Progressive supranuclear palsy

Progressive supranuclear palsy (PSP) is a progressive neurodegenerative tauopathy that affects movement, balance, eye and eyelid control, speech, swallowing, behavior, and thinking. Presentation varies. The classic PSP-Richardson pattern includes early postural instability or falls, slowed vertical saccades or vertical supranuclear gaze palsy, axial rigidity, and frontal-executive change, but other recognized PSP phenotypes may begin with parkinsonism, gait freezing, speech or language change, or corticobasal features.1

Urgent safety

Seek urgent assessment for choking, breathing difficulty, inability to clear secretions, recurrent fever or chest symptoms after swallowing change, dehydration, rapid weight loss, or a fall with possible head or neck injury. Aspiration may be silent, and early falls can cause serious injury.2

Rapidly changing confusion, weakness, vision, or consciousness should not be attributed to PSP without urgent assessment for another cause.

Clinical pattern and diagnosis

Features may include:

• unexplained falls, gait freezing, backward instability, bradykinesia, and axial rigidity;
• slow vertical eye movements, difficulty looking up or down, impaired eyelid opening, involuntary eyelid closure, or reduced blinking;
• dysarthria, apraxia of speech, language change, and dysphagia;
• slowed processing, impaired planning or judgment, apathy, impulsivity, irritability, or emotional lability.

Diagnosis is clinical and specialist-led. The Movement Disorder Society criteria use combinations of ocular motor, postural instability, akinesia, and cognitive features to describe levels of diagnostic certainty and multiple phenotypes. MRI and other investigations can support the assessment or exclude alternatives, but a characteristic scan or tau-imaging result is not a stand-alone routine diagnosis.1

Treatment, falls, and daily activity

There is no established disease-modifying treatment. Symptom management is individualized. A specialist may trial levodopa for selected parkinsonian symptoms, but response is often limited. Medication choices and changes require specialist review because benefits and adverse effects differ by symptom and person.2

Falls and transfers warrant early, repeated physical and occupational assessment, home-safety review, and caregiver training. Do not prescribe a walker, rollator, wheelchair, or transfer method from the diagnosis alone. Impulsivity, visual scanning difficulty, backward instability, freezing, and poor device control can make some mobility aids unsafe unless tested and fitted directly.2

Swallowing and communication

Speech or swallowing change may occur early. Assessment should consider coughing, voice change, prolonged meals, fatigue, weight and hydration, respiratory history, saliva management, and whether instrumental swallowing evaluation is indicated. Texture, posture, pacing, feeding assistance, and exercises require direct assessment; absence of coughing does not rule out aspiration.2

Reduced speech, slowed initiation, apathy, or executive difficulty can be mistaken for refusal or lack of understanding. Allow extra response time, reduce competing demands, use short concrete choices without infantilizing, write key words, confirm the person's intended message, and support participation in decisions.

AAC should be introduced while the person can help select and learn it. Options may include writing, alphabet or topic boards, stored phrases, text-to-speech, and speech-generating devices. Trial access in real tasks and positions. Eye gaze is not a diagnosis-default for PSP because gaze palsy, slow saccades, eyelid problems, visual attention, and calibration can make it unreliable. Direct touch, switches, partner-assisted scanning, or other access may be better at a given time. Keep a low-tech backup and train communication partners.2 For evaluation, trials, funding, and implementation, use the AAC device acquisition guide.

Coding

• ICD-10-CM G23.1: Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski].

Use current documentation and local coding rules; the code does not capture the person's phenotype, functional profile, or support needs.5

Sources

1. Höglinger et al. Clinical diagnosis of progressive supranuclear palsy: Movement Disorder Society criteria — diagnostic certainty, domains, and variant phenotypes (2017; PMID 28467028).
2. Bluett et al. Best practices in the clinical management of PSP and corticobasal syndrome — CurePSP Centers of Care consensus on symptom management, falls, swallowing, communication, and care planning (2021; PMID 34276544).
3. National Institute of Neurological Disorders and Stroke: Progressive supranuclear palsy — current clinical overview and major safety complications.
4. American Speech-Language-Hearing Association: Augmentative and Alternative Communication — individualized, multimodal AAC assessment.
5. Centers for Medicare & Medicaid Services: FY2026 ICD-10-CM definitions — G23.1 descriptor.

Review boundary

This page cannot diagnose PSP or remotely determine swallowing, aspiration, fall, or decision-making risk. Urgent symptoms require immediate assessment. Medication, diet, exercise, mobility, communication, and care-planning decisions require direct clinical evaluation and the person's participation.