Suspected Parkinson's

 

Parkinsonism diagnosis:

(consider if bradykinesia is present plus at least one other feature)

• Bradykinesia - slowness of voluntary movement and difficulty with fine movements e.g. fastening buttons
• Resting tremor – absent during sleep, may be unilateral initially
• Muscular rigidity – cogwheeling, lead-pipe rigidity, stiff often flexed posture.
• Gait instability

 

Other features of Parkinson’s disease:

• Cognitive impairment, depression, tiredness, slow and quiet monotonous speech, small handwriting, stiffness and aching limbs, fixed facial expression with infrequent blinking, sleep disorders (insomnia, daytime somnolence, REM sleep disorder, restless leg syndrome)
• Autonomic dysfunction – dysphagia, postural hypotension, incontinence, impotence, double vision, sweating, constipation.
• Normal muscle strength, power, and reflexes

 

Check for drugs known to cause parkinsonism:

• Dopamine-blocking drugs:
• Antiemetics: prochlorperazine, metoclopramide, cyclizine
• Antipsychotics including antypical antipsychotics
• Sedating antihistamines – Chlorpheniramine, cinnarizine, clemastine, promethazine, alimemazine tartrate
• Dopamine-depleting agents – tetrabenazine
• Miscellaneous drugs:
  • Amiodarone
  • Calcium channel blockers
  • Chemotherapy with multiple agents
  • Lithium
  • Phenytoin
  • Sodium valproate

 

Consider differential diagnoses:

• Essential tremor
• Lewy body dementia (dementia usually precedes Parkinsonism)
• Parkinson's plus syndromes– multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration (Prominent autonomic symptoms). Consider if:
  • Early cognitive impairment
  • Early hallucinations
  • Significant speech or swallowing problems at presentation
  • Visual-spatial impairments and apraxia
• Secondary Parkinsonism:
  • Vascular Parkinsonism
  • Repeated head trauma or structural brain lesions
  • Metabolic – Wilson's disease, toxins
  • Infective causes – HIV, prion disease
  • Drug-related (see causes above)

 

 

Routine bloods including Ferritin, B12, folate, TFTs

 

1. Stop or reduce any drugs known to cause parkinsonism (see above) if possible. Symptoms should improve after 2 weeks
    
2. Do not start parkinson’s medication prior to diagnosis and referral.
    
3. If the patient’s has a confirmed diagnosis of Parkinson’s ensure they are aware of:
   - Driving issues and the need to inform the DVLA
   - Impulse control disorders that can arise from dopaminergic medications

 

 

1. Do not start parkinson’s medication prior to diagnosis and referral.
    
2. Refer patients with no prior diagnoses to a clinic dependent on patient demographic:
   
   Eldercare movement disorders clinic for:
   Older patients (e.g. over 65 years old)
   Or patients with cognitive impairment, social problems or co-morbidities
   
   Neurology clinic for:
   Younger patients (Note generally referrals for Parkinson's are triaged as routine referrals unless there are features such as clear significant progression, decompensation, risk-to life)
    
3. Those where other movement disorders are in the differential e.g. Huntingdon's
    
4. If suspected atypical Parkinson’s or a Parkinson’s plus syndrome (see above) then refer urgently.
    
5. Note advice & guidance is only available for Neurology referrals

 

 

 

For professionals:

• NICE Guidance – Parkinson's Disease in Adults
• Parkinson's UK – UK Parkinson's Excellence Network

 

For patients:

• NHS Cornwall Partnership – Parkinson’s Nurse Specialist Service
• Parkinson's UK – Newly Diagnosed with Parkinson's
• Patient UK – Parkinson's Disease

 

 

 

Review date – December 2023

Next review due – December 2026

Reviewing GP – Dr Madeleine Attridge

Other contributors: Lynne Osborne (Parkinson’s disease specialist nurse), Dr Oliver Leach, Dr Rod Bland, Dr Simon Parkin.