Drugs play the most important role in symptom relief. No agent has yet been found to alter the progressive course of the disease.
Treatment should begin only when it is judged necessary in each individual case. For example, a young man with a physically demanding job will require treatment before an older retired person. Two conflicting objectives have to be balanced: the desire for satisfactory relief of current symptoms and the avoidance of adverse effects as a result of long-continued treatment. There is debate as to whether the treatment should commence with levodopa or a synthetic dopamine agonist. Levodopa provides the biggest improvement in motor symptoms but its use is associated with the development dyskinesias, which are inevitable after some 5-10 years, and sometimes sooner. Dopamine agonists have a much less powerful motor effect but are less likely to produce dyskinesias. Some neurologists therefore prefer a dopamine agonist alone as the initial choice. Unfortunately, only about 30% of patients obtain a satisfactory motor response. An alternative, therefore, is to begin treatment with levodopa in low dose to get a good motor response, and to add a dopamine agonist when the initial benefit begins to wane. With either approach, it seems likely that the position after 5 years treatment may well be the same, but that by starting with levodopa the patient will have had the benefit of a earlier motor response.
Antimuscarinic drugs are suitable only for younger patients predominantly troubled with tremor and rigidity. They do not benefit bradykinesia, the main disabling symptom. The unwanted effects of acute angle glaucoma, retention of urine, constipation and psychiatric disturbance are general contraindications to the use of antimuscarinics in the elderly.
Amantadine or selegiline can delay the use of either levodopa or a synthetic dopamine agonist in the early stages of the disease if mild symptomatic benefit is required, but this approach is seldom necessary.
A typical course is that for about 2-4 years on treatment with levodopa or a dopamine agonist, the patient's disability and motor performance remains near normal despite progression of the underlying disease. After some 5 years, about 50% of patients
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