Parkinson’s Disease

History

• Tremor: Resting, often “pill-rolling” in the hands

• Mobility Issues: Difficulty rising from a chair, stiffness in arms/legs, slower movements

• Constipation: Common non-motor feature

• Loss of Smell (anosmia)

• Falls (postural instability in later disease)

• Non-Motor Symptoms: Fatigue, depression, REM sleep behaviour disorder (may precede motor signs)

Examination

• Resting Tremor: Pill-rolling type, reduces with intentional movement

• Shuffling Gait: Reduced arm swing, stooped posture

• Rigidity: “Cogwheel” or “lead-pipe” in arms/legs

• Bradykinesia: Slowness of movements, reduced facial expression (masked facies)

• Power, Reflexes, Sensation: Typically normal

• Postural Instability: Tends to occur in later disease stages

Investigations

• Primarily a clinical diagnosis.

• Response to Levodopa can support diagnosis.

• DaTScan (dopamine transporter scan) sometimes used in atypical or uncertain presentations.

Management

1. Neurology Referral

   • For confirmation of diagnosis and tailoring therapy.

2. Patient Education

   • Chronic, progressive nature of disease.

   • Discuss realistic goals, importance of exercise, and support services.

3. Pharmacotherapy

   • Levodopa + Carbidopa (first-line)

   • Dopamine Agonists (pramipexole, ropinirole) or Anticholinergics (e.g. benztropine) in younger patients or tremor-dominant disease to delay levodopa side effects.

   • Manage side effects (dyskinesias, motor fluctuations) as disease progresses.

4. Allied Health and Support

   • Physiotherapy: Improves mobility, gait training, reduces falls.

   • Psychology or counselling: CBT for depression or anxiety, connect with Parkinson’s support groups.

   • Speech Therapy: If dysarthria, swallowing issues.

   • Occupational Therapy: Home safety, assistive devices, falls prevention.

5. Comorbidities & Lifestyle

   • Screen for dementia, depression, anxiety (common in Parkinson’s).

   • Falls prevention strategies, regular exercise.

   • Avoid dopamine-blocking medications (e.g. typical antipsychotics, metoclopramide, prochlorperazine) that worsen symptoms.

   • If antiemetic needed → use domperidone (10 mg TDS, max 7 days) as it doesn’t cross BBB significantly.

Note

• Parkinson-plus syndromes (e.g. progressive supranuclear palsy) do not improve well with levodopa/carbidopa, often have additional features atypical for PD (vertical gaze palsy, early falls, etc.)