Checked: 13-01-2017 by
vicky.ryan Next Review: 18-01-2019
Parkinson's suspected NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
diagnosis and management of Parkinson's disease (PD) in adults and the elderly − this includes considerations on:
assessment and diagnosis:
clinical features − motor and non-motor symptoms
radiological and biochemical investigations
symptomatic pharmacological management in early and late PD and contra-indicated medications
neuroprotective pharmacological agents
surgical management options for PD
supportive and palliative care options for PD
non-motor complications of PD
PD is a lifelong chronic progressive neurodegenerative condition 
parkinsonism is a generic term for the core motor features of PD which include [2,3]:
tremor when at rest
non-motor signs of PD include deficits in:
NB: PD is the most common form of parkinsonism .
This care map has been updated to include new recommendations on the use of domperidone in line with the following guideline:
 Medicines and Healthcare products Regulatory Agency (MHRA). Domperidone: risk of cardiac side effects - restricted indication, new contraindications, and reduced dose and duration of use. London: MHRA; 2014.
Please see the care map’s Provenance for additional information on references, contributors, and the editorial methodology.
This care map has been drafted using the Map of Medicine editorial methodology and represents best clinical practice according to the highest quality evidence available, including the following guidelines:
 Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and pharmacological management of Parkinson's disease. A national clinical guideline. SIGN publication no. 113. Edinburgh: SIGN; 2010
 PRODIGY. Parkinson's disease. Version 1.3. Newcastle upon Tyne: PRODIGY; 2009
 National Collaborating Centre for Chronic Conditions. Parkinson's disease. National clinical guideline for diagnosis and management in primary and secondary care. London: Royal College of Physicians (RCP); 2006
 Suchowersky O, Reich S, Perlmutter J et al. Practice Parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 66: 968-75.
 Oertel WH, Berardelli A, Bloem BR et al. European Handbook of Neurological Management: Volume 1, 2nd edition. Chapter 14: Early (uncomplicated) Parkinson's disease. London: Blackwell Publishing Ltd; 2011.
 Suchowersky O, Gronseth G, Perlmutter J et al. Practice Parameter: neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 66: 976-82.
 Zesiewicz TA, Sullivan KL, Arnulf I et al. Practice Parameter: treatment of nonmotor symptoms of Parkinson disease: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010; 74: 924-31.
 Oertel WH, Berardelli A, Bloem BR et al. European Handbook of Neurological Management: Volume 1, 2nd edition. Chapter 15: Late (complicated) Parkinson's disease. London: Blackwell Publishing Ltd; 2011.
 British National Formulary (BNF). BNF 62. London: BMJ Group and RPS Publishing; 2011.
Further information was provided by the following references including practice-based knowledge: [7,11-13].
Core clinical features include :
bradykinesia or hypokinesia, eg:
difficulty with fine movements such as:
handwriting − micrographia
slow, shuffling gait
difficulty turning in bed
rest tremor (30% of diagnosed patients won't have a rest tremor)
Clinical features which may appear early in the disease (and may precede motor symptoms) include :
reduced ability to smell
Clinical features which may appear late in the disease include :
postural (orthostatic) hypotension
slowed movements [1-3], eg:
reduced facial expression [2,3]
reduced arm swing [2,3]
slow, shuffling gait 
rest tremor [1-3]:
usually improves on moving 
may appear in the :
thumb and index finger − 'pill-rolling'
Screen the patient for depression :
a structured interview is the gold standard method of assessment − this includes :
a focus on low mood
exercising caution in relation to interpretation of cognitive/somatic symptoms that may be features of PD rather than depression
consider self-rating of clinician-rated scales as an aid to screening − recommended scales include :
consider collecting supplementary information from relatives or carers who know the patient well 
Examine the patient for:
lead-pipe rigidity − a constant resistance is felt when a limb is passively flexed in the presence of increased tone without tremor 
cogwheel rigidity − regular intermittent relaxation of tension is felt when a limb is passively flexed in the presence of tremor and increased tone 
postural instability [1,3] unrelated to :
primary visual dysfunction
The following findings suggest an alternate diagnosis to Parkinson's disease (PD):
falls at onset and early in the disease course 
symmetry at onset [2,4]
lack of tremor [2,4] or tremor that :
is not associated with bradykinesia and postural instability
worsens with stress, excitement, caffeine, or sleep deprivation
involves the head, neck, or voice as well as the limbs
improves, ie decreases, with alcohol and beta-blockers
has a family history
has a rate of 5-10 tremors per second − tremor due to PD will be slower
absence of rigidity 
definite encephalitis and/or oculogyric crises on no medication 
other neurological features :
supranuclear gaze palsy
early severe autonomic involvement
early severe dementia with disturbances of language, memory or praxis
exposure to known neurotoxin
presence of cerebral tumour or communicating hydrocephalus on neuroimaging
urinary retention requiring catheterisation
persistent erectile failure
symptomatic orthostatic hypotension
appearance of symptoms whilst patient is taking a substance known to induce parkinsonism − this includes the presence of akathisia and dystonia in a patient taking neuroleptics [2,3]
a history of:
repeated strokes with stepwise progression 
repeated head injury 
poor response to levodopa [3,4]
strictly unilateral features after 3 years 
a family history of more than one affected relative 
signs and symptoms which suggest:
sustained remission 
rapid progression [2,4]
Refer patients with suspected Parkinson's disease (PD) untreated to a hospital clinician with sufficient expertise in movement disorders [1,2] − patients with suspected :
early/mild PD should be seen within 6 weeks
late/severe PD should be seen within 2 weeks
Local administrative information
Refer to WGH Movement Disorder Clinic via Choose and Book or e-referrals
The standard RSS referral form is available as an EMIS template
The diagnosis of Parkinson's disease (PD) is largely clinical [1,3] and is based on the presence of the following core features:
rest tremor [1,3]
postural instability [1,3]
Be aware of the poor specificity of a clinical diagnosis of PD in the early stages − as the signs of PD evolve gradually over many years, diagnostic accuracy may improve over the course of the disease :
consider this initial diagnostic uncertainty when providing information to the patient and when planning management 
offer patients long term, regular follow up to review the diagnosis [1,3] − this includes a review of the ongoing benefits in those started on dopamine replacement therapy 
NB: Advise patients diagnosed with PD to inform the Driver and Vehicle Licensing Agency (DVLA) and their car insurer of their condition .
Patients will be seen by the Community Parkinson's Specalist Health Care Practitioner, initially on a monthly basis.
Prescribing is introduced by Secondary Care
Local administrative information
Contact Details for Parkinsons Specialist Health Care Practitioner - NSCP:
Louise Griffiths 01275 885428
Contact details for NBT Parkinson's Disease Nurse Specialist:
Kathryn Prout 0117 330 2521
Patients will be seen by the Parkinson's Nurse in Weston General Hospital, initially on a monthly basis.
Local administrative information
Contact Details for Parkinson's Disease Nurse Specialist - WAHT
Sarah Barber 01934 647152
Offer a regular medication review to check adherence with medication, identify any adverse effects and to ask about any motor or non-motor complications where management may require specialist advice or review. Parkinson’s UK have developed a ‘Non-motor symptoms questionnaire’ that can be completed by the patient or carer which may assist healthcare professionals to assess symptoms which can be found at: https://www.parkinsons.org.uk/professionals/resources/non-motor-symptoms-questionnaire
Offer referral to other members of the multi-disciliplinary team, such as speech and language therapy, physiotherapy, occupational therapy, adult social care, community nursing, continence and urology specialists, and psychology and mental health services, as necessary.
Primary care clinicians should be aware of dopamine dysregulation syndrome, an uncommon disorder in which dopaminergic medication misuse is associated with abnormal behaviours, including hyper-sexuality, pathological gambling and stereotypic motor acts. This syndrome can be difficult to manage and if identified should be referred to the PD specialist for input. A patient leaflet produced by Parkinson’s UK is available: https://www.parkinsons.org.uk/information-and-support/impulsive-and-compulsive-behaviour
Be mindful of drugs that can exacerbate parkinsonism or interact with anti-parkinsonian medication when managing any co-morbidities.
Offer the opportunity to discuss advance care planning and end of life issues at any stage after the initial diagnosis, offering referral to the palliative care team as appropriate.
Although a person with confirmed PD should be under the care of a specialist in movement disorders and a MDT including a PD nurse, primary care clinicians should ensure that a comprehensive review is taking place at least every 6-12 months.
Provide the person and family/carers with additional sources of information and support such as Parkinson’s UK
If Parkinson's appears to have suddenly deteriorated please check for:
If no improvement following treatment, refer to specialist Nurses as appropriate - see local information.
are managed by Mental Health not Parkinson's specialists.
Motor symptoms or complications are usually related to the use of anti-parkinsonian medication and PD specialists will be able to advise on the management of these symptoms or complications. They may include:
· Deteriorating function
· Loss of drug effect
· Motor fluctuations
· Freezing of gait
· Falls- may require input from the falls team or referral to a specific specialist nurse if progressive supranuclear palsy is suspected because the falls have occurred soon after PD diagnosis.
Non-motor symptoms include:
· Constipation, nausea and vomiting
· Sleep disturbance and daytime hypersomnolence
· Depression and anxiety
· Dementia and cognitive impairment
· Impulse control disorders and psychosis
· Postural hypotension
· Dysphagia and weight loss
· Excessive salivation and sweating
· Bladder and sexual problems
Primary care clinicians may be able to manage some of these issues, depensing on local guidelines and expertise.