---
title: Parkinson Disease Management
description: A comprehensive clinical reference on the diagnosis, treatment, and monitoring of Parkinson's disease.
keywords: [Parkinson's disease, levodopa, dopamine agonists, deep brain stimulation, motor symptoms, non-motor symptoms]
category: clinical
---

## Diagnostic Criteria

Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by the cardinal motor symptoms of resting tremor, bradykinesia, rigidity, and postural instability. The diagnosis of PD is primarily clinical, based on the presence of these motor features and a positive response to dopaminergic therapy.

The UK Parkinson's Disease Society Brain Bank clinical diagnostic criteria are commonly used to establish a PD diagnosis. These criteria require the presence of bradykinesia plus either resting tremor, rigidity, or postural instability. Secondary features that support the diagnosis include unilateral onset, persistent asymmetry, excellent response to levodopa, severe dopaminergic motor fluctuations, and Lewy bodies on pathology.

Non-motor symptoms, such as cognitive impairment, mood disorders, autonomic dysfunction, and sleep disturbances, are also common in PD and should be assessed. Neuroimaging with dopamine transporter (DAT) imaging can help differentiate PD from other parkinsonian syndromes, but is not required for diagnosis.

## Treatment Approach

The management of PD involves a multidisciplinary approach targeting both motor and non-motor symptoms. Pharmacotherapy remains the mainstay of treatment, with levodopa and dopamine agonists as the primary medication classes.

### Levodopa
Levodopa is the most effective symptomatic treatment for the motor symptoms of PD. It is typically initiated at a low dose (e.g., carbidopa-levodopa 25/100 mg three times daily) and titrated up gradually to the minimum effective dose. Common starting doses are 300-600 mg of levodopa per day, divided into 3-4 doses.

Levodopa is associated with the development of motor complications, including wearing-off, dyskinesias, and unpredictable "on-off" fluctuations, particularly with long-term use. These complications can be managed through adjustments in levodopa dosing, the addition of adjunctive medications (e.g., catechol-O-methyltransferase [COMT] inhibitors, monoamine oxidase-B [MAO-B] inhibitors), or the use of advanced therapies like deep brain stimulation.

### Dopamine Agonists
Dopamine agonists, such as pramipexole, ropinirole, and rotigotine, are often used as initial therapy or as adjuncts to levodopa. They can delay the need for levodopa and may be associated with a lower risk of motor complications. Typical starting doses are pramipexole 0.125 mg three times daily, ropinirole 0.25 mg three times daily, or rotigotine 2 mg/24 hours transdermal patch.

Dopamine agonists can cause adverse effects like somnolence, orthostatic hypotension, and impulse control disorders, which require close monitoring.

### Advanced Therapies
For patients with advanced PD and refractory motor complications, advanced therapies may be considered:

- Continuous subcutaneous apomorphine infusion
- Levodopa-carbidopa intestinal gel (LCIG) infusion
- Deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus

These therapies can provide more consistent dopaminergic stimulation and improve motor fluctuations, but require specialized expertise and careful patient selection.

## Non-Motor Symptom Management

Non-motor symptoms, such as cognitive impairment, depression, anxiety, sleep disorders, and autonomic dysfunction, are common in PD and can significantly impact quality of life. These symptoms should be actively screened for and managed.

### Cognitive Impairment
Cognitive impairment, ranging from mild cognitive deficits to dementia, can occur in PD. The Montreal Cognitive Assessment (MoCA) is a useful screening tool. Cholinesterase inhibitors, such as rivastigmine or donepezil, may be considered for the treatment of PD-related dementia.

### Mood Disorders
Depression and anxiety are prevalent in PD and should be treated with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), such as sertraline or venlafaxine.

### Sleep Disorders
Sleep disturbances, including rapid eye movement (REM) sleep behavior disorder, insomnia, and excessive daytime sleepiness, are common in PD. Melatonin, clonazepam, or modafinil may be helpful, depending on the specific sleep disorder.

### Autonomic Dysfunction
Autonomic symptoms, such as orthostatic hypotension, urinary dysfunction, and constipation, can be managed with lifestyle modifications, hydration, compression stockings, and targeted pharmacotherapy (e.g., midodrine, fludrocortisone, alpha-blockers).

## Monitoring and Follow-up

Patients with PD require regular follow-up and monitoring to assess disease progression, medication efficacy, and the development of complications.

### Clinical Assessments
At each visit, the following should be evaluated:
- Motor symptoms (using the Unified Parkinson's Disease Rating Scale [UPDRS])
- Non-motor symptoms (using validated scales for cognition, mood, sleep, and autonomic function)
- Medication side effects
- Activities of daily living and quality of life

### Laboratory Monitoring
Routine laboratory tests, such as a complete blood count, comprehensive metabolic panel, and thyroid function tests, should be performed periodically to monitor for potential medication-related adverse effects.

### Imaging
Dopamine transporter (DAT) imaging with single-photon emission computed tomography (SPECT) or positron emission tomography (PET) may be considered in atypical cases to help differentiate PD from other parkinsonian syndromes.

## Comorbidities and Contraindications

Parkinson's disease often co-occurs with other medical conditions, which can complicate management. Clinicians should be aware of the following:

### Cardiovascular Disease
Patients with PD and concomitant cardiovascular disease may have an increased risk of orthostatic hypotension with certain PD medications, such as dopamine agonists.

### Cognitive Impairment
Patients with PD and dementia may have a higher risk of adverse effects from anticholinergic medications, which should be avoided.

### Psychiatric Disorders
Patients with PD and psychiatric comorbidities, such as depression or psychosis, may require additional monitoring and adjustments to their medication regimen.

### Gastrointestinal Disorders
Constipation is a common non-motor symptom in PD, and certain medications (e.g., anticholinergics) can exacerbate this issue.

In summary, the management of Parkinson's disease requires a comprehensive, multidisciplinary approach targeting both motor and non-motor symptoms. Careful consideration of medication selection, dosing, and monitoring, as well as the management of comorbidities, is essential for optimizing patient outcomes.