What is the recommended assessment and management approach for patients presenting with parkinsonism symptoms, including cognitive impairment and motor dysfunction?

Assessment and Management of Parkinsonism Symptoms

Patients presenting with parkinsonism symptoms should undergo comprehensive neurological examination by a movement disorder specialist or neurologist to confirm diagnosis, followed by standardized assessment using the Unified Parkinson's Disease Rating Scale (UPDRS) for motor symptoms and formal neuropsychological evaluation when cognitive impairment is suspected or office-based testing is insufficient. 1, 2

Initial Diagnostic Approach

Specialist Referral is Essential

Refer immediately to a neurologist or movement disorder specialist for diagnostic confirmation, as correctly diagnosing parkinsonian syndromes on clinical features alone is challenging and requires specialized expertise. 1 Primary care providers should not attempt definitive diagnosis independently, as missing atypical parkinsonian syndromes (Progressive Supranuclear Palsy, Multiple System Atrophy, Corticobasal Degeneration) leads to different prognoses and treatment responses. 1

Key Clinical Features to Document

The specialist evaluation must identify:

• Bradykinesia (essential feature) plus at least one of: resting tremor, rigidity, or postural instability 1
• Motor symptom asymmetry - asymmetric rigidity with alien hand phenomenon suggests Corticobasal Syndrome rather than idiopathic Parkinson's disease 1
• Red flag features indicating atypical parkinsonism:
  • Vertical gaze palsy (especially downward) suggests Progressive Supranuclear Palsy 1
  • Early severe autonomic dysfunction, cerebellar signs, or pyramidal signs suggest Multiple System Atrophy 1
  • Ataxia, rapid progression, or fluctuating course 2

Rigidity Assessment Technique

To properly assess rigidity in patients with bradykinesia:

• Have the patient relax completely while passively moving their limbs through full range of motion 1
• Test both upper and lower extremities at varying speeds, comparing sides for asymmetry 1
• Use activation maneuvers (ask patient to open/close the opposite hand) to enhance detection of subtle rigidity 1
• Note constant resistance throughout movement (lead-pipe rigidity) or ratchet-like jerky resistance when combined with tremor (cogwheel phenomenon) 1

Common pitfall: Failure to have the patient completely relax leads to false positives from voluntary muscle contraction. 1

Cognitive Assessment Strategy

When to Perform Neuropsychological Evaluation

Neuropsychological evaluation is mandatory when:

• Patient or caregiver reports concerning cognitive symptoms in daily life but patient performs within normal limits on office-based cognitive examination 2
• Office-based examination shows abnormalities but interpretation is uncertain due to complex clinical profile or confounding demographic characteristics 2
• Sensorimotor dysfunction co-occurs with cognitive or behavioral impairments, particularly gait and balance problems pointing to Parkinson's spectrum disorders (Dementia with Lewy Bodies or Parkinson's disease dementia) 2

Required Cognitive Domains for Testing

The neuropsychological evaluation must minimally include normed testing of:

• Learning and memory (particularly delayed free and cued recall/recognition) 2
• Attention and processing speed 2, 3
• Executive function (problem-solving, speed of decision making, judgment) 2, 3
• Visuospatial function 2
• Language 2

Critical consideration: Executive dysfunction may not appear on formal testing in early stages, so consider qualitative evidence when examining task performance. 3

Standardized Motor Assessment

Unified Parkinson's Disease Rating Scale (UPDRS)

Use the UPDRS or Movement Disorder Society-UPDRS (MDS-UPDRS) as the standard clinical assessment tool for disease severity and monitoring. 1, 4

The UPDRS consists of four parts:

• Part I: Mentation (cognitive function) 4
• Part II: Activities of Daily Living (13 questions, scored 0-4 each, maximum score 52) 4
• Part III: Motor examination (27 questions for 14 items assessing tremor, rigidity, bradykinesia, postural instability across body regions, maximum score 108) 4
• Part IV: Complications of therapy 4

The MDS-UPDRS provides improved evaluation of non-motor aspects, freezing of gait, and tremor subtypes compared to the original UPDRS. 1

Additional Motor Assessments

• Document falls systematically - falling in Dementia with Lewy Bodies is associated with substantial morbidity and mortality, yet standard UPDRS does not include fall measurement 2
• Assess gait and balance using validated scales, as these impairments substantially increase fall risk when co-occurring with cognitive impairments 2
• Monitor medication state - consider whether standardizing assessments in the "off" dopaminergic medication state is required 2

Functional and Neuropsychiatric Assessment

Activities of Daily Living Evaluation

Assess both instrumental ADLs (IADLs) and basic ADLs (BADLs) across the dementia spectrum:

• Use validated instruments like the Lawton-Brody Activities of Daily Living Scale for tracking leisure activities, IADLs, and BADLs 2
• Focus on executive components of instrumental items to detect early impairment 2
• Evaluate initiation, organizing, planning, and effective implementation for each activity category 2

Neuropsychiatric Symptom Assessment

Depression and apathy are associated with increased risk of cognitive impairment, especially executive dysfunction, in Parkinson's disease patients. 5 Therefore:

• Screen for depression using validated scales (Center for Epidemiological Studies-Depression or Geriatric Depression Scale) 3
• Assess for apathy, anxiety, psychosis, and impulse control disorders - these neuropsychiatric symptoms are highly prevalent and can be the most debilitating features 6
• Distinguish treatment side effects (parkinsonism, dyskinesias, cognitive side effects, sleep and mood changes) from disease symptoms 2

Diagnostic Imaging Protocol

Structural Imaging First

Obtain MRI brain without IV contrast as the optimal initial imaging modality before any nuclear medicine study, due to superior soft-tissue characterization and sensitivity to iron deposition. 1 MRI rules out structural causes, focal lesions, or vascular disease and is often normal in early Parkinson's disease but essential to exclude alternative diagnoses. 1

Functional Imaging When Diagnosis is Uncertain

Order I-123 ioflupane SPECT/CT (DaTscan) when clinical presentation is unclear to differentiate true Parkinsonian syndromes from essential tremor or drug-induced tremor. 1 This study shows decreased radiotracer uptake in the striatum (usually beginning in putamen and progressing to caudate). 1

A normal I-123 ioflupane SPECT/CT essentially excludes Parkinsonian syndromes. 1

Critical pitfalls to avoid:

• Do not order amyloid PET/CT - no relevant literature supports its use in Parkinsonian syndrome evaluation 1
• Do not order tau PET/CT for initial workup 1
• Do not skip structural imaging before functional imaging 1

Sensorimotor Evaluation

Vision and Hearing Assessment

Assess hearing and vision systematically, as hearing loss (presbycusis) is a known and potentially reversible dementia risk factor, and sensory dysfunction related to primary sensory inputs is amenable to treatments that can mitigate cognitive or behavioral symptoms. 2

Comprehensive Sensory Testing

Evaluate multiple sensory modalities including:

• Vision, visual fields, and visual attention 3
• Distal polysensory neuropathy (particularly feet/legs) - common in older individuals, can be idiopathic or due to chronic microvascular insufficiency, and represents a fall risk that may be treated (e.g., vitamin B12 deficiency) or mitigated 2

Serial Monitoring Strategy

Follow-up Assessment Schedule

Conduct serial assessments with the same instrument at intervals of at least 6 months to reduce practice effects artificially inflating test scores and determine whether the patient is declining, improving, or remaining stable. 2

Nutritional and Functional Monitoring

Regular monitoring throughout disease course is essential, including:

• Body weight changes 1
• Vitamin status (particularly B12 given neuropathy risk) 2, 1
• Dysphagia screening 1
• Nutritional risk assessment (15% of community-dwelling Parkinson's disease patients are malnourished, 24% at medium-high risk) 1

Management Considerations

Physical and Occupational Therapy

Refer for formal physical therapy assessment and treatment of gait and balance, home occupational therapy, and safety assessment. 2 Improved balance or limb motor function benefits daily functions and reduces safety risks. 2

Safety Interventions

Implement fall prevention strategies:

• Use of assistive devices 2
• Night lights 2
• Shower grab bars 2
• Eliminate trip hazards 2

These interventions are particularly important given that fall risk is substantially increased when sensorimotor, gait, or balance problems co-occur with cognitive or behavioral impairments in insight, judgment, impulse control, attention, memory, psychomotor processing, and visuospatial awareness. 2