Parkinson's disease

doi:10.1136/bmj.39289.437454.AD

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C E Clarke, professor of clinical neurology, University of Birmingham

Department of Neurology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B18 7QH

c.e.clarke{at}bham.ac.uk

Summary points

• Parkinson's disease should be suspected in someone with tremor, stiffness, slowness, balance problems, or gait disorders
• All patients with suspected Parkinson's disease should be referred untreated to a specialist in differential diagnosis and be reviewed regularly by the specialist for accurate diagnosis and treatment
• Much debate surrounds which drug class should be used as initial treatment for Parkinson's disease and which adjuvant therapy should be added when patients taking levodopa develop motor complications
• Patients should have access to a Parkinson's disease nurse specialist and allied health professionals throughout the course of the disease

Tremor, often combined with slowness and stiffness in an arm, presents frequently in general practice. It may be caused by essential tremor, which affects 2-3% of the population.1 Parkinson's disease is less common (prevalence 0.2%), although its prevalence increases with age (4% of those aged over 80 years).2 Differentiating essential tremor from Parkinson's disease can be difficult, even for experienced physicians.

Recently published guidelines from the National Institute for Health and Clinical Excellence (NICE) advise that all patients with suspected Parkinson's disease should be referred to an expert in secondary care for an accurate diagnosis and management of the condition.3 However, non-experts need to be aware of the features of Parkinson's disease to ensure rapid referral and should have a basic understanding of how the condition is treated to facilitate shared care between primary and secondary care.

How does Parkinson's disease present?

The cardinal symptoms of Parkinson's disease are shaking, stiffness, and slowness and poverty of movement. The condition leads to physical signs including tremor at rest, rigidity on passive movement, slowness of movement (bradykinesia), and poverty of movement (hypokinesia). These features are unilateral at onset, but become bilateral as the condition progresses. Later, postural instability and falls, orthostatic hypotension, and dementia can develop.