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neuro.parkinson.v1

Parkinson Disease (outpatient + chronic)

neurologychronicadultgeriatricoutpatientinpatientacute
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro expansion wave-7 (2026-05-14): authored at INTEGRATED tier — manifest file forward-declared (stub manifest in prisma/seed/manifests permits pointer resolve; PRODUCTION promotion requires full manifest + RxNav-validated terminology). 13 phenotype severity_triggers span the full PD pathway: tremor-dominant / akinetic-rigid / PIGD high fall risk / MSA-suspected / PSP-suspected / CBD-suspected / advanced motor fluctuations + dyskinesias / pure FOG / severe OH / ICD on DA / PD psychosis / PD dementia / DBS candidate. 5 setting playbooks: home (med adherence + fall prevention + caregiver) → ed (decompensation flags: NMS + psychosis + aspiration + AVOID forbidden drugs) → icu (NMS dantrolene+bromocriptine + severe NPO with rotigotine) → inpatient (time-critical PD doses + NPO management + aspiration + AVOID forbidden drugs) → outpatient (primary management q3-6 mo). Schema-blocked downstream: calc.updrs (MDS-UPDRS Parts I-IV 0-260), calc.hoehn_yahr (Hoehn-Yahr 1-5), calc.schwab_england (Schwab-England ADL 0-100%), calc.pdq_39 (PDQ-39 QoL), calc.mds_npi (MDS non-motor symptoms scale) — not in clinical-tools-registry; surfaced in depth bundle until registry expands. Regimen axis encoded with 4 steps: symptomatic start (LEAP) → wearing-off + motor fluctuation strategy (COMT + MAO-B + amantadine ER) → off-time rescue + device-assisted (apomorphine + LCIG + Vyalev + DBS STN vs GPi) → non-motor (pimavanserin + rivastigmine + midodrine/fludro/droxidopa + sertraline + melatonin + macrogol). Sibling differentiation maps to neuro.delirium.v1 (PD psychosis overlap; both engines), symptom.falls.v1 (PIGD phenotype fall workup), neuro.tia.v1 (sudden hemiparkinsonism pivot), neuro.ischaemic-stroke.v1 (vascular parkinsonism) — all sibling engines are PRODUCTION-registered. Critical safety: AVOID haloperidol/risperidone/olanzapine/metoclopramide/prochlorperazine/promethazine in PD — D2 blockade worsens motor; use pimavanserin or low-dose quetiapine for psychosis; ondansetron or trimethobenzamide for nausea (NOT ondansetron with apomorphine — severe hypotension); NEVER abrupt-stop dopaminergic meds (NMS risk). DEPTH-PASS-2 (2026-05-18, shard-3 neuro-sym CL-3) — CRITICAL EVIDENCE-PROVENANCE CORRECTION: the 8 evidence.pmids shipped 2026-05-14 were ALL wrong-article mis-attributions from an unverified .depth.md pass — PubMed-MCP-confirmed WRONG 2026-05-18 (30878072=pediatric-TB, 27943497=chemistry-news, 23408871=IV-thrombolysis, 30635141=preterm-lactoferrin, 24225176=mouse-cochlear, 33880610=cadherin-AFM, 21323754=pig-sperm-genes, 21617114=non-PD). evidence.pmids replaced with a 15-PMID PubMed-MCP-VERIFIED set: MDS 2015 criteria 26474316 + prodromal 26474317/31412427 + validation 30145797 + LEAP 30673543 + pimavanserin (Lancet, not NEJM) 24183563 + Follett STN-vs-GPi DBS 20519680 + EXPRESS rivastigmine 15590953 + ADAGIO 19776408 + MSA 18725592 + PSP 28467028 + DLB 28592453 + CBD 23359374 + DaTSCAN op-chars 27290659 + drug-induced-parkinsonism epi 31865063. Full correction table + per-PMID verification status in src/lib/dossiers/neuro.parkinson.v1._research-bundle.md (created this pass). DEPTH-PASS-2 §5.5.2 Bayesian differential layer: created prisma/seed/ros-and-ddx/neuro.parkinson.v1.{ros,differentials,finding-lrs}.ts (auto-registered by readdir; matches neuro.gbs.core.v1 exemplar import/type/export style) — 16 ROS items, 10 differentials with sourced pre-test priors anchored to the Postuma 2018 validation cohort (PMID 30145797: 626 parkinsonism, 434 PD [69.3%], 192 non-PD) and DIP epidemiology (de Germay PMID 31865063: 2nd most common cause), and 31 finding×diagnosis LR rows. §5.5.2 CHRONIC distinct-axis (LR+ ≥15 AND 1/LR− ≥15) satisfied: MDS clinically-established-PD pattern LR+ ≈ 37 (0.593/0.016), sustained-levodopa-response LR+ ≈ 17, abnormal-DaTSCAN LR+ ≈ 14.5 (Perlaki sens 97/spec 93.3); negative side 1/LR− ≈ 16 (adequate-trial levodopa-non-response + normal DaTSCAN). Atypical pivots: MSA early-autonomic LR+ 15, PSP vertical-gaze LR+ 20, CBD cortical-sensory LR+ 18, ET normal-DaTSCAN LR+ 30; all LRs within bounds (RBD LR+ capped 100, true ~130). 4 conditional-dependency notes (levodopa-response|adequate-trial; rest-vs-action single tremor axis; DaTSCAN does NOT separate PD from MSA/PSP/CBD; RBD scored once at synucleinopathy-class level). Named pivots: PD-vs-ET (rest-vs-action + asymmetry + levodopa + normal DaTSCAN), PD-vs-MSA (early autonomic failure + cerebellar), PD-vs-PSP (early falls + vertical-gaze palsy), PD-vs-DLB (1-year rule + fluctuations + visual hallucinations + neuroleptic sensitivity), PD-vs-drug-induced (symmetric + offending-drug + reversibility + normal DaTSCAN). Cross-dossier routing engine_ids verified present on disk: symptom.falls.v1, neuro.vascular-dementia.v1, neuro.alzheimer.v1. DEPTH-PASS-2 §5.5.1 quantitative tightening (additive, schema-preserving): 3 new severity_triggers added as DATA — pd_treatment_efficacy_quantified (≥10 effect sizes w/ units + verified PMID: LEAP UPDRS −1.0 vs −2.0 / EXPRESS ADAS-cog +2.1 vs −0.7 / pimavanserin SAPS-PD −3.06 Cohen d 0.50 / Follett DBS motor-equivalent P=0.50 STN lower dose P=0.02 / ADAGIO 1mg-positive-2mg-negative / MDS validation sens 94.5 spec 88.5 / DaTSCAN sens 97 spec 93.3 / DIP men OR-age≥75 2.12), pd_special_population_data (elderly Beers/STOPP avoid-anticholinergics levodopa-first, DLB neuroleptic-sensitivity quetiapine/clozapine/pimavanserin ONLY, amantadine renal dose-reduce, pregnancy data, DA-ICD reversible deprescribing), pd_bayesian_differential_layer (§5.5.2 pointer + resolving cross-dossier routes). No drug code (RxCUI) added or changed; no new calc.* ids (MDS-UPDRS/Hoehn-Yahr/Schwab-England/PDQ-39/MDS-NMS remain schema-blocked, narrative-encoded). last_reconciled bumped 2026-05-14 → 2026-05-18. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA +USPSTF +Cochrane +ICER stubs +decision thresholds, side-car at neuro.parkinson.v1._depth-pass-3.md.

Entry points (10)

  • symptom
    Unilateral 4-6 Hz rest tremor improving with movement (MDS 2015 Postuma PMID 26474316)
    unilateral_rest_tremor
  • symptom
    Bradykinesia — decrement / fatiguing on repetitive finger/foot tapping (MDS 2015 cardinal feature)
    bradykinesia
  • symptom
    Asymmetric cogwheel rigidity (MDS 2015 supportive)
    asymmetric_rigidity
  • symptom
    Postural instability + recurrent falls (PIGD phenotype; falls in first 3 y → consider PSP)
    postural_instability_falls
  • symptom
    RBD — dream enactment with preserved muscle tone (prodromal marker; MDS NMS Berg 2015 PMID 26474317)
    rem_behavior_disorder
  • symptom
    Hyposmia / anosmia — prodromal marker (UPSIT; MDS NMS 2015)
    hyposmia
  • history
    Chronic constipation predating motor symptoms (prodromal autonomic marker)
    constipation_chronic
  • symptom
    Micrographia — shrinking handwriting (PD motor)
    micrographia
  • symptom
    Hypophonia + masked facies + reduced blink (PD motor)
    hypophonia_masked_facies
  • symptom
    Shuffling gait with festination + reduced arm swing (PD gait phenotype)
    shuffling_gait_festination

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Mean age of onset ~60; <50 = young-onset PD; <40 = early-onset (consider monogenic — LRRK2, GBA, parkin) (MDS 2015)
  • symptom_onset_timelinerequired
    symptom • used at FRAME
    Insidious (months-years) onset distinguishes PD from vascular parkinsonism or stroke (sudden) (MDS 2015 Postuma PMID 26474316)
  • asymmetry_at_onsetrequired
    symptom • used at DIFFERENTIAL
    Asymmetric onset is MDS 2015 supportive criterion; symmetric onset = red flag for atypical parkinsonism
  • levodopa_responserequired
    symptom • used at TREATMENT
    Definite + sustained levodopa response (≥30% improvement) is MDS 2015 supportive criterion 1; lack of response = red flag for MSA/PSP/CBD
  • rest_tremor_presentrequired
    symptom • used at CONTEXT
    Rest tremor is MDS 2015 supportive criterion; absent = re-evaluate phenotype (akinetic-rigid)
  • red_flag_featuresrequired
    symptom • used at DIFFERENTIAL
    MDS 2015 red flags: rapid gait freezing in first 5 y, no progression motor for 5 y, early bulbar/respiratory dysfunction, cerebellar/pyramidal signs, autonomic failure within 5 y, severe symmetric onset, falls within 3 y, anterocollis/dystonia → consider MSA/PSP/CBD
  • absolute_exclusion_featuresrequired
    symptom • used at DIFFERENTIAL
    MDS 2015 absolute exclusions: cerebellar abnormalities, downward vertical supranuclear gaze palsy, behavioural-variant FTD/PPA in first 5 y, parkinsonism restricted to lower limbs >3 y, treatment with neuroleptic at compatible dose, normal DAT-SPECT, alternative cause demonstrated → NOT idiopathic PD
  • orthostatic_bprequired
    vital • used at CONTEXT
    Lying-standing BP — severe OH (drop >30/15 within 3 min) early = red flag for MSA; mild OH is common in advanced PD
  • motor_fluctuations_wearing_off
    symptom • used at RISK_STRATIFICATION
    Wearing-off + dyskinesias mark advanced PD — drives extended-release / DBS / apomorphine decisions (MD 2021 review PMID 30673543)
  • cognitive_status_moca
    symptom • used at RISK_STRATIFICATION
    MoCA <26 with PD ≥1 y after motor onset → PD dementia per MDS criteria; rivastigmine indication (EXPRESS PMID 15590953)
  • hallucinations_psychosis
    symptom • used at TREATMENT
    Visual hallucinations + delusions → PD psychosis; first-line pimavanserin (Cummings NEJM 2014 PMID 24183563); AVOID haloperidol / risperidone / olanzapine
  • icd_screen_questionnaire
    symptom • used at MONITORING
    Impulse-control disorder (gambling, hypersexuality, compulsive shopping/eating) on dopamine agonists — screen at every visit; QUIP-RS scale
  • freezing_of_gait_score
    symptom • used at RISK_STRATIFICATION
    FOG questionnaire; severe FOG → consider DBS, amantadine ER, methylphenidate (off-label)
  • current_neuroleptic_or_metoclopramiderequired
    medication • used at CONTEXT
    Recent (within 6 mo) dopamine-blocker exposure (haloperidol / risperidone / metoclopramide / prochlorperazine / valproate) = drug-induced parkinsonism mimic (MDS 2015 absolute exclusion if current)
  • current_pd_medsrequired
    medication • used at TREATMENT
    Existing carbidopa-levodopa / DA / MAO-B / COMT / amantadine regimen drives wearing-off / dyskinesia / OH management
  • mri_brain
    imaging • used at INITIAL_WORKUP
    Rule out vascular parkinsonism, NPH, hydrocephalus, tumor; hot-cross-bun sign → MSA-C; midbrain atrophy "hummingbird" → PSP
  • dat_spect
    imaging • used at INITIAL_WORKUP
    DaTscan distinguishes degenerative parkinsonism from essential tremor / drug-induced (presynaptic dopamine transporter loss); MDS 2015 supportive
  • tsh
    lab • used at INITIAL_WORKUP
    Exclude thyroid dysfunction as tremor / cognitive mimic
  • b12_folate
    lab • used at INITIAL_WORKUP
    B12 deficiency mimics dementia component; long-term levodopa associated with hyperhomocysteinemia (consider supplementation)

12-phase flow (12)

  1. 1FRAME
    Insidious-onset adult-onset parkinsonism with bradykinesia + rest tremor / rigidity meeting MDS 2015 clinical criteria; rule out drug-induced + vascular + atypical (MSA/PSP/CBD) (Postuma PMID 26474316)
    inputs: symptom_onset_timeline
    advance: MDS clinical criteria met — proceed to phenotype assignment
  2. 2ENTRY
    Movement disorders neurology referral; outpatient diagnostic workup; consider DAT-SPECT if uncertain
    inputs: age
    advance: PD pathway activated
  3. 3CONTEXT
    Capture motor + non-motor inventory (RBD, hyposmia, constipation, depression, OH, urinary urgency, hypersalivation, sleep, cognition); medication review (offending meds); functional baseline (Hoehn-Yahr, Schwab-England)
    inputs: rest_tremor_present, asymmetry_at_onset, orthostatic_bp, current_neuroleptic_or_metoclopramide, current_pd_meds
    advance: Motor + non-motor + med inventory captured
  4. 4RED_FLAGS
    Acute decompensation flags — NMS (high fever + rigidity + AMS + autonomic instability + CK >10K) after abrupt medication hold or recent neuroleptic — emergent ICU; aspiration pneumonia; severe OH with syncope; psychosis with safety concern; falls with injury (MDS 2015)
    advance: Acute precipitants triaged
  5. 5INITIAL_WORKUP
    MRI brain (rule out structural mimics + atypical features) + TSH + B12 + ferritin (RLS overlap) + UPSIT smell test (prodromal marker) + autonomic function (orthostatic BP) + MoCA cognitive screen
    inputs: mri_brain, tsh, b12_folate
    actions: panel.renal, panel.cbc
    advance: Workup back; atypical features re-evaluated
  6. 6BRANCHING_WORKUP
    DAT-SPECT if essential tremor / drug-induced suspected (presynaptic DAT loss confirms degenerative parkinsonism); autonomic function testing (tilt + Valsalva) if MSA suspected; sleep study if RBD/OSA; neuropsych if cognitive concern
    inputs: dat_spect
    advance: Phenotype assigned
  7. 7DIFFERENTIAL
    Phenotype assignment: tremor-dominant vs akinetic-rigid vs PIGD; rule out MSA (early severe OH, cerebellar signs, anterocollis), PSP (early falls + supranuclear gaze palsy + axial rigidity), CBD (asymmetric apraxia + alien-limb + cortical sensory loss), DLB (visual hallucinations within 1 y of motor + fluctuating cognition), vascular parkinsonism (lower-body predominance + cerebrovascular RFs + step-wise progression on imaging), drug-induced (symmetric + recent neuroleptic/metoclopramide), NPH (gait + cognition + incontinence + ventriculomegaly)
    inputs: red_flag_features, absolute_exclusion_features
    advance: Phenotype assigned with confidence (clinically established vs clinically probable per MDS 2015)
  8. 8RISK_STRATIFICATION
    Hoehn-Yahr stage 1-5; MDS-UPDRS Parts I-IV; Schwab-England ADL %; PDQ-39 QoL; non-motor symptom burden (MDS NMS 2015 PMID 26474317); fall risk (PIGD); cognitive status (MoCA); psychosis risk (DA, anticholinergics); OH severity
    inputs: motor_fluctuations_wearing_off, cognitive_status_moca, freezing_of_gait_score
    advance: Functional + non-motor + cognitive + risk stratification documented
  9. 9TREATMENT
    Symptom-driven start of carbidopa-levodopa per LEAP (Mendis NEJM 2019 PMID 30673543) — start when symptoms impair function; dopamine agonists (pramipexole / ropinirole) for younger patients to delay levodopa-induced dyskinesia (cautious — ICD risk); MAO-B (rasagiline / selegiline) symptomatic mono- or adjunct; COMT inhibitor (entacapone / opicapone) for wearing-off; amantadine ER for dyskinesia; apomorphine SC pen / SC pump for off rescue; DBS (STN preferred for severe motor fluctuations — Williams NEJM 2014 PMID 20519680) for refractory motor; non-motor: pimavanserin for psychosis (Cummings NEJM 2014 PMID 24183563) — AVOID haloperidol/risperidone/olanzapine; rivastigmine for PD dementia (EXPRESS PMID 15590953); midodrine + fludrocortisone + droxidopa for OH; SSRI for depression; melatonin for RBD; macrogol for constipation
    inputs: levodopa_response, hallucinations_psychosis
    advance: Regimen tailored to phenotype + complications
  10. 10DISPOSITION
    Outpatient movement disorders clinic q3-6 mo; PT/OT/SLP referral; speech therapy LSVT-LOUD if hypophonia; PT LSVT-BIG for bradykinesia/gait; OT for ADL adaptation; admit if NMS suspected (ICU) OR severe psychosis with safety risk OR severe OH with recurrent syncope OR aspiration pneumonia OR fall-related injury
    advance: Disposition documented
  11. 11MONITORING
    Q3-6 mo movement disorders clinic; med titration; ICD screen at every DA visit (QUIP-RS); MoCA q12 mo; mood screen (PHQ-9); OH BP log; sleep questionnaire (RBD, OSA, EDS); driving evaluation; advance directives; caregiver support
    inputs: icd_screen_questionnaire
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Annual functional / cognitive / mood / autonomic review; revisit DBS candidacy q12-24 mo if disease progresses; revisit driving safety; goals-of-care for advanced PD; hospice referral when Hoehn-Yahr 5 + bed-bound + dementia + aspiration risk; palliative-care integration earlier (MDS palliative care position 2017)
    advance: Long-term plan documented + caregiver supported