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neuro.parkinson.v1PRODUCTION
neuro.parkinson.v1

Parkinson Disease (outpatient + chronic)

neurologychronicadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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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)

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MDS clinical criteria met — proceed to phenotype assignment

Patient inputs (19)

Mean age of onset ~60; <50 = young-onset PD; <40 = early-onset (consider monogenic — LRRK2, GBA, parkin) (MDS 2015)

Rest tremor is MDS 2015 supportive criterion; absent = re-evaluate phenotype (akinetic-rigid)

Lying-standing BP — severe OH (drop >30/15 within 3 min) early = red flag for MSA; mild OH is common in advanced PD

Recent (within 6 mo) dopamine-blocker exposure (haloperidol / risperidone / metoclopramide / prochlorperazine / valproate) = drug-induced parkinsonism mimic (MDS 2015 absolute exclusion if current)

Asymmetric onset is MDS 2015 supportive criterion; symmetric onset = red flag for atypical parkinsonism

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

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

Insidious (months-years) onset distinguishes PD from vascular parkinsonism or stroke (sudden) (MDS 2015 Postuma PMID 26474316)

Definite + sustained levodopa response (≥30% improvement) is MDS 2015 supportive criterion 1; lack of response = red flag for MSA/PSP/CBD

Existing carbidopa-levodopa / DA / MAO-B / COMT / amantadine regimen drives wearing-off / dyskinesia / OH management

Rule out vascular parkinsonism, NPH, hydrocephalus, tumor; hot-cross-bun sign → MSA-C; midbrain atrophy "hummingbird" → PSP

DaTscan distinguishes degenerative parkinsonism from essential tremor / drug-induced (presynaptic dopamine transporter loss); MDS 2015 supportive

Exclude thyroid dysfunction as tremor / cognitive mimic

B12 deficiency mimics dementia component; long-term levodopa associated with hyperhomocysteinemia (consider supplementation)

Impulse-control disorder (gambling, hypersexuality, compulsive shopping/eating) on dopamine agonists — screen at every visit; QUIP-RS scale

Wearing-off + dyskinesias mark advanced PD — drives extended-release / DBS / apomorphine decisions (MD 2021 review PMID 30673543)

MoCA <26 with PD ≥1 y after motor onset → PD dementia per MDS criteria; rivastigmine indication (EXPRESS PMID 15590953)

FOG questionnaire; severe FOG → consider DBS, amantadine ER, methylphenidate (off-label)

Visual hallucinations + delusions → PD psychosis; first-line pimavanserin (Cummings NEJM 2014 PMID 24183563); AVOID haloperidol / risperidone / olanzapine

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Severity triggers (16)

16 need judgement
  • informationalseverepigd_phenotype_high_fall_risk
    PIGD phenotype — postural instability + gait disorder + freezing predominant; high fall risk; consider PSP if falls within 3 y of onset
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremsa_suspected_early_severe_oh
    MSA suspected — early (within 5 y of motor onset) severe autonomic failure (OH, urinary retention/incontinence, ED), cerebellar features, pyramidal signs, anterocollis, or poor levodopa response (MDS criteria 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepsp_suspected_early_falls_supranuclear_gaze
    PSP suspected — falls within 3 y of onset + vertical (especially downward) supranuclear gaze palsy + axial rigidity + cognitive/behavioral changes (MDS criteria 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecbd_suspected_asymmetric_apraxia
    CBD suspected — asymmetric apraxia + alien-limb + cortical sensory loss + asymmetric rigidity + myoclonus + poor levodopa response
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereadvanced_pd_motor_fluctuations_dyskinesias
    Advanced PD — wearing-off + dyskinesias + off-time >2 h/day refractory to oral combos; candidate for device-assisted therapy (DBS, LCIG, foslevodopa-foscarbidopa) (MD 2021 review PMID 30673543)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepure_freezing_of_gait_severe
    Severe freezing of gait — on or off; refractory to medication adjustments; high fall risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_orthostatic_hypotension_pd
    Severe OH — drop ≥30/15 within 3 min lying-to-standing with recurrent syncope; if EARLY (<5 y) suspect MSA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepd_dementia_moca_low
    PD dementia — MoCA <26 with PD ≥1 y after motor onset (MDS criteria Emre 2007); rivastigmine indicated (EXPRESS Emre NEJM 2004 PMID 15590953)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredbs_candidate_refractory_motor
    DBS candidate — refractory motor fluctuations + preserved levodopa response + cognition intact + multidisciplinary review (Williams NEJM 2014 PMID 20519680)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateakinetic_rigid_pd
    Akinetic-rigid phenotype — bradykinesia + rigidity without prominent tremor; faster motor + cognitive decline; consider atypical parkinsonism if severe (MDS 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateimpulse_control_disorder_on_da
    Impulse-control disorder on dopamine agonist — gambling / hypersexuality / compulsive shopping / binge eating; QUIP-RS positive
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepd_psychosis_visual_hallucinations
    PD psychosis — visual hallucinations, illusions, delusions (often paranoid); affects 30-50% of advanced PD; AVOID typical antipsychotics (Cummings NEJM 2014 PMID 24183563)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepd_treatment_efficacy_quantified
    Quantified PD treatment-efficacy data: (1) LEVODOPA is the most effective motor drug — LEAP (Verschuur NEJM 2019 PMID 30673543, n=445) showed early vs delayed carbidopa-levodopa UPDRS change −1.0 vs −2.0 pts at 80 wk (diff 1.0, 95% CI −1.5 to 3.5, P=0.44): no disease-modifying effect AND no harm from early start → symptom-driven initiation (do NOT delay levodopa for "neuroprotection"). (2) RIVASTIGMINE for PD-dementia — EXPRESS (Emre NEJM 2004 PMID 15590953, n=541): ADAS-cog +2.1 vs −0.7 placebo (P<0.001), ADCS-CGIC improvement 19.8% vs 14.5%; adverse nausea 29% / vomiting 16.6% / tremor 10.2% (vs placebo) → patch lowers GI burden. (3) PIMAVANSERIN for PD psychosis — Cummings Lancet 2014 PMID 24183563 (n=199): SAPS-PD −5.79 vs −2.73 (diff −3.06, P=0.001, Cohen d 0.50), no motor worsening. (4) DBS — Follett NEJM 2010 PMID 20519680 (n=299): STN vs GPi motor-UPDRS-III change EQUIVALENT (P=0.50); STN lower dopaminergic dose (P=0.02) but worse visuomotor processing (P=0.03) + worse mood (P=0.02) → GPi when cognition/mood is a concern. (5) RASAGILINE — ADAGIO (Olanow NEJM 2009 PMID 19776408, n=1176): 1 mg met all 3 disease-modification endpoints but 2 mg did NOT → claim NOT robust; symptomatic MAO-Bi only.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepd_special_population_data
    Special-population PD data. ELDERLY: start-low-go-slow carbidopa-levodopa (LEAP confirms no penalty for levodopa-first); AVOID anticholinergics (trihexyphenidyl/benztropine — Beers: cognitive impairment + falls); dopamine agonists carry ICD + visual-hallucination + sleep-attack + orthostatic-hypotension risk → prefer levodopa-first in older/cognitively-frail patients (STOPP). DLB / NEUROLEPTIC SENSITIVITY: severe (potentially fatal) sensitivity to typical and MOST atypical antipsychotics — ONLY quetiapine / clozapine (or pimavanserin) acceptable; AVOID haloperidol / risperidone / olanzapine / aripiprazole (McKeith DLB 4th consensus PMID 28592453); the "1-year rule" (dementia before/within 1 y of motor onset = DLB, not PD-dementia) drives this gate. RENAL: amantadine renally cleared — reduce/avoid in low eGFR (confusion / livedo reticularis / leg oedema). HEPATIC: MAO-Bi (rasagiline/selegiline) + COMT inhibitor hepatic-metabolism considerations. PREGNANCY: rare in PD (mean onset ~60 y); if it occurs carbidopa-levodopa is the least-data-poor option, dopamine agonists/amantadine generally avoided (data — no RCT anchor, conservative). DEPRESCRIBING/ICD: dopamine-agonist impulse-control disorder is REVERSIBLE on DA dose reduction → cross-taper toward levodopa-based regimen (do NOT up-titrate the DA).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildtremor_dominant_pd
    Tremor-dominant phenotype — prominent unilateral rest tremor (4-6 Hz) with minimal axial / gait features; better long-term motor prognosis (MDS 2015 Postuma PMID 26474316)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpd_bayesian_differential_layer
    §5.5.2 Bayesian differential layer (DEPTH-PASS-2 2026-05-18): the diagnostic discrimination is encoded in prisma/seed/ros-and-ddx/neuro.parkinson.v1.{ros,differentials,finding-lrs}.ts (auto-registered by readdir) — 16 ROS items, 10 differentials with sourced pre-test priors (idiopathic PD 0.69 [Postuma 2018 validation PMID 30145797: 434/626], drug-induced parkinsonism 0.07 [de Germay 2019 PMID 31865063: 2nd most common cause], MSA 0.04, PSP 0.05, CBD 0.02, DLB 0.05, vascular 0.04, essential tremor 0.06, NPH 0.02, Wilson 0.01), and 31 finding×diagnosis LR rows. PD-defining axis carries LR+ ≥15 (MDS clinically-established pattern LR+ ≈ 37 [59.3% PD vs 1.6% non-PD]; sustained excellent levodopa response LR+ ≈ 17; abnormal DaTSCAN LR+ ≈ 14.5 [Perlaki 2016 PMID 27290659 sens 97/spec 93.3]) with the negative side reaching 1/LR− ≈ 16 (adequate-trial levodopa-non-response + normal DaTSCAN). Atypical pivots: MSA early-autonomic-failure LR+ 15 (Gilman PMID 18725592), PSP vertical-gaze-palsy LR+ 20 (Hoglinger PMID 28467028), CBD cortical-sensory/alien-limb LR+ 18 (Armstrong PMID 23359374), ET normal-DaTSCAN LR+ 30. 4 conditional-dependency notes (levodopa-response | adequate dose+duration; rest-vs-action single tremor axis; DaTSCAN does NOT separate PD from MSA/PSP/CBD; RBD scored once at synucleinopathy-class level). Cross-dossier routing (verified on disk): symptom.falls.v1, neuro.vascular-dementia.v1, neuro.alzheimer.v1.
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

PD motor management — symptom-driven start + advanced motor fluctuation strategy (MDS 2015 + LEAP PMID 30673543)
axis: pd_chronic_motor_managementstep 1 - Step 1 — Symptomatic start (motor symptoms impair function); LEAP supports start-when-needed strategy (Mendis NEJM 2019 PMID 30673543)
Selected step "Step 1 — Symptomatic start (motor symptoms impair function); LEAP supports start-when-needed strategy (Mendis NEJM 2019 PMID 30673543)" — Motor symptoms impair work / ADLs / safety; functional impact > 6 mo expected
  • carbidopa-levodopa
    first line
    dopamine_precursor_combo
    25/100 mg PO ½ tab TID with meals; titrate to 1-2 tabs TID over 4 wk • PO • TID-QID (max: Highly individualised — typically 600-1500 mg levodopa/day; advanced disease 2000+)
    triggers: motor_symptoms_impair_adl, age_>=65_or_function_first
    Most efficacious motor agent; LEAP (Mendis NEJM 2019) — early start does NOT worsen course; preferred over DA in older or functionally limited patients per MD 2021 review PMID 30673543
    rxcui 103990
  • pramipexole
    first line
    dopamine_agonist_non_ergot
    0.125 mg PO TID; titrate weekly to 0.5-1.5 mg TID • PO • TID (max: 4.5 mg/day)
    triggers: younger_patient, delay_dyskinesia_strategy
    Younger patients may favour DA to delay levodopa-induced dyskinesia; CAUTION — ICD risk (gambling/hypersexuality/binge eating) — screen at every visit (QUIP-RS); also OH + somnolence + sleep attacks driving risk
    rxcui 236747
  • ropinirole
    first line
    dopamine_agonist_non_ergot
    0.25 mg PO TID; titrate weekly to 1-8 mg TID • PO • TID (max: 24 mg/day)
    triggers: younger_patient, pramipexole_intolerance
    Alternative non-ergot DA; same ICD/somnolence cautions
    rxcui 236553

outpatient playbook — drug actions (10)

  1. 1. carbidopa-levodopa
    Symptom-driven start 25/100 ½-1 tab TID; titrate • PO • TID-QID; advanced 5-6 doses/d
    trigger: Motor symptoms impair function
    LEAP PMID 30673543 — most efficacious; no harm with early start
  2. 2. pramipexole / ropinirole
    Pramipexole 0.125 mg TID titrate; ropinirole 0.25 mg TID titrate • PO • TID
    trigger: Younger patient; delay dyskinesia strategy
    Less dyskinesia long-term; ICD + somnolence cautions
  3. 3. rasagiline 1 mg daily
    1 mg PO daily • PO • daily
    trigger: Early monotherapy or wearing-off adjunct
    ADAGIO PMID 19776408; symptomatic
  4. 4. amantadine ER 137-274 mg HS
    137-274 mg PO HS • PO • HS
    trigger: Levodopa-induced dyskinesia
    EASE-LID 1/2 reduces dyskinesia ~50%
  5. 5. pimavanserin 34 mg daily
    34 mg PO daily • PO • daily
    trigger: PD psychosis (visual hallucinations + delusions)
    Cummings NEJM 2014 PMID 24183563; no D2 blockade
  6. 6. rivastigmine
    3-6 mg BID PO or 4.6-9.5 mg/24h patch • PO or transdermal • BID or patch daily
    trigger: PD dementia (MoCA <26 with PD ≥1 y motor)
    EXPRESS PMID 15590953
  7. 7. sertraline
    25-200 mg PO daily • PO • daily
    trigger: PHQ-9 ≥10
    PD depression first-line; avoid TCA/paroxetine (anticholinergic)
  8. 8. midodrine + fludrocortisone + droxidopa
    Midodrine 2.5-10 TID; fludro 0.1-0.3 daily; droxidopa 100-600 TID • PO • TID + daily + TID
    trigger: Symptomatic OH
    Stepwise OH management; supine HTN risk
  9. 9. melatonin 3-12 mg HS
    3-12 mg PO HS • PO • HS
    trigger: RBD with dream enactment
    Safer than clonazepam in elderly
  10. 10. macrogol PEG 17 g daily
    17 g PO daily • PO • daily
    trigger: Chronic constipation
    60-80% prevalence; precipitates delirium + falls

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unilateral 4-6 Hz rest tremor improving with movement (MDS 2015 Postuma PMID 26474316); Bradykinesia — decrement / fatiguing on repetitive finger/foot tapping (MDS 2015 cardinal feature); Asymmetric cogwheel rigidity (MDS 2015 supportive).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Parkinson Disease (outpatient + chronic)** (neuro.parkinson.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **PD motor management — symptom-driven start + advanced motor fluctuation strategy (MDS 2015 + LEAP PMID 30673543)** — step "Step 1 — Symptomatic start (motor symptoms impair function); LEAP supports start-when-needed strategy (Mendis NEJM 2019 PMID 30673543)".
1. carbidopa-levodopa 25/100 mg PO ½ tab TID with meals; titrate to 1-2 tabs TID over 4 wk PO TID-QID (dopamine_precursor_combo, first line) — Most efficacious motor agent; LEAP (Mendis NEJM 2019) — early start does NOT worsen course; preferred over DA in older or functionally limited patients per MD 2021 review PMID 30673543
2. pramipexole 0.125 mg PO TID; titrate weekly to 0.5-1.5 mg TID PO TID (dopamine_agonist_non_ergot, first line) — Younger patients may favour DA to delay levodopa-induced dyskinesia; CAUTION — ICD risk (gambling/hypersexuality/binge eating) — screen at every visit (QUIP-RS); also OH + somnolence + sleep attacks driving risk
3. ropinirole 0.25 mg PO TID; titrate weekly to 1-8 mg TID PO TID (dopamine_agonist_non_ergot, first line) — Alternative non-ergot DA; same ICD/somnolence cautions

Setting playbook (outpatient) — Primary care setting — comprehensive PD management q3-6 mo: motor + non-motor inventory, med titration, ICD/QUIP screen, MoCA, PHQ-9, OH workup, fall + driving safety, advance directives, caregiver support, DBS candidacy re-evaluation, hospice planning when appropriate
4. carbidopa-levodopa Symptom-driven start 25/100 ½-1 tab TID; titrate PO TID-QID; advanced 5-6 doses/d — Motor symptoms impair function (LEAP PMID 30673543 — most efficacious; no harm with early start)
5. pramipexole / ropinirole Pramipexole 0.125 mg TID titrate; ropinirole 0.25 mg TID titrate PO TID — Younger patient; delay dyskinesia strategy (Less dyskinesia long-term; ICD + somnolence cautions)
6. rasagiline 1 mg daily 1 mg PO daily PO daily — Early monotherapy or wearing-off adjunct (ADAGIO PMID 19776408; symptomatic)
7. amantadine ER 137-274 mg HS 137-274 mg PO HS PO HS — Levodopa-induced dyskinesia (EASE-LID 1/2 reduces dyskinesia ~50%)
8. pimavanserin 34 mg daily 34 mg PO daily PO daily — PD psychosis (visual hallucinations + delusions) (Cummings NEJM 2014 PMID 24183563; no D2 blockade)
9. rivastigmine 3-6 mg BID PO or 4.6-9.5 mg/24h patch PO or transdermal BID or patch daily — PD dementia (MoCA <26 with PD ≥1 y motor) (EXPRESS PMID 15590953)
10. sertraline 25-200 mg PO daily PO daily — PHQ-9 ≥10 (PD depression first-line; avoid TCA/paroxetine (anticholinergic))
11. midodrine + fludrocortisone + droxidopa Midodrine 2.5-10 TID; fludro 0.1-0.3 daily; droxidopa 100-600 TID PO TID + daily + TID — Symptomatic OH (Stepwise OH management; supine HTN risk)
12. melatonin 3-12 mg HS 3-12 mg PO HS PO HS — RBD with dream enactment (Safer than clonazepam in elderly)
13. macrogol PEG 17 g daily 17 g PO daily PO daily — Chronic constipation (60-80% prevalence; precipitates delirium + falls)

Non-pharmacologic actions:
- LSVT-BIG (PT) + LSVT-LOUD (SLP) referral at diagnosis + annually
- Aerobic exercise prescription 150 min/wk moderate intensity (AAN Class I)
- Tai chi + dance + boxing programs (community)
- Cueing strategies for FOG (visual lines, metronome, counting, attentional focus)
- Home safety review (PT/OT)
- Driving evaluation per state + functional decline → driving cessation
- Caregiver education + respite resources
- Support groups (APDA, Michael J. Fox Foundation, Parkinson Foundation)
- Sleep hygiene + sleep study if STOP-BANG ≥3 or RBD severe
- Nutrition counseling (protein redistribution if levodopa absorption issue; high-fiber for constipation)
- Bone health: DEXA at diagnosis + q2 y; vitamin D + calcium; bisphosphonate if osteoporosis
- Annual influenza + pneumococcal + COVID + RSV vaccinations
- DBS candidacy re-evaluation q12-24 mo (Williams NEJM 2014 PMID 20519680)
- Goals of care discussions annually + palliative care integration (MDS palliative care position 2017)
- Hospice referral when Hoehn-Yahr 5 + dementia + bed-bound + recurrent aspiration

AVOID / contraindication checks:
- AVOID_haloperidol_risperidone_olanzapine_in_PD_psychosis (D2 blockade worsens motor; pimavanserin preferred — Cummings NEJM 2014 PMID 24183563)
- AVOID_metoclopramide_prochlorperazine_in_PD (D2 antiemetics worsen motor; use ondansetron or trimethobenzamide)
- NEVER_abrupt_stop_PD_meds (NMS risk — must taper or substitute when NPO; rotigotine patch for NPO)
- DBS_requires_cognitive_screen_and_neuropsych (executive dysfunction or dementia worsens with STN — favor GPi if cognitive concern; Williams NEJM 2014 PMID 20519680)
- Apomorphine_no_5HT3_antagonists (ondansetron/granisetron combo causes severe hypotension; use trimethobenzamide pre med)
- Dopamine_agonist_ICD_screen_every_visit (QUIP RS; counsel patient + family; reduce/discontinue if positive)
- Rasagiline_selegiline_tyramine_meperidine_SSRI_interactions (MAO B caution at higher doses; food tyramine concern less than non selective)
- Droxidopa_midodrine_supine_HTN (counsel HOB elevation; avoid dose ≥4 h before bed)

Monitoring

Regimen monitoring:
- Motor + non-motor inventory q3-6 mo (MDS-UPDRS Parts I-IV)
- Hoehn-Yahr + Schwab-England ADL at every visit
- MoCA annually; sooner if cognitive complaint (rivastigmine threshold PDD)
- PHQ-9 + anxiety screen q6 mo
- QUIP-RS (ICD screen) at every visit if on DA
- Orthostatic BP at every visit (severe OH = MSA red flag)
- Sleep questionnaire (RBD, OSA, EDS) annually
- Driving evaluation per state law + clinician judgment
- CBC q3 mo if on clozapine per REMS
- CK + vitals if recent neuroleptic change → rule out NMS
- B12 + homocysteine annually on long-term levodopa

Setting (outpatient) monitoring:
- Movement disorders clinic q3-6 mo
- Med titration as needed
- Annual neuropsychiatric battery if cognitive change
- Quarterly orthostatic BP if OH
- Quarterly ICD screen (QUIP-RS) if on DA
- Annual PDQ-39 + Hoehn-Yahr

Follow-up plan: 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)
- Close-out criterion: Long-term plan documented + caregiver supported

Monitoring phase: 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

Disposition

Current setting: outpatient — Primary care setting — comprehensive PD management q3-6 mo: motor + non-motor inventory, med titration, ICD/QUIP screen, MoCA, PHQ-9, OH workup, fall + driving safety, advance directives, caregiver support, DBS candidacy re-evaluation, hospice planning when appropriate

Disposition criteria:
- Continue indefinite PD management; transition to palliative/hospice when life-limiting features
- Refer to subspecialty MD clinic if available (movement disorders fellow + neuropsych + PT/OT/SLP + social work)

Escalation triggers (move to higher acuity):
- Acute decompensation (NMS, severe psychosis, aspiration, fall with injury) → ED
- Severe motor fluctuations refractory to oral combos → DBS referral or LCIG / Vyalev
- Severe psychosis refractory to pimavanserin + quetiapine → clozapine consult
- Severe OH with syncope → urgent autonomic workup + droxidopa
- ICD positive (QUIP-RS) → reduce/discontinue DA, switch to levodopa
- Severe RBD with injury → clonazepam carefully or melatonin escalation
- Cognitive decline interfering with function → rivastigmine + driving cessation + caregiver intensification

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] PIGD phenotype — postural instability + gait disorder + freezing predominant; high fall risk; consider PSP if falls within 3 y of onset
- [SEVERE] MSA suspected — early (within 5 y of motor onset) severe autonomic failure (OH, urinary retention/incontinence, ED), cerebellar features, pyramidal signs, anterocollis, or poor levodopa response (MDS criteria 2015)
- [SEVERE] PSP suspected — falls within 3 y of onset + vertical (especially downward) supranuclear gaze palsy + axial rigidity + cognitive/behavioral changes (MDS criteria 2015)

Citations

- 2015 MDS Clinical Diagnostic Criteria for PD (Postuma, Mov Disord 2015;30:1591-601) + MDS prodromal criteria 2015/2019 (Berg/Heinzel) + MDS criteria validation (Postuma 2018) + AAN-aligned therapy landmark RCTs (LEAP, ADAGIO, Follett STN-vs-GPi DBS, EXPRESS rivastigmine, Cummings pimavanserin) + MSA/PSP/DLB/CBD diagnostic-criteria consensus statements [PMID:26474316](https://pubmed.ncbi.nlm.nih.gov/26474316/)
- Cited evidence (PMID 26474317) [PMID:26474317](https://pubmed.ncbi.nlm.nih.gov/26474317/)
- Cited evidence (PMID 31412427) [PMID:31412427](https://pubmed.ncbi.nlm.nih.gov/31412427/)
- Cited evidence (PMID 30145797) [PMID:30145797](https://pubmed.ncbi.nlm.nih.gov/30145797/)
- Cited evidence (PMID 30673543) [PMID:30673543](https://pubmed.ncbi.nlm.nih.gov/30673543/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2015 MDS Clinical Diagnostic Criteria for PD (Postuma, Mov Disord 2015;30:1591-601) + MDS prodromal criteria 2015/2019 (Berg/Heinzel) + MDS criteria validation (Postuma 2018) + AAN-aligned therapy landmark RCTs (LEAP, ADAGIO, Follett STN-vs-GPi DBS, EXPRESS rivastigmine, Cummings pimavanserin) + MSA/PSP/DLB/CBD diagnostic-criteria consensus statements — PMID:26474316
  • Cited evidence (PMID 26474317) — PMID:26474317
  • Cited evidence (PMID 31412427) — PMID:31412427
  • Cited evidence (PMID 30145797) — PMID:30145797
  • Cited evidence (PMID 30673543) — PMID:30673543