Initiating therapy for Parkinson's disease

Accurate diagnosis and individualized assessment of the risks and benefits of available antiparkinsonian medications should guide initiation of treatment for patients with early Parkinson's disease (PD). In general, the goals of treatment for younger patients (less than age 60 years) are control of impairing symptoms, sparing of levodopa to minimize long-term complications, and consideration of neuroprotection. The primary initial medication choices for patients under age 50 years include selegiline, amantadine, and anticholinergic agents. Patients in their fifties may require a dopamine agonist in addition to or instead of selegiline to achieve adequate symptom control. If the desired response is still not achieved, sustained-release carbidopa-levodopa should be added, followed by adjunctive amantadine or anticholinergic therapy. For older patients (60 years and over), improvement of functional impairment is the primary goal. For these patients, a special concern is to avoid inducing or exacerbating cognitive impairment. Sustained-release carbidopa-levodopa is considered first-line treatment for these patients. Inadequate response can be handled by a trial of immediate-release carbidopa-levodopa and then addition of a dopamine agonist when maximum levodopa doses are reached. Anticholinergic agents, amantadine, and selegiline should be avoided because of their CNS effects.