Spontaneous wriggling or writhing movements which can occur when the medicine is working (i.e. the patient is 'on').
A rhythmic, oscillating movement, most commonly of the hands and or limbs.
When the patient is adequately treated and movements are reasonably fluent and spontaneous.
When when the patient's medication has worn off and movements are slow, deliberate and difficult. Other less visible symptoms of pain and distress may be a feature for some patients.
A noticeable transition from 'on' to 'off' occurring between doses of medication.
An umbrella term for the motor complications of more 'brittle' advanced disease. Patients can fluctuate from 'off', to 'on' and "on with dyskinesia." The change may be gradual or a sudden switch.
Patients who:
  • don't switch 'off' before their next dose
  • can mobilise before their first dose in the morning
  • don't have peak dose dyskinesia
  • are swallowing fine
  1. Unsafe swallow
  2. Acute delirium with hallucinations
  3. Severe dyskinesia
  4. Complex PD medication regime More than 2 classes of PD drug and / or > 5 doses a day On Apomorphine or Duodopa infusion
  5. Patient using a deep brain stimulator
NMLS is a rare but life threatening complication of the cessation of L-Dopa therapy, with acute confusion, high fever, labile blood pressure and marked generalised rigidity which can cause rhabdomyolysis and renal failure.
  • Monopolar surgical diathermy should not be used but bipolar diathermy is safe
  • MRI scans in the presence of an implanted DBS should be avoided - seek neurosurgical advice if necessary

For Clinicians

Parkinson's Disease


What is Parkinson's Disease?

Care of the Dying Pathway

Inpatient Care

Non Motor Symptoms

PD Care - Top 12 Tips

PD & Surgical Admissions

The first 24 hours

Medications & NBM Guidelines

Help us track our patients

Other web resources

Criteria for Urgent Review

Parkinson's Service - Contacts

PD and Surgical Admissions

The majority of patients with early PD can do well in hospital if they are given their medication and can swallow it - make sure they get it!

Zero tolerance for pharmacy code 4 in Parkinson's patients!

But Parkinson's Disease patients are vulnerable in hospital, especially for surgery.

  • Medication gets missed
  • Mobility and stiffness gets worse in bed or without normal medicines
  • Swallowing declines; aspiration and pneumonia are common
  • Nutrition at risk from poor hand dexterity and swallow
  • Communication takes time – and worsens without medicines
  • Delirium is common

Medication around surgery:

A PD patient will stiffen up without medication every few hours.

For well controlled, early PD patients:

  • Prescribe their normal PD medication at their usual home timings (consider self-medication)
  • Ensure medication is actually given – and on time
  • Do not omit prior to surgery
  • Restart as soon as possible afterwards
  • Mobilise early

For complex patients, you need to contact the PD team urgently.

Click here for advice if patient is unable to take medicine orally.

Don't just omit medication:

When PD medications are withdrawn abruptly patients are at risk of developing
Neuroleptic Malignant Like Syndrome.

Special case: PD patients who have a Deep Brain Stimulator – DIATHERMY and MRI CAUTION

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