DIAGNOSIS FOR PARKINSON’S DISEASE
How a Diagnosis is Made
The bedside examination by a neurologist remains the first and most
important diagnostic tool for Parkinson’s disease (PD). Researchers
are working to develop a standard biological marker such as a blood
test or an imaging scan that is sensitive and specific for Parkinson’s
disease.
A neurologist will make the diagnosis based on:
 A detailed history of symptoms, medical problems, current
and past medications. Certain medical conditions, as well
as some medications, can cause symptoms similar to
Parkinson’s.
 A detailed neurological examination during which a
neurologist will ask you to perform tasks to assess the
agility of arms and legs, muscle tone, gait and balance, to
see if:
 Expression and speech are animated.
 Tremor can be observed in your extremities at rest or in
action.
 There is stiffness in extremities or neck.
 You can maintain your balance and examine your posture.
 You may notice that a neurologist records your exam into a
table, called Unified Parkinson’s Disease Rating Scale
(UPDRS). This is a universal scale used by neurologists
and movement disorder specialists to comprehensively
assess and document the exam of a person with PD at a
baseline, judge the effect of medication and track the
progression of disease during future visits.
 Most commonly, people with PD respond well to
dopaminergic medications. Lack of response to
medications may prompt the doctor to seek an alternative
diagnosis such as atypical parkinsonism and order further
testing such as an MRI (magnetic resonance imaging) of
the brain.
 When unsure of a PD diagnosis, neurologists often refer
patients to movement disorders specialists and order
DaTscans.
Diagnostic Studies
Because there is no specific diagnostic test for PD, the diagnosis is
based on the history and the clinical features. A firm diagnosis can
be made only when at least two of the three signs of the classic triad
are present: tremor, rigidity, and bradykinesia. The ultimate
confirmation of PD is a positive response to antiparkinsonian drugs.
Research is ongoing regarding the role of genetic testing and MRI in
diagnosing patients with PD
Source: https://www.nhs.uk/conditions/parkinsons-disease/diagnosis/
- No tests can conclusively show that you have Parkinson's
disease. Your doctor will base a diagnosis on your
symptoms, medical history and a detailed physical
examination.
- A diagnosis of Parkinson's disease is likely if you have at
least 2 of the 3 following symptoms:
 shaking or tremor in a part of your body that
usually only occurs at rest
 slowness of movement (bradykinesia)
 muscle stiffness (rigidity)
- If your symptoms improve after taking a medication called
levodopa, it's more likely you have Parkinson's disease.
Special brain scans, such as a single photon emission
computed tomography (SPECT) scan, may also be carried
out in some cases to try to rule out other causes of your
symptoms.
Other source: https://www.parkinson.org/Understanding-
Parkinsons/Diagnosis
There is no “one way” to diagnose Parkinson’s disease (PD).
However, there are various symptoms and diagnostic tests used in
combination. Making an accurate diagnosis of Parkinson’s —
particularly in its early stages — is difficult, but a skilled practitioner
can come to a reasoned conclusion that it is PD. It is important to
remember that two of the four main symptoms must be present over
a period of time for a neurologist to consider a PD diagnosis:
 Shaking or tremor
 Slowness of movement, called bradykinesia
 Stiffness or rigidity of the arms, legs or trunk
 Trouble with balance and possible falls, also called postural
instability
Often, a Parkinson’s diagnosis is first made by an internist or family
physician. Many people seek an additional opinion from
a neurologist with experience and specific training in the assessment
and treatment of PD — referred to as a movement disorder
specialist.
MANETIC RESONANCE IMAGING (MRI)
A noninvasive technique, skeletal magnetic resonance imaging (MRI)
produces clear and sensitive images of bone and soft tissue. The
scan provides superior contrast of body tissues and allows imaging
of multiple planes, including direct sagittal and coronal views in
regions that can’t be easily visualized with X-rays or computed
tomography scans. MRI eliminates any risks associated with
exposure to X-ray beams and causes no known harm to cells.
Patient Preparation
1. Make sure the scanner can accommodate the patient’s
weight and abdominal girth.
2. Explain to the patient that skeletal MRI assesses bone and
soft tissue. Tell him who will perform the test and where it
will take place.
3. Explain that the test takes 30 to 90 minutes.
4. Explain to the patient that although MRI is painless and
involves no exposure to radiation from the scanner, a
contrast medium may be used, depending on the type of
tissue being studied.
5. If the patient is claustrophobic or if extensive time is
required for scanning, explain to him that a mild sedative
may be administered to reduce anxiety. Open scanners
have been developed for use on the patient with extreme
claustrophobia or morbid obesity, but tests using such
machine take longer.
6. An anesthesiologist may need to be present to monitor a
heavily sedated patient.
7. Tell the patient that he must lie flat, and describe the test
procedure.
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 8. Explain to the patient that he’ll hear the scanner clicking,
whirring, and thumping as it moves inside its housing.
9. Ask whether the patient has any surgically implanted joints,
pins, clips, valves, pumps, or pacemakers containing metal
that could be attracted to strong MRI magnet. If he does,
he won’t be able to have the test.
10. Make sure that the patient or a responsible family member
has signed an informed consent form, if required.
Nursing Interventions for MRI
1. Provide patient with comfort measures as needed.
2. Tell the patient to resume his normal diet and activities
unless otherwise indicated.
3. Monitor vital signs.
4. Monitor the patient for orthostatic hypotension.
MRI Complications
 Orthostatic hypotension
 Anxiety
 Claustrophobia
CT SCAN (COMPUTED TOPOGRAPY)
Computed tomography (CT) scan, also known as computerized axial
tomography (CAT), or CT scanning computerized tomography is a
painless, non-invasive diagnostic imaging procedure that produces
cross-sectional images of several types of tissue not clearly seen on
a traditional X-ray.
Brain
Also known as “cranial CT scan” or “Head CT”. It is indicated to
provide detailed information on head injuries, stroke, brain tumors
and other diseases affecting the brain.
 Look for allergies. Assess for any history of allergies to
iodinated dye or shellfish if contrast media is to be used.
 Get health history. Ask the patient about any recent
illnesses or other medical conditions and current
medications being taken. The specific type of CT scan
determines the need for an oral or I.V. contrast medium
 Check for NPO status. Instruct the patient to not to eat or
drink for a period amount of time especially if a contrast
material will be used.
 Get dressed up. Instruct the patient to wear comfortable,
loose-fitting clothing during the exam.
 Provide information about the contrast medium. Tell the
patient that a mild transient pain from the needle puncture
and a flushed sensation from an I.V. contrast medium will
be experienced.
 Instruct the patient to remain still. During the examination,
tell the patient to remain still and to immediately report
symptoms of itching, difficulty breathing or swallowing,
nausea, vomiting, dizziness, and headache.
 Inform about the duration of the procedure. Inform the
patient that the procedure takes from five (5) minutes to
one (1) hour depending on the type of CT scan and his
ability to relax and remain still.
After the procedure
The nurse should be aware of these post-procedure nursing
interventions after computed tomography (CT) scan:
 Diet as usual. Instruct the patient to resume the usual diet
and activities unless otherwise ordered.
 Encourage the patient to increase fluid intake (if a contrast
is given). This is so to promote excretion of the dye.

Contraindication
 Pregnant patient (absolute contraindication)
 Patients with a known allergy to iodine
 Patients with claustrophobia
 Patients with renal impairment unless the benefits outweigh
the risks
 Patients with hyperthyroidism or toxic goiter (induce
thyrotoxic crisis)
 Patients with complications after a previous administration
of a contrast
 Patients with severe obesity (usually more than 300
pounds)

Nursing Responsibilities for CT Scan

The following are the nursing interventions and nursing care
considerations for a patient undergoing computed tomography:

Before the procedure

The following are the nursing interventions before computed
tomography:

 Informed Consent. Obtain an informed consent properly

signed.

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POSITRON EMISSION TOMOGRAPHY SCAN
- a PET scan is used to assess activity and function of brain
regions involved in movement.
A PET (positron emission tomography) scan is a test that can help a
healthcare provider diagnose cancer, heart disease, and some brain
diseases. It takes digital pictures that may show abnormal cells in
your body. The test is painless, usually has no side effects, and takes
about 2 hours. Because of the special equipment needed, you'll get a
PET scan in the hospital or an outpatient testing center.
During the procedure
When you are ready, you'll lie on a narrow, padded table that slides
into the scanner. During the scan you'll need to lie very still so that
the images aren't blurred. It takes about 30 minutes to complete the
test. The machine makes buzzing and clicking sounds.
The test is painless. If you're afraid of enclosed spaces, you may feel
some anxiety while in the scanner. Be sure to tell the nurse or
technologist about any anxiety causing you discomfort. He or she
may give you a drug to help you relax.
In some cases you may have a CT and PET scan in the same
machine during the same appointment. The CT scan will be done
first and take about 10 minutes.
After the procedure
After the test you can carry on with your day as usual, unless your
doctor tells you otherwise. You'll need to drink plenty of fluids to help
flush the tracer from your body.
Da Tscan
 a tool used to confirm the diagnosis of Parkinson's disease.
It is a specific type of single-photon emission computed
tomography (SPECT) imaging technique that helps
visualize dopamine transporter levels in the brain.
 While a DaTscan cannot diagnose PD, doctors use them to
confirm a diagnosis. A negative DaTscan result does not
rule out a Parkinson's diagnosis, but a positive result helps
confirm it
A DaTscan is an imaging technology that uses small amounts of a
radioactive drug to help determine how much dopamine is available
in a person's brain. A SPECT scanner is used to measure the
amount and location of the drug in the brain.
While a DaTscan cannot diagnose PD, doctors use them to confirm a
diagnosis. A negative DaTscan result does not rule out a Parkinson’s
diagnosis, but a positive result helps confirm it. The problem with
positive results is that it does not differentiate Parkinson’s disease
from other forms of parkinsonism, such as multiple system atrophy
(MSA) or progressive supranuclear palsy (PSP), that can also
produce a loss of dopamine in the brain. A positive DaTscan can
differentiate PD from Essential Tremor (ET) as there is no dopamine
deficiency in the latter.
Are there risks associated with DaTscan?
Possible adverse reactions such as headache, nausea, vertigo, dry
mouth and mild to moderate dizziness were reported, hypersensitivity
reaction and injection site pain have also been reported.
I have PD and several symptoms. Should I get a DaTscan?
Likely no. There is no need for DaTscan when your history and exam
suggests Parkinson’s disease and you meet the diagnostic criteria.
Occasionally, if signs and symptoms are mild or you don’t meet the
diagnostic criteria then your neurologist or movement disorder
specialist will refer you for a DaTscan. Keep in mind that ultimately
the diagnosis is based on your history and physical exam and the
DaTscan is most commonly used to complete the picture and is not a
necessary test for a diagnosis.
How does a DaT scan work?
DaTscan is a drug that is injected into the bloodstream to assess
dopamine containing neurons, which are involved in controlling
movement. One of our subspecialized imaging physicians will then
use a gamma camera to take pictures of your brain.
 Ioflupane
Drug
 Ioflupane is the International Nonproprietary Name of a
cocaine analogue which is a neuro-imaging
radiopharmaceutical drug, used in nuclear medicine for the
diagnosis of Parkinson's disease and the differential
diagnosis of Parkinson's disease over other disorders
presenting similar symptoms.
 What is a nuclear medicine DAT scan?
 What is a DaTSCAN? A DaTSCAN is a scan of the brain.
DaTSCAN contains the active substance ioflupane (I123)
which is used to help diagnose abnormalities in the brain. It
belongs to a group of medicines called
“radiopharmaceuticals”, which contain a small amount of
radioactivity.
Preparation for the DaTSCAN
Please inform us before you attend:
 If you are or think you may be pregnant
 If you are breastfeeding
 If you have problems weight bearing and need a hoist to be
transferred
 If you are unable to lie still and flat on your back for 45
minutes
After effects of a DaTSCAN
There are no known after effects from a DaTSCAN. You will be able
to drive, travel by public transport and return to work if necessary.
You will be advised to drink plenty of fluids and empty your bladder
often. This assists the tracer to discard from your body quickly.
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You will not need to take any precautions.
What are the risks of a DaTSCAN Scan?
The amount of radiation that you will receive from this investigation is
very low and similar to the natural background radiation we all
receive from the environment over a period of 24 months.
Where is a DaTSCAN performed?
The DaTSCAN is only performed in the Nuclear Medicine SPECT CT
Department which is situated in the X-Ray Department. On arrival,
please book in at X-Ray Reception on the Ground Floor, close to the
Outpatient Entrance.
Who can accompany me for the scan?
HWe would prefer that you do not bring more than one person with
you.
A. Rating scales
 A rating scale is a means of providing information on a
particular feature by assigning a value to it. In Parkinson’s,
rating scales require the ‘rater’ (the person deciding on the
points scored) to put a value to the feature or symptom in
question, according to a set scale. The rater may be the
person with Parkinson’s or a healthcare professional.
 Parkinson’s rating scales are a means of assessing the
symptoms of the condition. They provide information on the
course of the condition and/or assess quality of life. They
may also help to evaluate treatment and management
strategies, which can be useful to researchers as well as to
people with Parkinson’s, their carers and medical team.
 Motor (movement) scales are the best-known and most
widely used, but non-motor symptom scales are equally
important. Combined with a motor scale, these give a more
balanced picture of how a person is affected by the
condition. A low motor score may suggest that a person
has mild Parkinson’s but, at the same time, the person may
have disabling non-motor symptoms, which impact on
quality of life.
1. The Unified Parkinson’s Disease Rating Scale (UPDRS) is
a more comprehensive tool used to account for non-motor
symptoms, including mental functioning, mood and social
interaction. Accounts for cognitive difficulties, ability to
carry out daily activities and treatment complications.
 More comprehensive tool used to account for
non-motor symptoms, including mental
functioning, mood and social interaction.
 The UPDRS testing is carried out by a healthcare
professional. Points are assigned to every item
based on the person’s response, as well as
observation and physical examination. The total
cumulative score will range from 0 (no disability)
to 199 (total disability).
 The scale has three sections which evaluate key
areas of disability, together with a fourth section
that evaluates any complications of treatment.
The UPDRS is often used with two other
Parkinson’s rating scales: the Hoehn and Yahr
2. Hoehn and Yahr stages
 used to measure how Parkinson’s symptoms
progress and the level of disability.
 The Hoehn and Yahr Scale is used to measure
how Parkinson’s symptoms progress and the
level of disability. Originally published in 1967 in
the journal Neurology by Melvin Yahr and
Margaret Hoehn, it included stages 1 to 5. Since
then, stage 0 has been added and stages 1.5
and 2.5 have been proposed and are widely
used.
 follow a simple rating scale. Clinicians use it to
describe how motor symptoms progress in PD.
Rates symptoms on a scale of 1 to 5. On this
scale, 1 and 2 represent early-stage, 2 and 3
mid-stage, and 4 and 5 advanced-stage
Parkinson's.
 used to describe how motor symptoms progress
in PD.
 rates symptoms on a scale of 1 to 5. On this
scale, 1 and 2 represent early-stage, 2 and 3
mid-stage, and 4 and 5 advanced-stage
Parkinson's.
Stage 0 - No signs of disease
Stage 1 - Symptoms on one side only (unilateral)
Stage 1.5 - Symptoms unilateral and also involving the neck and
spine
Stage 2 - Symptoms on both sides but no impairment of balance
Stage 2.5 - Mild symptoms on both sides, with recovery when the
‘pull’ test is given (the doctor stands behind the person and asks
them to maintain their balance when pulled backwards)
Stage 3 - Balance impairment, mild to moderate disease, physically
independent
Stage 4 - Severe disability, but still able to walk or stand unassisted
Stage 5 - Needing a wheelchair or bedridden unless assisted.
3. Schwab and England Activites of Daily Living (ADL) Scale
The Schwab and England ADL Scale is a means of measuring a
person’s ability to perform daily activities in terms of speed and
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independence through a percentage figure. The rating may be made monotone voice, fading volume after starting to speak
by a professional or by the person being tested. High percentages loudly, or slurring speech. There also may be stiffness or
indicate a high level of independence while low percentages indicate rigidity of the muscles in the trunk that may result in neck or
dependence: back pain, stooped posture, and general slowness in all
activities of daily living. Diagnosis may be easy at this
 100% - Completely independent. Able to do all activities stage if the patient has a tremor, however, if stage one was
without slowness, difficulty or impairment missed and the only symptoms of stage two are slowness
 90% - Completely independent. Able to do all activities with or lack of spontaneous movement, PD could be
some slowness, difficulty or impairment. Activities may take misinterpreted as only advancing age.
twice as long to complete  Stage Three of Parkinson’s Disease – Stage three is
 80% - Independent in most activities, but activities take considered mid-stage and is characterized by loss of
twice as long. Conscious of difficulty and slowing balance and slowness of movement. Balance is
 70% - Not completely independent. More difficulty with compromised by the inability to make the rapid, automatic,
activities, which may take three to four times as long. May and involuntary adjustments necessary to prevent falling,
take large part of day for chores and falls are common at this stage. All other symptoms of
 60% - Some dependency. Can do most activities, but very PD are also present at this stage, and generally diagnosis
slowly and with much effort, but some chores are is not in doubt at stage three. An important clarifying factor
impossible of stage three is that the patient is still fully independent in
 50% - More dependent. Help required with half of chores. their daily living activities, such as dressing, hygiene, and
Difficulty with everything eating.
 40% - Very dependent. Can assist with all chores but can  Stage Four of Parkinson’s Disease – In stage four, PD has
manage few alone progressed to a severely disabling disease. Patients with
 30% - With effort, now and then does a few chores alone or stage four PD may be able to walk and stand unassisted,
begins alone. Much help needed but they are noticeably incapacitated. Many use a walker to
help them. At this stage, the patient is unable to live an
 20% - Cannot do anything alone. Can give some slight help
independent life and needs assistance with some activities
with some chores. Severe invalid
of daily living.
 10% - Totally dependent, helpless
 Stage Five of Parkinson’s Disease – Stage five is the most
 0% - Vegetative functions such as swallowing
advanced and is characterized by confinement to a bed or
wheelchair. People with stage five PD may be unable to
The Hoehn and Yahr scale
rise from a chair or get out of bed without help, they may
The Hoehn and Yahr scale, named for its authors, was published in
have a tendency to fall when standing or turning, and they
1967 and was the first rating scale to describe the progression of PD.
may freeze or stumble when walking. Around-the-clock
The Hoehn and Yahr scale describes five stages to PD progression:
assistance is required at this stage to reduce the risk of
falling and help the patient with all daily activities. At stage
 Stage One of Parkinson’s Disease – In stage one, the
five, the patient may also experience hallucinations or
earliest stage, the symptoms of PD are mild and only seen
delusions.1,2
on one side of the body (unilateral involvement), and there
 While the symptoms worsen over time, it is worth noting
is usually minimal or no functional impairment. The
that some patients with PD never reach stage five. People
symptoms of PD at stage one may be so mild that the
with PD may also never experience some of the above
person doesn’t seek medical attention or the physician is
symptoms. In addition, there are treatments available that
unable to make a diagnosis. Symptoms at stage one may
can help at every stage of the disease.
include tremor, rigidity, or slowness of movement in the
arm or leg on one side of the body, or one side of the face
Unified Parkinson’s Disease Rating Scale
may be affected, impacting the expression.
The Unified Parkinson’s Disease Rating Scale (UPDRS) has four
 Stage Two of Parkinson’s Disease – Stage two is still
parts. Each part has multiple points that are individually scored, using
considered early disease in PD, and it is characterized by
zero for normal or no problems, 1 for minimal problems, 2 for mild
symptoms on both sides of the body (bilateral involvement)
problems, 3 for moderate problems, and 4 for severe problems.
or at the midline without impairment to balance. Stage two
These scores are tallied to indicate the severity of the disease, with
may develop months or years after stage one. Symptoms
199 points being the worst and total disability and 0 meaning no
of PD in stage two may include the loss of facial expression
disability.3
on both sides of the face and decreased blinking. Speech
abnormalities may be present, such as soft voice,
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In 2001, the Movement Disorder Society (MDS) updated the rating
scale with involvement from patients and caregivers. The updated
scale is referred to as the UPDRS-MDS, and it was published in
2008. It now includes the following sections
Deep Brain Stimulation Surgery
Deep brain stimulation (DBS) is the most commonly performed
surgical treatment for Parkinson's. A surgeon places thin metal wires
in the brain; these wires send electrical pulses to the brain to help
control some motor symptoms.
While transformative for some, DBS is not for everyone. This
treatment is approved for people who have had Parkinson's disease
for at least four years and who get a benefit from medication but
have motor complications, such as significant "off" time (periods
when symptoms return because medication isn't working well) and/or
dyskinesia (uncontrolled, involuntary movements).
DBS typically works best to lessen motor symptoms of stiffness,
slowness and tremor. It doesn't work as well for imbalance, freezing
of gait (sudden inability to move when walking) or non-motor
symptoms. As DBS may worsen thinking or memory problems, it's
not recommended for people with dementia.
Deep Brain Stimulation Surgery
A team of experts, including a movement disorder specialist (a
neurologist with extra training in Parkinson's) and a brain surgeon,
conducts an extensive assessment when considering DBS for
someone. They review your medications and symptoms, examine
you when you're on and off Parkinson's medication, and take brain
imaging scans. They also may do detailed memory/thinking testing to
detect any problems that could worsen with DBS. If your doctors do
recommend you for DBS and you are considering the surgery,
discuss with your care team the potential benefits (decreased tremor,
fewer medications, etc.) as each person's experience is unique. It's
also critical to discuss the potential surgical risks, including bleeding,
stroke and infection.
In DBS surgery, the surgeon places thin wires called electrodes into
one or both sides of the brain, in specific areas (either the
subthalamic nucleus or the globus pallidus interna) that control
movement. Usually you remain awake during surgery so you can
answer questions and perform certain tasks to make sure the
electrodes are positioned correctly. Some medical centers now use
brain imaging to guide the electrodes to the right spot while a person
is asleep. Each method has its pros and cons and may not be
suitable for everyone or available everywhere.
Once the electrodes are in place, the surgeon connects them to a
battery-operated device (similar to a cardiac pacemaker), which
usually is placed under the skin below the collarbone. This device,
called a neurostimulator, delivers continuous electrical pulses
through the electrodes.
A few weeks after surgery, a movement disorder specialist programs
the neurostimulator to help treat your unique symptoms. Your doctor
will gradually tweak your DBS settings over time while adjusting your
medications. Most people are able to decrease (but not completely
discontinue) Parkinson's drugs after DBS. Determining the optimal
combination of drugs and DBS settings — with the greatest benefit
and the fewest side effects — can take several months and even up
to a year.
In Parkinson’s, parts of the basal ganglia are either under- or over-
stimulated. Normal movement is replaced by tremor, rigidity and
stiffness. DBS of specific ganglia alters the abnormal electrical
circuits and helps stabilize the feedback loops, thus reducing
symptoms.
Electrodes can be placed in the following brain areas (Fig 2):
 Subthalamic nucleus (STN) – effective for tremor,
slowness, rigidity, dystonia and dyskinesia. Most commonly
used to treat Parkinson's disease.
 Thalamus (VIM) – effective for tremor. It is often used to
treat essential tremor.
 Globus pallidus (GPi) – effective for tremor, slowness,
rigidity, dystonia and dyskinesia. It is used to treat dystonia
and Parkinson's disease.
DBS may not be an option if you have severe untreated depression,
advanced dementia, or if you have symptoms that are not typical for
Parkinson's. DBS can help treat many of the symptoms caused by:
 Parkinson's disease: tremor, rigidity, and slowness of
movement caused by the death of dopamine-producing
nerve cells responsible for relaying messages that control
body movement.
 Essential tremor: involuntary rhythmic tremors of the hands
and arms, occurring both at rest and during purposeful
movement. Also may affect the head in a "no-no" motion.
 Dystonia: involuntary movements and prolonged muscle
contraction, resulting in twisting or writhing body motions,
tremor, and abnormal posture. May involve the entire body,
or only an isolated area. Spasms can often be suppressed
by "sensory tricks," such as touching the face, eyebrows, or
hands.
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