Parkinson's disease is the second most common neurodegenerative disorder, second only to Alzheimer's disease. Parkinson's is characterized by varying degrees of muscle stiffness (rigidity), slowness of movement (bradykinesia), postural instability (gait imbalance) and tremor. A little-known fact is that thirty percent of all Parkinson's patients do not have tremor. When people begin to experience tremor, frequently they will jump to the conclusion that Parkinson's disease is to blame. However, neurologists frequently find themselves correcting a mistaken Parkinson's diagnosis.The diagnosis for Parkinson's is made on the basis of a detailed medical history and neurological exam. There is no diagnostic test to make the diagnosis of Parkinson's disease. The disease usually starts in individuals over the age of 65. The first symptom may be a mild resting tremor in one hand. It is very common to have tremor on only one side. Other patients may start off with gait imbalance and slowness of movement. Parkinson's patients have a very characteristic masked facial expression. Their faces tend to have a blank, staring look, lacking in emotional expression. To make an accurate diagnosis, a patient needs to have 3 of the 4 major criteria listed. It is not uncommon for a patient to have symptoms for 1-2 years prior to an accurate diagnosis, particularly in the absence of tremor. The disease progresses slowly, often lasting 15-20 years or more.At the time a patient with the disease sees their doctor, they are usually experiencing significant slowness of walking and other movement. Family members or a spouse will say that it takes the patient twice as long to get dressed or ready to go. Stumbling or falling can also be a reason for seeking out medical attention. An accurate diagnosis can only be made by carefully assessing the symptoms and performing a detailed neurological exam. Neuroimaging with CT or MRI is usually not necessary; nor is getting lab work.Once the diagnosis is made, treatment can be started. Studies have suggested that starting patients on rasagiline (Azilect) may have benefit in slowing down the progression of Parkinson's. This medication or selegiline should be one of the first medications started. Symptomatic treatment for tremor can be started with Artane, an anticholinergic compound. If a patient has more trouble with slowness of movement or rigidity, amantadine can be started.Once a patient's symptoms become too troublesome, the dopamine agonists are the next line of medications indicated. Dopamine is the brain transmitter which is deficient in Parkinson's patients. Dopamine agonists mimic the action of dopamine, stimulating the dopamine receptors. Mirapex and Requip are examples of dopamine agonists. They can help to reduce tremor and improve movement in Parkinson's patients. Apomorphine is a dopamine agonist that is available by injection or cream form. It has a short duration of action but can help Parkinson's patients who suffering from freezing or "off time," where they become "stuck."Once a patient reaches the stage of the disease where daily activities are significantly affected and no other medication is working, Sinemet (levodopa-carbidopa) therapy is indicated. Although dopamine is deficient in Parkinson disease, it cannot be taken orally as it does not cross the blood-brain barrier. Levodopa can be taken orally and will cross the blood-brain barrier. In the brain, levodopa is converted into dopamine. This dopamine can then be effective in relieving many of the symptoms of Parkinson's disease. Starting levodopa therapy too soon, however, can have negative effects on patients. Levodopa has a useful window of symptomatic relief of about 5 years. After taking levodopa for longer than 5 years, patients can develop motor fluctuations, such as freezing, sudden "off times" and involuntary movements (known as dyskinesias).In summary, the diagnosis and treatment of Parkinson's disease is clinically complex. Not all persons suffering from tremor have Parkinson's disease. Affected patients would best be served by seeing a neurologist specializing in movement disorders and especially in Parkinson's disease.