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Parkinson Disease Management Î Bradykinesia + at least 1 of following: > Muscular rigidity > 4–6 Hz unilateral resting tremor > Postural instability/gait instability (not due to primary visual, vestibular, cerebellar, or proprioceptive dysfunction) Î Tremor as initial presentation [more benign course/longer response to dopaminergic therapy] Î Older age (57–78 yr) at onset [more rapid motor decline, earlier cognitive decline and dementia] Î Rigidity/hypokinesia as presenting signs [more rapid motor decline, earlier cognitive decline and dementia] Î Associated comorbidities [faster motor decline] Î Male sex [faster motor decline] Features predicting rates of progression of Parkinson disease Î Consider deep brain stimulation of subthalamic nucleus to: > Improve motor function > Reduce motor fluctuations, dyskinesia, and antiparkinsonian medication usage Î Candidate patients: > Levodopa-responsive, non-demented, and neuropsychiatrically intact > Intractable motor fluctuations, dyskinesia, or tremor Surgical option for Parkinson disease [see Table 2] Î Unilateral onset Î Persistent asymmetry of motor signs, mostly affecting side of onset Î Progressive signs/symptoms Î Falls occurring later as disease progresses Î Clinical course of ≥10 yr Î Significant loss of smell (hyposmia/anosmia) Î Excellent response to levodopa and apomorphine challenges Î Severe levodopa induced chorea Î Response to levodopa ≥10 yr Features supporting diagnosis of Parkinson disease [ ≥3 of following for presumptive diagnosis]: Presenting parkinsonism signs/symptoms Î Consider an MAO-B inhibitor as initial treatment for mild symptomatic relief before instituting dopaminergic therapy Î Dopaminergic therapy: > Dopamine agonists: > Fewer motor complications (e.g., wearing off, dyskinesias, on-off motor f luctuations) > More frequent adverse events (e.g., hallucinations, somnolence, edema) > Levodopa > Better improvement of motor disability > No difference in rate of motor complications between immediate- and sustained-release formulations Î Adjunctive therapy: > MAO-B Inhibitors > COMT Inhibitors > Dopamine Agonists Symptomatic therapy for Parkinson disease [see Table 3] OR