Recognizing Parkinson's disease

In this video, taken from our Neurology Masterclass: Managing Common Diseases course, we look at the signs and symptoms to watch for, and the questions you need to ask, in order to diagnose a patient with Parkinson’s disease.

Many practitioners feel intimidated when they encounter a patient with a neurological dysfunction. This course will teach you how to diagnose and manage the neurological disorders commonly seen in primary and acute care situations. You will learn to confidently localize the affected region of the nervous system, order appropriate diagnostic studies, initiate intervention, and follow patient progress.

The brain has multiple overlapping systems involved in the initiation and execution of smooth, controlled and coordinated movement. These systems influence and modify the motor commands going out from the primary motor cortex, that is the motor strip. The basal ganglia comprise one such system, and much of their output is actually inhibitory.

It acts like a braking system on movement. The neurotransmitter dopamine through the nigrostriatal track acts to lift this brake off of the motor system and allows movement. Parkinson's disease involves a loss of cells that provide the dopamine input to the basal ganglia, and thus the brakes are essentially left engaged, slowing down and inhibiting movement.

This is thought to be the mechanism of one of the principal symptoms of Parkinson's disease, bradykinesia that is slow movement. Parkinson's disease usually occurs in a patient's sixties and progresses slowly. Although it eventually results in severe disability and often dementia, life expectancy is not significantly shortened. So how do we diagnose Parkinson's disease?

There is no definitive objective radiological test or laboratory study that will make the diagnosis of Parkinson's disease. It is purely a clinical diagnosis. So what should you look for? When suspecting early Parkinson's disease, start by asking about constipation, vocal changes or loss of vocal strength and range, and or difficulty with swallowing, as well as loss of fine motor skills.

These are all common early signs. Ask the patient whether they've experienced restless legs or cramping in the legs at night. Also, ask whether they've been experiencing balance issues, or falls, or sleep disturbances. Since all these are common early signs in Parkinson's disease. None of these symptoms however, are specific for the disease, but they may help you strengthen your diagnosis.

Assess the patient's sense of smell. I like to use a packet of coffee. Loss of smell is often an early sign in Parkinson's disease. Look for apparent blunted affect. Parkinson's disease patients often lose facial animation and appear unemotional, unfriendly, and depressed. They seldom smile. If you find yourself feeling like you're having trouble connecting with your patient, they may have Parkinson's disease.

Check for a tremor. This usually begins unilaterally or at least asymmetrically, and involves the hands at rest. It should go away with intentional movement. If it gets worse with intentional movement, the patient may have essential tremor. A small percentage of people with essential tremor can go on to develop Parkinson's, but essential tremor and resting tremor are not usually seen together.

Bradykinesia defined as slow movements and/or difficulty initiating movement, is also common. This is most easily observed by watching the patient's spontaneous activity, or asking them to do simple things like getting up and walking across a room. Patients with Parkinson's disease often show rigidity.

Move the patient's arms passively and look for stiffness that may be smooth, known as lead pipe rigidity, or jerky known as cogwheel rigidity. Check for postural instability and poor balance, including if the patient is easily pushed off of balance. Look for altered gait, in Parkinson's disease, you'll often see a shuffling, short stepped, and hunched over gait with decreased arm swing.

Please be aware, depression can look like Parkinson's disease and vice versa and is often a component of the disease itself. Recognize that there are several other Parkinson's disease like disorders that while similar to Parkinson's disease are not technically classified as Parkinson's disease. These diseases may not respond as well to treatments as Parkinson's disease does.

Evaluate the patient for signs and symptoms which may indicate the patient may not have classic Parkinson's disease. These will include urinary or fecal incontinence, disabling orthostatic hypotension, signs and symptoms in patients younger than 50 years of age, poor responses to Parkinson's disease medications, symmetry of findings early in the disease, and lack of tremor.

When suspecting Parkinson's disease, or a related disease, go ahead with an MRI of the brain to rule out disorders such as tumors, demyelinating diseases, and basal ganglion strokes. Arrange for consultation with a movement disorder specialist for initial management plan.