Method Literature review and original work for Parkinson’s Academy Masterclass.

Aim To enhance the depth and breadth of evaluation of risk in the management of ICD secondary to dopaminergic therapies in PD.

Summary Impulse control disorder (ICDs) can result in serious consequences for patients, their carers and families. They are characterized by a failure to resist a temptation, urge or impulse that may cause harm to oneself or others. They occur secondary to dopaminergic therapies in Parkinson’s, especially Dopamine agonists (DA). There is a dose and duration of treatment association. They may be accompanied by a degree of compulsion to act which increases risk. Risk factors associated their development have been identified including younger age at onset, being male, living alone, genetic and family history and preceding history of impulse control traits. A variety of screening tools exist but do not replace the detailed clinical interview. They may lead to criminal acts and consequent judicial proceedings, and whilst sentences may be commuted due to impaired capacity, the impact is frequently devastating. Class action law suits have been sought against the drug companies and prescribers have a clear medico-ethical responsibility for monitoring the drugs they prescribe. Management is often difficult and limited, necessitating slow withdrawal of the agent, and risk needs to be evaluated and managed throughout this period. An outline structure for evaluating risk is delineated focusing on areas of pre-disposing factors; detailed history of ICDs; degree of control and elucidation of risks.

Conclusion Whilst screening tools are helpful in identifying and assessing certain ICDs, they do not replace the clinical interview. There is an issue regarding self- reporting. Insight by the patient or reluctance to share the nature or degree of the ICD may lead to low identification of ICDs. Collateral information from carers or other involved professionals is essential in a comprehensive evaluation of risk. Whilst a structured risk assessment is likely to be less targeted to the specific risks dependant on the nature of the ICD, a framework for evaluating and thinking about risk with patient, carers and other professionals involved could enhance practice and more accurately meet the guidance established for monitoring and managing risk outlined in GMC and NICE guidance.