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Parkinson’s Disease Referrals

Parkinsonism is a syndrome of:

  • bradykinesia (slowness of movement)
  • muscular rigidity - increased tone
  • rest tremor - frequency of 4-6 Hz
  • gait instability

Non-motor symptoms are wide ranging and often precede the motor symptoms.  These include loss of smell, constipation, pain, depression, sleep disturbance, and autonomic disturbances (incontinence, dysphagia, constipation, impotence, hypotension and sweating).  Cognitive impairment is also an important factor in the disease spectrum.

Main message is careful history and examination

There are no easily available tests in primary care to help make the diagnosis. DAT scanning is available in secondary care for specific indications

Prior to Referral:

·         Consider differential diagnosis (see below)

·         Stop any culprit medications if possible (see below)

·         Basic investigations: Bloods including TFTs.

Referral:

1.      Patient with no previous diagnosis - refer to a consultant clinic.

Consultant clinics are run by both Neurology and Eldercare departments

§  Eldercare PD clinics Particularly suitable for patients of any age with medical co-morbidities, mobility and/or social problems.

  

§  Neurology PD clinics - Particularly suitable for patients of any age with neurological symptoms where diagnosis is uncertain (eg possible Wilson’s disease, degenerative neuromuscular diseases, post trauma).

 

 

 

 

2.      Patient with known Parkinson’s disease

 

Acute deterioration of PD symptoms – see pathway below for useful prompts to possible causes.

 

For help with acute deterioration or review of symptom control, refer to Parkinson’s nurse or contact patient’s usual consultant

§  Parkinson’s nursing service – locality based nurses, contact by telephone on 01209 881655

 

Differential Diagnosis of Parkinsonism:

o   Essential Tremor

o   Dementia with Lewy Bodies (dementia usually precedes parkinsonism)

o   Corticobasal degeneration

o   Parkinson’s Plus syndromes (Multiple system atrophy, Progressive Supranuclear Palsy)

o   Late stages of Alzheimer’s disease

 

Secondary Parkinsonism:

o   Vascular Parkinsonism (cerebrovascular disease)

o   Drug induced

o   Repeated head trauma

o   Toxins (organic solvents)

o   Structural brain lesions

o   Metabolic (Wilson’s disease)

o   Infective (HIV/AIDS, prion disease)

 

Drugs associated with Parkinsonism or tremor:

o   Antipsychotics – haloperidol, risperidone, chlorpromazine, aripiprazole

o   Antiemetics – stemetil, maxolon

o   Cinnarizine

o   Methylodopa

o   Valproate

o   Lithium

o   Amiodarone

 

 

Acute deterioration in motor symptoms in Parkinson’s disease