PassFinals
Neurology

Parkinson's disease

A progressive neurodegenerative disorder causing bradykinesia with rigidity or tremor, usually asymmetrically at onset, with treatment focused on individualised motor control, non-motor symptoms, rehabilitation, safe medicines and future planning.

In a nutshell

Parkinson's disease is a clinical syndrome of bradykinesia with rigidity or tremor, usually asymmetric at onset, caused by progressive dopaminergic pathway degeneration. Treatment is individualised symptomatic dopamine replacement plus rehabilitation, non-motor care, safe administration and future planning; it is not disease-modifying.

Classic presentation

An older adult develops insidious asymmetric bradykinesia with decrement, a resting tremor or rigidity, reduced arm swing, hypomimia and a shuffling gait, with constipation, hyposmia or REM sleep behaviour disorder as possible earlier clues.

Key points

  • Diagnose clinically: bradykinesia plus rigidity or rest tremor; refer promptly and untreated to a movement-disorder specialist.
  • Use DaTscan only when a specialist cannot clinically distinguish essential tremor from parkinsonism; structural MRI does not diagnose Parkinson's disease.
  • Offer levodopa when motor symptoms affect quality of life; otherwise consider levodopa, a dopamine agonist or an MAO-B inhibitor after discussing benefits and harms.
  • Dopamine agonists carry important risks of impulse-control disorders, sleep attacks, hallucinations and other adverse effects; ask about these directly and repeatedly.
  • Never stop or delay antiparkinsonian medicines abruptly, including in hospital, peri-operatively or when the person is nil by mouth.
  • Wearing-off and dyskinesia need specialist adjustment; advanced options include apomorphine, deep brain stimulation, intestinal gels and foslevodopa-foscarbidopa for selected patients.
  • Treat non-motor disease and complications: psychosis, cognition, orthostatic symptoms, sleep, mood, swallowing, saliva, constipation, bladder symptoms and falls.
  • Provide Parkinson's-specific physiotherapy, occupational therapy, speech and language therapy, specialist nursing, carer support, palliative care and advance-care planning.

First-line investigation

Clinical history and neurological examination demonstrating bradykinesia with rigidity or rest tremor; reserve specialist DaTscan for clinically uncertain tremor or parkinsonism.

Management

Protect against acute deterioration

  • Treat sudden focal neurological symptoms as possible stroke, and urgently escalate missed-dose akinesia, inability to swallow, fever, rigidity, altered consciousness, aspiration or repeated falls.7,3

Confirm the clinical syndrome

  • Look for bradykinesia with rigidity or rest tremor, review medicines and atypical features, and refer quickly and untreated to a specialist; reserve DaTscan for diagnostic uncertainty.1,2

Choose motor treatment

  • Offer levodopa when motor symptoms affect quality of life; otherwise discuss levodopa, a dopamine agonist or an MAO-B inhibitor, considering motor benefit, sleepiness, psychosis and impulse-control risk (see BNF).4,10,6

Rehabilitate and manage non-motor disease

  • Provide Parkinson's-specific physiotherapy, occupational therapy, speech and language therapy, specialist nursing and care planning, while screening for falls, swallowing, cognition, mood, sleep, autonomic symptoms and medication harm.17,5,9

Treat psychosis and advanced motor complications safely

  • Address triggers and adjust Parkinson's medicines with specialist advice; avoid motor-worsening antipsychotics, use quetiapine or clozapine only as NICE specifies, and refer advanced fluctuating disease for apomorphine, DBS, intestinal-gel or foslevodopa-foscarbidopa assessment.15,11,12,13

Plan the future

  • Review the diagnosis and treatment regularly, discuss prognosis, driving, carers, advance decisions, DNACPR, lasting power of attorney, palliative care and end-of-life support early and revisit them as needs change.9,19,18

Exam traps

  • Do not diagnose Parkinson's disease from tremor alone: bradykinesia is required for parkinsonism.
  • Early falls, gaze palsy, severe autonomic failure, early dementia, rapid progression or poor levodopa response suggest atypical parkinsonism.
  • A sudden focal deficit is a stroke emergency, not a routine Parkinson's fluctuation.
  • Do not stop or delay Parkinson's medicines because a patient is nil by mouth; involve the specialist team and use a safe alternative plan.
  • Ask about gambling, hypersexuality, binge eating, shopping and sleep attacks even if the patient or carer does not volunteer them.
  • Avoid metoclopramide, prochlorperazine, olanzapine and other dopamine-blocking medicines where they worsen Parkinsonism; use specialist and BNF guidance.

Illustrations

Parkinsonian gait and postureIllustration of stooped posture, reduced arm swing and shuffling, festinant gait characteristic of Parkinson's disease.PassFinals · original
Dopamine-transporter SPECT (DaTscan): striatal tracer uptakeDopamine-transporter SPECT showing reduced putaminal uptake, producing a full-stop rather than the normal comma shape in the striatum.Jonnylaney, Wikimedia Commons · Public domain

Key sources

  1. NICE NG71: Diagnosing Parkinson's disease (Section 1.2; last reviewed 19 December 2024)
  2. NHS: Parkinson's disease diagnosis (Clinical diagnosis, specialist referral and possible SPECT scanning)
  3. NHS: Parkinson's disease (Condition overview, symptoms, causes, treatment and support)
  4. NICE NG71: Pharmacological management of motor symptoms (Section 1.3 on initial treatment, motor complications and medication safety)
  5. NICE NG71: Pharmacological management of non-motor symptoms (Section 1.5 on sleepiness, sleep disorders, orthostatic hypotension, psychosis and dementia)
  6. BNF online: Parkinsonism and related disorders (Check current levodopa, dopamine agonist, MAO-B inhibitor, COMT inhibitor, apomorphine, antipsychotic and antiemetic monographs for dose, interactions, contraindications and monitoring)
  7. NICE NG71: Safe administration and withdrawal of antiparkinsonian medicines (Recommendations 1.3.2 to 1.3.4)
  8. NHS: Parkinson's disease symptoms (Common motor and non-motor symptoms and progression)
  9. NICE NG71: Communication, care planning and support (Section 1.1 on communication, care plans, specialist contact, carers and driving)
  10. NICE NG71: Impulse-control disorders (Section 1.4 on risk, counselling, monitoring and specialist reduction of dopamine agonists)
  11. NICE NG71: Advanced Parkinson's disease (Section 1.8, including current links to foslevodopa-foscarbidopa and intestinal-gel commissioning)
  12. NICE TA934: Foslevodopa-foscarbidopa for advanced Parkinson's disease (Technology appraisal recommendation for selected advanced levodopa-responsive disease)
  13. NHS England: Levodopa-carbidopa intestinal gel and levodopa-carbidopa-entacapone intestinal gel (Clinical commissioning policy for adults with advanced Parkinson's disease, updated May 2025)
  14. NICE QS164: Information about impulse-control disorders (Quality statement 2 on counselling at treatment start and at least annually)
  15. NICE NG71: Hallucinations and delusions (Recommendations 1.5.12 to 1.5.20)
  16. NICE NG71: Parkinson's disease dementia (Recommendation 1.5.22)
  17. NICE NG71: Non-pharmacological management and rehabilitation (Section 1.7 on Parkinson's nurse, physiotherapy, occupational therapy, speech and language therapy and nutrition)
  18. NHS: Parkinson's disease treatment (Supportive therapies, medicines, surgery and monitoring)
  19. NICE NG71: Palliative care (Section 1.9 on prognosis, advance care planning, support and referral)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.