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iStock-935411624%20%281%29.jpgWorld Parkinson’s Day takes place every year on 11th April. Parkinson’s UK is using this year’s event to highlight the realities of living with Parkinson’s disease, helping patients to feel more understood1.

Parkinson’s disease was first described in ‘An essay on the shaking palsy’, written by Dr James Parkinson, an English physician and surgeon, in 18172. This paper established Parkinson’s disease as a recognised medical condition, which NICE defines as: “a progressive neurodegenerative condition resulting from the death of dopamine-containing cells of the substantia nigra in the brain”3. The substantia nigra pars compacta plays an important role in controlling the body’s movement and coordination, in conjunction with the caudate nucleus and putamen.

Parkinson’s is one of the most common neurological conditions and it’s estimated that it affects up to 16 people per 10,0003. According to a report by Parkinson’s UK, the estimated prevalence in the UK for 2018 was 145,519. The charity also found that prevalence was 1.5 times higher in men than in women within the 50-89 age group. In terms of incidence, Parkinson’s UK estimates that approximately 1 in 37 people are diagnosed with Parkinson’s at some point in their lifetime. They predict that the prevalence of the disease will rise by 18% between 2018 and 2025, due to population growth and an increasingly ageing population4.

Typical presentations of Parkinson’s disease include symptoms and signs described as ‘Parkinsonism’: bradykinesia (slow movements), rigidity (abnormal stiffness), resting tremor (typically ‘pill rolling’) and postural instability (loss of balance)1. These symptoms are typically asymmetrical2.

Rigidity can present in different forms including lead-pipe (sustained rigidity, where the limb is heavy and resistant to passive movements) and cogwheel (intermittent rigidity, where the limb moves with jerky and ratcheting motions)5. A ‘pill rolling’ tremor is often seen and is so named because it looks like the patient is rolling a pill between their thumb and index finger. It occurs at rest and can often be alleviated by moving the affected limb. A resting tremor can also occur in other parts of the body such as the legs and lips5. Postural instability is a major reason why people with Parkinson’s disease are at risk of falls: Parkinson’s affects the basal ganglia, which have an inhibitory action on movement. Releasing this inhibition requires the release of dopamine, so the deficiency results in hypokinesia. Freezing gait can also contribute to falls as it can cause patients to stop involuntarily when walking. They may then find themselves unable to initiate movement for several seconds/minutes5. In addition, basal ganglia control balance through cortico-spinal pathways, including auto-adjustment of posture to maintain stability, so reflexes which try to prevent falling are significantly impacted.

Examples of bradykinesia and rigidity include2:

  • reduced arm swing
  • shuffled gait
  • softened voice
  • decreased blink rate and facial expression.

Non-motor symptoms include2:

  • fatigue
  • autonomic dysfunction
  • sleep disturbance.

It’s important to note that some conditions may look like Parkinson’s disease. For example, progressive supranuclear palsy, multiple system atrophy or extra-pyramidal side effects of drugs, such as antipsychotics or antiemetics can cause Parkinsonian features3.

James%20Parkinson%20essay%20image%20-%20Parkinson’s disease is usually diagnosed in secondary care, so any suspected cases should be referred to a neurologist to be seen within 6 weeks3. There are no laboratory or imaging tests that can offer a definitive diagnosis, so diagnosis is usually made based on a detailed clinical history and examination3,6. A specialist in secondary care may use the Parkinson’s UK Brain Bank Criteria to assist with diagnosis6.

The majority of management is in secondary care and it is recommended that patients receive a follow up every 6-12 months with a specialist who monitors treatment and progression of the condition. Patients with Parkinson’s disease are usually assigned to a Parkinson’s Disease Nurse Specialist (PDNS) who can co-ordinate care with the patient, carer, GP and specialist6. Patients should also be given access to occupational therapy, physiotherapy and speech therapy - depending on the severity of their symptoms - to assist with their independence and safety6.

Medication is initiated in secondary care and can be prescribed by the GP after this, in accordance with the local shared care guidelines. Occasionally GPs may be involved with monitoring medication, in liaison with the PDNS6. The following medications are common pharmacological treatments for Parkinson’s disease:



This is a dopamine precursor that converts to endogenous dopamine in the brain. Itis offered to patients in the early stages of the disease, where motor symptoms are already having an impact on their quality of life3,6. Levodopa is considered the core medication in treating Parkinson’s, but it requires close monitoring to get the dosage right. If the dosage is too high, it can result in hallucinations and psychotic behaviour. As the disease progresses and higher doses are needed, adverse effects of levodopa, such as dyskinesias, are more common. Adjusting the dosage, timing and type of preparation can help to manage these effects6.

Dopamine agonists

Another treatment option is the use of drugs that have a dopamine-like action. These stimulate dopamine receptors in the brain and can be used on their own or with levodopa. Patients are likely to experience less long-term side effects from dopamine agonists, but they can cause side effects such as nausea, dizziness and sickness if not introduced gradually. Older patients may experience hallucinations. A small percentage of Parkinson’s patients may experience impulsive and compulsive behaviour when taking dopamine agonists. These patients may also be more prone to ‘dopamine agonist withdrawal syndrome’ when their treatment is stopped or reduced6.

Other key medications in the treatment of Parkinson’s disease include MAO-B inhibitors and COMT inhibitors. The NICE guidance on Parkinson’s disease in Adults (NG71) and the NICE Clinical Knowledge Summary on Parkinson’s disease provides more information on these, as well as more comprehensive lists of Parkinson’s medications and possible side effects.

Some medications may be contraindicated as they may cause worsening of the disease by antagonising dopamine receptors. As mentioned before, antipsychotics and anti-sickness drugs can cause extra-pyramidal side effects. These drugs can increase the severity of the Parkinsonian symptoms, particularly rigidity and bradykinesia, and sometimes irreversibly. A list of drugs to avoid can be found in the ‘drug treatments’ section of the Parkinson’s UK website.

GPs are a great source of support for patients with Parkinson’s disease, along with their family members and carers. Through support from their GP, patients are encouraged to take part in decision making and judgements about their own care. As Parkinson’s can affect a patient’s cognition and communication, NICE recommend that any information that is communicated throughout their disease should be given both verbally and in written form3. Family members and carers should also be kept informed about the patient’s condition, advised about their entitlements as a carer, encouraged to request a carer’s assessment from the local authority, and signposted to support services3. As mentioned earlier on, patients with Parkinson’s disease can be prone to falls due to their hypokinesia and balance impairment, so GPs will need to bear this mind when managing other medical conditions connected to falls, such as blood pressure. Orthostatic hypotension is common in Parkinson’s so extra care is needed when prescribing antihypertensives.

As a patient’s disease progresses, GPs are advised to be vigilant to any cognitive impairment. Parkinson’s is associated with Lewy body dementia and if this is suspected, referral to a consultant in older person’s mental health is recommended. As with any chronic disease, GPs should also look out for any signs of depression and screen for this intermittently. Signs of depression may be harder to detect due to the impaired facial expression and verbal difficulties that patients with Parkinson’s disease can experience.


To find out more about Parkinson’s disease and the GP’s role, RCGP members can benefit from access to the following online resources:

EKU6 - Diagnosis and Management of Parkinson's Disease

EKU12 - The Professional's Guide to Parkinson's Disease



1 Parkinson’s UK, 2019. Parkinson’s is. [Online] Available at:

2 British Medical Journal, 2018. BMJ Best Practice – Parkinson’s disease. [Online] Available at:

3 NICE, 2017. Parkinson’s disease in adults (NG71). [Online] Available at:

4 Parkinson’s UK, 2018. The incidence and prevalence of Parkinson’s in the UK report. [Online] Available at:

5 European Parkinson’s Disease Association, 2017. Motor symptoms. [Online] Available at:

6 Guidelines, 2012. The GP’s guide to Parkinson’s – by Parkinson’s UK. [Online] Available at:

'An essay on the shaking palsy by James Parkinson' image from Wellcome Collection.

[ Modified: Monday, 22 January 2024, 12:03 PM ]
Anyone in the world

iStock-680399060.jpgWorld Bipolar Day takes place every year on 30th March and is organised by various international charity organisations, who support people with bipolar disorder. The aim of the awareness day is to inform people about bipolar disorder and to improve attitudes towards the condition by eliminating the social stigma around it1. Bipolar disorder (previously known as manic depression) is a lifelong mental health condition, consisting of recurring episodes of depression and mania or hypomania2. Whilst bipolar disorder is usually diagnosed in secondary care, patients are likely to present in primary care first. Therefore, it is important for GPs to be able to recognise the signs and symptoms in order to refer to secondary care for formal diagnosis.

The National Institute for Health and Care Excellence (NICE) estimate that the peak age of onset is 15-19 years old. As bipolar disorder can often be difficult to detect initially, there is usually a significant delay between onset and first contact with mental health services3,4.

The Adult Psychiatric Morbidity Survey, conducted in 2014, found that 2% of the English population screened positive for bipolar spectrum disorders2.

The elevated mood in bipolar may be hypomania or mania, the definitions of which are as follows6:

Mania – Abnormally and persistently elevated or irritable mood for a distinct period of at least one week (with or without psychotic symptoms).

Hypomania – Mild mood elevation with increased energy and irritability, that lasts for 4 or more continuous days.


iStock-1129212634.jpgDepressive symptoms are the most common initial presentation in primary care, which makes it difficult to recognise them as being part of bipolar disorder. Patients may present with symptoms such as depression, anxiety, mood swings, sleep disturbance, irritability, fatigue and difficulty in focus and concentration4. To make a distinction between depression and bipolar disorder, ask the patient about periods of elated, excited or irritable mood lasting four days or more. It is also recommended that GPs take a family history of mania and depression7.

Patients who have been diagnosed and treated in secondary care should return to primary care with a mutually agreed care plan in place. This includes their recovery goals, a crisis plan which indicates early warning symptoms of a relapse and what do in this instance, an assessment of their mental state, and a medication plan with a date for review3. Both the patient and their GP should have a copy of this plan so that the GP can begin monitoring their condition in primary care.

Following diagnosis and stabilisation, the primary care team’s role is to optimise physical health, check mental state and review the patient’s medication (as would happen in any chronic disease management). Unwell patients will need help from their mental health teams if destabilisation occurs which cannot be managed in primary care.


From the care plan provided, the GP should have all the details concerning the patient’s medication and when it should be reviewed. However, NICE states that the secondary care team should be responsible for monitoring the efficacy of the patient’s antipsychotic medication for at least the first 12 months, or until the patient’s condition has stabilised, whichever is longer3. Following this, the responsibility for this monitoring may transfer to primary care under shared-care agreements.

If the patient is on lithium, the psychiatry team should provide a target lithium level (typically 0.6-0.8 mmol/L, depending on the patient). It is recommended that GPs check the levels every three months and monitor and adjust accordingly7, but if the patient becomes unstable they should be referred back to secondary care, in line with local shared care guidelines. The NICE guideline on ‘Bipolar disorder: assessment and management’ includes more specific information about the different pharmacological options for bipolar disorder and their use.

Physical health checks

As well as monitoring medication, it is recommended that GPs perform a physical health check on patients with bipolar disorder at least annually. According to NICE, these checks should include3:

  • Weight, BMI, diet and nutrition and levels of exercise
  • Pulse and blood pressure
  • Fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
  • Liver function
  • Renal and thyroid function
  • Calcium levels (for people taking long-term lithium)

It is estimated that the life expectancy for people living with severe mental illness is 15-20 years lower than the general population8. This statistic highlights the importance of carrying out the checks above and managing any potential comorbidities alongside treatment for bipolar disorder.


As part of their regular reviews, GPs should provide holistic support to bipolar disorder patients and their families/carers. This includes preparing for major life events: for example, all patients planning a pregnancy or who have become pregnant should be immediately referred to the perinatal mental health service to advise the patient on the management of their medication in relation to their pregnancy. A good social history during visits will reveal important life changes that might be detrimental to the patient’s health such as changes in social or family situations or their general wellbeing4.  As well as building relationships with the patient and their families/carers, the GP can help carrying out the care plans from secondary care and help with recovery goals.

For more information about the diagnosis and management of bipolar disorder, RCGP members can access the following eLearning resources for free:

EKU15: Assessment & Management of Bipolar Disorder in Adults, Children & Young People

EKU13 (Briefing): Bipolar Disorder – Diagnosis & Current Treatment Options



1 World Bipolar Day, 2019. About World Bipolar Day. [Online] Available at:

2 Marwaha S, Sal N, Bebbington P, 2016. ‘Chapter 9: Bipolar disorder’ in McManus S, Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Available at:

3 NICE, 2014. Bipolar disorder: assessment and management (CG185). [Online] Available at:

4 Culpepper L, 2010. ‘The role of primary care clinicians in diagnosing and treating bipolar disorder’. Primary care companion to the Journal of clinical psychiatry vol. 12, Suppl 1 (2010): 4-9. Available at:

5 Merikangas, Kathleen R et al. “Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative” Archives of general psychiatry vol. 68,3 (2011): 241-51. Available at:

6 Mind, 2018. What types of bipolar are there? [Online]. Available at:

7 Goodwin GM et al, 2016. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendation from the British Association for Psychopharmacology. Journal of Pharmacology 2016, Vol 30(6) 495-553. Available at:

8 NHS England, 2018. Improving physical healthcare for people living with severe mental illness (SMI) in primary care: Guidance for CCGs. [Online] Available at:

[ Modified: Tuesday, 12 March 2019, 10:44 AM ]
Anyone in the world

Hand palm with red skinThis February is “Raynaud’s Awareness Month”. This common dermatological phenomenon was named after Maurice Raynaud, who in 1862 described the condition afflicting a 26 year old female patient. Although epidemiology varies depending on local weather, work exposure and sex, most population-based surveys estimate its prevalence between 3 to 5%. Patients can be divided into two different groups: those with primary Raynaud’s phenomenon, which is diagnosed when no underlying disease is found; and those with secondary Raynaud’s phenomenon, which is diagnosed when there is an associated disease. The differentiation between the two of them is of importance, as secondary Raynaud’s has the potential for serious complications. Its associated diagnoses -systemic sclerosis, vasculitis, systemic lupus erythematosus, rheumatoid arthritis, peripheral vascular disease - are potentially serious and can cause deterioration in quality of life. As 30 to 50% of patients with primary Raynaud’s have a first degree relative condition, a genetic component is likely1.

Patients describe well demarcated, episodic blanching of one or more fingers (or toes, ears, nipples and ears) caused by peripheral vasospasm and triggered by a cold environment or emotional stress. This can be followed by a blueish, cyanotic colour (in a third of all patients), before the fingers turn bright red during a period of reperfusion, associated with stinging and throbbing. The symptoms can last for minutes and up to several hours.

Hands with dark patches on fingersRaynaud’s phenomenon isn’t the only diagnosis that can cause vascular symptoms in the periphery: exposure to the cold can cause physiological pallor, an acute cholesterol embolism can mimic the discolouration of Raynaud’s phenomenon  (though doesn’t have its episodic nature) and thrombangitis obliterans (recurrent thrombosis of small/medium arteries and veins) can cause similar distal extremity ischaemia2.

Patients who present with primary Raynaud’s are usually younger (between 15 and 30 years of age), don’t appear to have symptoms affecting their thumbs and lack ulceration, digital pitting or gangrene.  Patients presenting in general practice should be asked about the frequency and severity of the attacks, smoking and family history and for symptoms associated with the diagnoses underlying secondary Raynaud’s.

Examination should involve checks for peripheral vascular disease, blood pressure measurements and evidence of complications of secondary Raynaud’s. Examination of the capillaries of the nailbeds of the fingers can be attempted with an otoscope, ophthalmoscope or a dermatoscope, as dilated and distorted capillaries can point to underlying connective tissue disease3. Investigations should include FBC, ESR, ANA, U&Es, and urinalysis.

If examination and investigation points to primary Raynaud’s, pharmacological treatments are often not necessary, and lifestyle advice should be considered first: keeping warm, smoking cessation, avoiding exposure to cold weather. If non-pharmacological treatments in primary Raynaud’s are ineffective, calcium channel blockers such as nifedipine and nicardipine can be effective in reducing the frequency of attacks.

If treatment is ineffective or if there is suspicion of connective tissue disease or another underlying condition, the patient should be referred to the local rheumatology team4.

Images used with permission from the charity ‘Scleroderma & Raynaud’s UK’. Their website has extensive guidance for patients with Raynaud’s. 


Fredrick M. Wigley and Nicholas A. Flavahan:  Raynaud’s Phenomenon. August 11, 2016. N Engl J Med 2016; 375:556-565

Drerup, C; Ehrchen, J:Raynaud’s phenomenon. Practical management for dermatologists. Hautarzt 2019 · 70:131–141

3 Herrick, AL: Evidence-based management of Raynaud’s phenomenon. Ther Adv Musculoskel Dis, 2017, Vol. 9(12) 317–329

Pope, J: Raynaud’s phenomenon. BMJ Best practice. 2019.

[ Modified: Friday, 22 March 2024, 9:54 AM ]
_ RCGP Learning
by _ RCGP Learning - Wednesday, 9 January 2019, 9:55 AM
Anyone in the world

iStock-897821744.jpgYoung Carers Awareness Day takes place on 31st January 2019 and, according to the Carers Trust, the aim is to “identify young carers and raise awareness of the vital role that they play in supporting their sick and disabled family members”1. The number of young carers in England is difficult to determine; the latest census in 2011 found that there were around 175,0002,  but a more recent survey by BBC News and Nottingham University estimates around 800,000 in secondary school alone3. One of the main reasons for this uncertainty is that young carers and their families are often reluctant to make themselves known to authorities for various reasons. This can make it extremely difficult for GPs to identify young carers in primary care and therefore support them effectively.

The theme of this year’s Young Carers Awareness Day is the importance of mental health, which can be significantly impacted when a child or young person is expected to juggle caring alongside their education and social life. Carers Trust estimates that around 45% of young adult carers have mental health problems4. The pressure of caring for one or multiple family members can cause a great deal of anxiety for both children and young adults, who are often the primary source of emotional support for the person/people they care for. The Dearden and Becker ‘Young Carers in the UK’ survey found that 82% of young carers provide emotional support as well as nursing-type care, intimate care and child care5.

It is not only a young carer’s mental health that is impacted by their caring role. Their physical health is often impaired due to lack of sleep, poor diet and having to lift a heavy adult6. These issues, combined with their responsibilities at home, can have a significant impact on their education and school life. It is estimated that young carers miss or cut short around 48 school days a year on average and only half have a person at school that knows about their caring role4. Barnardo’s, the children’s charity, highlight that young carers are often bullieddue to being ‘different’ from their peers and therefore feel isolated7. There are also limited opportunities for social activities and to build relationships outside of the family home. Around three quarters of young carers find the school holidays particularly difficult, due to feeling socially isolated and to the increase in their responsibilities at home4.

iStock-653888206.jpgWhilst young carers face many difficulties, it is common for them to feel a sense of pride and independence due to their caring role. They also may not be fully aware that their life is different to their peers, which is one of the reasons why many young carers still remain ‘hidden’ from social services. Some families don’t recognise their children as ‘carers’, especially if the child helps their parents care for a sibling, so it is often not declared to local authorities. In other cases, the family is aware of their child’s caring role but worry about the repercussions of involving social services, such as interventions and the possibility of family separation8.

Without the involvement of social services, it is unlikely that a young carer would be known to their practice or GP. It is therefore important for GPs and practice teams to identify any young carers at the practice, so that they are aware of this during consultations and can signpost them to helpful resources. Young carers may also need to be involved in the care for the person they look after, such as appointments and medications. Some ways in which young carers can be identified include9:

  • Putting posters and leaflets around in the waiting room, asking them to self-identify
  • Adding a question in the new patient questionnaire at registration
  • Looking out for any children or young people that bring an elderly, sick, disabled or frail patient in for an appointment and asking if they are the patient’s carer
  • Ask any patients with chronic conditions that require a carer about who their carer is

For more information about identifying and supporting young carers, the RCGP has the following resources available to all healthcare professionals for free:

Supporting Carers in General Practice eLearning course – 3 CPD points

Taking Action to Support Carers in Practice Teams  eLearning course - 2 CPD points

Carers Support clinical resource from the RCGP

RCGP Members can also access the following resources about carers:

EKU2017.1: Dementia: supporting people with dementia and their carers in health and social care

EKU9 Briefing: Assessing and helping carers of older people

EKU4: Supporting Carers. An action guide for general practitioners and their teams

GPs can also use the following resources to signpost patients and their families to:

Carers Trust

Carers UK


NHS – Help for young carers


1 Carers Trust. 2018. Young Carers Awareness Day 2019

Office for National Statistics. 2011. 2011 Census

3 BBC. 2018. Being a young carer

4 Carers Trust. 2015. Key facts about carers and the people they care for

5 Dearden, C. and Becker, S., 2004. Young carers in the UK: the 2004 report. London: Carers UK. Available from:

6 Carers Trust Professionals. 2014. Who are young carers?

7 Barnado’s. 2018. Young carers.

8 Department for Education. 2016. The lives of young carers in England.  

9 Royal College of General Practitioners. 2013. Supporting Carers in General Practice

[ Modified: Wednesday, 9 January 2019, 10:07 AM ]