Summary
Definition
History and exam
Key diagnostic factors
- bradykinesia
- resting tremor
- rigidity
- postural instability
Other diagnostic factors
- masked facies
- hypophonia
- hypokinetic dysarthria
- micrographia
- stooped posture
- shuffling gait
- conjugate gaze disorders
- fatigue
- constipation
- depression
- anxiety
- dementia
- exposure to antipsychotics or antiemetics
- features of atypical parkinsonism
- hyposmia/anosmia
- sleep disorders
Risk factors
- increasing age
- history of familial PD in younger-onset disease
- mutation in gene encoding glucocerebrosidase
- 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) exposure
- chronic exposure to metals
- male sex
- additional genetic risk factors
- head trauma
- geographic influence
- toxin exposure
- occupation
Diagnostic tests
1st tests to order
- dopaminergic agent trial
Tests to consider
- MRI brain
- functional neuroimaging (dopamine transporter imaging such as FP-CIT or beta-CIT SPECT, or fluorodopa PET)
- olfactory testing
- genetic testing
- neuropsychometric testing
- serum ceruloplasmin
- 24-hour urine copper
- cardiac sympathetic innervation using iodine-123 meta-iodobenzylguanidine (MIBG)
- brain pathology (postmortem)
Emerging tests
- skin biopsy
Treatment algorithm
mild parkinsonism
moderate parkinsonism
advanced parkinsonism
Contributors
Authors
Delaram Safarpour, MD, MSCE
Assistant Professor of Neurology
Department of Neurology
School of Medicine
Oregon Health & Science University
Portland
OR
Disclosures
DS has received honoraria for participation in advisory boards for Boston Scientific (the manufacturer of Deep Brain Stimulation device) and Abbvie (the manufacturer of Duopa). She has received consultation fees from Abbott (the manufacturer of Deep Brain Stimulation device). DS has received an institutional grant and has received an honorarium for lectures from Parkinson Study Group.
Marian L. Dale, MD, MCR
Assistant Professor of Neurology
Department of Neurology
Oregon Health & Science University
Staff Neurologist
Portland VA Medical Center
Portland
OR
Disclosures
MLD has received consulting honoraria from Synergic Medical Technologies and UCB, and has received grant funding from the NIH and the Collins Medical Trust.
Lauren S. Talman, MD
Assistant Professor of Neurology
Department of Neurology
School of Medicine
Oregon Health & Science University
Portland
OR
Disclosures
LST declares that she has no competing interests.
Acknowledgements
Dr Delaram Safarpour, Dr Marian L. Dale, and Dr Lauren S. Talman would like to gratefully acknowledge Dr Avram Fraint, Dr Danny Bega, Dr Meredith Spindler, Dr Jayne R. Wilkinson, and Dr Andrew D. Siderowf, the previous contributors to this topic.
Disclosures
DB served on the speaker's bureau for Teva Pharmaceuticals, and ACADIA Pharmaceutical, Inc; he has received consultancy fees from US WorldMeds and grant support from the Parkinson Foundation; he was on the board of directors for Rock Steady Boxing Windy City. AF, MS, JRW, and ADS declare that they have no competing interests.
Peer reviewers
Graham A. Glass, MD
Assistant Clinical Professor
Department of Neurology
UCSF Medical Center
Parkinson's Disease Research
Education and Clinical Center
San Francisco
CA
Disclosures
GAG declares that he has no competing interests.
Daniel Kremens, MD, JD
Assistant Professor of Neurology
Jefferson Medical College
Thomas Jefferson University
Philadelphia
PA
Disclosures
DK declares that he has no competing interests.
Donald Grosset, BSc (Honours), MB, ChB, MD, FRCP
Consultant Neurologist / Honorary Senior Lecturer
Institute of Neurological Sciences
Southern General Hospital / University of Glasgow
Glasgow
UK
Disclosures
DG is an author of a reference cited in this topic.
Patricia Dowsey Limousin, MD, PhD
Reader in Clinical Neurology
Honorary Consultant
Institute of Neurology
National Hospital for Neurology and Neurosurgery
London
UK
Disclosures
PDL declares that she has no competing interests.
Nikolaus McFarland, MD, PhD
Assistant Professor
Department of Neurology
University of Florida College of Medicine
Gainesville
FL
Disclosures
NM declares that he has no competing interests.
References
Key articles
Postuma RB, Berg D, Stern M, et al. MDS clinical diagnostic criteria for Parkinson's disease. Mov Disord. 2015 Oct;30(12):1591-601. Abstract
Internation Parkinson and Movement Disorder Society. MDS position paper: diagnosis of Parkinson's disease. Mar 2023 [internet publication].Full text
Pringsheim T, Day GS, Smith DB, et al; Guideline Subcommittee of the AAN. Dopaminergic therapy for motor symptoms in early Parkinson disease practice guideline summary: a report of the AAN Guideline Subcommittee. Neurology. 2021 Nov 16;97(20):942-57.Full text Abstract
Seppi K, Ray Chaudhuri K, Coelho M, et al. Update on treatments for nonmotor symptoms of Parkinson's disease - an evidence-based medicine review. Mov Disord. 2019 Feb;34(2):180-98.Full text Abstract
Fox SH, Katzenschlager R, Lim SY, et al. International Parkinson and Movement Disorder Society evidence-based medicine review: update on treatments for the motor symptoms of Parkinson's disease. Mov Disord. 2018 Aug;33(8):1248-66.Full text Abstract
Rughani A, Schwalb JM, Sidiropoulos C, et al. Congress of Neurological Surgeons systematic review and evidence-based guideline on subthalamic nucleus and globus pallidus internus deep brain stimulation for the treatment of patients with Parkinson's disease: executive summary. Neurosurgery. 2018 Jun 1;82(6):753-6.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Essential tremor
- Progressive supranuclear palsy (PSP)
- Multiple system atrophy (MSA; MSA-A, formerly Shy-Drager syndrome; MSA-P, striatonigral degeneration; MSA-C, olivopontocerebellar atrophy)
More DifferentialsGuidelines
- ACR–ACNM–SNMMI practice parameter for the performance of dopamine transporter (DaT) single photon emission computed tomography (SPECT) imaging for movement disorders
- European Academy of Neurology/Movement Disorder Society - European Section guideline on the treatment of Parkinson's disease: I. Invasive therapies
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