Synopsis
Recognise Parkinsonian syndromes and acute mobility decline, preserve exact time-critical dopaminergic therapy, identify infection, injury, delirium and adverse medicines, and restore transfers, swallowing and community function through specialist multidisciplinary care.
- Parkinsonism requires bradykinesia plus rigidity, rest tremor or postural instability; tremor alone does not establish Parkinson's disease.
- A rapid mobility decline is not usual progression: assess missed doses, infection, constipation, retention, dehydration, pain, injury, stroke, posture and new medicines.
- First-line inpatient safety is exact reconciliation of drug, formulation and individual administration times rather than standard ward-round times.
- Never stop levodopa or other dopaminergic treatment abruptly; missed therapy can cause profound akinesia, aspiration and parkinsonism-hyperpyrexia syndrome.
- If oral swallowing is unsafe, obtain same-day Parkinson's and pharmacy advice for dispersible, enteral, transdermal or infusion bridging based on the established regimen.
- Avoid dopamine-blocking antiemetics and antipsychotics such as metoclopramide, prochlorperazine and haloperidol unless specialist circumstances clearly justify them.
- Assess wearing-off, dyskinesia and freezing against dose and meal timing before interpreting a single corridor examination.
- First-line rehabilitation uses Parkinson's-specific physiotherapy for cueing, amplitude, turning, strength and falls, with OT and speech and language support.
- Measure lying-standing blood pressure and review antihypertensive and dopaminergic contributors while balancing motor control and syncope risk.
- Driving, cognition, swallowing, bone health, continence, carer strain and advance-care planning belong in ongoing specialist follow-up.
Key red flags
New unilateral weakness, speech change or abrupt ataxia requires emergency stroke assessment rather than Parkinson's attribution.
Fever, severe rigidity, reduced consciousness and autonomic instability after missed levodopa suggests parkinsonism-hyperpyrexia syndrome.
Choking, wet voice, weak cough, weight loss or recurrent chest infection requires urgent swallowing and aspiration assessment.
Painful inability to weight bear after a fall requires occult fracture precautions and imaging.
Syncope, marked orthostatic hypotension or sudden palpitations requires cardiovascular and medication review before mobility progression.
New hallucinations or delirium requires infection, medicines, pain, retention and metabolic assessment before antipsychotic treatment.
Fever, profound rigidity, reduced consciousness and autonomic instability follows abrupt dopaminergic interruption.
Abrupt immobility with delirium, pain, focal signs or hypoxia indicates a new medical process.
Investigation priorities
Relate deterioration to treatment exposure.
Management branches
A person with Parkinsonism becomes suddenly slower, rigid or unable to transfer.
- Use ABCDE and glucose and assess stroke, injury, infection, pain, retention, loading, dehydration and orthostatic physiology.
- Reconcile exact dopaminergic drugs, formulations and personal times and restore safe administration urgently.
- Treat the precipitant and begin swallowing, delirium, pressure and mobility support while monitoring return toward baseline.