Parkinson Disease

INTRODUCTION

The classic quintet of Parkinson disease:

• tremor (pill-rolling at rest)

• rigidity

• bradykinesia (poverty of movement)

• postural instability

• gait freezing

Power, reflexes and sensation usually normal. ≥2 signs = Parkinson disease.

PHARMACOLOGICAL MANAGEMENT

Don’t postpone—commence ASAP (Fig. P1). Refer for shared care.

Mild Minimal disability:

• levodopa preparation (low dose), e.g. levodopa 100 mg + carbidopa 25 mg (½ tab (o) bd—increase gradually as nec. to 1 tab tds)

• amantadine 100 mg (o) daily may help younger patients or

• selegiline—can be added if inadequate response

Moderate:

Independent but disabled (e.g. writing, movements, gait):

• levodopa preparation

• add if nec.—dopamine agonist preferably non-ergot dopamine agonist (e.g. pramipexole or rotigotine)—allows reduction of dose and improves motor fluctuations

Severe:

Disabled, dependent on others:

• levodopa (to max. tolerated dose) + non-ergot dopamine agonist

• add entacapone with each dose of levodopa

• consider antidepressants

Note: Education and support of both patient and family essential.

Apomorphine (+ anti-emetic) effective for severe rigidity.

If cognitive impairment with psychosis:

• ↑ levodopa slowly to max. tolerated dose, e.g. 450–600 mg/d

• eliminate other drugs

• add quetiapine or olanzapine at night