The purpose of this visit should be to address if symptoms have worsened or if new symptoms have developed (especially non-motor symptoms) and to assess the need for changes in treatment (pharmacological and non-pharmacological).
What You Should Ask Your Patients During This Visit
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Ask about motor symptoms. Has the patient noticed improvement or worsening? Are there any motor fluctuations? Ask about falls. Dyskinesia is a symptom secondary to levodopa, so it is important to assess presence or absence and impact on ADLs.
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Ask questions that address non-motor symptoms– pain, fatigue, drooling, cognitive impairment, depression, anxiety, psychosis, sleep disturbances, constipation, dysphagia, sexual dysfunction, urinary problems, and orthostatic hypotension.
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Parkinson's patients have a higher risk of developing melanoma; therefore, you should ask about changes in moles.
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Inquire about patient’s medications. Is patient tolerating his or her medications? Has another provider prescribed additional medication? Did patient try a medication and then suspend it?
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Ask about hospitalizations since their last visit. Falls and pneumonia are common causes of hospitalizations in PD patients.
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Ask about therapy, including physical, occupational, and speech therapy. Is it working? What are the barriers to attending therapy sessions?
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Exercise is very important for PD patients– inquire about exercise regimen in your patient.
Medical Examination
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You may not need to conduct a thorough medical examination, but you must remember that you are confirming the diagnosis in every visit, so a good motor and neurological examination is important.
See “Physical Examination” for more details about the medical examination.
Tests
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There is no test (blood, urine, or scan/MRI) to diagnose or monitor progression of PD.
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The use of MRI and SPECT (DaTSCANi) may help you rule out other conditions if there is sudden deterioration. The MRI and SPECT should not be performed as routine follow-up tests.
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Acute levodopa and apomorphine challenge should not be used to diagnose PD.
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If your patient is taking clozapine for visual hallucinations or psychosis, remember that this medication can cause agranulocytosis, so you may want to order a white blood cell count; WBC/ANC monitoring should also be conducted.
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The Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) are validated tests of cognition in PD.
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The Multi-dimensional Caregiver Strain Scale Index (MCSI) addresses caregiver burden. Whether or not you use this instrument to assess caregiver burden, it is important to address the health and well-being of the caregiver, especially if the caregiver's spouse has moderate to advanced PD.
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The Timed Up & Go test (TUG) measures, in seconds, the time taken by an individual to stand up from a standard arm chair, walk a distance of 3 meters, turn, walk back to the chair, and sit down. Older adults who take longer than 14 seconds to complete the TUG have a high risk for falls.
See “Diagnostic Tests” for additional information.
See “Symptoms” for more details on other symptoms.
Treatment
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Treatment should be tailored to each patient based on individual needs and preferences.
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Available drugs only treat symptoms.
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If you have not started treatment and you consider that you need to do so during this visit, consider starting with a carbidopa/levodopa or a dopamine agonist (pramipexole, ropinirole).
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In general, it is recommended that you start with a dopamine agonist if your patient is younger than 50 years; you should consider starting with carbidopa/levodopa if your patient is older than 70 years; either option is good if your patient is between 50 and 70 years.
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If your patient has been taking carbidopa/levodopa for a long time, remember that he or she may develop dyskinesias weeks or even months into therapy.
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There are no medications available that definitively slow down the progression of PD, although selegiline and rasagiline may have some effect in this regard (controversial to date).
See “Treatments” for more details on medications and alternative considerations in the treatment of your patient.
Referrals
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Your patient should be under treatment of a neurologist or movement disorder specialist. If not, you should refer your patient to one at this visit.
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Consider referrals to the following specialties, if you have not done so:
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Physical therapy—to help with exercise regimens, gait, balance
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Occupational therapy—to help with ADLs
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Speech therapy—to help with hypophonia or dysphagia
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Neuropsychology—if there is suspicion of mild cognitive impairment or dementia
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Nutrition
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Parkinson's patients have a higher risk of melanoma (perhaps 2-4 times the general population). Regular assessment by a dermatologist is recommended.
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Your PD patient may benefit from counseling/social work–consider a referral, if appropriate.
See “Referrals” for other expert opinion that should be considered.
Code for PD
ICD-9 code: 332 Parkinson’s disease
ICD-9 code: 332.1 Secondary parkinsonism
ICD-9 code: 333 Other extrapyramidal disease and abnormal movement disorders
Billing Codes
99211-99215 Established patient
99354 Prolonged services (30–74 minutes)
99355 Additional 30 minutes
See “Billing and Coding in PD” for more details on billing and coding.
