This guideline update reflects substantial changes in the literature on diagnosis and treatment of Parkinson disease, and adds information on palliative care.
Impulse control disorders can develop in a person with Parkinson disease who is on any dopaminergic therapy at any stage in the disease course, especially for those taking dopamine agonists.
Advanced therapies like deep brain stimulation and intrajejunal levodopa-carbidopa gel infusion are now routinely used in Parkinson disease to manage motor symptoms and fluctuations.
Evidence exists to support early institution of exercise at the time of diagnosis of Parkinson disease, in addition to the clear benefit now shown in those with well-established disease.
Palliative care requirements of people with Parkinson disease should be considered throughout all phases of the disease, which includes an option of medical assistance in dying.
Parkinson disease is chronic and progressive in nature, decreasing the quality of life for both patients with the disease and their caregivers and placing an onerous economic burden on society.1
The first Canadian guideline on Parkinson disease was published in 2012.2 Since that guideline, there have been substantial advances in the literature on the disease, particularly with respect to diagnostic criteria and treatment options. Parkinson Canada undertook to update the existing guideline to reflect these advances, as well as to add information on palliative care.
With the aim of enhancing care for all Canadians with Parkinson disease, this guideline is based on the best published evidence, involves expert consensus when there is a lack of evidence, offers practical clinical advice, takes patient choice and informed decision-making into account and is relevant to the Canadian health care system. The guideline has been divided into 5 main sections to improve the ease of use: communication, diagnosis and progression, treatment, nonmotor features and palliative care. The full guideline is available in Appendix 1, at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.181504/-/DC1.
Scope
The target users for this guideline are health care professionals. However, the guideline may also be used by policy-makers, funding bodies and people with Parkinson disease and their families. These recommendations are intended to serve as a guide for health care providers; clinical discretion should be used by all who follow these recommendations. Resource problems and individual patient preference may make it difficult to put every recommendation into practice, but the guideline is intended to improve the standard of and access to care for individuals with Parkinson disease in all regions of Canada.
Methods
Parkinson Canada sponsored this guideline update; the Knowledge Synthesis Group at the Ottawa Hospital Research Institute, Ottawa (P.B., B.H.), led the methodology used. Experts from the main Parkinson clinics across Canada were invited to participate. The steering committee for the overall development of the guidelines consisted of the authors of each of the sections, with 4 leads (D.G., B.H., M.F., P.B.). This guideline was updated with input from the guideline panel, which included experts in movement disorders, neurology, functional neurosurgery, psychiatry, family medicine, nursing, methodology, physiotherapy, occupational therapy, pharmacy, neuropsychology and patient advocacy (Parkinson Canada), as well as individuals with Parkinson disease.
The overall objective was to identify recently published scientific evidence that would require specific recommendations to be updated. A series of Web-based surveys was sent out to a group of 16 clinical experts from across Canada to gain insight from the clinical community as to which recommendations from the 2012 guideline2 needed to be prioritized for updating. The experts were asked to assess the validity of each recommendation based on their knowledge and whether they were aware of new evidence that they thought would warrant making an update to a recommendation. For those recommendations still considered valid, the experts were asked if they were aware of any new evidence that would change the grade or strength of evidence.
The Knowledge Synthesis Group used components of the ADAPTE process as the basis for the update.3 Literature searches included those in English from 2006 to December 2016, using the following databases: National Guideline Clearinghouse, the Guidelines International Network, National Library of Guidelines, CPG Infobase, Trip Medical Database, Google Scholar, Embase and Ovid MEDLINE (including Epub Ahead of Print, In-Process and Other Nonindexed Citations), Cochrane Library (limited to Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the Health Technology Assessment database). Research undertaken only in animals and opinion pieces were removed from the results.
The Knowledge Synthesis Group first searched for clinical practice guidelines on the care of patients with Parkinson disease. If no sufficiently high-quality guidelines or no guidelines were identified, then a staged approach to identification of evidence was implemented, where first moderate-to high-quality systematic reviews were systematically searched for and used as evidence. In the absence of such reviews, or if there were no systematic reviews, then randomized controlled trials (RCTs) were searched for.
The Knowledge Synthesis Group used the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument to assess the rigour of clinical practice guidelines,4 the 16-point A MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2)5 to assess systematic reviews, and the Cochrane Risk of Bias tool to assess RCTs.6
The Knowledge Synthesis group developed packages of information (including strengths of evidence, citations and summaries of new studies) and compiled them in the form of summaries for distribution to working groups of panel members with relevant expertise (e.g., treatment, communication, etc.) in preparation for a consensus meeting.
Before the consensus meeting, the guideline panel identified several additional topics that were thought to be important and that had not been initially captured because of the stringent topic search conducted. These included depression and Parkinson disease (the initial search had been restricted to amitriptyline, as it was the only antidepressant included in the original guideline), pimavanserin and rotigotine. The Knowledge Synthesis Group extracted data from systematic reviews for these topics, and produced additional summaries to be distributed in advance of the consensus meeting.
Many recommendations from the 2006 National Institute for Health and Care Excellence (NICE) guideline7 had been adapted for inclusion in the 2012 Canadian guideline. An updated version of the NICE guideline was not identified in the literature search, as its publication date was initially scheduled for June 2017 (published in July 2017).8 However, a draft version of the updated NICE guideline was available from October 2016 and was included in the materials supplied to the guideline panel for the consensus meeting.
A full-day meeting with 29 guideline panel members was held on Apr. 8, 2017 (Supplement Table 5 in Appendix 1). The working groups reviewed the relevant summaries and the full text of the new literature on their topic. Each working group chair presented their group’s recommendations to the entire guideline panel; this served as the basis for the initial voting matrix for each recommendation. An open voting process and summary discussion method identified 5 main areas on which to base the guideline update: communication, diagnosis and progression, treatment, nonmotor features and a new section on palliative care.
Working group members used recommendations from the clinical practice guidelines identified during the literature search to update or create new recommendations. (At the meeting, some recommendations that required updating were identified that had not been raised by the original survey of experts.) If no appropriate recommendation was found in the available clinical practice guidelines, the guideline panel discussed the topic and referred it to the Knowledge Synthesis Group for a follow-up search of systematic reviews and, if necessary, RCTs.
The guideline panel made substantial effort to maintain the phrasing of any recommendation extracted from another guideline, although some were modified slightly to achieve standardized terminology or to make the recommendation more specific. The source for each recommendation extracted from another guideline is cited at the end of the recommendation. When the recommendation was created de novo by the working groups from systematic review or RCT evidence or expert opinion, the recommendation is denoted as “CAN.” The classifications for determining the level of evidence used across the guidelines differed slightly, but the recommendation grade was maintained from the original source (i.e., if a recommendation had a grade of B in its source guideline, it was retained as grade B in this guideline update) (Box 1).
Grading scheme from SIGN, EFNS and NICE*
After the meeting, we created a voting matrix, organized into the 5 main themes with subsections. We conducted Web-based voting using SurveyMonkey (www.surveymonkey.com) to ensure that the majority (> 75%) agreed on each of the recommendation points. One recommendation did not reach 75% agreement but was considered to be an essential topic to include. The section leads subsequently modified the wording of this recommendation and the newly worded recommendation was approved by the guideline panel. More information on the methods used to develop this guideline is available in Appendix 1.
Management of competing interests
All guideline panel members agreed to terms of reference that included disclosure of all perceived and actual competing interests to the entire panel at the beginning and end of the guideline development process. Panellists with competing interests were permitted to participate in panel discussions, and later in the voting matrix, without restriction.
Recommendations
The complete list of recommendations appears in Tables 1⇓⇓⇓ to 5; a description of the underlying evidence for each recommendation is available in Appendix 1.This synopsis provides information on selected recommendations, along with the grade of and source for the recommendation. (When the term “CAN” is used as a source, it refers to a recommendation that was developed de novo for this guideline and was not adapted from another source.)
Summary of recommendations for communication
Summary of recommendations for diagnosis and progression
Summary of recommendations for treatment of motor symptoms
Summary of recommendations on treatment of nonmotor features of PD
Summary of recommendations for palliative care
Communication
Communication with people with Parkinson disease should be aimed at empowering them to participate in the judgments and choices about their own care (grade: D; source: NICE7).
Discussions should be aimed at achieving a balance between the provision of honest, realistic information about the condition and the promotion of a feeling of optimism (grade: D; source: NICE7).
Because people with Parkinson disease may develop impaired cognitive ability, a communication deficit or depression, they should be provided with both verbal and written communication throughout the course of the disease — which should be individually tailored and reinforced as necessary — and consistent communication from the professionals involved (grade: D, good practice point; source: NICE7).
Families and caregivers should be given information about the condition, their entitlements to care assessment and the support services available (grade: D, good practice point; source: NICE7).
Good communication is at the heart of every interaction between people with Parkinson disease, their caregivers and health professionals. Health care professionals committed to clear and empathic communication can make a meaningful difference to their patients. When people with Parkinson disease know what health care professionals recommend and why, they can participate in shared decision-making. Communication should be supported by the provision of evidence-based information, offered in a form that is tailored to the needs of the individual. Where possible, written material should be provided that includes instructions for medication use. Parkinson disease affects people living with the illness and their caregivers and family. It is important that they all have access to the same information and services.
Diagnosis and progression
Parkinson disease should be suspected in people presenting with tremor, stiffness, slowness, balance problems or gait disorders (grade: D, good practice point; source: NICE7).
Parkinson disease can be diagnosed using the Movement Disorder Society Clinical Diagnostic Criteria (grade: good practice point; source: CAN).
Parkinson disease is characterized by a constellation of clinical manifestations, which include slowness of movement (bradykinesia), rest tremor, rigidity and postural instability. The diagnosis of Parkinson disease is still based predominantly on its clinical features; in 2015, the Movement Disorder Society9 published new criteria for clinically established and probable Parkinson disease. Typical Parkinson disease must be differentiated from secondary parkinsonism or tremor resulting from neuroleptic drug exposure, essential tremor or structural changes in the brain, such as from normal pressure hydrocephalus, multiple small vessel disease strokes (i.e., vascular parkinsonism) and other neurodegenerative forms of parkinsonism, for example (Figure 1).
Diagnosis and prognosis of Parkinson disease (PD). Note: CT = computed tomography, MRI = magnetic resonance imaging, MSA = multiple system atrophy, NPH = normal pressure hydrocephalus, PSP = progressive supranuclear palsy.
Patients initially considered to have a possible diagnosis of Parkinson disease may benefit from a trial of dopamine replacement therapy to assist with an accurate diagnosis (grade: good practice point; source: SIGN13).
A clear response to dopamine replacement therapy (e.g., levodopa/carbidopa 600 mg/d) in an individual with Parkinson disease could help to reinforce that an accurate diagnosis has been established.
Routine use of functional imaging is not recommended for the differential diagnosis of Parkinson disease and Parkinson plus disorders such as progressive supranuclear palsy and multiple system atrophy (grade: C; source: SIGN13).
Positron emission tomography scanning is not recommended as part of the diagnostic work-up of parkinsonian syndromes, except within a research framework (grade: good practice point; source: SIGN13).
123I-ioflupane (123I-FP-CIT) single-photon emission computed tomography (SPECT) scanning should be considered as an aid to clinical diagnosis in patients where there is uncertainty between Parkinson disease and nondegenerative parkinsonism or tremor disorders (grade: B; source: SIGN13).
Computed tomography or magnetic resonance imaging brain scanning should not be routinely applied in the diagnosis of idiopathic Parkinson disease (grade: C; source: SIGN13).
Imaging modalities have been extensively researched over the years for a more accurate diagnosis of Parkinson disease, in the differential diagnosis of parkinsonian disorders, as well as in the consideration of a possible progression marker for typical Parkinson disease. However, to date, no single test has been shown to have sufficient sensitivity and specificity to accomplish all 3 objectives.
Genetic testing for monogenic parkinsonism is not recommended in routine clinical practice (grade: good practice point; source: SIGN13).
To date, there is no established therapy for any of the genetic risk factors that have been convincingly identified in the development of either early-onset, monogenic parkinsonism or for the “complex disease-type,” late-onset Parkinson disease variant; this is one reason why genetic testing is not recommended in routine clinical practice at this time.
Treatment
Many symptomatic treatments are available for Parkinson disease. These include medications, surgical procedures, physiotherapy, occupational therapy and other support services. These treatments can have a substantial impact on improving an affected individual’s quality of life and should be made available. Despite the increase in nonpharmacologic treatments, individuals with Parkinson disease become more reliant on their medication to maintain their ability to function as the disease progresses. A balance between the adverse effects of the medication and the benefit often becomes more difficult with time (Table 6).
Potential benefit and harms of initial Parkinson disease medication options
Levodopa
Levodopa may be used as a symptomatic treatment for people with early Parkinson disease (grade: A; source: NICE7).
Levodopa remains the most effective medication for the treatment of motor symptoms and there is no reason to delay its use for those with bothersome motor symptoms.
Dopamine agonists
Dopamine agonists may be used as a symptomatic treatment for people with early Parkinson disease (grade: A; source: NICE7).
A dopamine agonist should be titrated to a clinically efficacious dose. If adverse effects prevent this, another agonist or a drug from another class should be used in its place (grade: D, good practice point; source: NICE7).
Although dopamine agonists are effective in the initial treatment of Parkinson disease, the risk of adverse effects is higher than with levodopa. In patients older than 70 years, dopamine agonists should be used with even more caution, if at all. There is no good evidence that one dopamine agonist is superior to another regarding control of motor symptoms in Parkinson disease, but only nonergot dopamine agonists should be used because of the risk of pulmonary and cardiac fibrosis seen with the older ergot agonists (e.g., bromocriptine). A transdermally administered dopamine agonist (rotigotine) is now available in Canada and has the convenience of a single, daily, nonoral administration.
Subcutaneous apomorphine infusions or injections may be considered for the management of severe motor complications, but should be provided only in units that have sufficient experience and resources (grade: C; source: SIGN13).
Apomorphine is a nonergot dopamine agonist that can be administered in the form of subcutaneous injection. Health Canada has recently approved the latter formulation for the acute, intermittent treatment of “off” episodes. However, training is required for patients and caregivers.
When starting dopamine agonist therapy, people and their family members and caregivers (as appropriate) should be given verbal and written information about the following, and the discussion should be recorded as having taken place:
The increased risk of developing impulse control disorders when taking dopamine agonist therapy, and that these may be concealed by the person affected.
The different types of impulse control disorders (e.g., compulsive gambling, hypersexuality, binge eating and obsessive shopping).
Who to contact if impulse control disorders develop.
The possibility that if problematic impulse control disorders develop, dopamine agonist therapy will be reviewed and may be reduced or stopped (grade: good practice point; source: NICE8).
It should be recognized that impulse control disorders can develop in a person with Parkinson disease who is on any dopaminergic therapy at any stage in the disease course (grade: good practice point; source: NICE8).
While impulse control disorders can develop at any time when dopaminergic therapies are used, it occurs in nearly half of those taking dopamine agonists over a prolonged period.10
Device-aided therapies
Deep brain stimulation of the subthalamic nucleus or the globus pallidus interna is effective against motor fluctuations and dyskinesia (grade: A; source: EFNS14).
Deep brain stimulation is currently the surgical treatment of choice in appropriately selected patients with substantial motor complications when optimized medical treatment has failed in treating motor symptoms (such as motor fluctuations or dyskinesia).
Intrajejunal levodopa-carbidopa enteric gel administered through percutaneous gastrostomy may be considered for the reduction of off-time or to reduce dyskinesia (grade: C; source: EFNS14).
The intrajejunal levodopa-carbidopa gel infusion through a percutaneous enteral tube is now available in Canada. It is accessible under limited use in tertiary movement disorders centres and can substantially reduce off-times when compared with standard oral levodopa.14
Rehabilitation
Consideration should be given to referring people who are in the early stages of Parkinson disease to a physiotherapist with experience of the disease for assessment, education and advice, including information about physical activity (grade: B; source: NICE8).
Physiotherapy specific to Parkinson disease should be offered to people who are experiencing balance or motor function problems (grade: B; source: NICE8).
Although previously relegated to later stages of illness, rehabilitative therapies have much to offer patients who have recently received a diagnosis of Parkinson disease. Evidence exists to support early institution of exercise at the time of diagnosis, in addition to the clear benefit now shown in those with well-established disease. It improves not only how people with Parkinson disease feel, but also their ability to perform activities of daily living.8 Physical and exercise therapies should focus on gait re-education, improvement of balance and flexibility, enhancement of aerobic capacity and strength, improvement of movement initiation, augmentation of functional independence — including with transfers, overall mobility and activities of daily living — and the provision of advice regarding safety in the home environment. Continued therapy is required to sustain benefits, and this is particularly important in Parkinson disease as apathy is a barrier to patient adherence in the absence of scheduled lessons or training.
Occupational therapy specific to Parkinson disease should be offered to people who are having difficulties with activities of daily living (grade: A; source: NICE7).
Consideration should be given to referring people who are in the early stages of Parkinson disease to an occupational therapist with experience of Parkinson disease for assessment, education and advice on motor and nonmotor symptoms (grade: B; source: NICE8).
Speech and language therapy should be offered to people with Parkinson disease who are experiencing problems with communication, swallowing or saliva. Therapy should include (grade: A; source: NICE8):
Strategies to improve the safety and efficiency of swallowing to minimize the risk of aspiration, such as expiratory muscle stress
Strategies to improve speech and communication, such as attention to effort therapies
Parkinson disease–specific occupational therapy, as well as speech and language therapy, are indicated for people who are having difficulties with activities of daily living, but also early on, for prevention.
Nonmotor features
Autonomic dysfunction is a common complication of Parkinson disease and can include cardiovascular, gastrointestinal, urogenital and thermoregulatory problems. These have a substantial negative impact on quality of life; however, the quality of evidence to guide management is poor.
Botulinum toxin A is efficacious for the symptomatic control of sialorrhea in Parkinson disease (grade: A; source: MDS16).
Sialorrhea can be cosmetically disturbing and can contribute to functional disability. Botulinum toxin A injections into the salivary glands have been shown to be efficacious to treat sialorrhea.16
For orthostatic hypotension, drug therapy includes the addition of:
midodrine (grade: A; source: EFNS14)
fludrocortisone (grade: good practice point; source: EFNS14)
domperidone (grade: good practice point; source: CAN)
Symptoms of orthostatic hypotension are likely under-reported in patients with Parkinson disease. Movement disorder specialists in Canada have used domperidone for decades. Domperidone given either before a meal or 30 minutes before each dose of dopaminergic medication may prevent peripheral vasodilation. Although good evidence of efficacy for its use is lacking, it was included in the guideline given its widespread use. There is, however, a Health Canada warning18 about concerns of QT prolongation with domperidone. It should therefore be used with caution in conjunction with other drugs known to prolong QT interval and in those patients with Parkinson disease with a history of cardiovascular disease.11
Care should be taken to identify rapid eye movement (REM) sleep behaviour disorder in people with Parkinson disease. Melatonin or clonazepam may be useful if pharmacologic treatment is required (grade: good practice point; source: NICE8).
Rapid eye movement sleep behaviour disorder can pre-date the diagnosis of Parkinson disease; most patients with idiopathic REM sleep behaviour disorder in middle age will develop a neurodegenerative synucleinopathy (e.g., Parkinson disease, Lewy body dementia).12 In observational studies, both clonazepam (0.25–1 mg hs) and melatonin (3–12 mg hs) could suppress REM sleep behaviour disorder; clonazepam was more effective than melatonin, but had a higher adverse effect profile, particularly with sedation, balance impairment and cognitive changes.8
The management of depression in people with Parkinson disease should be tailored to the individual — in particular, to their coexisting therapy (grade: D, good practice point; source: NICE7).
Depression frequently manifests even before the onset of motor symptoms of Parkinson disease and becomes more prominent and increasingly challenging to treat with disease progression. Unfortunately, there continues to be a paucity of high-quality research trials to support the choice of symptomatic therapies. The principles guiding the use of antidepressants in Parkinson disease are similar to those guiding their use in other medically ill populations in general: start low and go slow, with the effective dose often being less than that recommended for the general population.
For patients with Parkinson disease and psychosis needing treatment:
Quetiapine is possibly useful (grade: good practice point; source: EFNS14)
Clozapine is useful but requires monitoring (grade: A; source: EFNS14)
Pimavanserin could be considered as a treatment for Parkinson disease psychosis (grade: B; source: CAN).
For patients with Parkinson disease and psychosis needing treatment, quetiapine and clozapine have been standard treatment, but a recent addition to the treatment armamentarium of psychosis in Parkinson disease is pimavanserin, a selective serotonin 5-hydroxytryptamine 2A (5-HT2a) inverse agonist; however, this is not yet available in Canada.
For Parkinson disease dementia, cholinesterase inhibitors could be added: rivastigmine (grade: A), donepezil (grade: A), or galantamine (grade: C). There may be idiosyncrasy in clinical response and adverse effects, so it is worth trying an alternative agent (grade: good practice point). Memantine can be added or substituted if cholinesterase inhibitors are not tolerated or lack efficacy (grade: C). (Source: EFNS.14)
Cholinesterase inhibitors have shown efficacy for the treatment of cognitive decline in PD.14
Palliative care
There is growing information with respect to palliative care in Parkinson disease and the guideline panel therefore thought that the topic was an important addition to the new guideline.
People with Parkinson disease and their family members and caregivers (as appropriate) should be offered opportunities to discuss the prognosis of their condition. These discussions should promote people’s priorities, shared decision-making and patient-centred care (grade: D; source: NICE8).
People with Parkinson disease and their family members and caregivers should be given appropriate verbal and written information about the following, and it should be recorded that the discussion has taken place (grade: D; source: NICE8):
Progression of Parkinson disease
Possible future adverse effects of medicines for Parkinson disease
Advance care planning, including orders for advanced decisions to refuse treatment and do not attempt resuscitation, and lasting power of attorney for finance and health and social care
Options for future management
What could happen at the end of life
Available support services; for example, personal care, equipment and practical support, financial support and advice, care at home and respite care.
When discussing palliative care, it should be recognized that family members and caregivers may have different information needs from the person with Parkinson disease (grade: D; source: NICE8).
Palliative care requirements of people with Parkinson disease should be considered throughout all phases of the disease; this includes an option of medical assistance in dying (grade: good practice point; source: CAN).
End-of-life choices, including advance care planning with an open and frank discussion with the patient and the person designated as decision-maker, should be initiated early in the disease process. Conversations occurring in the ambulatory setting are likely to be more productive and less crisis driven than leaving such conversations until an acute stay in hospital.
Implementation
Parkinson Canada will assist in disseminating print and electronic versions of the guideline to health care providers, individuals with Parkinson disease and their families, as well as post the full guideline on its website. As part of the Parkinson Canada affiliation with the Neurological Health Charities Canada, the guideline will be used to assist in advocacy efforts to federal and provincial governments to improve the care of individuals with Parkinson disease, as well as other brain diseases.
A clear barrier to the implementation of this guideline is a lack of adequate access to health care providers with expertise in dealing with individuals with Parkinson disease. This includes not only specialty physicians but also nurses, speech, occupational and physical therapists with adequate training to deal with these patients who have this very complex condition. Access to palliative care treatment is also lacking for Canadians with neurodegenerative disease and should be addressed at local and national levels of care delivery.
Deep brain stimulation therapy and intrajejunal levodopacarbidopa enteric gel therapy are expensive and complex to use, and most centres have limited budgetary or human resources with respect to the number of procedures they can perform and continue to manage.
The cost of care for neurodegenerative diseases in general will increase as our population ages. The limits that our publicly funded health care system can provide must be addressed, but are outside the scope of this guideline. Parkinson Canada, as well as patients and their families, will continue to play an important role in advocating for more resources and the dissemination of knowledge to improve the care and support of all of those affected by this disease.
Other guidelines
This guideline draws on the recommendations of the Scottish Intercollegiate Guidelines Network,13 the European Federation of Neurological Societies,14,15 the Movement Disorder Society,16 the National Institute for Health and Clinical Excellence7,8 and the American Academy practice parameters.17 We used knowledge taken from these other guidelines to form the basis of this guideline update, and we chose the recommendations for their relevance to our Canadian health care system.
Gaps in knowledge
There remain important knowledge gaps with respect to many areas of Parkinson disease. Understanding the pathophysiology of the disease will allow for the development of more effective and potentially disease-modifying treatments. Even if we do not yet fully understand disease-causing mechanisms, having good biomarkers for Parkinson disease will accelerate the development of new therapies. Progress has been made in our understanding and management of nonmotor features of Parkinson disease, but evidence for optimal treatment, especially for this area in Parkinson disease, is lacking, as can be appreciated by the low grade of many recommendations in this section.
Conclusion
Important strides have been made in improving our understanding of Parkinson disease, as well as its treatment. Management of the disease remains complex, and all members of the health care team need access to the most up-to-date information available. Effectively communicating information among all members of the health care team and the patient is essential for optimal care delivery, yet obstacles remain. The cost of care for Parkinson disease and neurodegenerative diseases in general will increase as our population ages. Decisions about the limits that our publicly funded health care system can provide need to be addressed.
Acknowledgements
The authors thank the panel of health care professionals who contributed their expertise. The authors also thank their patients and caregivers, who continue to educate and inspire them, as well as the Knowledge Synthesis Group at The Ottawa Hospital, who played a critical role in developing the methods needed for the guideline.
Footnotes
A French version of this article as well as the full guideline in English and French are available in Appendix 1 at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.181504/-/DC1
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/181504-guide
Competing interests: Michael Schlossmacher reports receiving research funding from the Canadian Institutes of Health Research (CIHR), Michael J. Fox Foundation, Weston Brain Institute, Ontario Brain Institute, Parkinson Canada, Parkinson Research Consortium Ottawa, Department of Medicine (The Ottawa Hospital) and the Uttra and Sam Bhargava Family to conduct research into the pathogenesis of Parkinson disease and to model its variants. Dr. Schlossmacher is co-inventor of several patents to explore potential therapeutics based on the link between the GBA1 gene and synucleinopathy disorders, which have been licensed to Genzyme-Sanofi. All funding was outside the current work. David Grimes reports receiving personal fees from the Department of Justice (Government of Canada), from Allergan and from Ipsen, outside the submitted work. Suneil Kalia reports receiving grants from CIHR and the Michael J. Fox Foundation, as well as an honorarium (speaker fee) from Medtronic, outside the submitted work. Kerrie Schoffer reports receiving a funding grant from Medtronic to attend a deep brain stimulation course. Anne-Louise Lafontaine reports receiving personal fees from AbbVie (advisory board), during the conduct of the study. Janis Miyasaki reports receiving grants from the Patient Centered Outcomes Research Institute and from Merz, and royalties from UpToDate, outside the submitted work. Alexander Rajput reports receiving personal fees from Teva and Ipsen, outside the submitted work. Susan Fox reports receiving consultancy fees from Sunovion and Paladian, speaker honoraria from Teva and Zambon, and advisory board fees from Acadia, outside the submitted work. Brian Hutton reports receiving honoraria from the Cornerstone Research Group, outside the submitted work. Ronald Postuma reports receiving grants and personal fees from Fonds de la Recherche en Santé; grants from CIHR, Parkinson Canada, the W. Garfield Weston Foundation, the Michael J. Fox Foundation and the R. Howard Webster Foundation; personal fees from Takeda, Roche and Prothena, Teva Neuroscience, Novartis Canada, Biogen, Boehringer Ingelheim, Theranexus, GE Healthcare, Jazz Pharmaceuticals, AbbVie, Janssen, Otsuka Pharmaceutical, PhotoPharmics and Inception Sciences, all outside the submitted work. Dr. Postuma also reports being the Chair of the Scientific Advisory Board of Parkinson Canada, outside the submitted work. Tiago Mestre reports receiving personal fees from AbbVie and Medtronic, during the conduct of the study. Olga Suchowersky reports receiving personal fees from Sunovion, and grants from AbbVie, Apopharma and Biotie, during the conduct of the study. Dr. Suchowersky also reports receiving a grant from Teva outside the submitted work. No other competing interests were declared.
This article has been peer reviewed.
Contributors: All of the authors contributed to the conception and design of the work, and the acquisition, analysis, and interpretation of data. David Grimes drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.
Funding: This guideline update was supported by a grant from Parkinson Canada with no participants or authors receiving any personal funding for their creation.
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