Because new-onset Parkinson’s disease presents so differently from patient to patient, the neurologist cannot follow a single uniform approach. The management strategy of a single person’s disease must be tailored very carefully to their specific presentation. Here are 10 principles that generally guide that strategy:
1. Because the diagnosis is purely based on the clinical impression and no definitive lab tests, biomarkers or scan results, other possible causes must be ruled out aggressively (eg. certain drugs for treating psychiatric symptoms and even one for treating esophageal acid reflux can cause a syndrome that mimics Parkinson’s).
2. There is always the possibility that the first clinical impression could be contradicted by the later development of other symptoms more suggestive of another neurological disease.
3. Sometimes one has to wait to make an accurate diagnosis to a point where more of the so-called “cardinal” symptoms develop.
4. A good response to drugs that increase dopamine (levodopa) or mimic dopamine (dopamine agonists like pramipexole or ropinirole) is supportive of the correct diagnosis.
5. At least early on, often the NMS (non-motor symptoms) can be more disabling and disturbing than tremor and other early motor symptoms. For instance, EDS(excessive daytime sleepiness) can impair job performance and become a real danger (eg. driving) for patients.
6. Patients should be urged to engage in a program of regular daily exercise immediately. Exercise is probably the single best measure at keeping symptom worsening at bay.
7. Patients and family need to be educated that the traditional image of a severely disabled person who can barely walk is not usually around the corner.
8. Treatment needs to be tailored to what is most disturbing to the patient not the doctor. Some patients, for instance, are very conscious of tremor while others are most upset by daytime sleepiness. The drug therapy for either can be very different. Getting rid of tremor for instance may worsen daytime sleepiness and stimulant drugs for sleepiness can often make tremor worse.
9. Drug treatment offers many options however levodopa, the strongest drug, is usually reserved for patients that respond poorly to other weaker drugs with fewer side effects.
10. In prescribing the so-called “milder” drugs, particularly the dopamine agonists pramipexole and ropinirole, patients must be carefully warned about and watched for impulse control disorder/dopamine dysregulation syndrome characterized by compulsive gambling, sex, spending, eating, drug abuse etc. often to great detriment and financial loss to sufferers.
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