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KEY CONCEPTS
Awareness and continuous surveillance of motor and nonmotor symptoms in combination with thoughtful consideration of initial and adjunctive therapies with adjustment of drug dosing throughout the course of idiopathic Parkinson disease (PD) is required to optimize long-term therapeutic outcomes, minimize adverse effects, and improve quality of life.
In general, treatment should be initiated when the disease begins to interfere with activities of daily living, employment, or quality of life.
Surgery is an option for patients who require additional symptomatic relief or control of motor complications.
Anticholinergic medication can be useful for mild symptoms of PD but, due to anticholinergic side effects, should be used with caution in the elderly and in those with pre-existing cognitive difficulties.
Monotherapy, amantadine and the irreversible monoamine oxidase type B (MAO-B) inhibitors provide symptomatic benefit, but less than that of dopamine agonists or carbidopa/levodopa (L-dopa).
Carbidopa/L-dopa is the most effective medication for symptomatic treatment.
Most carbidopa/L-dopa–treated patients will develop motor complications (eg, fluctuations and dyskinesias).
MAO-B inhibitors (irreversible and reversible) and catechol-O-methyltransferase (COMT) inhibitors are useful add-on therapies to attenuate motor fluctuations in carbidopa/L-dopa–treated patients.
Amantadine is a useful add-on agent to attenuate dyskinesias.
Dopamine agonists are effective and, compared to L-dopa, associated with less risk of developing motor complications but more risk of causing psychiatric symptoms, such as hallucinations and impulse control disorders.
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Patient Care Process for Parkinson Disease
Collect
Patient characteristics (eg, age, race, sex, hand dominance)
Patient history (past medical, family, social—dietary habits, alcohol and tobacco use)
Motor and nonmotor symptoms (see Tables 76-1 and 76-2)
Current medications, prior medication use for Parkinson disease and response to prior medications for Parkinson disease (eg, effectiveness, side effects), prior use of dopamine receptor blockers
Objective data
Height, weight
Labs (eg, serum creatinine [Scr], liver function tests [LFTs])
Other diagnostic tests when indicated (eg, neuroimaging)
Assess
Past and current use of medications associated with drug-induced parkinsonism (eg, antipsychotics, metoclopramide, tetrabenazine)
Difficulties with performing activities of daily living
Gait difficulties and fall risk
Motor or nonmotor symptoms that are most troublesome for the patient
Appropriateness, effectiveness, and side effects of current medications for the motor and nonmotor symptoms of Parkinson disease
Presence of motor complications (eg, motor fluctuations, dyskinesias, freezing)
Plan*
Tailored lifestyle modifications (eg, exercise)
Drug therapy regimen including specific medications for Parkinson disease, dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Table 76-3)
Monitoring parameters including efficacy (eg, symptom improvement) and tolerability medication-specific adverse effects; see Table 76-4), and time frame
Patient education (eg, purpose of treatment, lifestyle modification, drug therapy, side effects)
Self-monitoring of symptoms—where and how to record results
Referrals to other providers when appropriate (eg, physician, physical therapy, speech therapy)
Implement*