Parkinson’s Disease

Parkinson’s disease is a progressive neurodegenerative disorder affecting motor function, caused by the loss of dopaminergic neurons in the substantia nigra, located in the midbrain.

For prehospital professionals, early recognition and appropriate support is essential for Parkinson’s disease—especially during falls, aspiration, or medication-related issues, in addition to communication, mobility, and airway management.

This article outlines the background, risk factors, symptoms, assessment, and management of Parkinson’s disease.

Background

Parkinson’s disease is a progressive neurodegenerative disorder affecting around 145,000 people in the UK, with incidence rising with age, particularly over 60 (NICE, 2022). It results from the degeneration of dopaminergic neurons in the substantia nigra (located in the midbrain), leading to reduced dopamine and disrupted motor control.

Key features include bradykinesia (the slowness of movement, making everyday tasks difficult and reducing overall mobility), resting tremor, rigidity, and postural instability. Non-motor symptoms like orthostatic hypotension (a sudden drop in blood pressure when standing up, causing dizziness or fainting) and autonomic dysfunction also impacts prehospital care.

For paramedics, this explains common presentations such as falls, aspiration pneumonia, airway compromise, and reduced mobility.

Risk Factors

The exact cause of Parkinson’s disease (PD) remains unclear, but it is believed to result from a combination of genetic susceptibility and environmental exposures that contribute to the degeneration of dopaminergic neurons in the brain (NIH, 2024).

Symptoms & Patient History

Parkinson’s disease typically presents with gradual onset of motor symptoms, often overlooked in early stages. Recognising key features during prehospital assessment is vital for identifying deterioration or underlying complications.

Common presentations include:

Bradykinesia – slowed movement and difficulty initiating tasks (e.g., getting up, walking).

Resting tremor – often a unilateral “pill-rolling” tremor, most noticeable at rest.

Muscle rigidity – stiffness in limbs, leading to a shuffling gait and reduced arm swing.

Postural instability – frequent falls, imbalance, or stooped posture.

Speech changes – soft or monotone speech (hypophonia), slurred articulation.

Facial masking – reduced facial expression (hypomimia).

Autonomic symptoms – drooling, constipation, urinary urgency, orthostatic hypotension.

Patient history clues to note in prehospital care:

• Age and family history may raise suspicion in undiagnosed patients.
• Occupational exposure (e.g., agricultural work or industrial settings) may support a possible environmental cause.
• History of falls, tremor, or medication for movement disorders can indicate known or suspected Parkinson’s disease.
• Previous head injuries may also be a contributing factor worth noting during assessment.

Understanding these risk factors aids in forming a clearer clinical picture, particularly when encountering patients with undiagnosed symptoms or those presenting with complications.

Assessment Of Parkinson’s Disease

Patient history: Ask about tremor, stiffness, movement difficulties, and recent falls. Note diagnosis, stage of disease, and medications (especially timing of last dose, as missed medication can worsen symptoms).

Observations: Monitor GCS, BP (check for postural drop), respiratory rate, and oxygen saturation, especially in cases of suspected aspiration or hypoventilation.

Red flags 🚩

Sudden loss of mobility or inability to swallow (risk of aspiration).

Reduced GCS or responsiveness in advanced PD.

Signs of sepsis, pneumonia, or head injury following a fall.

‘Off’ periods — temporary worsening of symptoms when medication effects wear off.

Signs of Parkinson’s crisis — acute immobility, severe rigidity, autonomic dysfunction, often triggered by illness or missed medication (JRCALC, 2022).

Acute Management Of Parkinson’s Disease

While Parkinson’s disease is a chronic condition, prehospital presentations are often due to acute complications such as falls, aspiration pneumonia, reduced mobility, or medication-related crises. Effective prehospital management hinges on a structured ABCDE assessment, early recognition of deterioration, and appropriate supportive care.

A – Airway

Assess for obstruction due to reduced muscle tone, dysphagia, or aspiration risk.

Be alert for silent aspiration – especially in advanced PD or during reduced consciousness.

Responsive consciousness can be assessed by observing purposeful movements, eye contact, verbal responses, or reactions to stimuli (e.g., following commands, withdrawing from pain).

Suction if required for drooling or pooled secretions (JRCALC, 2022).

B – Breathing

Monitor rate, rhythm, and oxygen saturation.

Administer oxygen therapy as per JRCALC guidelines — titrate to SpO₂ 94–98%, or 88–92% if risk of CO₂ retention suspected.

Consider pneumonia in patients with cough, dyspnoea, or fever.

C – Circulation

Check blood pressure, including postural measurements — orthostatic hypotension is common.

IV access may be required for fluid resuscitation in cases of sepsis, dehydration, or hypotension.

Administer 0.9% sodium chloride IV fluid bolus (250–500ml) as per JRCALC if hypotensive and clinically indicated.

D – Disability (Neurological)

Assess AVPU/GCS, pupil response, and signs of acute deterioration.

Consider causes of reduced responsiveness: medication ‘off’ periods, infection, hypoxia, head injury.

Evaluate for Parkinson’s crisis: acute worsening of motor symptoms, autonomic instability, and potential airway risk — often due to missed medication or infection.

E – Exposure / Environment

Check for pressure sores, infection signs, injury from falls, or skin breakdown.

Maintain dignity and warmth, especially in frail or immobile patients.

care.

Medication Timing

Levodopa preparations (e.g., co-careldopa, co-beneldopa) must be given on time — delayed or missed doses can cause rapid symptom worsening. Paramedics may need to communicate urgency to ED staff if doses are due or missed.

Elderly patients

Higher risk of falls, delirium, hypotension, pneumonia, and polypharmacy interactions. Monitor closely for red flags.

Advanced Parkinson’s disease or Parkinson’s crisis

Requires urgent transport and hospital management. Early identification can reduce morbidity.

Pain Relief (JRCALC)

Paracetamol 1g PO/IV (if able to swallow or IV access established)

Morphine sulphate IV titrated to effect if significant trauma or pain, with consideration of airway status and respiratory depression risk.

Transport To Hospital

Safe transport of Parkinson’s patients requires careful handling due to mobility issues, fall risk, and airway concerns (JRCALC, 2022).

Positioning – Upright if possible to reduce aspiration risk.

Airway & Breathing – Monitor for dysphagia, hypoventilation, or aspiration pneumonia.

Medication – Bring patient’s levodopa to avoid “off” episodes.

Falls & Fractures – Assess for head injury, orthostatic hypotension, or fractures.

Cognitive Changes – Consider delirium, dementia, or hallucinations affecting consent and history-taking.

Early hospital notification may be needed for specialist input, particularly if the patient has advanced PD or complications (NICE, 2022).

Long Term Management Of Parkinson’s Disease

Managing Parkinson’s disease (PD) requires a multidisciplinary approach focusing on symptom control, mobility, and complication prevention (NICE, 2022).

Levodopa (with carbidopa/benserazide)

Levodopa is the gold-standard treatment for Parkinson’s Disease. It is converted into dopamine in the brain, compensating for the dopamine deficit in Parkinson’s.

However, levodopa alone is largely metabolised before reaching the brain, so it’s always given with a peripheral dopa-decarboxylase inhibitor (carbidopa or benserazide) to increase CNS availability.

Other Drugs

Dopamine agonists (e.g., pramipexole, ropinirole) – Risk of impulse control disorders.

MAO-B inhibitors (e.g., rasagiline, selegiline) – Reduce dopamine breakdown.

COMT inhibitors (e.g., entacapone, opicapone) – Prolong levodopa effects.

Physiotherapy – Reduces fall risk.

Speech and Language Therapy – Manages dysphagia and speech impairment.

Occupational Therapy – Assists daily activities.

Cognitive Support – Addresses dementia and psychiatric symptoms (BMJ, 2023).

Deep Brain Stimulation (DBS) – For medication-resistant symptoms.

Palliative Care – Symptom relief, advance care planning, and carer support (JRCALC, 2022).

Differential Diagnosis

Parkinson’s disease shares features with several conditions, requiring careful assessment. Key differentials include:

Parkinson-Plus Syndromes – Poor response to levodopa with additional signs:

• MSA (severe autonomic dysfunction)
• PSP (early falls, vertical gaze palsy)
• CBD (asymmetry, apraxia)
• DLB (early dementia, hallucinations)

Drug-Induced Parkinsonism – Caused by antipsychotics, antiemetics, or calcium channel blockers. Often bilateral and resolves after stopping the drug.

Essential Tremor – Action tremor (not resting), no bradykinesia/rigidity, often familial.

Vascular Parkinsonism – Gait disturbance, history of stroke/hypertension, minimal tremor.

Normal Pressure Hydrocephalus (NPH) – Gait disturbance, incontinence, cognitive decline, may be reversible.

✅ Symmetry – Parkinson’s disease is asymmetric, Drug-Induced Parkinsonism is bilateral.
✅ Falls/Gait – Early falls? Think Parkinson-Plus Syndrome or Normal Pressure Hydrocephalus.
✅ Autonomic Signs – Severe postural hypotension suggests Parkinson-Plus Syndrome MSA.
✅ Medication History – Recent neuroleptics or antiemetics? Consider Drug-Induced Parkinsonism.
✅ Cognition – Early dementia suggests Parkinson-Plus Syndrome DLB.

Key Points

Bibliography

BMJ Best Practice (2023) Parkinson’s disease – Overview. BMJ Publishing Group. https://bestpractice.bmj.com/topics/en-gb/3000109

Hohman Rehab and Sports Therapy (2020) Parkinson’s Disease. https://hohmanrehab.com/treatments/parkinsons-disease

Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (2022) UK ambulance services clinical practice guidelines. Class Professional Publishing

National Institute for Health (NIH) (2024) Environmental Risk Factors for Parkinson’s Disease: A Critical Review and Policy Implications. https://pubmed.ncbi.nlm.nih.gov/39601461

National Institute for Health and Care Excellence (NICE) (2022) Parkinson’s disease in adults: Diagnosis and management (NICE Guideline NG71). https://www.nice.org.uk/guidance/ng71