arkinson 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/# 
- 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. 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) guideline 7 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).
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.)

# COMMUNICATION
n People with Parkinson disease should be encouraged to participate in choices about their own care.
n Communication should be in verbal and written form.
n Discussions should aim to achieve a balance between providing realistic information and promoting optimism.
n Families and caregivers should be informed about the condition and available support services.

# DIAGNOSIS AND PROGRESSION
n Parkinson disease should be suspected in anyone with tremor, sti ness, slowness, balance problems or gait disorders.
n CT or MRI brain scanning should not be routinely used to diagnose Parkinson disease.
n Patients, especially young, who request genetic testing should be assessed by a movement disorders specialist.
n No therapies are e ective for slowing or stopping brain degeneration in Parkinson disease.

# NONMOTOR FEATURES
n Botulinum toxin A helps control drooling.
n Drug therapy for low blood pressure includes midodrine, udrocortisone and domperidone.
n Management of depression should be tailored to the individual and their current therapy.
n Dementia should not exclude a diagnosis of Parkinson disease, even if present early.
n Rapid eye movement sleep behaviour disorder can pre-date the diagnosis of Parkinson disease.

# PALLIATIVE CARE
n The palliative care needs of people with Parkinson disease should be considered throughout all phases of the disease.
n If the patient asks, the option of medical assistance in dying should be discussed.

# TREATMENT
n Levodopa is the most e ective medication and may be used early.
n A regular exercise regimen begun early has proven bene t.  

# C1
Communication with people with PD should be aimed at empowering them to participate in the judgments and choices about their own care.

# NICE 7 D C2
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.

# NICE 7 D C3
Because people with PD 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.

# NICE 7 D GPP C4
Families and caregivers should be given information about the condition, their entitlements to care assessment and the support services available.  

# 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: NICE 7 ).
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: NICE 7 ).
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 individ ually tailored and reinforced as necessary -and consistent com munication from the professionals involved (grade: D, good prac tice point; source: NICE 7 ).
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: NICE 7 ).
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 materi al 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. 

# C9
Clinicians should be aware of the poor specificity of a clinical diagnosis of PD in the early stages of the disease, and consider this uncertainty when giving information to the patient and when planning management.
SIGN 13 C C10 Patients should be offered long-term, regular follow-up to review the diagnosis of PD. This should include a review of the ongoing benefits in those started on dopamine replacement therapy.
SIGN 13 GPP

# C11
Patients initially considered to have a possible diagnosis of PD may benefit from a trial of dopamine replacement therapy to assist with an accurate diagnosis.
SIGN 13 

# GPP C12
Patients with suspected PD, with substantial disability or exclusion criteria or red flags as per the MDS diagnostic criteria, should be seen by a clinician with sufficient expertise in movement disorders to make the diagnosis.
SIGN 13 C GPP

# C13
Acute challenge testing with either levodopa or apomorphine should not be used in the diagnosis of PD. Patients with suspected PD should be considered for a trial of chronic levodopa treatment.

# SIGN 13 A C14
Objective olfactory testing is not recommended in the diagnosis of PD. SIGN 13 B C15 Routine use of functional imaging is not recommended for the differential diagnosis of PD and Parkinson plus disorders such as progressive supranuclear palsy and multiple system atrophy.

# SIGN 13 C C16
PET scanning is not recommended as part of the diagnostic work-up of parkinsonian syndromes, except within a research framework.

# SIGN 13 GPP C17
123 I-FP-CIT SPECT scanning should be considered as an aid to clinical diagnosis in patients where there is uncertainty between PD and nondegenerative parkinsonism or tremor disorders.
SIGN 13 B

# C18
Computed tomography or MRI brain scanning should not be routinely applied in the diagnosis of idiopathic PD. SIGN 13 C C19 Vitamin E should not be used as a neuroprotective therapy for people with PD. Co-enzyme Q10 should not be used as a neuroprotective therapy for people with PD.
NICE 8 A C20 Levodopa (grade: GPP), amantadine (grade: GPP), dopamine agonists (pramipexole, ropinirole, rotigotine, apomorphine, bromocriptine) (grade: A), or MAO inhibitors (selegiline, rasagiline) (grade: A) should not be used as neuroprotective therapies for people with PD, except in the context of clinical trials.

# CAN Varied

# C21
Genetic testing for monogenic parkinsonism is not recommended in routine clinical practice. SIGN 13 

# GPP C22
Patients who request genetic testing, particularly those with young-onset parkinsonism, should be assessed in a specialist movement disorders clinic for consideration of counselling and testing.  

# General considerations

# C23
People with PD should have regular access to the following:
- Clinical monitoring and medication adjustment - A continuing point of contact for support, including home visits, when appropriate - A reliable source of information about clinical and social matters of concern to people with PD and their caregivers, which may be provided by a PD nurse specialist.

# NICE C C24
Antiparkinsonian medication should not be withdrawn abruptly or allowed to fail suddenly owing to poor absorption (e.g., gastroenteritis, abdominal surgery), to avoid the potential for acute akinesia or neuroleptic malignant syndrome.

# NICE D GPP C25
The practice of withdrawing patients from their antiparkinsonian drugs (so-called "drug holidays") to reduce motor complications should not be undertaken because of the risk of neuroleptic malignant syndrome.

# NICE D GPP C26
In view of the risks of sudden changes in antiparkinsonian medication, people with PD who are admitted to hospital or care homes should have their medication: i) given at the appropriate times, which in some cases may mean allowing self-medication; ii) adjusted by, or adjusted only after discussion with, a specialist in the management of PD.

# NICE D GPP C27
Surveillance for dopamine dysregulation syndrome should be undertaken in patients receiving levodopa or intermittent apomorphine.

# SIGN 13 GPP C28
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.

# NICE GPP C29
It should be recognized that impulse control disorders can develop in a person with PD who is on any dopaminergic therapy at any stage in the disease course.

# NICE GPP

# Pharmacologic therapy in early PD

# C30
Before starting treatment for people with PD, the following should be discussed: 

# C39
There is insufficient evidence to support the use of amantadine in the treatment of patients with early PD.
SIGN 13 A 

# Rehabilitation

# C56
Consideration should be given to referring people who are in the early stages of PD to a physiotherapist with experience of the disease for assessment, education and advice, including information about physical activity.

# NICE 8 B C57
Physiotherapy specific to PD should be offered to people who are experiencing balance or motor function problems.

# NICE 8 A C58
Consideration should be given to referring people who are in the early stages of PD to an occupational therapist with experience of PD for assessment, education and advice on motor and nonmotor symptoms.

# NICE 8 B C59
Occupational therapy specific to PD should be offered to people who are having difficulties with activities of daily living.
NICE 7 A

# 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: NICE 7 ).
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 Society 9 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).
Patients initially considered to have a possible diagnosis of Parkin son disease may benefit from a trial of dopamine replacement ther apy to assist with an accurate diagnosis (grade: good practice point; source: SIGN 13 ).
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 dif ferential diagnosis of Parkinson disease and Parkinson plus disor
ders such as progressive supranuclear palsy and multiple system atrophy (grade: C; source: SIGN 13 ).
Positron emission tomography scanning is not recommended as part of the diagnostic workup of parkinsonian syndromes, except within a research framework (grade: good practice point; source: SIGN 13 ).
123 Iioflupane ( 123 IFPCIT) singlephoton 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: SIGN 13 ).
Computed tomography or magnetic resonance imaging brain scanning should not be routinely applied in the diagnosis of idio pathic Parkinson disease (grade: C; source: SIGN 13 ).
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.  

# Autonomic dysfunction C67
Botulinum toxin A is efficacious for the symptomatic control of sialorrhea in PD. MDS 16 A C68 General measures for treating urinary urgency and incontinence include before bedtime, avoiding coffee and limiting water ingestion. When symptoms appear suddenly, exclude urinary tract infection.
- Nocturia: reduce intake of fluid after 6 pm. Sleep with head-up tilt of bed to reduce urine production. - Nighttime dopaminergic therapy should be optimized.
- For urinary urgency (overactive bladder), anticholinergic or antispasmodic drugs may be useful, but care must be taken regarding central adverse effects. - Botulinum toxin type A injected in the detrusor muscle.
EFNS 15 GPP C69 For orthostatic hypotension, general measures would include the following:
- Avoid aggravating factors such as large meals, alcohol, exposure to a warm environment and drugs known to cause orthostatic hypotension, such as diuretics or antihypertensive drugs.
Levodopa and dopamine agonists may also worsen orthostatic hypotension. - Increase salt intake in symptomatic orthostatic hypotension.
- Ensure head-up tilt of the bed at night. - Wear elastic stockings.
- Highlight postprandial effects. In some patients, hypotension occurs only postprandially.
Warning the patient about this effect and taking frequent small meals may be helpful.
EFNS 15 GPP C70 For orthostatic hypotension, drug therapy includes the addition of:
- Midodrine - Fludrocortisone - Domperidone.

# EFNS 14 EFNS 14 CAN
A GPP GPP

# C71
For gastrointestinal motility problems in PD, general measures for treating constipation should be applied:
- Increased intake of fluid and fibre is recommended (grade: GPP).
- Increased physical activity can be beneficial (grade: GPP).
- Polyethylene glycol solution (macrogol) is recommended (grade: A).
- Fibre supplements such as psyllium (grade: B) or methylcellulose and osmotic laxatives (e.g., lactulose) are recommended (grade: GPP). - Short-term irritant laxatives for selected patients are recommended (grade: GPP).
- The use of drugs with anticholinergics activity should be reduced or discontinued (grade: GPP).
- Domperidone should be added (grade: B). EFNS 14 Varied C72 For individuals with PD and erectile dysfunction:
- Drugs associated with erectile dysfunction (e.g., -blockers) or anorgasmia (e.g., selective serotonin reuptake inhibitors) should be discontinued. Dopaminergic therapy can have both negative and positive effects on this symptom (grade: GPP). - Sildenafil 50-100 mg, 1 h before sex, can be tried in patients with PD with these problems (grade: B). - Other drugs of this class, such as tadalafil (10 mg, 30 min-12 h before sex) or vardenafil (10 mg, 1 h before sex) can be alternative choices (grade: GPP). - In some patients, apomorphine injections (5-10 min before sex) can also be an alternative treatment (grade: GPP). - Intracavernous injections of papaverine or alprostadil can be considered in selected patients (grade: GPP).

# EFNS 15 Varied
Cognitive impairment

# C73
The diagnoses of dementia associated with PD and of mild cognitive impairment in PD can be made using the Movement Disorder Society Clinical Diagnostic Criteria. These require reports of subjective cognitive decline and difficulties on psychometric testing.

# CAN GPP C74
For PD 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: GPP). Memantine can be added or substituted if cholinesterase inhibitors are not tolerated or lack efficacy (grade: C).

# EFNS 14 Varied

# C75
No interventions have been proven to reduce the risk of progression of PD from mild cognitive impairment to dementia but lifestyle modifications, such as engaging in cognitive and social activities and physical exercise, are encouraged. 

# CAN GPP

# C84
Clinicians should be aware that there are difficulties in diagnosing mild depression in people with PD because the clinical features of depression overlap with the motor features of PD.

# NICE 7 D GPP C85
Self-rating or clinician-rated scales may be used to screen for depression in patients with PD.
- Diagnosis of depression should not be made on the basis of rating scale score alone.
- Assessment or formulation of depression should be carried out via clinical interview, with a focus on low mood, and with due caution in relation to interpretation of cognitive or somatic symptoms that may be symptoms of PD rather than depression. - Relatives or caregivers who know the patient well should be invited to provide supplementary information to assist the diagnosis, particularly in the context of cognitive impairment. 
C GPP GPP GPP C86
The management of depression in people with PD should be tailored to the individual -in particular, to their co-existing therapy.

# NICE 7 D GPP

# Psychosis

# C87
All people with PD and psychosis should receive a general medical evaluation and treatment for any precipitating condition.

# NICE 7 D GPP C88
For patients with PD and psychosis, polypharmacy should be reduced.
- Anticholinergic antidepressants should be reduced or stopped; anxiolytics or sedatives should be reduced or stopped. - Antiparkinsonian drugs should be reduced. Anticholinergics should be stopped, amantadine should be stopped, dopamine agonists should be reduced or stopped, MAO-B and COMT inhibitors should be reduced or stopped and, lastly, levodopa should be reduced.

# EFNS 14 GPP
Genetic testing for monogenic parkinsonism is not recommended in routine clinical practice (grade: good practice point; source: SIGN 13 ).
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  

# C93
People with PD 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.

# NICE 8 D C94
People with PD 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:
- Progression of PD - Possible future adverse effects of medicines for PD - 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.

# NICE 8 D C95
When discussing palliative care, it should be recognized that family members and caregivers may have different information needs from the person with PD.

# NICE 8 D C96
Consideration should be given to referring people at any stage of PD to the palliative care team to give them and their family members or caregivers (as appropriate) the opportunity to discuss palliative care and care at the end of life. disease progresses. A balance between the adverse effects of the medication and the benefit often becomes more difficult with time (Table 6).

# Levodopa
Levodopa may be used as a symptomatic treatment for people with early Parkinson disease (grade: A; source: NICE 7 ).
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: NICE 7 ).
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: NICE 7 ).
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 conven ience of a single, daily, nonoral administration.   Subcutaneous apomorphine infusions or injections may be con sidered for the management of severe motor complications, but should be provided only in units that have sufficient experience and resources (grade: C; source: SIGN 13 ).
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., compul sive 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: NICE 8 ).
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: NICE 8 ).
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 dyskin esia (grade: A; source: EFNS 14 ).
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 levodopacarbidopa enteric gel administered through percutaneous gastrostomy may be considered for the reduction of offtime or to reduce dyskinesia (grade: C; source: EFNS 14 ).
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 experi ence of the disease for assessment, education and advice, includ ing information about physical activity (grade: B; source: NICE 8 ). 

# 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 sial orrhea in Parkinson disease (grade: A; source: MDS 16 ).
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: EFNS 14  The management of depression in people with Parkinson disease should be tailored to the individual -in particular, to their co existing therapy (grade: D, good practice point; source: NICE 7 ).
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. 

# 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. 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 Excellence 7,8 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.
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.