Synopsis
Choose person-centred motor treatment, preserve time-critical dopaminergic dosing and manage wearing-off, dyskinesia and advanced disease without overlooking behavioural and non-motor harms.
- Offer levodopa when early motor symptoms affect quality of life; if they do not, discuss levodopa, a non-ergot dopamine agonist or an MAO-B inhibitor using individual risks and preferences.
- Doses must be given at the person's established times, not merely standard drug-round times. Delayed or omitted levodopa can cause profound immobility, aspiration and a hyperpyrexia syndrome.
- Wearing-off is predictable return of symptoms before the next dose; delayed-on reflects slow absorption, while sudden unpredictable immobility is an on-off phenomenon.
- Peak-dose dyskinesia occurs when levodopa effect is greatest; diphasic dyskinesia appears as concentration rises and falls, so an accurate timing diary precedes dose manipulation.
- For troublesome fluctuations despite optimal levodopa, specialist add-on choices include a dopamine agonist, MAO-B inhibitor or COMT inhibitor; amantadine may be considered for dyskinesia.
- All dopaminergic therapy can cause impulse-control disorders, with higher risk from dopamine agonists; warn the patient and family about gambling, shopping, binge eating and hypersexuality before starting.
- Hallucinations, daytime sleepiness, postural hypotension, confusion and compulsive behaviour may cause more harm than a modest motor gain, particularly in frailty or cognitive impairment.
- Protein can alter levodopa absorption in some people with fluctuations, but dietary redistribution should be supervised so weight loss and malnutrition are not worsened.
- Advanced options include intermittent or continuous apomorphine, deep-brain stimulation and commissioned intestinal or subcutaneous levodopa systems after multidisciplinary assessment.
- Physiotherapy, occupational therapy, speech and language therapy, exercise, falls prevention and palliative approaches are treatments throughout the illness, not substitutes offered only when medicines fail.
Key red flags
New gambling, spending, eating, sexual behaviour, hobbyism or compulsive medicine use may be concealed from the patient; collateral history and non-judgemental direct questions are essential.
Visual hallucinations, delusions, daytime sleepiness or confusion emerge after dose escalation, infection or cognitive decline. Physical triggers and the whole medicines list need review before antipsychotic treatment.
Missed or abruptly stopped dopaminergic treatment is followed by severe rigidity, fever, dysphagia, autonomic instability, confusion and raised creatine kinase, resembling neuroleptic malignant syndrome.
Investigation priorities
Map each exact dose against on-time, wearing-off, freezing, dyskinesia, sleep and food to classify the motor complication.
Management branches
A specialist has confirmed Parkinson disease and motor symptoms need treatment.
- Define which activities, discomfort or participation the person wants to improve and assess cognition, postural pressure, sleepiness, hallucination and impulse-control vulnerability.
- Offer levodopa when motor symptoms impair quality of life; for lesser impact, discuss levodopa, non-ergot dopamine agonist and MAO-B inhibitor with comparative benefits and harms.
- Record counselling on sleep attacks, driving, hallucinations and impulse-control behaviours, invite family observations with consent and arrange an early response and tolerability review.
- Refer for Parkinson-specific physiotherapy, occupational or speech-and-language assessment when balance, activity, communication, saliva or swallowing would benefit.