Treatment strategy

Mild

(minimal disability):

• levodopa preparation (low dose)

e.g. levodopa 100 mg + carbidopa 25 mg (^ tab bd—increase gradually as necessary to 1 tab (o) tds)

• amantadine 100 mg (o) bd may help the young or the elderly for up to 12 months

• selegiline (can postpone need for L-dopa)

Moderate 10

(independent but disabled, e.g. writing, movements, gait):

• levodopa preparation

• add if necessary—pergolide or selegiline pergolide 50 •g (o) bd, gradually increasing to 1.5 mg (max) bd selegiline 2.5 mg (o) daily, increasing to 5 mg (max) bd

Severe

(disabled, dependent on others):

• levodopa (to maximum tolerated dose) + pergolide or selegiline

• consider antidepressants

Table 29.4 Parkinson's disease: symptoms and signs (a checklist)

General • Lethargy

• Restlessness

Tremor

Rigidity

Bradykinesia/hypokinesia

Gait disorder

Disequilibrium Posture

Autonomic symptoms Psychiatric

• Alternating, especially arms

• Pill-rolling (severe cases)

Note: may be absent or unilateral

'Cogwheel' Lead pipe

Slowness of initiating a movement Difficulty with fine finger tasks Micrographia (Fig. 29.3) Masked facies Relative lack of blinking Impaired convergence of eyes Excessive salivation (late)

Difficulty turning over in bed and rising from a chair Slow monotonous speech/dysarthria

No arm swing on one or both sides Start hesitation Slow and shuffling Short steps (petit pas) Slow turning circle

'Freezing' when approaching an obstacle Festination

Poor balance Impaired righting reflexes Falls (usually late)

Progressive forward flexion of trunk Flexion of elbow at affected side

Constipation (common) Postural hypotension Depression (early)

Progressive dementia in 30-40% usually after 10 years

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