Progressive supranuclear palsy

Also called PSP, Multiple system atrophy, MSA, Parkinson's-plus

Two conditions mistaken for Parkinson's for years. Backward falls early, and eye movement problems, are the clues that it is something else.

What it is

Two rare, progressive neurological conditions grouped together because they are both routinely misdiagnosed as Parkinson's disease and because the practical support they need is similar.

**Progressive supranuclear palsy** affects balance, eye movements, swallowing and thinking. The distinguishing features are falls backwards within the first year, which almost never happens early in Parkinson's, and difficulty moving the eyes vertically, especially looking down. People describe a staring expression and difficulty seeing food on the plate or the next stair.

**Multiple system atrophy** combines parkinsonism with severe autonomic failure: blood pressure dropping on standing, bladder problems, and sometimes early erectile dysfunction, often years before the movement problems.

Both differ from Parkinson's in a way that matters practically: they respond poorly or briefly to levodopa, they progress faster, and the falls come much earlier.

Getting the diagnosis right changes everything about planning, because the timeline is shorter and the support needed arrives sooner. Both need early speech and language therapy for swallowing, early occupational therapy, and early advance care planning.

Signs you might notice

PSP: falls, especially backwards, in the first year; difficulty looking down; a fixed, staring facial expression; slurred speech; swallowing difficulty; changes in behaviour, apathy and impulsivity.

MSA: dizziness or fainting on standing; bladder urgency, frequency or retention; erectile dysfunction early; stiffness and slowness; a quiet, strained voice; noisy breathing or stridor at night; and cold, blue hands.

Both: symmetrical stiffness rather than the one-sided start typical of Parkinson's, and little sustained benefit from levodopa.

Urgent: choking or coughing on food and drink; noisy breathing or stridor, which in MSA can be dangerous; and any fall with a head injury.

The pattern that should trigger a rethink is a Parkinson's diagnosis with early falls, early swallowing problems, or a poor response to medication.

How it can affect day-to-day life

Falls dominate, and they happen without protective reflexes because the person does not perceive the imbalance. Standard falls advice underestimates this; many people need a wheelchair much earlier than expected, and framing that as freedom rather than defeat matters.

Swallowing deteriorates and aspiration pneumonia is a leading cause of death. Speech and language therapy input should start at diagnosis, not when choking begins.

In PSP, the eye movement problem makes reading, eating and stairs hard, and prism glasses can help.

In MSA, blood pressure falling on standing causes falls and collapses and needs specific management: slow rising, compression stockings, more salt and fluid, raising the head of the bed, and sometimes medication.

Cognitive and behaviour changes in PSP are frequently misread as personality or depression, and families need that explained.

Both progress faster than Parkinson's, and honest information about the timeline, given kindly and early, is what allows people to make choices while they can.

Supporting someone well

Question a Parkinson's diagnosis when there are early falls, early swallowing problems, early bladder or blood pressure problems, or no real benefit from levodopa. Ask for a specialist movement disorder opinion.

Ask for speech and language therapy at diagnosis, and act on choking or wet voice immediately.

Ask for occupational therapy and a falls assessment early, and consider a wheelchair sooner than feels right.

For MSA, measure blood pressure lying and standing, and manage the drop actively.

Start advance care planning early, while communication is easy. See mental capacity.

Ask for a specialist nurse, and for carer support in their own right.

Report noisy breathing at night in MSA; it needs assessment.

Where to get help

A GP practice for referral to a neurologist with a movement disorder interest.

PSPA run a helpline and cover both PSP and MSA. They are the specialist charity.

Parkinson's UK on 0808 800 0303, who also support people with these related conditions.

Marie Curie on 0800 090 2309 for planning ahead.