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Disease Report: Parkinson's disease


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Certainly! Here is a comprehensive answer based on the latest international guidelines (NICE, Canadian, and AAN), with references and detailed explanations.

1. Disease Summary:

Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder characterized primarily by motor symptoms (bradykinesia, rigidity, resting tremor, postural instability) and a wide range of non-motor symptoms (cognitive impairment, mood disorders, sleep disturbances, autonomic dysfunction, etc.). The disease is caused by the loss of dopamine-producing neurons in the substantia nigra of the brain. PD typically affects people over the age of 60, but younger onset is possible. The course of the disease is variable, and management is complex, requiring individualized, multidisciplinary care.
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2. Standard of Care:

A. Diagnosis and Initial Assessment

  • Clinical diagnosis is based on history and examination, using criteria such as the UK Parkinson’s Disease Society Brain Bank Clinical Diagnostic Criteria.
  • Referral to a specialist (neurologist or movement disorder specialist) is recommended for confirmation and management planning.
  • Imaging (e.g., DaTscan/SPECT) may be used if the diagnosis is unclear.
  • Regular review of diagnosis is recommended, especially if atypical features develop.
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B. Pharmacological Management of Motor Symptoms

  • First-line therapy:
    • Levodopa (with carbidopa or benserazide) is recommended for patients whose motor symptoms impact quality of life.
    • Dopamine agonists or MAO-B inhibitors may be considered for those with less impact on quality of life, but levodopa is generally preferred due to efficacy.
    • Non-ergot dopamine agonists are preferred over ergot-derived agents due to safety.
  • Motor fluctuations/dyskinesia:
    • Adjust levodopa dosing.
    • Add dopamine agonists, MAO-B inhibitors, or COMT inhibitors as adjuncts.
    • Amantadine may be considered for dyskinesia.
  • Abrupt withdrawal of antiparkinsonian drugs should be avoided due to risk of severe complications.
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C. Non-Pharmacological Management

  • Multidisciplinary care is essential, including:
    • Physiotherapy: For gait, balance, and mobility issues.
    • Occupational therapy: For activities of daily living and adaptive strategies.
    • Speech and language therapy: For dysarthria, dysphagia, and communication.
    • Dietitian referral: For nutrition, weight management, and protein redistribution if needed.
    • Parkinson’s disease nurse specialist: For ongoing support and care coordination.
  • Exercise and physical activity are strongly encouraged at all stages.
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D. Management of Non-Motor Symptoms

  • Depression, anxiety, psychosis: Screen regularly; treat with appropriate medications (e.g., SSRIs for depression, quetiapine/clozapine for psychosis).
  • Cognitive impairment/dementia: Cholinesterase inhibitors (e.g., rivastigmine) may be considered.
  • Sleep disturbances: Address underlying causes; consider melatonin or clonazepam for REM sleep behavior disorder.
  • Autonomic dysfunction: Manage orthostatic hypotension, constipation, urinary symptoms, etc., with targeted therapies.
  • Impulse control disorders: Monitor for compulsive behaviors, especially with dopamine agonists; adjust therapy as needed.
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E. Advanced Therapies

  • For advanced PD with refractory motor fluctuations/dyskinesia:
    • Deep brain stimulation (DBS): Consider for those not adequately controlled with best medical therapy.
    • Apomorphine infusion or levodopa-carbidopa intestinal gel may be options.
    • Foslevodopa–foscarbidopa is a newer option for severe cases (per NICE TA934).
  • Best medical therapy should always be optimized before considering device-aided therapies.
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F. Palliative Care and Advance Care Planning

  • Palliative care should be integrated early and throughout the disease course, not just at end-of-life.
  • Advance care planning (including discussions about prognosis, future care preferences, and legal directives) is recommended.
  • Support for caregivers and family is essential.
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G. Communication and Patient-Centered Care

  • Shared decision-making is emphasized throughout all guidelines.
  • Comprehensive care plans should be developed with the patient, family, and multidisciplinary team.
  • Education and support for patients and caregivers are vital.
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3. Additional Context:

  • Care should be individualized based on patient symptoms, comorbidities, preferences, and social circumstances.
  • Regular follow-up is necessary to monitor disease progression, treatment efficacy, and side effects.
  • Multidisciplinary teams (neurologists, nurses, physiotherapists, occupational therapists, speech therapists, dietitians, social workers, and palliative care specialists) are key to optimal management.
  • Education and support for patients and caregivers improve outcomes and quality of life.
  • Guidelines are regularly updated as new evidence emerges; clinicians should consult the latest versions.

4. References:

In summary:
The standard of care for Parkinson’s disease is a patient-centered, multidisciplinary approach that includes accurate diagnosis, individualized pharmacological and non-pharmacological management, regular monitoring, management of motor and non-motor symptoms, timely use of advanced therapies, integration of palliative care, and ongoing education and support for patients and caregivers. This approach is supported by major international guidelines and is continually updated as new evidence emerges.