The Clinical Scenario: A Possible Solution to the Neglect of Non-motor Symptoms in Clinic
First, tools such as NMSQuest do not consume clinical interactions; the patient completes them and they help direct the consultation with nurse specialist or consultant. The clinician can then grade the non-motor symptoms burden numerically (Box 2). Patients are then usually asked to flag the most bothersome symptoms. These are then addressed either through pharmacological, allied health specialist therapies, neuropsychological or neuropsychiatric input (figure 3). A yearly documentation of non-motor symptoms score helps to chart the progress of these symptoms. Pharmaceutical companies have developed and distributed alternative self-completed tools—such as the Parkinson well-being map—but have not been validated in PD. Figure 4 shows the importance of using such tools in the clinic. Two newly diagnosed patients, untreated and with similar motor disability, completed NMSQuests (figure 4A,B). The first patient reports only five non-motor symptoms: mainly problems with dribbling of saliva at night, urgency to pass urine, unexplained pain and dizziness. The second patient reports a wider range of non-motor symptoms (19/30): problems related to sleep, dribbling of saliva and other autonomic symptoms. Each of them needs a different management plan for their non-motor symptoms, as well as the treatment of the motor symptoms. These observations have been confirmed by two recent studies in untreated PD and early PD (compared with controls).
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Figure 3.
Suggested algorithm of addressing non-motor symptoms in clinic (modified from Chaudhuri et al). HCP, healthcare professional; QoL, quality of life; PDSS, Parkinson's Disease Sleep Scale; HADS, Hospital Anxiety and Depression Scale; Scopa AUT, Scales for Outcomes in Parkinson's disease—Autonomic; ICD, impulse control disorders.
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Figure 4.
(A) Non-motor symptoms (NMS) Quest, drug-naïve patient, H&Y 1, 5/30.
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Figure 4.
(B) NMS Quest, drug-naïve patient, H&Y 1, 19/30.
A simple grading using patient-completed NMSQuest has stages of severity burden of non-motor symptoms ranging between levels 1 and 4 (proposed as the Kings-ISCIII grading). This classification has been validated using the NMSS, the latter being particularly aimed towards research-based studies. NMSQ grading of the burden can influence treatment and screening in primary care is particularly recommended. For instance, for the patient cited in figure 4B, Hoehn and Yahr stage 1 would have NMSQ grade 4 and should be referred for treatment more promptly than the patient cited in figure 4A. Both NMSQ and NMSS burden grades have highly significant inverse correlations with HRQol of patients.