Follow Up Visit with a PD Patient

Key Facts

  • Goal of this visit should be to address symptoms and response to treatment.
  • Non-motor symptoms are as important as motor symptoms.
  • Treatment varies in each patient.
  • If your patient has not been seen by a neurologist/movement disorder specialist, you should refer him or her to one during this visit.
  • Referrals to PT, OT, speech therapy, social worker, and dermatologist should be considered.
  • Dyskinesias may be developed in patients taking carbidopa/levodopa.

Clinical Best Practices

  • Reconsider the PD diagnosis at every visit.
  • Conduct a full medical examination. Neurological exam in not sufficient.
  • Tailor treatment to each patient based on individual needs and preferences.

Although your patient may be diagnosed with PD (either by you or by another physician) the diagnostic accuracy is about 60% for all physicians.  The accuracy rate is higher for those treating primarily neurodegenerative diseases (about 80%). Every physician should reconsider the diagnosis at every visit, especially if atypical features have developed.

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

  • 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.
  • 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.
  • Parkinson's patients have a higher risk of developing melanoma; therefore, you should ask about changes in moles.
  • 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?
  • Ask about hospitalizations since their last visit. Falls and pneumonia are common causes of hospitalizations in PD patients.
  • Ask about therapy, including physical, occupational, and speech therapy. Is it working? What are the barriers to attending therapy sessions?
  • Exercise is very important for PD patients– inquire about exercise regimen in your patient.

Medical Examination

  • 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

  • There is no test (blood, urine, or scan/MRI) to diagnose or monitor progression of PD.
  • 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.
  • Acute levodopa and apomorphine challenge should not be used to diagnose PD.
  • 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.
  • The Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) are validated tests of cognition in PD.
  • 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.
  • 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

  • Treatment should be tailored to each patient based on individual needs and preferences.
  • Available drugs only treat symptoms.
  • 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).
  • 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.
  • 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.
  • 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

  • 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.
  • Consider referrals to the following specialties, if you have not done so:
  • Physical therapy—to help with exercise regimens, gait, balance
  • Occupational therapy—to help with ADLs
  • Speech therapy—to help with hypophonia or dysphagia
  • Neuropsychology—if there is suspicion of mild cognitive impairment or dementia
  • Nutrition
  • Parkinson's patients have a higher risk of melanoma (perhaps 2-4 times the general population). Regular assessment by a dermatologist is recommended.
  • 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.