Intended for healthcare professionals

Practice Guidelines

Diagnosis and pharmacological management of Parkinson’s disease: summary of SIGN guidelines

BMJ 2010; 340 doi: (Published 12 January 2010) Cite this as: BMJ 2010;340:b5614
  1. D G Grosset, consultant neurologist1,
  2. G J A Macphee, consultant in medicine for the elderly1,
  3. M Nairn, programme manager2,
  4. on behalf of the Guideline Development Group
  1. 1Department of Neurology, Southern General Hospital, Glasgow G51 4TF
  2. 2Scottish Intercollegiate Guidelines Network, Edinburgh EH7 5EA
  1. Correspondence to: M Nairn moray.nairn{at}

    Why read this summary?

    Parkinson’s disease is a common neurodegenerative disease diagnosed in 1% of people aged over 65 years. It has a considerable impact on patients and their families as well as healthcare and social care systems. With an ageing population, the number of cases in Scotland may increase by 30% in the next 25 years.1 Accurate diagnosis can be difficult, particularly at first presentation. As the disease progresses, treatment with complex combinations of drugs often becomes the norm. This article summarises the recommendations from the Scottish Intercollegiate Guideline Network (SIGN) on the diagnosis and drug management of Parkinson’s disease.2


    SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (fig 1), but the grading does not reflect the clinical importance of the recommendation. Recommended best practice (“good practice points”), based on the clinical experience of the Guideline Development Group, is also indicated (as GPP).

    Explanation of SIGN grades of recommendations


    • Diagnosis depends largely on:

      • -The presence of a specific set of clinical features (using research derived diagnostic criteria, such as the UK Brain Bank criteria)3—bradykinesia, rigidity, rest tremor, and postural instability

      • -The absence of atypical features

      • -A slow, progressive course

      • -A good response to drug treatment for Parkinson’s disease.

    • Observe the patient for non-motor features (box), which may predate motor features, particularly impaired olfaction, REM (rapid eye movement) sleep behaviour disorder, constipation, and depression.4 A combination of several such features raises diagnostic suspicion of Parkinson’s disease.

    • Be aware of the potential inaccuracy of clinical diagnosis in the early stages of the disease. For instance, not all patients with parkinsonism have Parkinson’s disease; the term parkinsonism does not specify cause but describes a clinical syndrome of bradykinesia plus at least one of three …

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