Table 2:

Summary of recommendations for diagnosis and progression

Recommendation numberRecommendationSourceGrade
C7PD should be suspected in people presenting with tremor, stiffness, slowness, balance problems or gait disorders.NICE7D
GPP
C8PD can be diagnosed using the MDS Clinical Diagnostic Criteria.CANGPP
C9Clinicians should be aware of the poor specificity of a clinical diagnosis of PD in the early stages of the disease, and consider this uncertainty when giving information to the patient and when planning management.SIGN13C
C10Patients should be offered long-term, regular follow-up to review the diagnosis of PD. This should include a review of the ongoing benefits in those started on dopamine replacement therapy.SIGN13GPP
C11Patients initially considered to have a possible diagnosis of PD may benefit from a trial of dopamine replacement therapy to assist with an accurate diagnosis.SIGN13GPP
C12Patients with suspected PD, with substantial disability or exclusion criteria or red flags as per the MDS diagnostic criteria, should be seen by a clinician with sufficient expertise in movement disorders to make the diagnosis.SIGN13C
GPP
C13Acute challenge testing with either levodopa or apomorphine should not be used in the diagnosis of PD. Patients with suspected PD should be considered for a trial of chronic levodopa treatment.SIGN13A
C14Objective olfactory testing is not recommended in the diagnosis of PD.SIGN13B
C15Routine use of functional imaging is not recommended for the differential diagnosis of PD and Parkinson plus disorders such as progressive supranuclear palsy and multiple system atrophy.SIGN13C
C16PET scanning is not recommended as part of the diagnostic work-up of parkinsonian syndromes, except within a research framework.SIGN13GPP
C17123I-FP-CIT SPECT scanning should be considered as an aid to clinical diagnosis in patients where there is uncertainty between PD and nondegenerative parkinsonism or tremor disorders.SIGN13B
C18Computed tomography or MRI brain scanning should not be routinely applied in the diagnosis of idiopathic PD.SIGN13C
C19Vitamin E should not be used as a neuroprotective therapy for people with PD. Co-enzyme Q10 should not be used as a neuroprotective therapy for people with PD.NICE8A
C20Levodopa (grade: GPP), amantadine (grade: GPP), dopamine agonists (pramipexole, ropinirole, rotigotine, apomorphine, bromocriptine) (grade: A), or MAO inhibitors (selegiline, rasagiline) (grade: A) should not be used as neuroprotective therapies for people with PD, except in the context of clinical trials.CANVaried
C21Genetic testing for monogenic parkinsonism is not recommended in routine clinical practice.SIGN13GPP
C22Patients who request genetic testing, particularly those with young-onset parkinsonism, should be assessed in a specialist movement disorders clinic for consideration of counselling and testing.SIGN13GPP
  • Note: 123I-FP-CIT = 123I-ioflupane, CAN = new Canadian Guideline recommendation, GPP = good practice point, MAO = monoamine oxidase, MDS = Movement Disorder Society Evidence-Based Medicine Review,16 MRI = magnetic resonance imaging, NICE7 = National Institute for Health and Clinical Excellence 2006 PD Guidelines,7 NICE8 = National Institute for Health and Clinical Excellence — 2017 PD Guidelines,8 PD = Parkinson disease, PET = positron emission tomography, SIGN13 = Scottish Intercollegiate Guidelines Network,13 SPECT = single-photon emission computed tomography.