Parkinsonism and Movement Disorders

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.

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:

• Do not start Parkinson's medication
• 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:

• Eldercare Movement Disorders Clinic: particularly useful for older patients especially with co-morbidity, social problems, cognitive impairment
• Neurology clinic: particularly useful for young patients

   

2.      Patient with known Parkinson’s disease

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

• Refer to Parkinson’s Specialist Nurse for advice/patient support via Pdnurses.cornwall@nhs.net or  01209 318048. Referrals are triaged and undertaken face to face or via telephone.
• Contact patient’s usual consultant by telephone/email.

 

Differential Diagnosis of Parkinsonism:

• Essential Tremor
• Dementia with Lewy Bodies (dementia usually precedes parkinsonism)
• “Parkinson’s Plus” syndromes (Multiple system atrophy, Progressive Supranuclear Palsy, Corticobasal degeneration)
• Secondary Parkinsonism:

o   Vascular Parkinsonism (cerebrovascular disease)

o   Drug induced (see below for culprit drugs)

o   Repeated head trauma, structural brain lesions

o   Metabolic (Wilson’s disease), toxins

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   Methyldopa

o   Valproate

o   Lithium

o   Amiodarone

 

 

Acute deterioration in motor symptoms in Parkinson’s disease