TREATMENT OF

PARKINSON DISEASE
MEDICAL PHYSICAL THERAPIES
DOPAMINERGIC P.T.
AGENTS O.T.
ANTI-CHOLINERGICS; SPEECH
etc. OMT, BIOFEEDBACK
SURGICAL EXERCISE Rx, TAI-CHI
ABLATIVE PSYCHOTHERAPIES
RESTORATIVE COUNSELLING
D.B.S. SOCIAL WORK
MEDS., etc.
WHEN TO START TREATMENT
FOR PARKINSON DISEASE
WHEN DISEASE MANIFESTATIONS
INTERFERE WITH SOCIAL AND
VOCATIONAL ACTIVITIES,
WORSENING OR GAIT OR BALANCE
OR OTHER ACTIVITIES OF DAILY
LIVING.
PARTNERSHIP WITH PATIENT!
 WHY DELAY THERAPY?
MINIMAL EFFECT ON ADL
PATIENT PREFERENCE
DRUG SIDE EFFECTS
LEVODOPA SPARING STRATEGY
TO FORESTALL LONG TERM
COMPLICATIONS OF THE DRUG
 WHAT ABOUT
NEUROPROTECTIVE AGENTS?
ATTEMPT TO SLOW OR IMPEDE DISEASE
PROGRESSION AND CELL DEATH. HARD
TO EVALUATE AS SOME AGENTS ALSO
CONFER A SYMPTOMATIC BENEFIT.
IDENTIFICATION OF PRE-CLINICAL
DISEASE STATE AND BIOMARKER IS A
PRIORITY OF CURRENT RESEARCH.
PET AND SPECT?
 SOME NEUROPROTECTIVE
AGENTS
MANY ONGOING STUDIES
SERMS PROTECT AGAINST DOPA-ERGIC
NEURONAL DEGENERATION
VITAMIN E (TS) ENRICHES SUBST NIGRA
MITOCHONDRIA, DECREASED OXIDATIVE
STRESS
COENZYME Q10 ATTENUATES MPTP EFFECTS
ON DOPAMINE NEURONS
SELEGILINE PRESERVES MITOCHONDRIAL CO-
Q10 LEVELS
MINOCYCLINE INTERFERES WITH ACTIVATION
OF APOPTOTIC PATHWAYS
 MORE
NEUROPROTECTIVE AGENTS
AMANTADINE NMDA RECEPTOR ANTAGONIST
DOPAMINE AGONISTS ANTI-OXIDANT, PROTECT
DOPAMINE NEURONS, etc.
CALM-PD STUDY PRAMIPEXOLE VS. L-DOPA
SPECT
REAL-PET STUDY ROPINIROLE VS. L-DOPA FD-
PET
EARLY PD - CO-Q-10, MAOBIS. DOPAMINE
AGONISTS AS SYMPTOMATIC TREATMENT
 MORE
NEUROPROTECTIVE AGENTS
AMANTADINE NMDA RECEPTOR ANTAGONIST
DOPAMINE AGONISTS ANTI-OXIDANT, PROTECT
DOPAMINE NEURONS, etc.
CALM-PD STUDY PRAMIPEXOLE VS. L-DOPA
SPECT
REAL-PET STUDY ROPINIROLE VS. L-DOPA FD-
PET
EARLY PD - CO-Q-10, MAOBIS. DOPAMINE
AGONISTS AS SYMPTOMATIC TREATMENT
 TREATMENT OF EARLY
PARKINSON DISEASE
CONSIDER: CO-Q-10, VITAMIN E (TS) MAY HELP
LEG CRAMPS?
SELEGILINE OR RASAGILINE (2ND GENERATION
MAOBI) AMPHETAMINE EFFECT?
AMANTADINE RAPID ONSET OF ACTION, AVOID
IN COGNITIVE PROBLEMS
ANTI-CHOLINERGICS ESPECIALLY GOOD FOR
TREMOR NOT SO FOR ELDERLY
DOPAMINE AGONISTS PRAMIPEXOLE AND
ROPINIROLE. LONG ACTING
 WHAT ABOUT
LEVODOPA/CARBIDOPA?
STILL THE BEST, ESPECIALLY SHORT
TERM
LONG TERM USE MOTOR
FLUCTUATIONS, DYSKINESIAS
INVERSELY PROPORTIONAL TO AGE
BUT NEARLY ALL PATIENTS
EVENTUALLY REQUIRE IT
COMTAN EXTENDS HALF-LIFE OF
LEVODOPA, EARLY USE??
 WHEN TO START
LEVODOPA/CARBIDOPA
FOR EARLY SYMPTOMATIC TREATMENT AND
FOR RAPID RESPONSE, i.e. TO AID PATIENT TO
CONTINUE WORKING ESPECIALLY FOR
RIGIDITY & BRADYKINESIA
WHEN OTHER MEDS FAIL OR BECOME LESS
EFFECTIVE
AS ADD-ON TREATMENT TO DOPAMINE
AGONISTS, etc.
FOR DE NOVO ELDERLY PATIENT. DOPAMINE
AGONISTS SIDE EFFECTS?
 SOME STRATEGIES TO
ENHANCE L-DOPA EFFECT
SELTZER WATER//Parcopa//something new
BREAK CRS IN HALF
LIMIT DIETARY PROTEIN DURING THE
DAY
USE CR FORM AT BEDTIME
START OFF THE DAY WITH BOTH
REGULAR AND CR MEDS
ADD COMTAN TO PROLONG EFFECT AND
INCREASE ON-TIME
 OTHER THERAPEUTIC
OPTIONS - SURGERY
ABLATIVE THALAMOTOMY,
PALLIDOTOMY IRREVERSIBLE
RESTORATIVE EMBRYONIC
DOPAMINERGIC TISSUE
TRANSPLANTATION SOME GRAFTED
NEURONS DIFFERENTIATED AND RE-
INNERVATED
DEEP BRAIN STIMULATION THALAMIC,
PALLIDAL, SUBTHALAMIC MORE
TREATMENT FLEXIBILITY
 WHAT ABOUT DEEP BRAIN
STIMULATION?
OFTEN HELPFUL IN TREATMENT OF
MOTOR FLUCTUATIONS
MOST COMMON TYPE IS DEEP BRAIN
STIMULUS OF STN. ACTS LIKE
ELECTRONIC LEVODOPA. REDUCES
TREMOR, RIGIDITY AND BRADYKINESIA,
ALLOWS REDUCTION OF L-DOPA DOSE,
BUT ANTI PD-EFFECT NO BETTER THAN
L-DOPA.
 MORE ON DEEP BRAIN
STIMULATION
DEEP BRAIN STIMULATION IS ACTUALLY
BETTER FOR TREMOR ALONE THAN
L-DOPA
CONTRAINDICATIONS INCLUDE LACK OF
RESPONSE TO L-DOPA AND COGNITIVE
PROBLEMS
ADVERSE EFFECTS OF DBS
HEMORRHAGE, INFECTION, WIRE
BREAKAGE, SPEECH IMPAIRMENT,
DYSTONIA