Parkinson's Disease

DIAGNOSIS: Parkinson's Disease ICD-10: G20 (Parkinson's disease), G20.A1 (Parkinson's disease without dyskinesia, without motor fluctuations), G20.A2 (Parkinson's disease without dyskinesia, with motor fluctuations), G20.B1 (Parkinson's disease with dyskinesia, without motor fluctuations), G20.B2 (Parkinson's disease with dyskinesia, with motor fluctuations), G20.C (Parkinsonism, unspecified)

CPT CODES: 85025 (CBC), 80048 (BMP), 80076 (Hepatic panel (LFTs)), 84443 (TSH), 82607 (Vitamin B12), 82306 (Vitamin D, 25-hydroxy), 82390 (Ceruloplasmin), 82728 (Ferritin), 86592 (RPR or VDRL), 87389 (HIV testing), 70551 (MRI Brain without contrast), 78830 (DaTscan), 95810 (Sleep study (polysomnography)), 95924 (Autonomic function testing), 78608 (FDG-PET) SYNONYMS: Parkinson's disease, PD, parkinsonism, idiopathic Parkinson's disease, paralysis agitans, shaking palsy, Parkinson disease, dopamine deficiency syndrome, tremor-dominant PD, PIGD 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: Approved

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

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SECTION A: ACTION ITEMS

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1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
CBC (CPT 85025)	Baseline; rule out anemia contributing to fatigue	Normal	STAT	ROUTINE	ROUTINE	-
BMP (CPT 80048)	Renal function for medication dosing; electrolytes	Normal	STAT	ROUTINE	ROUTINE	-
Hepatic panel (LFTs) (CPT 80076)	Baseline before COMT inhibitors	Normal	-	ROUTINE	ROUTINE	-
TSH (CPT 84443)	Rule out hypothyroidism mimicking bradykinesia	Normal	-	ROUTINE	ROUTINE	-
Vitamin B12 (CPT 82607)	Deficiency can cause parkinsonism; common in elderly	>300 pg/mL	-	ROUTINE	ROUTINE	-
Vitamin D, 25-hydroxy (CPT 82306)	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 (CPT 82390), serum copper (CPT 82390)	Wilson's disease if age <50	Normal	-	EXT	ROUTINE	-
24-hour urine copper	Wilson's disease confirmation	<100 μg/24hr	-	-	EXT	-
Ferritin (CPT 82728), iron studies (CPT 83540, 83550)	Neurodegeneration with brain iron accumulation	Normal	-	ROUTINE	ROUTINE	-
RPR or VDRL (CPT 86592)	Syphilis can cause parkinsonism	Nonreactive	-	EXT	EXT	-
HIV testing (CPT 87389)	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	-

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain without contrast (CPT 70551)	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 (CPT 78830)	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) (CPT 95810)	REM sleep behavior disorder evaluation	Confirms RBD (prodromal marker)	None	-	-	ROUTINE	-
Autonomic function testing (CPT 95924)	Dysautonomia assessment	Orthostatic hypotension, abnormal HR variability	None	-	ROUTINE	ROUTINE	-

2C. Rare/Specialized

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
FDG-PET (CPT 78608)	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	-

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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 :: per home regimen :: 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 :: per home regimen :: 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 :: PRN :: 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 :: daily :: 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 :: TID :: 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 :: TID :: 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 :: BID :: 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 :: TID :: 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 :: TID :: 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 :: TID :: 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 :: daily :: 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 :: BID :: 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 :: daily :: 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 :: daily :: 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 :: with each dose :: 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 :: QHS :: 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 :: TID :: 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 :: QHS :: 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 :: TID :: 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 :: BID :: 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 :: daily :: 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 :: daily :: 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 :: QHS :: 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 :: QHS :: 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 :: BID :: 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 :: QHS :: 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 :: BID :: 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 :: TID :: 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 :: TID :: 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 :: daily :: 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 :: daily :: 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 :: daily :: 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 :: BID :: 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 :: QHS :: 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 :: QHS :: 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 :: QHS :: 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 :: TID :: 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 :: per session :: 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 :: once :: 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 :: continuous :: 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 :: continuous :: Via subcutaneous pump; typical 3-8 mg/hr during waking hours	Caregiver training	Same as SC apomorphine	Same as SC apomorphine	-	EXT	ROUTINE	-

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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

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SECTION B: REFERENCE

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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

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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	-

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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

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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

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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

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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