NICE guideline:

Suspect Parkinson's disease in people presenting with tremor, stiffness, slowness, balance problems and/or gait disorders.

If Parkinson's disease is suspected, refer people quickly and untreated to a specialist with expertise in the differential diagnosis of this condition.

Clinical diagnosis

Diagnose Parkinson's disease clinically, based on the UK Parkinson's Disease Society Brain Bank Clinical Diagnostic Criteria.

UK Parkinson’s Disease Society Brain Bank Diagnostic Criteria

STEP 1 Diagnosis of Parkinsonian syndrome

Bradykinesia (slowness of initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions).

And at least one of the following:

1. muscular rigidity
2. resting tremor
3. postural instability not caused by primary visual, vestibular, cerebellar or proprioceptive dysfunction.

STEP 2 Exclusion criteria for Parkinson’s disease

History of repeated strokes with stepwise progression of Parkinsonian features.

History of repeated head injury.

History of definite encephalitis.

Oculogyric crises.

Neuroleptic treatment at onset of symptoms.

More than one affected relative.

Sustained remission.

Strictly unilateral features after three years.

Supranuclear gaze palsy.

Cerebellar signs.

Early severe autonomic involvement.

Early severe dementia with disturbances of memory, language and praxis.

Babinski sign.

Presence of a cerebral tumour or communicating hydrocephalus on CT scan.

Negative response to large doses of levodopa (if malabsorption excluded).

MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) exposure.

STEP 3 Supportive prospective positive criteria for Parkinson’s disease. Three or more required for diagnosis of definite Parkinson’s disease

Unilateral onset.

Rest tremor present.

Progressive disorder.

Persistent asymmetry affecting the side of onset most.

Excellent response (70–100%) to levodopa.

Severe levodopa-induced chorea.

Levodopa response for 5 years or more.

Clinical course of 10 years or more.

Review of diagnosis

Review the diagnosis of Parkinson's disease regularly, and reconsider it if atypical clinical features develop. (People diagnosed with Parkinson's disease should be seen at regular intervals of 6 to 12 months to review their diagnosis.)

Radiological Tests

Parkinson disease is a clinical diagnosis. No laboratory biomarkers exist for the condition, and findings on routine magnetic resonance imaging and computed tomography scans are unremarkable. Patients who do not have tremor should generally be considered for MRI evaluation to exclude brain lesions such as stroke, tumor, or demyelination.

In patients with an unusual presentation, diagnostic testing may be indicated to exclude other disorders in the differential diagnosis.

Single photon emission computed tomography (SPECT)

Consider SPECT for people with tremor if essential tremor cannot be clinically differentiated from parkinsonism.

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