Parkinson’s Disease

Guidance for medical examiners when assessing a patient for either a general topic or condition - Parkinson’s Disease.

Definition

This guidance should be used for applicants with:

  • clinically confirmed Parkinson's disease after other causes of parkinsonism have been excluded and at least 3 months have elapsed from first presentation for specialist neurology assessment.

Aeromedical implications

Effect of aviation on condition

  • 'g' loading may cause loss of consciousness in context of autonomic dysfunction
  • Jet lag may exacerbate sleep dysfunction

Effect of condition on aviation

  • Overt incapacitation from hyper-somnolence, wearing-off effect, dyskinesia
  • Subtle incapacitation from cognitive impairment, depression, reduced reaction times, vision impairment

Effect of treatment on aviation

  • Sedative effects and impulse control disorders secondary to dopaminergic therapy

Approach to medical certification

Based on the condition

  • Certainty of diagnosis (differential diagnoses may have less predictable prognosis)

Based on treatment

  • Watchful waiting
  • Medication

Demonstrated stability

  • Absence of rapid and progressive aero-medically significant impairment
  • Medication stability

Risk assessment protocol - information required

New cases

Neurologist report

  • Confirmed diagnosis
  • Clinical status
    • initial presentation (please include dates)
    • symptoms and signs
    • progress
    • history of falls, motor vehicle or aircraft accidents
    • assessment against standardised disease rating scale (UPDRS 1987). Scoring sheet will be required for baseline and future comparison
    • the report should include an assessment of sleep disturbance, mood disturbance, visual dysfunction, autonomic dysfunction and cognitive changes
  • Investigations conducted
    • indication for imaging if performed
    • result of imaging
    • results of any other investigations performed including indication
  • Management
    • treatment
    • side-effects
    • monitoring
  • Follow-up plan.

Neuropsychological assessment

  • Screening for mild cognitive impairment should be performed at time of diagnosis and regularly thereafter
  • Tests of frontal executive function must be included
  • Neuropsychological screening should be undertaken in 'ON' and 'OFF' state (where appropriate)
  • Screening for dementia is also required

Ophthalmologist report

  • A report  from a Designated Aviation Ophthalmologist or Credentialed Optometrist will be required including:
    • CASA Eye Report
    • colour vision sensitivity
    • contrast sensitivity.

Operational flight test

  • A flight test conducted by an Approved Testing Officer, Flying Operations Inspector or Chief Flying Instructor is required. Test protocol will be supplied to the testing officer on request to CASA (Aviation Medicine)

Renewal

Neurologist report

  • Clinical status
    • symptoms and signs
    • progress
    • history of falls, motor vehicle or aircraft accidents
    • assessment against standardised disease rating scale (UPDRS 1987). Scoring sheet will be required for baseline and future comparison.
    • the report should include an assessment of sleep disturbance, mood disturbance, visual dysfunction, autonomic dysfunction and cognitive changes
  • Investigations conducted
    • indication for imaging if performed
    • result of imaging
    • results of any other investigations performed including indication
  • Management
    • treatment
    • side-effects
    • monitoring
  • Follow-up plan.

Neuropsychological assessment

  • Test selection must include repeats of initial baseline tests to enable comparison. If not possible, explanation to be provided

Ophthalmologist report

  • Test selection must include repeats of initial baseline tests to enable comparison. If not possible, explanation to be provided

Operational flight test

  • A flight test conducted by an Approved Testing Officer, Flying Operations Inspector or Chief Flying Instructor is required. Test protocol will be supplied to the testing officer on request to CASA (Aviation Medicine)

Indicative outcomes

  • The functional effects of Parkinsonism can be global and variable
  • Certification is possible when there is preserved cognitive function, acceptable motor control, absence of significant medication side effects and absence of significant non-motor impairment
  • If Parkinson's disease medications are changed, pilots and controllers should ground themselves and present to their DAME for review:
    • the DAME will ascertain the reason for the change in medications
    • the grounding should continue for a minimum of four weeks and until stability can once again be confirmed
    • if function is impaired, change of condition MUST be referred to CASA for consideration of clearance
    • if no functional impairment, the DAME should notify CASA prior to issuing a clearance.

Favourable

  • Management by watchful waiting in context of mild disease with minimal motor and non-motor impairment
  • Management of motor impairment with medication (not dopamine agonists) with sustained and predictable response without wearing-off phenomena or dyskinesia in the absence of significant non-motor impairment
  • Levodopa, Dopa-decarboxylase inhibitors, Monoamine-oxidase B inhibitors, Catechol-O-methytransferase inhibitors, Amantadine

Unfavourable

  • Dopamine agonists, Anticholinergics
  • Surgical management of Parkinson's disease in context of advanced disease resistant to medical management

Pilot and controller information

  • Pilots and controllers should 'ground' themselves and notify their DAME or CASA if they are diagnosed with Parkinson's disease. DAME will in turn notify CASA
  • If Parkinson's disease medications are changed, pilots and controllers should ground themselves and present to their DAME for review
  • Parkinson's Disease is an unpredictable and highly variable disease. This is why a wide range of tests is required
  • CASA data indicates that the average time from diagnosis to loss of certification is 3-4 years

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.

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