1. In patients with suspected Parkinson’s disease, accurately distinguish idiopathic Parkinson’s disease from atypical Parkinson’s disease (e.g., disease at a young age, drug-related disease), as treatment differs.
  2. In the care of all patients with Parkinson’s disease, involve other health care professionals to enhance the patient’s functional status.
  3. In an elderly patient with a deterioration in functional status, look for and recognize Parkinson’s disease when it is present, as it is a potentially reversible contribution to the deterioration.
  4. In a patient with a tremor, do an appropriate physical examination (e.g., observation, use of techniques to enhance the tremor) to distinguish the resting tremor of parkinsonism from other (e.g., essential) tremors.
  5. As part of the management of patients with Parkinson’s disease, identify anticipated side effects of medications, especially those with which you are unfamiliar.
  6. As part of the ongoing follow-up care of patients with Parkinson’s disease:
    • Assess functional status.
    • Monitor them for medication side effects.
    • Look for other problems (e.g., depression, dementia, falls, constipation), as they are more common

General Overview

Typical features

  • >60yo
  • Resting tremor, often unilateral, 4-6 Hz (cycles per second), pill-rolling, increased with stress, decreased with voluntary activity
  • Muscle rigidity/cogwheeling (resistance to passive movement)
  • Bradykinesia (slow movements)
  • Postural instability, falls
  • Shuffling gait, decreased arm swing, unsteady turning, difficulty stopping, stooped/flexed posture
  • Mask-life facial expression, infrequent blinking
  • Speech changes (hypophonia), micrographia
  • Non-motor: Constipation, rapid eye movement (REM) sleep disorder, depression, olfaction impairment, personality changes

Atypical features (suspect secondary or other syndromes)

  • Young <60yo
  • Secondary causes: Drug-induced (Antipsychotics, antiemetics, CCB), Head trauma, Wilson disease, cerebrovascular, CNS infections
  • Rapid progression (motor symptoms, dysphonia)
  • Early autonomic dysfunction (urinary incontinence, syncope, orthostatic hypotension), r/o multisystem atrophy parkinsonism
  • Early recurrent falls (more than once a year within 3y of onset)
  • Bilateral symmetric symptoms at onset
  • Absent resting tremor
  • Poor response to levodopa
  • Ocular movement disorder, r/o supranuclear palsy


  • Improve quality of life and function
  • Refer to neurology untreated within 6w
  • Physical therapy
    • Gait, balance, flexibility
  • Occupational therapy
    • Mobility, self-care, safety
  • Speech therapy
    • Vocal loudness, swallowing
  • Parkinson Society of Canada / Support Groups


  • First-line: Levodopa/carbidopa (Dopamine precursor)
    • Brief duration of action (needs multidose regimen)
      • Side effects:
        • Impulse control disorder (eg. compulsive gambling, hypersexuality, binge eating and obsessive shopping)
        • Dyskinesia
        • Somnolence
        • Orthostatic hypotension/dizziness
        • Nausea, Dyspepsia
        • Psychotic symptoms and hallucinations
  • Other treatments
    • Dopamine agonists - pramipexole (best early in disease)
    • Anticholinergics - benztropine
    • NMDA-receptor antagonist - amantadine
    • MAOIs - selegiline
    • COMT inhibitor - entacapone
  • Monitor for Depression, Dementia, Psychotic symptoms, Sleep disturbance, Autonomic dysfunction
    • Psychosis
      • Consider antipsychotics that have less antidopamine effects (Clozapine, Pimavanserin, Quetiapine)
    • Postural hypotension
      • Increase salt, head up, elastic stockings
      • Midodrine or fludrocortisone