Diagnosis

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Diagnosis

Parkinson's Disease

- Reduce the dose of or discontinue medications contributing medications -Non-pharm → change positions slowly, avoid large meals/excessive alcohol, increase fluid intake, elevate head on pillows - Consider initiation of domperidone, fludrocortisone or midodrine

Assess for Complications

Hallucinations

- Gradually decrease dose + eliminate PD medications w/ potential for hallucinations in the following order : Anticholinergics, MAO-B inhibitors, DA, Levodopa - If above fails, consider antipsychotics (quetiapine, clozapine)

Freezing

- Increase levodopa dose - Add DA or MAO-B - Non Pharm → sensory cues + devices

Dyskinesias

- Increase (diphasic) or reduction (peak-dose) in levodopa dose - Add DA - Increase dose of DA if on concurrent therapy - Add Amantadine

Motor Complications "Wearing Off"

-increase Levodopa dose if patient does not have dyskinesia or increase frequency if patient has dyskinesia. Addition of a dopamine agonist, COMT or MAO-B inhibitor can also be considered.

Lower dose of Levodopa

Treat with SSRIs/TCAs/Benzodiazepines

Anxiety

Adjust dopaminergic drugs

Autonomic Dysfunction (GI disorders, Orthostatic Hypotension, Sexual Dysfunction, Urinary Incontinence)

Urinary Incontinence

Oxybutynin, Tolterodine, Propantheline

Sexual Dysfunction

Sildenafil

Orthostatic Hypotension

Fludrocortisone, Domperidone, midodrine

GI Disorders

PEG, stool softeners, Lactulose, Domperidone

Excessive Daytime Sleepiness

Modafinil

Monitoring

With changes in pharmacotherapy follow-up every 1-2 weeks then every 3-6 months once on a stable regimen

Assess Benefit

Check for decrease in tremor, rigidity, sluggish movements and gait disturbances

Suboptimal Response

Consider, increasing the dose of the agent; initiating Levodopa/Dopamine agonist; adding therapy (i.e. dopamine agonist, MAO-B i, COMT-i, etc); changing time of administration/formulation

mild bradykinesia

Non-Motor Symptoms

Patient Factors

Age

Age ≥ 60 years

Dopamine precursor + decarboxylase

Age < 60 years

COMT-inhibitors

NMDA antagonist

Initiate treatment when symptoms interfere with functionality and quality of life

Rigidity

MAO-B inhibitors

Dopamine Agonists

Anti-cholinergics

Motor Symptoms

Sleep Dysfunction

RLS/PLMD

REM Behaviour Sleep Disorders

Eliminate TCAs and adjust

Insomnia

Doxepin

Mood Disorders (Anxiety, Depression)

Depression

Treat with SSRIs/TCAs

Cognitive Disorders (Impairment, Dementia)

Treat with acetylcholinesterase inhibitors such as donepezil, rivastigmine or galantamine

Gradually discontinue anticholinergic medications

Akinesia

severe bradykinesia

Postural instability

Tremor