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Treatment of Parkinson’s Disease

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The treatment of Parkinson's disease is symptomatic and in daily clinical practice is indicated taking into account the functional impact of the symptoms. There are no scientifically valid treatments available that act on the mechanisms that cause the disease or change its course.

At the time of the diagnosis, it is important to provide health education relative to the disease, as well as the psychosocial support of the patient and their family and friends.

Non-pharmacological treatment

Healthy life habits. It is advised to follow a Mediterranean diet and carry out physical and intellectual activities, adapted to each case.

Speech therapy. Speech therapy is recommended in patients with speech or swallowing (dysphagia) problems. Thickeners can also help in the management of dysphagia, which in severe cases may require feeding by a gastrostomy tube.

Cognitive stimulation. It is advised for patients that have cognitive changes, which are sometimes manifested from the beginning, and others later, and can be from mild to a dementia comparable to that of Alzheimer’s disease.

Physical activity and diet. It is recommended in those patients with involvement of the autonomous nervous system that regulates visceral functions (dysautonomia), if they are constipated, to increase physical activity and have a diet rich in fibre; while for those that their arterial pressure is lower when they change posture (orthostatic hypotension), it is recommended to increase fluid intake, as well as a diet with salt or eat often, but in small amounts.

Vitamin supplements. There is no scientific evidence that supports the prescription of vitamin supplements in general. However, some patients may have vitamin deficiencies that can sometimes show symptoms. If this is detected, it is necessary to supplement the vitamin in question.

Pharmacological treatment

In initial phases, and with no, or very little, functional repercussion, it is recommended not to start a treatment for the symptoms. In this phase, there is the possibility of offering patients to participate in clinical trials with experimental treatments that aim to act on the mechanisms of the disease and modify its course.

The pharmacological treatment acts on the symptoms with variable effectiveness. It is usual to start with low doses, and increase them gradually, in order to ensure tolerance (to avoid nausea, essentially).

There are three large groups for symptomatic treatment:

Dopamine precursors (levodopa in different formulas with different inhibitors of dopa-decarboxylase) to increase its bioavailability.

Dopaminergic receptor agonists (there are different availabilities by oral or transdermal route).

Enzyme inhibitors of levodopa degradation (inhibitors of the monoamine oxidase B (MAO-B) of catechol-O-methyltransferase (COMT) inhibitors).

The treatment is individualised, based on the needs of the patients, and always monitoring its efficacy, as well as the appearance of any side effects. In the treatment of the non-motor symptoms, laxatives are used for the constipation, anticholinergics for the urinary problems, drugs that increase blood pressure in cases of hypotension, antidepressants for the depression and apathy, or anticholinesterases for the cognitive impairment and dementia.

Drugs for Parkinson's disease

Los fármacos para la enfermedad de ...

Surgical Treatment

If the patient develops complications of refractory motor fluctuations to the pharmacological adjustments, complex therapies are available.

Deep brain stimulation by functional neurosurgery, usually of the subthalamic nucleus.

Continuous drug infusions that work on the premise that a continuous drug infusion avoids or minimises the motor fluctuations.

Continuous infusion of intestinal levodopa gel requires a surgical-endoscopic procedure (insertion of a gastrostomy tube).

Continuous subcutaneous infusion (with an infusion pump similar to that of continuous insulin infusions) of a dopaminergic antagonist (apomorphine).

The three treatments (deep brain stimulation, intestinal infusion of levodopa, and the subcutaneous infusion of apomorphine) are similar in indication and efficacy although with nuances, although there are no comparative studies of the three. Although surgery has its limitation on not being indicated in patients greater than 70 years-old, or with active cognitive or psychiatric anomalies, it appears to be more effective if the patients are well-selected.

Surgical treatment is currently performed in specialist centres and requires an assessment by experts in order to confirm that the patient is a candidate for the treatment. After the surgery is performed, adjustments are made to the stimulator parameters until optimal control of the symptoms is achieved.

Treatment complications

The most common side effects of the drugs are nausea (can be treated to decrease them) and the hallucinations in older patients and/or with previous cognitive impairment.

Levodopa is associated with the so-called chronic complications of treatment, such as motor fluctuations and involuntary generalised or focal movements (dyskinesia) that occur normally after a long-term treatment with levodopa and drugs that increase bioavailability.

The inability to control impulses is currently the most worrying side effect of dopaminergic agonists. These have a 20-30% risk of inability to control impulses (compulsive gambling, hypersexuality, binges, or compulsive shopping), with the highest risk being in young patients with a previous history of addictions.

The nausea, hallucinations, and the hypotension can be produced by all the treatments, but more with agonists than with levodopa. The agonists can also cause swelling (oedema), particularly of the legs, and erythromelalgia (reddening of the skin, oedema, an increase in temperature and pain that increases with the movement and positioning of the limbs, especially the legs) in extreme cases, whilst amantadine can cause livedo reticularis (a symptom that causes a reddish-blue colouring in the skin). The MAO-B inhibitors can severely interact with determined drugs (particularly some antidepressants) in a form of a tyramine reaction, or a serotoninergic syndrome (a group of symptoms caused by an excess of serotonin that affects good humour, sleep, diet, perception of colour, pleasure, and sexual desire).

Serious side effects of the surgery are rare, but might include less than 1% of cases of suffering a cerebral bleeding that is usually the trajectory of inserting the electrodes. There may also be other side effects, such as behavioural changes that require a more detailed control and adjustment of the parameters during the follow-up.

Substantiated information by:

Almudena Sánchez Gómez

Ana Cámara Lorenzo

Maria José Martí Head of the Parkinson's and Movement Disorders Unit

Yaroslau Compta Hirnyj Neurologist Neurology Service

Published: 8 July 2019
Updated: 14 November 2019

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