resources/
publications.html

Joining the Primary Care Neurology Society (P-CNS)

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professionals? For a reasonably modest one-off joining fee of £45, not only do you get access to various resources, including
video presentations (topics include headaches, Parkinson’s disease and multiple sclerosis), but you will also be able to access
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To find out more and to join, visit our website www.p-cns.org.uk

www.progressnp.com Progress in Neurology and Psychiatry September/October 2012 5