Difficulties in long term management of Parkinson's disease

It must be recognised that patients with idiopathic Parkinson's disease will eventually get worse and, where appropriate, realistic prognostications of the future should be conveyed to patients and their responsible relatives. Some 15 per cent of patients will not respond to levodopa. When a patient does not show a significant improvement on therapy a number of important questions should be considered. Is the diagnosis correct? Consider an alternative diagnosis such as progressive supranuclear palsy, drug effect, multi infarct dementia, Alzheimer's disease, striatonigral degeneration, senile or essential tremor and the Shy-Drager syndrome which all may be mistaken for Parkinson's disease. Is the patient complying with therapy? Is the dose adequate and the frequency of administration appropriate? Are the symptoms caused by drug therapy? Would the addition of other therapy assist, for example amantadine, anticholinergics or bromocriptine? Is the patient on other drugs which may be contributing to the impaired function? Is the patient depressed? Is there some other underlying condition aggravating the Parkinson's disease?