Managing the critical problems of advanced Parkinson's disease

The symptoms of Parkinson's disease can become increasingly difficult to control as the disease advances, particularly with the development of motor complications, such as end-of-dose wearing-off and dyskinesias, following long-term therapy. At this stage, the patient is frequently referred to a Parkinson's disease specialist for advice on their disease management. In this review, we provide an overview of the Parkinson's disease specialist's strategies for coping with such problems. This includes establishing the optimum and most rational L-dopa treatment schedule, improving L-dopa absorption, use of catechol-O-methyl transferase inhibition, the addition of oral dopaminergic agonists and the use of subcutaneous injections or infusions of apomorphine or lisuride. The role of new surgical procedures to treat Parkinson's disease is also reviewed. Finally, we highlight the increasing importance of treatment strategies that stimulate dopamine receptors in a more continuous, less pulsatile manner as a way of reducing the risk of developing treatment-associated motor complications.