Movement Disorder Screening Tips: A Provider Guide

Changes in gait, mobility, sleep, or involuntary movement may be early signs of Parkinsonism or another movement disorder. A few targeted screening questions can help identify patients who may benefit from specialty evaluation.

Alissa Higinbotham, MD, a neurologist who focuses on Parkinson’s disease and movement disorders, shares what to ask, what to look for, and when to refer.

What to Look for During Routine Visits

Providers who see patients for annual or ongoing care are often in a good position to notice early changes. Higinbotham recommends asking about new or worsening symptoms in a few key areas.

Ask About Gait and Mobility Changes

Consider asking whether the patient has noticed significant changes in the past year, such as:

• New trouble walking
• Slower movement
• Changes in balance
• Increased falls or near-falls
• Shuffling steps
• Difficulty getting up from a chair
• New stiffness or reduced arm swing

These changes may point to Parkinsonism or another movement disorder, especially when they are progressive or interfere with daily life.

Ask About Involuntary Movements

Patients may not always volunteer symptoms unless asked directly. Consider screening for:

• Tremor
• Jerking or twitching movements
• Abnormal posturing
• Uncontrolled movements that interfere with eating, writing, dressing, working, or other daily activities

“These are important screening review-of-systems questions because many movement disorders can result in significant disability if untreated,” Higinbotham says.

For example, essential tremor is the most common adult movement disorder and can have a major effect on quality of life. Higinbotham notes that up to 25% of patients with essential tremor change jobs or retire early because of their tremors.

Risk Factors That May Raise Concern

Some patients may have a higher risk of developing a movement disorder based on family history or non-motor symptoms.

Risk factors and early clues can include:

• Family history of a movement disorder
• Decreased sense of smell
• REM sleep behavior disorder, especially dream enactment behaviors such as moving, kicking, punching, or yelling during sleep

A history of hyposmia or REM sleep behavior disorder may be associated with increased risk of developing neurodegenerative movement disorders, including Parkinson’s disease or dementia with Lewy bodies.

Medications That Can Cause Parkinsonism

When a patient has symptoms and an exam consistent with Parkinsonism, Higinbotham recommends reviewing medication exposure.

Parkinsonism is typically defined by bradykinesia plus rest tremor and/or muscular rigidity. If these symptoms are present, ask whether the patient has taken medications that block dopamine or can otherwise contribute to Parkinsonism.

Common medication contributors include:

• First-generation antipsychotics
• Second-generation antipsychotics, including aripiprazole and cariprazine
• Valproic acid
• Lithium
• Anti-nausea medications, including metoclopramide and prochlorperazine

These medications are a common cause of drug-induced Parkinsonism.

“If these medications can be safely tapered off slowly, the Parkinsonism can improve within six months of cessation, and a movement disorders referral may no longer be needed,” Higinbotham says.

Medication changes should be made carefully and in coordination with the prescribing clinician, especially for psychiatric medications.

When to Refer for Specialty Evaluation

Consider referring a patient to a movement disorders specialist when they have:

• New or progressive gait or mobility changes
• Tremor or involuntary movements that interfere with daily function
• Symptoms concerning for parkinsonism that are not clearly medication-induced
• Ongoing symptoms despite appropriate medication review or adjustment
• Diagnostic uncertainty
• Complex symptoms that may benefit from multidisciplinary care

Referral may also be helpful when patients have movement symptoms along with concerning non-motor features, such as REM sleep behavior disorder or decreased sense of smell.