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Up Close with the Man Behind AAN's New PD Guidelines
In early April, at its 58th Annual Meeting in San Diego, California, the American Academy of Neurology (AAN) introduced new clinical practice guidelines for Parkinson's disease. The 2006 guidelines address four specific topics in Parkinson's: Neuroprotective Strategies and Alternative Therapies; Diagnosis and Prognosis of New Onset Parkinson's Disease; Evaluation and Treatment of Depression, Psychosis and Dementia; and Treatment of Parkinson's Disease with Motor Fluctuations and Dyskinesia. These guidelines complement AAN's previous Parkinson's disease guidelines that were issued in 2002.
The PDF News & Review staff had the opportunity to talk with Dr. William Weiner, Chair of the AAN Parkinson Disease Guideline Project and member of the Quality Standards Subcommittee. Here we share Dr. Weiner's explanation of how the guidelines were developed and what they mean for people living with Parkinson's disease.
Q: Why did the AAN establish guidelines for Parkinson's disease?
A: The AAN recognizes that Parkinson's disease is one of the major neurologic problems in America and thought it important to develop comprehensive guidelines for the diagnosis and treatment of the disease. AAN guidelines of this kind follow a specific format. They are evidence-based, which means that the appropriate neurologic literature related to Parkinson's disease is reviewed in a very stylized manner in order to present recommendations for how to treat patients based on the best available evidence.
Q: How were the guidelines created?
A: The process begins with the Quality Standards Subcommittee (QSS), a subcommittee of the AAN that consists of 18 neurologists who are specialists in different areas of neurology. The QSS committee appoints a facilitator or coordinator who, on behalf of the committee, invites a wide range of experts and general neurologists to participate in the project. For the Parkinson's project, four working groups were established, each representing physicians with three different experiences: general neurologists with expertise in clinical trials research; general neurologists who have an interest in Parkinson's; and Parkinson's disease specialists, both neurologists and psychiatrists. The groups were charged with coming up with a series of questions pertinent to the treatment of Parkinson's such as, "How do you make the diagnosis of Parkinson's disease?" or, "When a patient with Parkinson's disease is experiencing motor fluctuations or dyskinesias, what is the best medical or surgical therapy?"
After the questions were determined, the medical literature was searched with the help of a professional librarian and hundreds of articles bearing on each of the questions were reviewed to see if they were pertinent or not. The articles that met the pre-selected criteria were then given to the working groups for review and analysis.
Once each report, or "parameter," was written, it was sent out for additional review by another 40 general neurologists for comments and corrections. From there, it was sent for approval to the Practice Committee and the Board of Directors of the AAN. Once approved, the parameter was sent to the journal Neurology for another peer-review before being published. This demanding process ensures that each parameter properly reflects the state of the scientific literature and also represents the viewpoints of many different neurologists regarding the best treatment of Parkinson's disease.
Q: The guidelines fall under four areas. How were these chosen?
A: These four topics were chosen because the writing committee felt that these were areas where significant gaps in care could be identified - and where there was significant clinical research on record to provide a strong scientific basis for our recommendation.
Q: What were the major conclusions reached by the reviewers?
A: The major conclusions reached by the reviewers give clues to the accurate diagnosis of Parkinson's. One very important conclusion had to do with the signs, or "red flags," that can alert physicians that a suggested diagnosis of Parkinson's might in fact be wrong. Such "red flags" include early falling; poor response to levodopa; symmetrical onset of motor manifestations; lack of tremor; early autonomic nervous system dysfunction including urinary and bladder problems; and, in men, erectile dysfunction. Other important clues that reviewers identified can help indicate a poor prognosis in Parkinson's disease. These clues include older age of onset of these symptoms, less levodopa response and muscular rigidity as opposed to tremor.
Additional noteworthy conclusions from the literature review were that there are currently no proven neuroprotective strategies to slow disease progression and that no vitamin or nutritional supplements have any proven role in the treatment of Parkinson's disease. On the other hand, there are some approaches - including exercise programs, physical therapy and speech therapy - that have a useful treatment function.
For those patients with Parkinson's disease who experience motor fluctuations and dyskinesias, the reviewers found several medications that are potentially helpful. They also found that deep brain stimulation of the subthalamic nucleus can be useful in properly selected patients.
For those PD patients who exhibit signs of depression and dementia, the reviewers found some useful screening tools and several treatments.
Q: How will these guidelines be used by physicians?
A: These guidelines will be used by neurologists and other physicians to better manage and treat their patients with Parkinson's disease. These guidelines are not cookbook "decision-making" trees for doctors and patients. They are designed to enhance the knowledge of neurologists and physicians who take care of patients with Parkinson's disease and provide them with a framework with which to treat their individual patients.
A general practitioner can use these guidelines to help manage his or her patients who have Parkinson's disease. It is important to note that the diagnosis of Parkinson's disease can be difficult and complex, and if the general practitioner has any doubt regarding the diagnosis, a neurologist should be consulted.
Q: How does each guideline help improve the quality of life for a person with Parkinson's?
A: Each of these guidelines has the potential to improve the quality of life of a patient with Parkinson's disease. I will give an example from each guideline.
The guideline related to early and correct diagnosis of Parkinson's disease can improve the quality of life of a patient with Parkinson's disease because it will help produce an accurate diagnosis and a proper prognostic statement.
The guideline that addresses neuroprotective and alternative therapies in Parkinson's disease informs patients and families that there is no proven supplemental therapy that is effective for Parkinson's. This can surely save patients and families the money that is currently being spent in search of such a treatment.
In addressing treatment of motor fluctuations and dyskinesia, the third guideline can improve the quality of life because it presents a variety of medications which can be helpful in alleviating these problems. This guideline also addresses the role of deep brain stimulation in patients with more advanced disease and presents to the neurologist information about how best to select patients for surgery.
Finally, the fourth guideline covers the screening and treatment of depression, a seriously under-diagnosed problem in Parkinson's disease. Proper screening methods to discover depression and proper treatment of depression can make an enormous difference in an individual's quality of life.
The AAN is also publishing a version of the guidelines for patients and families. Patients can use these guidelines to better inform themselves of the possible therapeutic choices, and to question their neurologist regarding what is the best therapy available for their particular symptoms and problems.
For more information on the AAN guidelines, visit www.aan.com.
William J. Weiner, M.D., is the Chairman of the Department of Neurology at the University of Maryland School of Medicine and Director of the Maryland Parkinson's Disease and Movement Disorders Center. Dr. Weiner is a fellow of the American Academy of Neurology and an active member of both the American Neurological Association and the Movement Disorder Society.