How is the progression of Parkinsonism managed?

From the Guidelines

The management of Parkinson's disease progression requires a multifaceted approach combining medications, physical therapy, and supportive care, with a strong emphasis on nutritional therapy to improve well-being and quality of life, as recommended by the ESPEN guideline 1. The progression of Parkinsonism is a complex process that affects various aspects of a patient's life, including motor function, cognitive abilities, and overall quality of life.

Key Considerations

• The disease is characterized by the depletion of dopamine in the brain, leading to symptoms such as tremor, muscular rigidity, bradykinesia, and postural instability 1.
• As the disease progresses, patients may experience a range of other symptoms, including dysphagia, dysarthria, impaired gastrointestinal motility, fatigue, depression, and cognitive impairment 1.
• Malnutrition is a significant concern in patients with Parkinson's disease, with approximately 15% of community-dwelling patients and 24% of patients at medium or high risk of malnutrition 1.

Management Strategies

• Medical nutrition therapy is essential to improve well-being and quality of life in patients with Parkinson's disease, and should be tailored to individual requirements 1.
• A protein-redistribution dietary regimen can help maximize levodopa absorption and efficacy, particularly in patients experiencing motor fluctuations 1.
• Patients should be advised to take levodopa medications at least 30 minutes before meals, and to comply with controlled-protein dietary regimens to minimize interactions with dietary amino acids 1.
• Regular physical therapy, occupational therapy, and speech therapy can help maintain mobility, adapt to daily living, and address communication difficulties.
• Medications such as levodopa, dopamine agonists, COMT inhibitors, and MAO-B inhibitors can help control symptoms and manage motor fluctuations.

Quality of Life Considerations

• The management of Parkinson's disease progression should prioritize quality of life, with a focus on maintaining mobility, independence, and overall well-being.
• Individualized nutritional information and support can help improve quality of life and reduce the risk of malnutrition in patients with Parkinson's disease 1.
• Regular monitoring and adjustment of treatment plans can help address emerging cognitive symptoms, such as those treated with rivastigmine 1.

From the FDA Drug Label

Parkinson's disease is a progressive, neurodegenerative disorder of the extrapyramidal nervous system affecting the mobility and control of the skeletal muscular system. The progression of Parkinsonism is managed by treating its symptoms, as there is no cure for the disease.

• Symptomatic treatments: Such as levodopa therapies, may permit the patient better mobility.
• Mechanism of action: Levodopa crosses the blood-brain barrier and is converted to dopamine in the brain, relieving symptoms of Parkinson's disease.
• Pharmacodynamics: Carbidopa inhibits decarboxylation of peripheral levodopa, making more levodopa available for transport to the brain. The management of Parkinsonism progression involves the use of medications such as rasagiline, carbidopa, and levodopa to control symptoms and improve mobility 2, 3, 4.

From the Research

Progression of Parkinsonism

The progression of Parkinsonism is a complex process that involves the management of motor and non-motor symptoms.

• Parkinson disease is the most common form of parkinsonism, with over 6 million individuals worldwide affected by the disease 5.
• The disease has multiple variants with different prognoses, including a diffuse malignant subtype with prominent early motor and nonmotor symptoms, and a mild motor-predominant subtype with slower disease progression 5.

Management of Parkinsonism

The management of Parkinsonism involves a combination of pharmacologic and nonpharmacologic approaches.

• Dopamine-based therapies, such as levodopa, are typically used to help initial motor symptoms, while nonmotor symptoms require nondopaminergic approaches, such as selective serotonin reuptake inhibitors for psychiatric symptoms and cholinesterase inhibitors for cognition 5, 6.
• Rehabilitative therapy and exercise can complement pharmacologic treatments and help improve motor and nonmotor symptoms 5.
• Advanced treatments, such as deep brain stimulation and levodopa-carbidopa enteral suspension, can help individuals with medication-resistant tremor, worsening symptoms, and dyskinesias 5, 6.

Disease Progression

The progression of Parkinson disease is influenced by various factors, including the disease variant, response to medication, and presence of motor and nonmotor symptoms.

• Individuals with a diffuse malignant subtype of Parkinson disease have a faster disease progression, while those with a mild motor-predominant subtype have a slower disease progression 5.
• The emergence of motor complications, such as a wearing-off phenomenon, is a clinical problem that can be managed with newly developed agents and advances in device and formulation technology to deliver drugs continuously 7.
• Non-motor symptoms, such as depression and cognitive decline, can also impact disease progression and require careful management 8, 9.

Treatment Strategies

Treatment strategies for Parkinsonism involve a multidisciplinary approach that focuses on improving the patient's and family's quality of life.

• A balanced approach is necessary to manage advancing motor symptoms, progressive non-motor features, and potential pharmacologic adverse effects 9.
• Nonpharmacologic strategies, such as exercise and physical, occupational, and speech therapies, can be used to complement pharmacologic treatments and improve motor and nonmotor symptoms 5, 9.
• Palliative care is also an important part of Parkinson disease management, particularly in advanced stages of the disease 5.