St Helens and Knowsley Hospital (nhs) Trust Movement Disorder Service for Older People Referral Form

St Helens and Knowsley Hospital (NHS) Trust

Movement Disorder Service for Older People – Referral Form

To make a referral, please fax to 0151 430 1142

Telephone contact number 0151 430 1868

Referrer’s Details
Referring GP
GP address & postcode
GP Tel. No.
GP Fax. No.
Date seen by GP:
Date of referral:

Patient Details
Title & surname			Forename(s)
D.O.B.			Age:	Male □ Female □
Address
Postcode		Hospital No.
Tel. No. (day)		Tel No. (evening)
Mobile No.

Referral Information
Patient has movement disorder: Yes □ No □
Tremor □	Rigidity □	Bradykinesia □	Falls □
Do you suspect: Parkinson’s disease (see page 2)□ Essential Tremor □ Other □
Have you commenced medication: Yes □ No □				Date:
Medication (dose/frequency):

United Kingdom Parkinson's Disease Society brain bank diagnostic criteria for Parkinson’s disease Step 1: Diagnosis of Parkinsonism

Bradykinesia and at least one of the following: • Muscular rigidity • 4–6 Hz resting tremor • postural instability not caused by primary visual, vestibular, cerebellar or Proprioceptive dysfunction

Step 2: Features tending to exclude Parkinson’s disease as the cause of Parkinsonism

• History of repeated strokes with stepwise progression of parkinsonian features • History of repeated head injury • History of definite encephalitis • Neuroleptic treatment at onset of symptoms • >1 affected relatives • Sustained remission • Strictly unilateral features after 3 years • Supranuclear gaze palsy • Cerebellar signs • Early severe autonomic involvement • Early severe dementia with disturbances of memory, language and praxis • Babinski's sign • Presence of a cerebral tumour or communicating hydrocephalus on computed tomography scan • Negative response to large doses of levodopa (if malabsorption excluded) • MPTP exposure

Step 3: Features that support a diagnosis of Parkinson’s disease (three or more required for diagnosis of definite Parkinson’s disease)

• Unilateral onset • Rest tremor present • Progressive disorder • Persistent asymmetry affecting the side of onset most • Excellent (70–100%) response to levodopa • Severe levodopa-induced chorea • Levodopa response for ≥5 years • Clinical course of ≥10 years

NICE (2006)

Parkinson Disease: National Clinical Guidelines for diagnosis and management in primary and secondary care
3.1 Key priorities for implementation

• 
  Referral to expert for accurate diagnosis
  

People with suspected PD should be referred quickly* and untreated to a specialist with

expertise in the differential diagnosis of this condition.

• 
  Diagnosis and expert review
  

The diagnosis of PD should be reviewed regularly** and reconsidered if atypical clinical features develop.

*The GDG considered that people with suspected mild PD should be seen within 6 weeks but new referrals in later disease with more complex problems require an appointment within 2 weeks.

**The GDG considered that people diagnosed with PD should be seen at regular intervals of 6 to 12 months to review their diagnosis.

3.3 Parkinson’s disease algorithm
Disease progression

Diagnosis and early disease

Later disease

Throughout disease

Refer untreated to a specialist who makes and reviews diagnosis:

• 
  use UK PDS Brain Bank Criteria
  
• 
  consider ¹²³ I-FP-CIT SPECT
  
• 
  specialist should review diagnosis at regular intervals (6-12 months)
  

Consider management of non-motor symptoms in particular:

• 
  depression
  
• 
  psychosis
  
• 
  dementia
  
• 
  sleep disturbance
  

It is not possible to identify a universal first choice adjuvant drug therapy for people with later PD. The choice of drug prescribed should take into account:

• 
  clinical and lifestyle characteristics
  
• 
  patient preference
  

It is not possible to identify a universal first choice drug therapy for people with early PD. The Choice of drug first prescribed should take into account:

• 
  clinical and lifestyle characteristics
  
• 
  patient preference
  

Provide regular access to specialist care particularly for:

• 
  clinical monitoring and medication adjustment
  
• 
  a continuing point of contact for support, including home visits when appropriate,
  

which may be provided by a Parkinson’s disease nurse specialist

Consider access to rehabilitation therapies, particularly to:

• 
  maintain independence, including activities of daily living and ensure home safety
  
• 
  help balance, flexibility, gait, movement initiation
  
• 
  enhance aerobic activity
  
• 
  assess and manage communication and swallowing
  

Consider Apomorphine in people with severe motor complications unresponsive to oral mediation:

• 
  intermittent injections to reduce off time
  
• 
  continuous subcutaneous infusion to reduce off time and dyskinesia
  

Consider surgery:

• 
  bilateral STN stimulation for suitable people refractory to best medical therapy
  
• 
  thalamic stimulation for people with severe tremor for whom STN stimulation is unsuitable
  

Interventions

Communication

Reach collaborative care decisions by taking into account :

• 
  patient preference and choice after provision of information
  
• 
  clinical characteristics, patient lifestyle and interventions available
  

Provide communication and information about:

• 
  PD services and entitlements
  
• 
  falls, palliative care and end-of-life issues
  
•