Guideline:
Parkinson's disease in the long-term care setting
Bibliographic Source(s)
- 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]
Guideline Status
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.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
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
Guideline Objective(s)
- 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
Target Population
Elderly residents of long-term care facilities with Parkinson's disease
Interventions and Practices Considered
Diagnosis/Assessment
- Relevant history physical examination assessment of physical function and mental emotional and cognitive status (e.g. mini-mental state examination)
- Assessment for signs of dysphagia and altered nutritional and functional status
- Assessment of medication use
- Assessment of the risk of developing comorbidities and complications and the need for specialty consultation
Management/Treatment
- Individualized care plan
- Nonpharmacologic interventions such as physical/occupational therapy speech therapy dietary therapy recreational therapy
- 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.
- Nutritional interventions as necessary
- Management of complications and comorbidities associated with PD
- Referral to community resources or palliative care as needed
- Monitoring of patient's response to interventions and subsequent adjustments of interventions as needed
- Monitoring the status and the need for a change in patient's level of care and review of relevant medications
Major Outcomes Considered
- Symptoms of Parkinson's disease
- Functional status/activities of daily living
- Adverse effects of treatment
- Quality of life
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
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.
Rating Scheme for the Strength of the Recommendations
Not applicable
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
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.
Major Recommendations
The Parkinson's Disease in the Long-Term Care Setting algorithm is to be used in conjunction with the clinical practice guideline. The numbers next to the different components of the algorithm correspond with the steps in the text. Refer to the "Guideline Availability" field for information on obtaining the full text guideline.
Clinical Algorithm(s)
An algorithm is provided in the original guideline document that summarizes the steps involved in managing Parkinson's disease in long-term care settings.
Type of Evidence supporting the Recommendations
The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.
Potential Benefits
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
Potential Harms
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.
Qualifying Statements
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.
Description of Implementation Strategy
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.
- 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.
- 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.
- 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.
- 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.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
End of Life Care
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety
Bibliographic Source(s)
- 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]
Adaptation
Not applicable: Guideline was not adapted from another source.
Guideline Developer Comment
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
Source(s) of Funding
Corporate supporters of this guideline include Aventis Pharmaceuticals Forest Laboratories Inc GlaxoSmithKline Janssen Eldercare LifeScan Novartis Pharmaceuticals Pfizer Inc Pharmacia Corporation and Organon Inc.
Guideline Committee
Steering Committee
Composition of Group that Authored the Guideline
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 MSCCC-SLP; Dianne Fiore OTR.; Ira Leroi MD; Jill Marjama-Lyons MD; Lu Anne Reed BSN RNC CRRN; Cynthia Ross CNA; Anne Skalmoski PT; Teresa Tempkin RNC MSN ANP
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
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.
Guideline Availability
Electronic copies: Not available at this time.
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy. Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
Availability of Companion Documents
The following is available:
- Guideline implementation: clinical practice guidelines. Columbia MD: American Medical Directors Association 1998 28 p.
Electronic copies: Not available at this time.
Print and CDROM copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy. Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
Patient Resources
None available
NGC STATUS
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.
COPYRIGHT STATEMENT
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.
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