Practice tips

• Levodopa is the gold standard for therapy.

• Longer acting levodopa preparations may reduce the 'end of dose' failure effect but remember the possible need for a 'kick start' with short-acting preparations, e.g. first thing in the morning.

• Ensure that a distinction is made between drug-induced involuntary movements and the tremor of Parkinson's disease.

• Keep the dose of levodopa as low as possible to avoid these drug-induced involuntary movements.

• In the elderly with a fractured hip always consider Parkinson's disease (a manifestation of disequilibrium).

• Remember the balance of psychosis and Parkinson's disease in treatment.

• Keep in mind the 'sundown' effect—patients often go psychotic as the sun goes down.

• Don't fail to attend to the needs of the family, who often suffer in silence.

• Bromocriptine and pergolide should be used very cautiously in the elderly because of possible acute psychotic reactions.

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