Parkinson's Disease¶
DIAGNOSIS: Parkinson's Disease ICD-10: G20 (Parkinson's disease) SCOPE: Diagnosis confirmation, dopaminergic therapy initiation and optimization, motor fluctuation management, and non-motor symptom treatment. Excludes Parkinson-plus syndromes (MSA, PSP, CBD, DLB - separate protocols).
STATUS: Draft - Pending Review
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
SECTION A: ACTION ITEMS¶
1. LABORATORY WORKUP¶
1A. Essential/Core Labs¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| CBC | Baseline; rule out anemia contributing to fatigue | Normal | STAT | ROUTINE | ROUTINE | - |
| BMP | Renal function for medication dosing; electrolytes | Normal | STAT | ROUTINE | ROUTINE | - |
| Hepatic panel (LFTs) | Baseline before COMT inhibitors | Normal | - | ROUTINE | ROUTINE | - |
| TSH | Rule out hypothyroidism mimicking bradykinesia | Normal | - | ROUTINE | ROUTINE | - |
| Vitamin B12 | Deficiency can cause parkinsonism; common in elderly | >300 pg/mL | - | ROUTINE | ROUTINE | - |
| Vitamin D, 25-hydroxy | Deficiency common; associated with falls and disease severity | >30 ng/mL | - | ROUTINE | ROUTINE | - |
1B. Extended Workup (Second-line)¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| Ceruloplasmin, serum copper | Wilson's disease if age <50 | Normal | - | EXT | ROUTINE | - |
| 24-hour urine copper | Wilson's disease confirmation | <100 μg/24hr | - | - | EXT | - |
| Ferritin, iron studies | Neurodegeneration with brain iron accumulation | Normal | - | ROUTINE | ROUTINE | - |
| RPR or VDRL | Syphilis can cause parkinsonism | Nonreactive | - | EXT | EXT | - |
| HIV testing | HIV-associated parkinsonism | Negative | - | EXT | EXT | - |
1C. Rare/Specialized (Refractory or Atypical)¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| Genetic testing (LRRK2, GBA, SNCA, PARK2, PINK1, DJ-1) | Family history or early-onset (<50 years) | Identifies genetic form | - | - | EXT | - |
| CSF biomarkers (alpha-synuclein, tau, amyloid) | Research/atypical; synuclein seed amplification assay | Abnormal synuclein aggregation | - | - | EXT | - |
| Skin biopsy for alpha-synuclein | Research; confirms synucleinopathy | Phosphorylated synuclein deposits | - | - | EXT | - |
2. DIAGNOSTIC IMAGING & STUDIES¶
2A. Essential/First-line¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| MRI Brain without contrast | At diagnosis | Normal (rules out structural causes, vascular parkinsonism, NPH) | MRI-incompatible devices | URGENT | ROUTINE | ROUTINE | - |
2B. Extended¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| DaTscan (ioflupane I-123 SPECT) | Diagnostic uncertainty; essential tremor vs PD | Reduced dopamine transporter uptake in striatum | Hypersensitivity to iodine | - | EXT | ROUTINE | - |
| MRI Brain with SWI sequence | Suspected atypical parkinsonism or iron deposition | No "hot cross bun" (MSA) or "hummingbird" (PSP) signs | MRI contraindications | - | EXT | ROUTINE | - |
| Cardiac MIBG scan | Differentiate PD from MSA | Reduced uptake in PD (preserved in MSA) | Recent MI; drugs affecting uptake | - | - | EXT | - |
| Sleep study (polysomnography) | REM sleep behavior disorder evaluation | Confirms RBD (prodromal marker) | None | - | - | ROUTINE | - |
| Autonomic function testing | Dysautonomia assessment | Orthostatic hypotension, abnormal HR variability | None | - | ROUTINE | ROUTINE | - |
2C. Rare/Specialized¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| FDG-PET | Atypical parkinsonism differentiation | Pattern recognition for PD vs PSP vs MSA | None | - | - | EXT | - |
| Transcranial ultrasound | Screening tool | Hyperechogenicity of substantia nigra | Inadequate bone window | - | - | EXT | - |
3. TREATMENT¶
3A. Acute/Emergent¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Carbidopa-Levodopa (continue home dose) | PO/NG | Admitted PD patient; DO NOT HOLD | Home dose, same timing :: PO :: :: Give at EXACT same times as home; crushing allowed; use NG if NPO | Active psychosis; MAOIs within 14 days | Dyskinesias, confusion | STAT | STAT | - | STAT |
| Carbidopa-Levodopa (NPO protocol) | IV/NG | Patient NPO >4 hours | Home dose equivalent :: NG :: :: Crush tablets; give via NG at home schedule; consult neurology for IV options if unavailable | Same as PO | Same as PO | STAT | STAT | - | STAT |
| Apomorphine SC | SC | Off episode in clinic/ED; NPO patient | 2 mg SC; 3 mg SC; 4 mg SC; 5 mg SC; 6 mg SC :: SC :: :: Test dose 2 mg; titrate by 1 mg to effect; max 6 mg; pretreat with trimethobenzamide | Concurrent 5-HT3 antagonists (ondansetron); severe hypotension | BP, nausea; may cause severe hypotension | URGENT | URGENT | ROUTINE | - |
| Rotigotine patch | TD | NPO patient; bridge therapy | 2 mg/24hr; 4 mg/24hr; 6 mg/24hr patch :: TD :: :: Apply patch equivalent to oral dopamine agonist dose; onset 2-3 hours | Sulfite allergy (adhesive) | Application site reactions | URGENT | URGENT | - | - |
| Trimethobenzamide | IM/PO | Pretreat before apomorphine to prevent nausea | 300 mg IM/PO :: IM/PO :: :: 300 mg TID starting 3 days before apomorphine initiation | Hypersensitivity | Drowsiness | URGENT | URGENT | ROUTINE | - |
3B. Symptomatic Treatments¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Carbidopa-Levodopa IR (Sinemet) | PO | Motor symptoms; first-line dopaminergic therapy | 25/100 TID; 25/250 TID :: PO :: :: Start 25/100 TID; titrate by 1 tablet q1-2wk; typical target 25/100-25/250 TID | Active psychosis; MAOIs within 14 days | Dyskinesias, nausea, orthostatic hypotension | - | ROUTINE | ROUTINE | - |
| Carbidopa-Levodopa CR (Sinemet CR) | PO | Nocturnal symptoms; wearing off | 25/100 CR qHS; 50/200 CR BID :: PO :: :: 25/100 to 50/200 CR at bedtime or BID; 70% bioavailability vs IR | Same as IR | Same as IR | - | ROUTINE | ROUTINE | - |
| Carbidopa-Levodopa ER (Rytary) | PO | Motor fluctuations; extend levodopa effect | 23.75/95 TID; 36.25/145 TID; 48.75/195 TID; 61.25/245 TID :: PO :: :: Convert from IR using manufacturer table; typically TID dosing | Same as IR | Same as IR | - | ROUTINE | ROUTINE | - |
| Pramipexole | PO | Adjunct to levodopa; monotherapy in early PD; tremor | 0.125 mg TID; 0.25 mg TID; 0.5 mg TID; 1 mg TID; 1.5 mg TID :: PO :: :: Start 0.125 mg TID; titrate by 0.125-0.25 mg TID q5-7 days; max 1.5 mg TID | Impulse control history | Impulse control disorders, somnolence, leg edema | - | ROUTINE | ROUTINE | - |
| Ropinirole | PO | Adjunct or monotherapy; similar to pramipexole | 0.25 mg TID; 0.5 mg TID; 1 mg TID; 2 mg TID; 3 mg TID :: PO :: :: Start 0.25 mg TID; titrate weekly; max 8 mg TID | Same as pramipexole | Same as pramipexole | - | ROUTINE | ROUTINE | - |
| Ropinirole XL | PO | Extended-release option for adherence | 2 mg daily; 4 mg daily; 6 mg daily; 8 mg daily :: PO :: :: Start 2 mg daily; titrate by 2 mg q1-2wk; max 24 mg daily | Same as IR | Same as IR | - | ROUTINE | ROUTINE | - |
| Selegiline | PO | MAO-B inhibitor; adjunct; mild neuroprotection theory | 5 mg BID :: PO :: :: 5 mg at breakfast and lunch (avoid evening due to insomnia); max 10 mg/day | MAOIs; meperidine; TCAs (caution) | Insomnia, hypertensive crisis with tyramine (rare at this dose) | - | ROUTINE | ROUTINE | - |
| Rasagiline | PO | MAO-B inhibitor; once daily; adjunct or monotherapy | 0.5 mg daily; 1 mg daily :: PO :: :: Start 0.5-1 mg daily; max 1 mg daily | Same as selegiline | Hypertensive crisis (rare); serotonin syndrome with other serotonergics | - | ROUTINE | ROUTINE | - |
| Safinamide | PO | MAO-B inhibitor with additional mechanisms; adjunct in fluctuations | 50 mg daily; 100 mg daily :: PO :: :: Start 50 mg daily; may increase to 100 mg daily after 2 weeks | Severe hepatic impairment; MAOIs; opioids | Same as rasagiline; may improve dyskinesia | - | ROUTINE | ROUTINE | - |
| Entacapone | PO | COMT inhibitor; extends levodopa effect; wearing off | 200 mg with each levodopa dose :: PO :: :: 200 mg with each levodopa dose; max 8 doses (1600 mg)/day | Hepatic impairment; concurrent MAOIs | Diarrhea, orange urine, dyskinesias | - | ROUTINE | ROUTINE | - |
| Opicapone | PO | COMT inhibitor; once daily alternative to entacapone | 50 mg qHS :: PO :: :: 50 mg once daily at bedtime; take 1 hour before or after levodopa | Pheochromocytoma; paraganglioma | Dyskinesias, constipation, dry mouth | - | ROUTINE | ROUTINE | - |
| Amantadine | PO | Dyskinesia reduction; mild motor benefit | 100 mg BID; 100 mg TID :: PO :: :: Start 100 mg daily; titrate to 100 mg BID-TID; max 400 mg/day; dose-reduce in renal impairment | End-stage renal disease; seizure history | Livedo reticularis, ankle edema, confusion, hallucinations | - | ROUTINE | ROUTINE | - |
| Amantadine ER (Gocovri) | PO | Dyskinesia; extended-release taken at bedtime | 137 mg qHS; 274 mg qHS :: PO :: :: Start 137 mg qHS; increase to 274 mg qHS after 1 week | Same as IR | Same as IR | - | ROUTINE | ROUTINE | - |
| Trihexyphenidyl | PO | Tremor-dominant PD; younger patients | 1 mg TID; 2 mg TID :: PO :: :: Start 1 mg TID; titrate by 2 mg/day q3-5 days; max 15 mg/day | Glaucoma; urinary retention; dementia; age >70 | Cognitive impairment, dry mouth, constipation, urinary retention | - | ROUTINE | ROUTINE | - |
| Benztropine | PO | Alternative anticholinergic for tremor | 0.5 mg BID; 1 mg BID; 2 mg BID :: PO :: :: Start 0.5 mg BID; titrate slowly; max 6 mg/day | Same as trihexyphenidyl | Same as trihexyphenidyl | - | ROUTINE | ROUTINE | - |
| Istradefylline | PO | Adenosine A2A antagonist; adjunct for OFF time | 20 mg daily; 40 mg daily :: PO :: :: Start 20 mg daily; may increase to 40 mg daily | Strong CYP3A4 inducers | Dyskinesias, dizziness, constipation, hallucinations | - | ROUTINE | ROUTINE | - |
3C. Non-Motor Symptom Treatments¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Pimavanserin (Nuplazid) | PO | Parkinson's disease psychosis (hallucinations, delusions) | 34 mg daily :: PO :: :: 34 mg once daily; takes 4-6 weeks for effect; no titration needed | Severe hepatic impairment; QT prolongation | QTc, efficacy assessment at 6 weeks | - | ROUTINE | ROUTINE | - |
| Quetiapine | PO | Psychosis; alternative if pimavanserin unavailable | 12.5 mg qHS; 25 mg qHS; 50 mg qHS :: PO :: :: Start 12.5-25 mg qHS; titrate slowly by 12.5-25 mg q3-7d; typical max 150 mg/day | Dementia with Lewy bodies (black box) | Sedation, metabolic effects, QTc | - | ROUTINE | ROUTINE | - |
| Clozapine | PO | Refractory psychosis; best evidence but monitoring required | 6.25 mg qHS; 12.5 mg qHS; 25 mg qHS; 50 mg qHS :: PO :: :: Start 6.25-12.5 mg qHS; titrate by 12.5 mg q1-2wk; max 50-100 mg/day in PD | REMS enrollment required | ANC weekly x 6 mo, then q2wk x 6 mo, then monthly; agranulocytosis risk | - | EXT | ROUTINE | - |
| Rivastigmine (Exelon) | PO/Patch | Parkinson's disease dementia | 1.5 mg BID; 3 mg BID; 4.5 mg BID; 6 mg BID; 9.5 mg/24hr patch; 13.3 mg/24hr patch :: PO/Patch :: :: Start 1.5 mg BID or 4.6 mg/24hr patch; titrate monthly; max 6 mg BID or 13.3 mg/24hr | Severe hepatic impairment | Nausea, weight loss, tremor worsening | - | ROUTINE | ROUTINE | - |
| Donepezil | PO | Parkinson's disease dementia; once daily option | 5 mg qHS; 10 mg qHS :: PO :: :: Start 5 mg qHS; increase to 10 mg after 4-6 weeks | GI bleeding; sick sinus syndrome | Nausea, bradycardia, vivid dreams | - | ROUTINE | ROUTINE | - |
| Memantine | PO | Moderate-severe dementia; add to cholinesterase inhibitor | 5 mg daily; 10 mg BID :: PO :: :: Start 5 mg daily; titrate by 5 mg/wk; target 10 mg BID | Severe renal impairment (dose adjust) | Confusion, constipation | - | ROUTINE | ROUTINE | - |
| Midodrine | PO | Orthostatic hypotension | 2.5 mg TID; 5 mg TID; 10 mg TID :: PO :: :: Start 2.5 mg TID (before arising, before lunch, mid-afternoon); titrate by 2.5 mg/dose; max 10 mg TID; last dose by 6 PM | Supine hypertension; urinary retention; severe cardiac disease | Supine BP (must avoid lying flat for 4 hours after dose) | - | ROUTINE | ROUTINE | - |
| Droxidopa (Northera) | PO | Neurogenic orthostatic hypotension | 100 mg TID; 200 mg TID; 300 mg TID; 600 mg TID :: PO :: :: Start 100 mg TID; titrate by 100 mg/dose q24-48h; max 600 mg TID | Supine hypertension | Supine BP, headache | - | ROUTINE | ROUTINE | - |
| Fludrocortisone | PO | Orthostatic hypotension adjunct | 0.1 mg daily; 0.2 mg daily :: PO :: :: Start 0.1 mg daily; may increase to 0.2 mg daily; max 0.3 mg | CHF; renal failure; severe hypertension | K+, edema, supine BP | - | ROUTINE | ROUTINE | - |
| Sertraline | PO | Depression in PD | 25 mg daily; 50 mg daily; 100 mg daily :: PO :: :: Start 25 mg daily; titrate by 25 mg q1-2wk; typical 50-100 mg daily | MAOIs within 14 days | Serotonin syndrome (caution with MAO-B inhibitors) | - | ROUTINE | ROUTINE | - |
| Venlafaxine XR | PO | Depression; anxiety in PD | 37.5 mg daily; 75 mg daily; 150 mg daily :: PO :: :: Start 37.5 mg daily; titrate q1-2wk; typical 75-150 mg daily | Same as sertraline | BP at higher doses | - | ROUTINE | ROUTINE | - |
| Polyethylene glycol (MiraLAX) | PO | Constipation (ubiquitous in PD) | 17 g daily; 17 g BID :: PO :: :: 17 g (1 capful) in 8 oz liquid daily; may increase to BID | Bowel obstruction | Diarrhea if excessive | - | ROUTINE | ROUTINE | - |
| Senna + docusate | PO | Constipation stimulant | 2 tablets qHS :: PO :: :: 2 tablets qHS; may increase to 4 tablets | Bowel obstruction; undiagnosed abdominal pain | Electrolytes with chronic use | - | ROUTINE | ROUTINE | - |
| Clonazepam | PO | REM sleep behavior disorder | 0.25 mg qHS; 0.5 mg qHS; 1 mg qHS :: PO :: :: Start 0.25-0.5 mg qHS; titrate to effect; typical 0.5-1 mg | Severe sleep apnea; respiratory compromise | Sedation, falls, cognitive effects | - | ROUTINE | ROUTINE | - |
| Melatonin | PO | REM sleep behavior disorder; sleep disturbance | 3 mg qHS; 6 mg qHS; 9 mg qHS; 12 mg qHS :: PO :: :: Start 3-6 mg qHS; may increase to 12 mg | None | Generally well-tolerated | - | ROUTINE | ROUTINE | - |
| Glycopyrrolate | PO | Sialorrhea (drooling) | 1 mg TID; 2 mg TID :: PO :: :: Start 1 mg TID; titrate to effect; max 2 mg TID | Glaucoma; urinary retention; GI obstruction | Dry mouth, constipation, urinary retention | - | ROUTINE | ROUTINE | - |
| OnabotulinumtoxinA (salivary glands) | IM | Sialorrhea refractory to oral therapy | 100 units total :: IM :: :: 30-50 units per parotid, 10-20 units per submandibular; repeat q3-4 months | Infection at site | Dysphagia (rare), dry mouth | - | - | ROUTINE | - |
3D. Advanced Therapies¶
| Treatment | Route | Indication | Dosing | Pre-Treatment Requirements | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|---|
| Deep brain stimulation (DBS) | Surgical | Motor fluctuations or tremor refractory to optimal medication | STN or GPi stimulation :: Surgical :: :: Unilateral or bilateral; programming done over weeks post-op | Neuropsych testing, MRI, off-medication evaluation | Dementia; active psychiatric disease; medical comorbidities | Programming optimization; battery checks | - | - | ROUTINE | - |
| Levodopa-carbidopa intestinal gel (Duopa) | Enteral | Severe motor fluctuations; 4+ hours OFF/day | Continuous infusion :: Enteral :: :: Via PEG-J; 16-hour infusion; morning bolus + continuous rate + extra doses | GI tract accessible | GI disease preventing PEG-J; coagulopathy | Tube site, infections, GI complications | - | EXT | ROUTINE | - |
| Apomorphine continuous infusion | SC | Severe motor fluctuations; not DBS candidate | 3-8 mg/hr continuous :: SC :: :: Via subcutaneous pump; typical 3-8 mg/hr during waking hours | Caregiver training | Same as SC apomorphine | Same as SC apomorphine | - | EXT | ROUTINE | - |
4. OTHER RECOMMENDATIONS¶
4A. Referrals & Consults¶
| Recommendation | ED | HOSP | OPD | ICU |
|---|---|---|---|---|
| Movement disorders specialist for diagnosis confirmation and advanced therapy evaluation | - | ROUTINE | ROUTINE | - |
| Physical therapy for gait training, balance exercises, and LSVT BIG program | - | ROUTINE | ROUTINE | - |
| Occupational therapy for ADL adaptation and fine motor strategies | - | ROUTINE | ROUTINE | - |
| Speech therapy (LSVT LOUD) for hypophonia and swallowing evaluation | - | ROUTINE | ROUTINE | - |
| Neuropsychology for cognitive assessment and DBS candidacy evaluation | - | - | ROUTINE | - |
| Psychiatry for depression, anxiety, impulse control disorders, or psychosis management | - | ROUTINE | ROUTINE | - |
| Palliative care for advanced disease symptom management and goals of care | - | ROUTINE | ROUTINE | - |
| Social work for caregiver support, community resources, and disability planning | - | ROUTINE | ROUTINE | - |
| Urology for urinary symptoms not responsive to first-line treatment | - | - | ROUTINE | - |
| Gastroenterology for severe constipation or Duopa tube placement | - | - | ROUTINE | - |
4B. Patient Instructions¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| CRITICAL: Do not skip or delay levodopa doses as this can cause severe OFF episodes and immobility | STAT | STAT | ROUTINE |
| Take levodopa 30-60 minutes before meals for better absorption (protein competes with levodopa transport) | - | ROUTINE | ROUTINE |
| Rise slowly from sitting or lying to prevent falls from orthostatic hypotension | URGENT | ROUTINE | ROUTINE |
| Inform all healthcare providers about PD medications to avoid drug interactions (especially antipsychotics, antiemetics) | URGENT | ROUTINE | ROUTINE |
| Report any new impulsive behaviors (gambling, shopping, hypersexuality) which may indicate impulse control disorder from dopamine agonists | - | ROUTINE | ROUTINE |
| Report hallucinations early as these can be managed with medication adjustment | - | ROUTINE | ROUTINE |
| Engage in regular exercise which may slow disease progression and improves mobility | - | ROUTINE | ROUTINE |
4C. Lifestyle & Prevention¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Regular aerobic exercise (30-60 min, 3-5x/week) improves motor function and may be neuroprotective | - | ROUTINE | ROUTINE |
| Tai chi or dance-based exercise programs improve balance and reduce falls | - | ROUTINE | ROUTINE |
| High-fiber diet and adequate hydration to prevent constipation | - | ROUTINE | ROUTINE |
| Avoid medications that worsen parkinsonism (metoclopramide, prochlorperazine, haloperidol, risperidone) | URGENT | ROUTINE | ROUTINE |
| Fall prevention: remove home hazards, adequate lighting, grab bars, non-slip surfaces | - | ROUTINE | ROUTINE |
| Mediterranean diet may have protective benefits based on observational studies | - | ROUTINE | ROUTINE |
| Coffee consumption associated with reduced PD risk; continued moderate use reasonable | - | ROUTINE | ROUTINE |
SECTION B: REFERENCE¶
5. DIFFERENTIAL DIAGNOSIS¶
| Alternative Diagnosis | Key Distinguishing Features | Tests to Differentiate |
|---|---|---|
| Drug-induced parkinsonism | Medication exposure (antipsychotics, metoclopramide); symmetric; no levodopa response | DaTscan normal; history of causative medication |
| Vascular parkinsonism | Stepwise progression; lower body predominant; vascular risk factors; pyramidal signs | MRI with subcortical/basal ganglia infarcts |
| Progressive supranuclear palsy (PSP) | Early falls; vertical gaze palsy; axial rigidity > limb; poor levodopa response | MRI "hummingbird sign"; clinical criteria |
| Multiple system atrophy (MSA) | Severe dysautonomia; cerebellar signs; stridor; poor levodopa response | MRI "hot cross bun" sign; MIBG preserved |
| Corticobasal degeneration (CBD) | Asymmetric rigidity; apraxia; alien limb; cortical sensory loss | MRI asymmetric cortical atrophy |
| Dementia with Lewy bodies (DLB) | Dementia before or within 1 year of motor symptoms; fluctuating cognition; visual hallucinations | Clinical criteria; DaTscan may be abnormal |
| Essential tremor | Action tremor > rest tremor; improves with alcohol; family history; no bradykinesia | DaTscan normal; clinical criteria |
| Normal pressure hydrocephalus | Gait apraxia ("magnetic gait"); urinary incontinence; dementia | MRI ventricular enlargement; LP with gait improvement |
6. MONITORING PARAMETERS¶
| Parameter | Frequency | Target/Threshold | Action if Abnormal | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| Motor function (UPDRS-III or MDS-UPDRS) | Every visit | Document trend; look for >30% change | Adjust medications if worsening | - | ROUTINE | ROUTINE | - |
| ON/OFF time diary | Daily for 1 week before visits | <2 hours OFF time/day | Add adjunct therapy; consider advanced options | - | ROUTINE | ROUTINE | - |
| Dyskinesia severity | Each visit | Minimize troublesome dyskinesia | Reduce levodopa; add amantadine; adjust timing | - | ROUTINE | ROUTINE | - |
| Orthostatic blood pressure | Each visit | <20 mmHg systolic drop on standing | Add midodrine or droxidopa | - | ROUTINE | ROUTINE | - |
| Cognition (MoCA) | Annually, more often if concerns | >26 normal; decline triggers action | Add cholinesterase inhibitor; adjust anticholinergics | - | - | ROUTINE | - |
| Mood (GDS, PHQ-9) | Annually | Screen negative | Add antidepressant; psychiatry referral | - | ROUTINE | ROUTINE | - |
| Impulse control screen (QUIP) | Each visit if on dopamine agonist | Negative | Reduce or discontinue dopamine agonist | - | ROUTINE | ROUTINE | - |
| Falls frequency | Each visit | Zero falls | PT referral; medication review; home safety evaluation | - | ROUTINE | ROUTINE | - |
| Swallowing function | Annually or if symptoms | No aspiration risk | Speech therapy; modify diet | - | ROUTINE | ROUTINE | - |
| ANC (if on clozapine) | Per REMS protocol | ANC >1500/μL | Hold clozapine if ANC <1000; discontinue if <500 | - | ROUTINE | ROUTINE | - |
7. DISPOSITION CRITERIA¶
| Disposition | Criteria |
|---|---|
| Discharge home | Stable motor status; able to take PO; adequate caregiver support; follow-up arranged |
| Admit to floor | Unable to take PO medications >24 hours; severe OFF episode; aspiration pneumonia; acute infection |
| Admit to ICU | Neuroleptic malignant syndrome; severe rigidity with rhabdomyolysis; respiratory compromise |
| Outpatient follow-up | Every 3-6 months for stable patients; more frequently during medication adjustments |
8. EVIDENCE & REFERENCES¶
| Recommendation | Evidence Level | Source |
|---|---|---|
| Levodopa most effective symptomatic treatment | Class I, Level A | Fahn et al. NEJM 2004 (ELLDOPA) |
| MAO-B inhibitors provide mild motor benefit | Class I, Level A | Rascol et al. NEJM 2005 (rasagiline) |
| Pimavanserin for PD psychosis | Class I, Level A | Cummings et al. Lancet 2014 |
| DBS improves motor fluctuations | Class I, Level A | Weaver et al. JAMA 2009 |
| Rivastigmine for PD dementia | Class I, Level A | Emre et al. NEJM 2004 |
| Exercise improves motor function | Class II, Level B | Schenkman et al. JAMA Neurol 2018 |
| LSVT LOUD improves speech | Class I, Level B | Ramig et al. JSLHR 2001 |
| Clonazepam and melatonin for RBD | Class II, Level B | Aurora et al. AASM 2010 |
| Amantadine reduces dyskinesia | Class I, Level A | Ory-Magne et al. Lancet Neurol 2014 |
| Duopa for motor fluctuations | Class I, Level A | Olanow et al. Lancet Neurol 2014 |
CHANGE LOG¶
v1.0 (January 27, 2026) - Initial template creation - Comprehensive motor and non-motor treatment coverage - Includes advanced therapies (DBS, Duopa, apomorphine pump) - Structured dosing format for order sentence generation
APPENDIX A: Medications to Avoid in Parkinson's Disease¶
| Drug Class | Examples | Why to Avoid |
|---|---|---|
| Typical antipsychotics | Haloperidol, chlorpromazine, fluphenazine | D2 blockade worsens parkinsonism |
| Most atypical antipsychotics | Risperidone, olanzapine, aripiprazole, ziprasidone | Significant D2 blockade |
| Antiemetics (D2 blockers) | Metoclopramide, prochlorperazine, promethazine | Cross blood-brain barrier; worsen parkinsonism |
| Valproic acid | Depakote | Can cause parkinsonism; tremor |
| Lithium | Lithobid | Can cause tremor; parkinsonism |
| Calcium channel blockers (some) | Flunarizine, cinnarizine | D2 blocking properties |
| Reserpine | Serpasil | Depletes dopamine |
Safe alternatives: - Antiemetics: Ondansetron, domperidone (not US), trimethobenzamide - Antipsychotics: Quetiapine (first-line), clozapine, pimavanserin