This article will reflect on the case of an 82-year-old woman, who was referred into community physiotherapy service with a 12–18-month history of reducing mobility, rapid shuffling gait and three falls in the last 6 months. Clinical history taking, (Table 1a; Table 1b), provided additional information congruent with symptoms relating to Parkinson's. To maintain anonymity a pseudonym of Mrs A will be utilised.
| Field | Recorded notes |
|---|---|
| Age | 82 years old |
| Sex | Female |
| History of presenting complaints and symptoms | Patient referred to physiotherapy due to shuffling gait and falls |
| Past medical history | Hypertension |
| Drug history | No recent short-term course of drugs and no drugs stopped within last 3 months |
| Allergies | Sensitivity to codeine—causes vomiting and red skin rash |
| Social history | Widowed schoolteacher, retired 24 years ago |
| Family history | Mother had cerebrovascular accident; no other known family history |
| Risks | Nonsmoker—stopped smoking tobacco cigarettes 40 years ago |
| Field | Recorded notes |
|---|---|
| Investigations and examination findings | Blood pressure: sitting 118/74. Initial standing 101/68; 2min standing 108/70 |
| Differential diagnosis(s) | Parkinson's disease |
| Potential management/referrals/communication | Refer on to specialist Parkinsons clinic for multidisciplinary team assessment to provide diagnosis if Parkinsons disease or a Parkinsonism, if present-made GP aware of referral |
Background
Parkinson's
Parkinson's is a neuro-degenerative disease presenting with motor symptoms, such as: altered movement patterns; bradykinesia or akinesia; gait disturbance; falls; and tremor (Eggers et al, 2018; Balestrino and Schapira, 2020; Hilton and Shivane, 2021). Non-motor symptoms (NMS) include: constipation; altered smell; sleep disorders; urinary changes; and depression (Bloem et al, 2021; Chen and Lin, 2022).
Prevalence
Parkinson's is a global disease affecting up to 6 million people worldwide (GBD 2016 Neurology Collaborators. Global, 2019) with an increasing incidence with age (Balestrino and Schapira, 2020). However, 25% of those diagnosed are under 65 years old and a further 5-10% are under 50 years old (Bloem et al, 2021). There has been a significant rise in cases of Parkinson's in high income areas of Europe (Deuschl et al, 2020). This is partially attributed to the inverse relationship between smoking cessation reducing dopamine prophylactic effects over the last 30 years (Rossi et al, 2018), combined with improvements in available healthcare and diagnostics (Moore et al, 2015). Schrag et al (2019) report that 3% of the European population over the age of 80 years old are diagnosed with Parkinson's, in line with Mrs A's age.
Nicoletti et al (2017) found a significantly increased risk of Parkinson's in men compared to women. However, Picillo and Fasano (2015) evidenced this ratio reduces with age, attributed to female hormonal changes post-menopause. Bloem et al (2021) also demonstrated later age of onset in women, correlating with the case study presentation and suggesting that oestrogen levels may influence disease prevention or progression.
Financial implications
According to Roger et al (2017) the cost of living per person with Parkinson's in the UK per year is £16 500, with additional health costs of £2118 attributed to the NHS. This trend of increased social care costs relative to health costs were shown to continue into end stage Parkinson's by Findley et al (2011), where patients could expect to spend 7% of the £62 147 cost of living in their last year on health and 93% on care needs.
Along with an increasing financial burden, disease progression results in reduction in quality of life, starting in the prodromal phase and becoming increasingly prevalent as motor symptoms develop into end stage disease (Eggers et al, 2018). Consequently, early diagnosis to facilitate symptom management can significantly improve quality of life (Fernandes et al, 2022).
Aetiology
The aetiology of Parkinson's is subject to ongoing research; currently, there are believed to be three main causes: genetics, environmental influences, and lifestyle choices (Stephenson et al, 2019). Balestrino and Schapira (2020) have cited that there are ten known genes linked to increased risk of developing Parkinson's, with an associated familial link of up to 15%. There is ongoing research into the benefits and cost implications of genetic testing in these instances; however, there are currently no guidelines for this within the UK.
There are a wide-ranging variety of environmental and lifestyle factors which interact to increase the risk of developing Parkinson's. Marras et al (2019) have identified reduced exercise, chemicals (e.g. pesticides), diet, emotional stress and non-smoking as the main adaptable causes. They suggest reduced use of pesticides, improved diet and levels of exercise could have a significant health benefit, with a reduced risk of Parkinson's as a likelihood.
In contrast to the above healthy lifestyle advice, Rossi et al (2018) have demonstrated the protective effects of nicotine and caffeine of delaying onset of, or even preventing, Parkinson's. Further analysis of related findings by Fang et al (2018), however, considered that the dopamine effect of smoking and caffeine ingestion may link closely with that of exercise. Consequently, if dopamine replacement activities coincide with smoking and caffeine cessation, this may void the heightened risk of Parkinson's, maintaining the known health benefits of cessation. In Mrs A's case, the combination of smoking cessation, age and reduced social and physical activities may have contributed to reduced dopamine prophylactic effects, thereby increasing possible disease progression.
Parkinson's phenotypes: body-first or brain-first?
Historically, Parkinson's was considered a neurological disorder caused by ‘the complex interplay of aberrant α-synuclein aggregation, dysfunction of mitochondria, lysosome transport, synaptic transport issues and neuroinflammation’ (Bloem et al, 2021; 2291). However, more recently, causation has been shown to stem from either body-first, with NMS prevalent for several years prior to motor symptoms, or brain-first, where brain dysfunction and motor symptoms are primary (Bohnen and Postuma, 2020). The brain-first phenotype is deemed to correlate with genetic cause, while body-first is thought to be closely linked with gut microbiota reactions to environmental factors (Varesi et al, 2022).
Body-first Parkinson's has been attributed to environmental factors affecting the microbial exchanges within the gut microbiota brain axis, which links the enteric nervous system with the brain (Varesi et al, 2022). Here there is a complex interplay with the immune system, within which, microbiota can cause the over production of α-synuclein, a folded protein which accumulates to form Lewy bodies, particularly in the substantia nigra, but also in other neural pathways, resulting in the manifestation of Parkinson's symptoms (Wakabayashi et al, 2013).
Symptoms
Molsberry et al (2022) highlighted that change in α-synuclein production, affecting mitochondrial function, initially causes prodromal NMS. Once patients reach the stage of motor symptoms, there is significant cell death of dopamine producing cells within the substantia nigra (Hilton and Shivane, 2021). Bohnen and Postuma (2020) have demonstrated that reduced dopaminergic input causes an alteration of hormonal and neuron activation within the brain leading to ‘strong inhibition of the ventral thalamus, and reduced excitation of the motor cortex’. This results in the defining symptoms of Parkinson's: bradykinesia; rigidity; tremor; or gait disturbance (Yenisetti, 2018), all of which were present on initial assessment of Mrs A.
Hilton and Shivane (2021) explained that some prodromal NMS arise from neurogenic changes caused by insufficient epinephrine response, most commonly, hypotension and olfactory changes. Lui et al (2022) have discussed the presence of neurogenic orthostatic hypotension in 40% of Parkinson's patients, concurrent with our case study, often presenting as dizziness or feeling faint. Moreover, National Institute for Health and Care Excellence (NICE) (2015) have emphasised asymptomatic orthostatic hypotension is common, as with Mrs A.
Lewy body formation throughout the nervous system can amplify existing NMS and is likely to affect cognitive function, resulting in Lewy body dementia (Wakabayashi et al, 2013). However, no cognitive changes were noted during assessment of Mrs A. As the disease progresses, motor symptoms become more pronounced and, over time, can affect essential functions such as swallowing and respiratory muscles, resulting in palliative care (Segura-Aguilar, 2021).
Diagnosis
Clinical history taking and examination
According to Fernandez et al (2021), clinical history taking and neurological assessment taking plays a significant role in identifying NMS and the progression of motor symptoms, in order to inform a differential diagnosis. Performing a thorough, subjective assessment informs the pertinent physical assessments to indicate diagnosis, onward referral or treatment options (Fernandez et al, 2021). Schrag et al (2019) have explained that patients are often unaware of linked NMS prior to development of motor symptoms in most Parkinsonism; hence a thorough clinical history taking, with apposite questions to common Parkinson's NMS to identify possibly prodromal symptoms, along with environmental risk factors and lifestyle choices that increase risk of Parkinson's, is required.
Advanced Practitioners (APs) are well placed to complete observations of blood pressure, temperature, heart rate, respiratory rate and oxygen saturations to provide a baseline for future assessments, provide a general overview of essential systems and may identify orthostatic hypotension, as with Mrs A (NICE, 2015; Chen-fei et al, 2022). Biswas et al (2019) highlighted the importance of awareness of neurogenic orthostatic hypotension to lead APs to screen, diagnose and contribute to management, resulting in a significant improvement to quality of life (Claassen et al, 2018).
Fernandez et al, (2021) emphasised that initial observation of the patient can often identify possible Parkinson's motor symptoms. Patients' gait pattern, freezing episodes, resting tremor and signs of bradykinesia are simple observational clues for nurses, APs or primary care clinicians completing an initial assessment, prompting further assessment for gait and balance, bradykinesia, rigidity and tremor.
Observation of gait pattern in Parkinson's patients is one of the most specific identifiers presenting as shortened stride length with a narrow base, often festinating and with freezing moments as the disease progresses (Carvajal-Castaño et al, 2022) as was present with Mrs A. Presence of gait asymmetry can be indicative of Parkinson's, so noting heel strike, arm swing and stride length discrepancies is important (Yenisetti, 2018) for clinicians. Depending on patient ability, using an outcome measure, such as the Timed Up and Go test (TUG), can provide the required observations and provide a repeatable measure to monitor gait in the future (Fujii et al, 2022). Mrs A completed a TUG in 26 seconds with altered gait, indicating bradykinesia and reduced balance (Moore and Cunnigham, 2021).
Fernandez et al, (2021) have recommended completing a comprehensive balance assessment in conjunction with gait, for example the Berg balance test, which can help to identify high falls risk patients who may need onward referral to other therapies (NICE, 2013). Mrs A was unable to complete a Berg assessment due to fatigue and knee pain; hence a Tinetti test was completed with the gait section analysis incorporated from the TUG, found by Park (2018) to improve falls risk identification when used in conjunction with the TUG.
According to Moore and Cunnigham (2021), bradykinesia can be denoted by any changes in speed, regularity or amplitude of movement during assessment. Yenisetti (2018) has explained that bradykinesia can be deemed present with a reduction in any of these three elements over the course of the repetitions. As was assessed with Mrs A, presence of asymmetrical symptoms increases the likelihood of Parkinson's (Bloem et al, 2021).
Fernandez et al, (2021) found rigidity in early motor-symptom Parkinson's patients to be very subtle. Full assessment (Table 2), with activation movements maximises identification of any minimal rigidity present (Moore and Cunnigham, 2021), as was found with Mrs A.
| Assessment | Steps |
|---|---|
| Bradykinesia assessment | Request the patient complete 10 repetitions of rapid gross movements, tapping forefinger to thumb, opening and closing fists and alternating full supination and pronation. These movements are to be completed with one hand at a time and the assessor is to note any changes in speed, regularity or amplitude of movement (Moore and Cunnigham, 2021). Fernandez et al (2021) suggest using toe tapping if unable to assess arms due to pain, amputation or arthritic changes |
| Rigidity assessment | To assess rigidity, support the patient's fully relaxed arm and complete passive wrist rotation or elbow flexion/extension; an increased resistance to movement indicates the presence of rigidity. However, as this may be extremely subtle, asking the patient to complete an activation movement of tapping their other hand against their thigh in a large amplitude movement, while repeating the passive movements can help to identify any minimal rigidity present (Fernandez et al, 2021) |
| Tremor assessment | Possibly the most well-known symptom of Parkinson's Disease is a resting tremor. Fernandez et al (2021) have highlighted the focal difference of a Parkinsonian tremor in that it is present at rest but subsides or disappears with movement and it is usually more prevalent on one side. In contrast, Hilton and Shivane (2021) explain an essential tremor is likely to be unchanged, or even worsen with activity, and is likely to present bilaterally. Having observed for tremor with hands held out in front of patient, ask the patient to complete finger to nose test in a slow, controlled movement ensuring full elbow extension, one arm at a time, allowing the clinician to observe whether the tremor is present throughout movement or only at rest, providing a valuable insight towards diagnosis (Moore and Cunnigham, 2021). |
The final common indicator of Parkinson's is a resting tremor (Balestrino and Schapira, 2020; Bloem et al, 2021; Hilton and Shivane, 2021). Although all these authors recognise that tremor is lacking in up to 30% of patients, as with Mrs A, Fernandez et al, (2021) found assessment, identifying asymmetry and effect of movement on tremor to be effective in differentiating essential tremor from resting tremor and more indicative of Parkinson's.
The extended, expert role of APs across settings provides the underpinning knowledge required to complete pertinent history taking, the assessments for bradykinesia, rigidity and tremor, along with the higher level of complex, autonomous clinical decision-making (Health Education England, 2023) required to correlate the possible pattern of motor and non-motor symptoms indicative of Parkinson's and signposting onward referral.
Referral
It is essential that APs and nurses within primary care in the UK are aware that NICE (2017) has recommended that the presence of tremor, rigidity or gait disturbance, in combination with bradykinesia, is indicative of Parkinson's and requires clinicians to complete onward referral to specialist centres for diagnosis and management. After initial assessment, the possibility of symptoms being caused by Parkinson's was discussed with Mrs A and her family. Options were given of onward referral to specialists for further assessment or to continue at home with input from primary care services without Parkinson's clinic input. The benefits of formal diagnosis, such as access to services, improvement to quality of life, reducing risk of falls and improved symptom management were outlined verbally and provided in a letter following the appointment. NICE (2019) has emphasised the benefit of using electronic systems to share patient information across nursing, primary and secondary services to provide timely multidisciplinary care. Once considered, Mrs A consented to an electronic referral to Parkinson's clinic, with a version uploaded to System One for access by all primary and secondary care providers with consent.
Differential diagnoses
The current consensus of evidence by Armstong and Okun (2020) has defined diagnosis of Parkinson's as an improvement of motor symptoms with dopaminergic drug therapy. However, there are other dopamine reducing neuro-degenerative diseases to consider, which are caused by protein malfunction and accumulation. These include: multiple systems atrophy; progressive supranuclear palsy; and cortico-basal degeneration (Hilton and Shivane, 2021). In line with NICE guidelines (2017), Armstrong and Okun (2020) have agreed that all types of brain imaging are only relevant if attempting to differentiate between Parkinson's and progressive supranuclear palsy, multiple systems atrophy or cortico-basal degeneration, where functional magnetic resonance imaging can be effective.
Due to having such similar pathophysiological causes, multiple systems atrophy, progressive supranuclear palsy and cortico-basal degeneration often present in a very similar manner to Parkinson's. According to Hilton and Shivane (2021), the main distinction between multiple systems atrophy and Parkinson's is the rapidity of deterioration. Multiple systems atrophy patients sometimes have an initial positive response to levodopa which rapidly nullifies. Multiple systems atrophy patients also tend to present exacerbated speech and swallowing difficulties more rapidly compared to Parkinson's patients (Veronese et al, 2015). This was not present in Mrs A.
Cortico-basal degeneration and progressive supranuclear palsy are caused by changes to Tau proteins, often affecting brain stem function along with other areas of the brain (Hilton and Shivane, 2021). Mazzucchi et al, (2022) theorised that although progressive supranuclear palsy and cortico-basal degeneration patients present with Parkinson's symptoms when Tau proteins interrupt substantia nigra processes, progressive supranuclear palsy patients additionally present with changes to eye movement and control and personality changes with emotional lability. Cortico-basal degeneration patients present with dysphagia and dysphasia; none of which are common to Parkinson's patients.
Additionally, Mazzucchi et al (2022) show that patients with multiple systems atrophy, progressive supranuclear palsy and cortico-basal degeneration all have a far more rapid deterioration than those with Parkinson's, with life expectancy of 3-5 years from onset of motor symptoms, compared to over a decade for Parkinson's. Considering this, Mrs A presented with NMS spanning 5 years, with motor symptom onset in the last 9-12 months, making diagnosis of progressive supranuclear palsy, cortico-basal degeneration or multiple systems atrophy less likely.
Another consideration for primary care and nurses on initial assessment is Secondary Parkinson's or Parkinsonism, where dopamine-producing cells are inhibited or have died due to drug use, most commonly neuroleptics (Shin and Chung, 2012, NICE, 2021), having an almost identical presentation of Parkinson's motor symptoms. Mrs A did not report any mental health diagnosis and her drug history does not identify any antipsychotics, making this an unlikely symptom cause. In addition, there is minimal disease progression in Parkinsonism (Bloem et al, 2021), and symptoms are often unresponsive to dopamine therapies, unlike Parkinson's (Balestrino and Schapira, 2020). Single photon emission computed tomography is indicated as a diagnostic test for essential tremor or Parkinsonism, where levodopa trial has been inconclusive (NICE, 2017).
Falls
The final differential diagnosis for this case study for consideration by primary care clinicians would be a general loss of balance and sarcopenia due to ageing and co-morbidity. Fernandez et al, (2019) found a strong correlation between age-related changes to attention and concentration, and high incidence of falls. Heinimann and Kressig (2014) further showed that these changes to multitask performances, in combination with general sarcopenia due to age-related protein metabolism changes, result in altered gait pattern, impaired balance and an increased risk of falls. In addition, Kováčiková et al, (2021) demonstrated that women display an increased falls risk compared to men in all age groups, and this discrepancy increases with age, linking with Mrs A's presentation. However, Kováčiková et al, (2021) found that falls in the elderly are primarily forward and secondly, to the dominant side. This was further corroborated by Bartosch et al (2020). Mrs A reported repeated backwards falling, which has been noted by Papa et al, (2021) as a classical component in Parkinson's patients due to postural stiffening with bradykinesia. Consequently, in combination with the discussed altered gait pattern, tremor, rigidity and NMS found during assessment, although age and sarcopenia with reduced social activity is likely to have contributed to multifactorial falls, it is unlikely to be the definitive cause.
Consideration for palliative care
Once Parkinson's has been diagnosed, its management, although sometimes spanning decades, is considered palliative, as there is no definitive cure. As such NICE (2017) recommend referral on to palliative care teams and ensuring patient and carer discussions around advanced decision-making at any point from diagnosis (NICE, 2019, NICE, 2021); which can be implemented and managed by nurses and primary care professionals alongside specialist services. Although a small cohort study, Kennedy et al (2015) highlighted benefits to patients and multidisciplinary teams that the fluidity of role available to APs can provide within palliative care settings; allowing practitioners to traverse both medical and nursing or allied health professional issues. George (2016) corroborated these findings with APs in the US improving quality of life and pain management when present in end-of-life care.
In addition, Fernandes et al (2022) found patient's mental health, self-worth, finances and quality of life are significantly improved with perceived good communication with health professionals across primary and secondary care; highlighting continual need to provide verbal and non-verbal sources of information for patients (NICE, 2021).
Treatment
There have been significant advances in management of motor and NMS and patients now have three main routes of improving their quality of life: pharmacological, therapeutic and deep brain stimulation (NICE, 2017; Balestrino and Schapiro, 2020).
To best manage early motor symptoms impacting quality of life, NICE (2017) recommended the prescription of levodopa, which Mrs A commenced following Parkinson's clinic assessment. The NICE (2023) highlights the risk of interactions between levodopa and 206 other medications, the majority of which may result in hypotension. This, with the prevalence of neurogenic orthostatic hypotension and falls in Parkinson's (Bartosch et al, 2020), is particularly important for nurses and primary care prescribing clinicians to have an awareness of.
An additional consideration in optimising levodopa prescription is the ’wearing-off‘ effect, where levodopa is rapidly processed by the brain, resulting in fluctuating motor symptoms dependant on timing of medications. This common issue is found to be of particular significance when a patient is out of their normal routine. The majority of evidence base emphasises the need to encourage independent management of Parkinson's medications in all settings where possible (Extebarria et al, 2021). Conversely a study within UK hospitals by Skelly et al, (2017) showed that 39% of levodopa doses were delayed by 30 minutes with no change to length of stay. Consequently, although it is best practise for patients, nurse and clinicians to ensure timely medication across settings, it may not significantly affect function as previously thought.
Segura-Agulia (2021) and NICE (2017) have found that dopaminergic therapies significantly increase the risk of patients developing impulse control disorders. There is charitable and NHS support available for patients who develop impulse control issues and healthcare professionals are advised by NICE (2017) to discuss risk factors and regularly review any changes in behaviour with the patient and their family. Faouzi et al, (2021) found the most effective impulse control management is a combination of altering dopaminergic medication with cognitive behavioural therapy, reinforcing NICE guidelines (NICE, 2017).
NICE (2017) move on to recommend prescription of either dopamine agonists, monoamine oxidase B inhibitors or Catechol-O-methyl transferase inhibitors as an adjunct to levodopa when patients' motor symptoms persist despite optimised levodopa regime, which primary care and nurses may be best placed to recognise due to increased patient contacts; all changes to Parkinson's medications are recommended to be completed by specialist services or clinics. NICE (2016) along with Lennaerts et al (2017) have highlighted the established benefit of APs (usually nurses) within Parkinson's services with a view to co-ordinate care, monitor medication adherence, manage non-motor symptoms and implement holistic care.
NMS treatments in Parkinson's patients are recommended by NICE (2017), as in the general population, with referral on to specialist services, teams and medication as indicated. In many settings this may be where the role of APs is most required. APs have a background understanding of Parkinson's, common non-motor symptoms, disease progression and medication management; they will inform holistic consideration of diagnosis and treatment options in primary and secondary care settings when encountered outside of Parkinson's clinics.
Importance of therapeutic input
A variety of therapeutic input has been found to be beneficial as an adjunct to pharmacological treatments for both motor and NMS (Fernandes et al, 2022). NICE (2017) have advocated referrals on to specialist Parkinson's nurses, physiotherapists, occupational therapists, speech and language therapists, and dieticians throughout the course of the progression of Parkinson's, as needed. Recent research by Fleisher et al, (2022) demonstrated an improved quality of life for patients, alongside improved pain management, with an interdisciplinary team approach, particularly when able to provide services in the home environment. This has also been recommended by NICE (2019). Stewart-Lord et al (2022) highlighted the developing role that APs from Allied Health Professional backgrounds can add to therapeutic services, facilitating prompter input and refining patient journeys. Mrs A continued with community physiotherapy input for mobility, strength, equipment and fall prevention, and reported improved confidence and quality of life.
Deep brain stimulation
The final management option, and only recommended surgical option for Parkinson's is deep brain stimulation (DBS) (Box 1). Despite its invasive application, alongside cost considerations, DBS is recommended for patients of any age where dopaminergic medications are no longer effective in controlling motor symptoms (Anderson and The Society of Innovative Neuroscience in Neurosurgery, 2019). Unfortunately, as with all Parkinson's management options, DBS is not curative and patients will eventually deteriorate to require palliative care.
DEEP BRAIN STIMULATION PROCESS
The surgery involves implanting two thin wires into brain structures, usually the subthalamic nucleus and globus pallidus pars interna, which connect to a subdermal device, commonly placed in the abdomen (Segura-Aguilar, 2021) Following healing from surgery, Anderson and The Society of Innovative Neuroscience in Neurosurgery (2019) have explained that an electrical stimulation is sent to the linked brain structures and the patients' therapies are slowly altered to become more stimulus-dependent and less medication-dependent Stimulus levels can be adjusted electronically externally, depending on presentation of motor symptoms.
Role of advanced practitioners
Globally, the role of APs varies greatly, with even ’across-country variations‘ (Maier and Aiken, 2016) affecting expectation of assessment, clinical knowledge and competency surrounding Parkinson's. There is a consensus within the literature (Maier, 2015; Maier and Aiken, 2016; Egerod et al, 2021) that task-shifting of more complex patients from medics to APs is an increasing norm; consequently, there is an increased likelihood that APs will provide initial contact for those presenting with Parkinson's symptoms prior to diagnosis, as with Mrs A, or will be managing co-morbidities or non-motor symptoms.
With an increased proportion of APs from an Allied Health Professional background (Stewart-Lord et al, 2020), rather than nursing, there is an increased variance in skill set. Therefore, having a standardised expectation from training and practice, for example, the four pillars of practice within the UK (Health Education England, 2023) or the European competencies proposed by Endacott et al (2022), will allow parity of care for patients.
Understanding the role of APs locally will inform best practice within that area; however, recognising global norms of practice will aid progression and deliver high standards of care for Parkinson's patients. In the UK, the NICE guidelines (2017) has provided a comprehensive policy supporting detection, diagnosis and varied treatment options; Koponen et al (2022) and Pringsheim et al (2021), on the other hand, have highlighted the lack of Parkinson's guidelines across Australia and the US, respectively, where drug treatment is the focal provision (Pringsheim et al, 2021); rather than providing a robust pathway for clinicians to consider.
In conjunction with clinical knowledge and skills, Greenwood (2019) and Hill (2017) both found that within the primary and community care settings APs have more patient time allocation than doctors, allowing holistic practice and so, are well placed to identify the complex range of motor and non-motor symptoms present prior to Parkinson's diagnosis. Htay and Whitehead (2021) comprehensively demonstrated the role of APs across primary and secondary care; they noted that they provide a positive impact in relation to holistic patient care and long-term condition management, which is essential for Parkinson's patients.
Conclusion
Overall, the ability of APs, nurses and primary care clinicians to identify prodromal NMS within a subjective assessment, possibly prior to motor symptoms, may aid an early indication of imminent Parkinson's risk. However, with current diagnostic differentials this is of limited benefit to patients. Once motor symptoms present, as with Mrs A, clinical assessment to identify defining features of Parkinson's allows early referral by nursing and primary care staff into specialist services, facilitating differential diagnosis between Parkinson's and other dopamine reducing neuro-degenerative diseases such as: multiple systems atrophy; progressive supranuclear palsy; and cortico-basal degeneration. As demonstrated with Mrs A, clear communication between services, patients and caregivers are instrumental in maximising and managing quality of life through therapeutic, pharmacological and palliative care for the span of this degenerative disease.