CCFP priority topic 74 of 105
Parkinsonism on the CCFP exam
6 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 6 key features for Parkinsonism. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 6
Drug or disease
Sort Parkinson's disease from look-alikes, like a drug cause, since care differs.
CFPC skill Clinical reasoningPhase DiagnosisSources Health Canada, Choosing Wisely Canada
On the exam
A woman, 84, in long-term care is slow and stiff after metoclopramide and risperidone. Expect a short menu (pick several from a list).
Pick the steps that treat the cause.
Common mistakes
Starting levodopa or ordering a brain scan because her brother has Parkinson's disease. The drugs caused it, and stopping them is the treatment.
Approach
- Look at every drug that blocks dopamine: metoclopramide, antipsychotics such as risperidone, and phenothiazine antiemetics such as prochlorperazine.
- Drug-induced signs tend to show on both sides. Parkinson's disease usually starts on one side, often with a hand that shakes at rest.
- Stop the cause. Parkinsonism on metoclopramide mostly starts in the first 6 months, and usually settles within 2 to 3 months of stopping.
- Levodopa is not recommended for a drug cause. Its monograph says so for drug-induced movement problems.
- For nausea, do not swap in another dopamine blocker. For settled agitation, do not restart an antipsychotic: they are not first choice for behaviour symptoms of dementia.
- Signs that last beyond 2 to 3 months off the drug need a fresh look for Parkinson's disease.
- Young onset or unusual features, such as early falls or poor up-and-down gaze: refer to a neurologist.
| Usual picture | Clue | |
|---|---|---|
| Parkinson's disease | Starts on one side, often with a hand shaking at rest | Slowness plus stiffness or a rest tremor |
| Drug-induced | Both sides, after a drug that blocks dopamine | Settles off the drug, usually within 2 to 3 months for metoclopramide |
| Vascular | Mainly walking and both legs, little tremor | Stroke risk factors |
| Progressive supranuclear palsy | Early falls, stiff neck and trunk | Poor up-and-down gaze, usually no rest tremor |
| Essential tremor | Both hands shake when used, not at rest | No slowness or stiffness |
Key feature 2 of 6
Bring in the team
Use therapists and other team members to keep the patient doing daily tasks.
CFPC skill Clinical reasoning, professionalismPhase Treatment, referralSources Choosing Wisely Canada
On the exam
A woman, 84, is recovering from drug-induced parkinsonism but nearly falls at every transfer. Expect one best answer.
Pick the best next step.
Common mistakes
Waiting for recovery before starting rehab. She is dependent and nearly falling now. Months without therapy risk a fracture and more lost strength.
Approach
- Physiotherapy: walking, balance, transfers, falls and an exercise plan.
- Occupational therapy: dressing, bathing, eating, room or home safety, and aids such as grab bars.
- Speech-language pathology: a quiet voice, trouble swallowing, and drooling.
- Review every medicine, with a pharmacist if you can. Many drugs in older adults add falls, confusion and loss of function.
- Teach nurses and care staff what to watch for each day: falls, choking, confusion.
- Bring in social work and support for caregivers as care needs grow.
Key feature 3 of 6
Decline in an older adult
When an older adult loses function, think of parkinsonism, a cause you can often reverse.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Health Canada, Choosing Wisely Canada
On the exam
A woman, 84, with dementia in long-term care is slower, stiffer and has fallen twice. Expect a short menu (pick several from a list).
Pick the findings to look for.
Common mistakes
Retesting memory because staff blame the dementia. Or a balance test with eyes closed, neck bending or reflexes. None of them shows slowness or stiff limbs.
Approach
- Watch her walk and turn: short shuffling steps, a stoop, less arm swing, slow turns.
- Test tone in the arms and legs. Look for stiffness through the whole movement, sometimes with a ratchet-like catch.
- Test speed: finger taps or hand opening that get smaller and slower.
- Look at the face and listen: a still face, a soft voice, drooling.
- Review every drug and when it started. Metoclopramide can cause slowness, tremor, ratchet-like stiffness and a mask-like face.
- Never add a drug without a full medicine review. In older adults, many drugs add falls and decline.
- A drug cause clears off the drug. Parkinson's disease is treatable, so finding it can restore function.
Key feature 4 of 6
The tremor exam
Examine a shaking hand to tell a rest tremor from an action tremor.
CFPC skill Clinical reasoningPhase Physical
On the exam
A man, 68, has 8 months of right-hand shaking and is slower to dress. Expect a short menu (pick several from a list).
Pick the exam steps that classify the tremor.
Common mistakes
Tests that cannot classify a tremor: heel-to-shin, reflexes, feeling the thyroid, wrist flexion for carpal tunnel. Or calling it essential tremor because his mother shook.
Approach
- Watch the hands resting in the lap, fully supported and relaxed. A rest tremor shows here.
- Distract him: count backwards, or open and close the other hand. A rest tremor often grows.
- Hold the arms out in front. Essential tremor shows at once. A Parkinson's tremor may fade, then return after a pause.
- Do finger-to-nose. A rest tremor eases with movement. Essential tremor stays or gets worse near the target.
- A tremor alone is not parkinsonism. Look for slowness, such as finger taps that shrink, and for limb stiffness.
- Ask him to write and to walk. Small cramped writing and less arm swing on one side fit Parkinson's disease.
| Parkinson's disease | Essential tremor | |
|---|---|---|
| When it shows | At rest; eases with movement | Holding a posture or moving |
| Sides | Starts on one side | Both hands; sometimes the head or voice |
| Other signs | Slowness and stiffness | No slowness or stiffness |
| Clues | Small writing, less arm swing | Family history; alcohol may ease it |
Key feature 5 of 6
Drug side effects
Know the harms each Parkinson's drug brings, above all ones you rarely use.
CFPC skill Clinical reasoning, professionalismPhase TreatmentSources Health Canada
On the exam
A man on pramipexole dozed off at the wheel with no warning. He lives 60 km from town. Expect one best answer.
Pick the safest advice today.
Common mistakes
Coffee, or short daytime drives only: the sleep comes without warning. Stopping pramipexole at once, or swapping to another agonist, is wrong too.
Approach
- Sudden sleep can happen on levodopa or a dopamine agonist, without warning, at any point in treatment.
- Tell him not to drive or run machinery. A lower dose reduces drowsiness but may not stop the episodes.
- Another agonist may not help. Sudden sleep is reported with the others too.
- Taper; do not stop at once. Fast withdrawal can bring fever, stiffness, confusion and unstable blood pressure and pulse.
- Ask him and his family about gambling, a raised sex drive, compulsive shopping and binge eating.
- Watch for hallucinations and confusion, which rise with age. Check for low blood pressure on standing as doses go up.
- Avoid drugs that block dopamine, such as metoclopramide and risperidone. They can undo the treatment.
| Drug | Watch for | Know this |
|---|---|---|
| Levodopa-carbidopa | Nausea, involuntary movements, low blood pressure on standing, hallucinations, sudden sleep | Involuntary movements mean the dose is too high. Iron and high-protein meals can lower absorption. |
| Dopamine agonist (pramipexole) | Sudden sleep, impulse problems, hallucinations, low blood pressure on standing | Hallucinations rise with age. Lower the dose in kidney disease. Taper by 0.75 mg a day to 0.75 mg, then by 0.375 mg a day. |
| Dopamine blockers (metoclopramide, antipsychotics) | New parkinsonism, or worse Parkinson's disease | Give metoclopramide cautiously, if at all, in Parkinson's disease. |
Key feature 6 of 6
Follow-up visits
At each review, check function, drug harms, and the problems that come with the disease.
CFPC skill Clinical reasoningPhase Hypothesis generation, follow-upSources Health Canada, Choosing Wisely Canada
On the exam
A man, 72, with Parkinson's disease has a steady tremor but has lost interest and wakes early. Expect a short menu (pick several from a list).
Pick what to ask about and screen for.
Common mistakes
Blaming the disease and raising his levodopa, or a sleeping pill for early waking. Both miss a treatable depression, and the pill adds falls.
Approach
- Each visit: daily tasks, falls, and drug harms such as sudden sleep, impulse problems, hallucinations and dizziness on standing.
- Screen for depression and ask about suicidal thoughts. The drug monographs flag both in Parkinson's disease.
- Ask about memory and thinking, and about seeing things that are not there.
- Ask about constipation, swallowing, weight, sleep and bladder control.
- Acting out dreams often starts years before the diagnosis. It does not explain new low mood or early waking.
- For sleep, do not reach for a sedative first. In older adults they roughly double falls, hip fractures and car crashes.
- Check the skin regularly. People with Parkinson's disease have a higher risk of melanoma.
Flashcards
Answer it first, then check.
KF 1Parkinsonism began on metoclopramide. How long after stopping should it clear?
Usually within 2 to 3 months. Signs that last longer need a fresh look for another cause. Source: Health Canada
KF 1Is levodopa the answer for parkinsonism caused by a drug?
No. Stop the drug. Levodopa is not recommended for drug-induced movement problems. Source: Health Canada
KF 3An older adult in care is slower, stiffer and falling. What do you review first?
Every drug and its start date. Then walking, limb tone, finger taps, face and voice. Source: Choosing Wisely Canada, Health Canada
KF 4How do you bring out a rest tremor during the exam?
Rest the hands in the lap, then distract: count backwards or move the other hand.
KF 5Sudden sleep on pramipexole. Will a different dopamine agonist fix it?
Not reliably. Sudden sleep is reported with other agonists too. The patient stops driving now. Source: Health Canada
KF 5Why taper pramipexole instead of stopping it at once?
Fast withdrawal can cause fever, stiffness, confusion and unstable vital signs, like neuroleptic malignant syndrome. Source: Health Canada
KF 5Name four impulse problems to ask about on dopamine drugs.
Gambling, a raised sex drive, compulsive shopping or spending, and binge eating. Source: Health Canada
KF 6Lost interest and early waking in Parkinson's disease. What do you screen for?
Depression, with a question about suicidal thoughts. Do not reach for a sleeping pill first. Source: Health Canada, Choosing Wisely Canada
FAQ
Is parkinsonism the same as Parkinson's disease?
No. Parkinsonism is the pattern: slowness with stiffness or a rest tremor. Parkinson's disease is one cause. Drugs, small strokes and rarer brain diseases can cause it too.
Can it be parkinsonism without a tremor?
Yes. Slowness is the core sign, and some people never shake. Look for slowness plus stiff limbs, a shuffling walk, a soft voice and a still face.
Do I need to memorize doses of Parkinson's drugs?
Rarely. Know each class and its main harms: levodopa, dopamine agonists, and the drugs that block dopamine. For a drug you seldom use, read its Canadian monograph.
Who should see a neurologist?
Anyone with an unclear diagnosis, young onset, early falls or poor eye movements. Refer too when signs last after the causing drug is stopped.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Drug Product DatabaseHealth Canada
- Choosing Wisely recommendationsChoosing Wisely Canada