A syndrome of motor and non-motor symptoms due to dopamine depletion in the basal ganglia.
Motor symptoms include bradykinesia, rigidity and resting tremor which can start unilaterally or bilaterally. Freezing and falls common.
Non-motor symptoms include sleep disturbance, constipation, urinary and sexual dysfunction, loss of smell, depression, dementia
Idiopathic versus other parkinsonian states – multiple system atrophy, progressive supranuclear palsy – red flags for these include prominent autonomic symptoms such as postural hypotension, falls

Diagnosis – clinical , can be supported by DAT scan. Positive response to levodopa can also support the diagnosis.

Management
Levo-dopa
* is the mainstay of treatment and usually should be 1st line.
* combined with carbidopa or benzeraside to reduce peripheral breakdown of levodopa
* typically start 100mg three times per day and titrate up (or 50mg tds for elderly)
* side effects: nausea, postural dizziness, somnolence. Over time dyskinesia can develop (amantadine can reduce this)
* fluctuations are common – ‘on time’/’off time’ – may need to increase frequency of levo-dopa
* in later stages, patients may need to preference more mobility with dyskinesia or less mobility with bradykinesia

Dopamine agonists (pramipexole, ropinirole)
* an option in mild parkinsons/younger patients but caution re: dyskinesia, confusion, compulsive behaviour (eg gambling), sleep attacks, lower leg oedema
* can be used as add-on therapy to levo-dopa

MAO-B inhibitors (rasagaline, selegiline)
* another option for mild symptoms

Non-motor symptoms – eg. clonazepam for insomnia, SSRI for depression

Refer patients to physiotherapy, exercise physiology, OT early on

Parkinson’s information hub