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

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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




Male □ Female □



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 □


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:

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:

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



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

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