Principles of Management

Basic Principles
Managing Early PD
Managing Early to Mid PD
Managing Mid/Late-Stage PD
Managing Late-Stage PD


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LINKS TO: Parkinson's Disease | Ongoing Research by Dr. Lynch et al

This page contains, with Dr. Lynch's permission, excerpts from his article "Treatment of Parkinson's Disease." The full text of this article may be found in the Irish Medical Times, Volume 34 No. 25, June 16, 2000. This is a medically oriented summary of the management of PD at its different stages.

Basic Principles of Management

  • Make the correct diagnosis
  • Educate, advise, support and motivate the patient and family
  • Individualise therapy
  • Maintain the patient's independent function for as long as possible
  • Advise on nutrition, e.g., antioxidant diet; possibly supplement diet with Vitamins C and E
  • Advocate physiotherapy, exercise, occupational therapy, speech therapy, mental exercise
  • Use pharmacology only if functionally impaired
  • Change only one medication at a time, otherwise confusion reigns
  • Change medication slowly, i.e., slow increase and/or slow decrease

Management of Early PD

  • Educate, support and advise Initiate protective therapies, e.g., antioxidants, selegiline 5mg daily
  • Treat constipation with dietary change, stool softeners or laxatives
  • Treat sleep disturbance with low dose tricyclic antidepressants, e.g., amytriptyline
  • Encourage physical and mental exercises
  • Start selegiline early (mild therapeutic effect; may slow down disease progression)

Management of Early to Mid-Stage PD

  • Continue antioxidant diet and selegiline
  • Add a dopamine agonist (e.g., ropinirole, pramipexole, bromocriptine, pergolide, cabergoline, lisuride, amantadine, apomorphine) for bradykniesia, tremor, stiffness or postural instability
  • Add an anticholinergic (e.g., trihexiphenidyl) for tremor if tolerated
  • Add levodopa for falls or in an older patient
  • Use combination therapy (e.g., levodopa therapy and dopamine agonists, or levodopa and COMT inhibitor) if wearing-off or fluctuations are present

Management of Mid/Late-Stage PD

  • Provide gait and balance training if falling is a problem
  • Treat constipation aggressively, as it can interfere with medication absorption
  • Add COMT inhibitor (entacapone) to levodopa if wearing-off or fluctuations develop
  • Adjust dopamine agonist dose if wearing-off or fluctuations occur, and take after meals or adjust the dose or change agonist if there are side-effects
  • Adjust levodopa dose, especially if falls or side-effects occur
  • Add amantadine for levodopa-induced dyskinesias and dystonia
  • Add apomorphine subcutaneously if the patient experiences sudden "offs" or severe motor fluctuations
  • Other agents which may be of benefit include benzodiazepines for anxiety and tremor, atypical neuroleptics for hallucinations, delusions or tremor, and liquid levodopa for rapid absorption and quick recovery from sudden "offs".

Management of Late-Stage PD

  • Management of dyautonomias (e.g., constipation, urinary and sexual dysfunction, orthostatic hypotension, pain)
  • Management of falls secondary to postural instability, freezing or orthostasis
  • Management of motor complications, fluctuations and dyskinesias (e.g., amantadine for dyskinesias, adjustment of levodopa dose or dopamine agonist dose for fluctuations)
  • Management of neuro-psychiatric problems, including hallucinations, delusions, depression, memory loss (e.g., atypical neuroleptics, electro-convulsive therapy)
  • Management of sleep disorders (e.g., insomnia, day time sleepiness, nightmares, REM sleep disorder and restless leg syndrome)


  1. Knowledge of the causes and pathogenesis of PD has changed dramatically over the past five years.
  2. New medical and surgical therapies are appearing, offering the Parkinson's patient an array of treatment options.
  3. This, however, makes the management of patients more complex, and requires a large amount of time and commitment on the part of the physician.

    Section One: Parkinson's Disease | Section Two: Current Treatments
    Section Three: Starting Treatment | Section Four: Glossary

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