Outpatient visit for Parkinson's disease

Article by Master, Doctor Vu Duy Dung - Department of General Internal Medicine - Vinmec Times City International Hospital

Parkinson's patients can most likely see a neurologist or a movement disorder specialist for treatment. Health care workers must pay attention to both motor and non-motor symptoms of the disease.

Information about any recent falls, swallowing problems, comorbidities, hospitalization, or a change in life should be collected. Non-motor symptoms including constipation, pain, and emotional turmoil should not be ignored (refer to the section on inactivity symptoms HERE). Patients should be encouraged to see their primary care physician and other specialists for overall health and mental health care.

When evaluating a patient with Parkinson's for medication adjustment, it is important to remember that this is a disease of timing. Failure to understand a patient's motor and non-motor response to their dosing schedule over the course of a day can prevent accurate medication management decisions. Rarely will this information be obtained by simply calculating the total daily dose of Parkinson's medications or asking general questions, such as "How are you doing?" or “Do you have a problem?”. Patient diaries, timing of administration, and 24-hour clinical response are often helpful in determining motor response patterns to drugs.
It is possible to adjust the drug after considering the Parkinson's drugs being taken, the time and the dose. Drawing a line chart can help. The number of doses taken during the day should be entered in the table according to when the patient said he took the medication. Care should be taken when drugs are used as rapid-release or controlled-release formulations.
Questions about motor response may include the following:
How long does it take for your Parkinson's medicine to work after each dose? How long does the effect of each drug last? (Indicate this information for each dose interval) Do you have any disturbances in the interval between doses? Does the dyskinesia occur toward the beginning or end of the dose range? Do you experience wearing off toward the end of the dose range? Can you estimate how long before the next dose starts to work? Do you have dystonia or pain or twisting in your extremities early in the morning? Does dystonia occur at other times of the day? Do you have periods of the day when the medication doesn't seem to work? Are these times around meal times?

With this information, the dose can be changed to provide maximum on time and minimum off time. For example, if wearing off is predictable, the dose may need to be increased or taken thicker or a different form of carbidopa/levodopa used. If early morning dyskinesia is present, patients may benefit from a controlled-release form of carbidopa/levodopa taken at bedtime. If patients report lack of effect after a high protein meal, they may be advised to eat a lower protein intake during the day. The dyskinesia can also be treated with an NMDA antagonist or by reallocating carbidopa/levodopa.

Parkinson's disease is a complex neurodegenerative disease presenting as a mixed disorder. Exciting research continues to be conducted on the etiology and pathogenesis of the disease. New imaging techniques such as SPECT can now aid in the diagnosis. New drug forms are available for easier application and improved clinical efficacy.
Treatment of Parkinson's disease continues to be symptomatic, and the disease is currently incurable. The recognition that Parkinson's disease has a preclinical phase has prompted the need to search for early biomarkers. Research continues to focus on neuroprotective and disease-modifying strategies, including therapies that target α-synuclein. Future research into the etiology, pathogenesis, and ultimately cure of Parkinson's disease remains hopeful, considering the remarkable progress that has been made over the past half-century.

Source: Theresa A. Zesiewicz. Parkinson's Disease. Continuum (Minneap Minn) 2019;25(4, Movement Disorders): 896-918.
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