Olfactory loss as a supporting feature in the diagnosis of Parkinson's disease: a pragmatic approach.

There is ample evidence from a large number of clinical and pathological studies of an early involvement of olfactory bulbs and cortex in the Lewy body pathology in idiopathic Parkinson's disease (iPD), the olfactory system being one of the first targets of degeneration in this condition. The olfactory dysfunction may be measurably present at the time of initial presentation and progresses in a proportion of patients as the disease advances. Patients with iPD have a more severe olfactory loss as compared to multisystem atrophy whereas the syndromes of corticobasal degeneration and progressive supranuclear palsy have no olfactory loss. A proportion of drug induced parkinsonism may have olfactory loss indicative of primary pathology of dopaminergic degeneration in these patients. Unlike single photon emission tomography, formal measurement of olfaction would provide a supportive role in diagnosing or excluding iPD depending on the duration of an individual patient's parkinsonian symptoms. Whilst olfaction may be only minimally impaired in early stages and may thus not help to differentiate from other syndromes, an intact olfaction in patients with parkinsonism of few years' duration would indicate a non-iPD pathology. Olfactory measurement is easy, cheap and now easily available in a number of tests, and olfactory assessment at different stages of parkinsonism should be used as a diagnostic aid for idiopathic PD and would enhance the diagnostic accuracy of iPD when used in conjunction with the UK Parkinson's disease society Brain Bank supportive criteria for diagnosis of idiopathic Parkinson's disease.