Parkinson’s neuro assessment – do’s and don’ts

Summary

What do secondary care teams need in a referral in order to make the appropriate diagnosis?

Parkinson’s clinicians receive large volumes of referrals from primary care colleagues, which can make getting the right patient on the right care pathway in a timely manner a challenge.

Asked what constitutes the “perfect referral letter,” Louise Ebenezer said it would include motor and non-motor symptoms as well as their duration and context.

“We want to know if the symptoms have started one sided. GPs can observe the patient walking into the room and notice if they have slumped down, if they dragging their leg, swinging their arms, and if they are ‘hugging’ the doorframe on the way in,” she added.

It can also help to know if their loved ones have noticed the patient slowing down, in terms of movement and/or speech, and whether they are able to take off and put their coat back on themselves.

“It’s quite a lot, but this kind of history can give us much more information than just saying they have a tremor,” said Louise.

Specialist teams also need to know about non-motor symptoms, so it can help if GPs ask about the patient’s sense of smell, any sleep disturbances, and bowel or bladder dysfunction.

Bradykinesia is a clear sign of Parkinson’s, but it can be difficult to examine with confidence. To extract the right information, Louise said GPs could ask if the person is able to turn over in bed without support, and whether they can still operate buttons and zips. “I also always ask if they can still wipe their feet on the doormat after being out on a rainy day. If they can’t, they may be losing fluidity of movement,” she said.

Dr Neil Archibald said it was useful to structure a referral letter by the history and nature of motor and non-motor symptoms, and their impact on daily living.

How should GPs approach examining someone they suspect may have Parkinson’s disease?

Neil outlined useful elements of a neuro exam that could be carried out during a 10-minute GP consultation, and how best to report them.

The first is a gait observation. Those with a Parkinsonian gait will walk with a slightly forward centre of gravity and exhibit festination, or small, rapid steps. Any reduction in arm swing is also important to note, along with any hesitancy or freezing in doorways or when changing direction.

Assessing and describing the tremor can also be useful to secondary care teams. Someone with Parkinson’s will have a resting tremor that is coarse and asymmetrical, often unilateral, and “you should be able to count the oscillations per second”.

“You are better off observing it out of the corner of your eye during history taking,” said Neil. He also advised GPs to ask their patients to stretch both arms out in front of them and keep them there so see if the tremor stops, then starts to come back again. “This re-emerging tremor is really very characteristic of a Parkinsonian syndrome,” he explained.

To test for bradykinesia, GPs can ask patients to make “quaky duck” motions with their hands, by tapping their fingers to their thumbs, or tap their feet, and noting if the movement slows.

What are the main drivers of hospital admissions and ward consultations?

Louise’s specialist nurse team receive calls every day from colleagues in departments including emergency care, pharmacy, and occupational therapy.

“Often, patients will come into orthopaedics with a fall or fracture. Frequently the call will relate to pneumonia, a chest infection, or a urinary tract infection, or they may be an issue with social care,” she explained.

Concerns often centre around a change in the patient's symptoms, whether that be swallowing, speech or language, after they have moved from emergency care to a ward.

“We don’t go to see all our patients, but we do give a lot of telephone advice,” said Louise, adding that ward staff often wanted to move the patient to a rotigotine transdermal patch, but that changing medication wasn’t usually advised.

“Especially if somebody's come in with a urine infection, we want them to treat the UTI first and we'll see them if they become deconditioned after their infection or if something else has deteriorated with their Parkinson's.”

Are there any red flags ward staff should be looking out for?

Sometimes, frequent hospitalisations could be a sign of the differential diagnosis of progressive supranuclear palsy (PSP), which is difficult to distinguish from Parkinson’s early on in the disease course.

“If a patients with a diagnostic label of Parkinson's is only two or three years into their diagnosis, but is getting repeatedly admitted to hospital – if they're falling, they're swallowing is off, they're on their second aspiration pneumonia of the year, their communication struggling and there's lots of caregiver strain – the diagnosis is probably wrong,” said Neil, adding the medication optimisation would be needed in this scenario.

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