Drug management in older Parkinson’s disease patients

Parkinson’s disease (PD) is a common degenerative neurological disorder in older people. Its management is primarily focused on symptom control and maintenance of self-care and quality of life. The use of medication for PD is affected by patient age, symptoms and degree of disability, clinician experience, and drug cost, availability and side effects, as well as patient choice. This article discusses practical tips and myths of drug management for older PD patients. Department of Medicine and Geriatrics, Fung Yiu King Hospital, Pokfulam, Hong Kong Correspondence to: Dr James KH Luk, Department of Medicine and Geriatrics, Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong. Email: lukkh@ha.org.hk be neuroprotective.4 It remains unclear whether levodopa can positively or negatively affect the natural history of PD.5 Compared with a dopamine agonist, levodopa results in a higher incidence of dyskinesia and motor fluctuations.6 Yet there is evidence that choice of initial therapy has little impact on such incidence. There is an unproven concept that patient responsiveness to levodopa is finite. It is uncertain whether reduction in responsiveness to levodopa over time is due to a decline in drug response or progression of disease. In older patients, it is advocated that levodopa should be the first-line therapy, as it is the most effective drug to improve PD symptoms.7 A ‘wait and watch’ policy may not be appropriate in older PD patients. Few PD patients can be satisfactorily maintained on dopamine agonist monotherapy for more than a few years before levodopa is needed. Dopamine agonists are more likely than levodopa to cause hallucinations.8,9 They may also induce somnolence or sleep attacks. Severe leg oedema can occur occasionally and is difficult to treat without drug cessation. Therefore, unless contraindicated, levodopa should be started early in older PD patients to enhance their QOL.