The diagnosis of Parkinson’s disease, which was first described at the beginning of the 19th century, is difficult, especially in the early stages, because usually not all symptoms are pronounced or other entities overlap in symptoms. Exclusion of other causes of parkinsonism, for example, secondary parkinsonism of toxic, vascular, or metabolic etiology or pseudoparkinsonism due to normal pressure hydrocephalus, is therefore of even greater importance. Here, morphological and functional imaging methods can provide valuable services. In addition to the exclusion procedure, the actual diagnosis “Parkinson’s disease” can be supported by means of specific classification analyses for individual manifestations.
The start of drug therapy must be determined individually, based on the patient’s personal level of suffering. Although most antiparkinsonian drugs are effective, levodopa is preferable in parkinsonisms and in the elderly and polymorbid. Motor fluctuations can also be treated initially by more frequent administration of levodopa or retard preparations. When administering adjunctive medications such as COMT inhibitors, dopamine agonists, or MAO-B inhibitors, a slight reduction in levodopa is recommended to avoid an increase in dyskinesias. In cases of severe fluctuations and advanced disease, pump treatment or invasive methods may be considered after conventional therapy has been exhausted.
Non-motor symptoms also increase during the course. They have a significant impact on the patient’s quality of life and are sometimes even worsened by antiparkinsonian drugs. Central to this is the proper medication regimen because it makes some of the most common non-motor symptoms treatable. Reduction of responsible medications is especially recommended for impulse control disorders and psychosis. Apathias, sleep disorders, and depression, for example, respond to dopaminergic therapy.
Last but not least, deep brain stimulation, which works by applying high-frequency pulses to specific brain areas, offers a way to reduce non-motor symptoms, such as levodopa-responsive pain. In addition, it has also proven to be a suitable therapeutic method for fluctuations.
It turns out that the possibilities of diagnosing and treating Parkinson’s disease have made great progress since its discovery a good 200 years ago. Nevertheless, this disease will remain a major challenge for the treating physician in the future, not least because it has a very high prevalence: Along with Alzheimer’s disease, it is one of the most common neurodegenerative diseases.
Cordial collegial greetings
Prof. Dr. med. Philippe Lyrer
Prof. Dr. med. Erich Seifritz
