Parkinson’s disease: A treatment guide

Consider tai chi, physical therapy to reduce falls

One study showed that tai chi, performed for an hour twice weekly, was significantly more effective at reducing falls when compared to the same amount of resistance training and strength training, and that the benefits remained 3 months after the completion of the 24-week study.²⁵ To date, tai chi is the only intervention that has been shown to affect fall risk.

The only medication that has evidence for reducing dyskinesias in patients with Parkinson's disease is amantadine.

Guidelines recommend that physical therapy be available to all patients.¹⁶ A Cochrane review performed in 2013 determined that physical therapy improves walking endurance and balance but does not affect quality of life in terms of fear of falling.²⁶

When meds no longer help, consider deep brain stimulation as a last resort

Deep brain stimulation consists of surgical implantation of a device to deliver electrical current to a targeted area of the brain. It can be considered for patients with PD who are no longer responsive to carbidopa/levodopa, not experiencing neuropsychiatric symptoms, and are experiencing significant motor complications despite optimal medical management.¹⁴ Referral to a specialist is recommended for these patients to assess their candidacy for this procedure.

Prognosis: Largely unchanged

While medications can improve quality of life and function, PD remains a chronic and progressive disorder that is associated with significant morbidity. A study performed in 2013 showed that older age at onset, cognitive dysfunction, and motor symptoms nonresponsive to levodopa were associated with faster progression toward disability.²⁷

Keep an eye on patients’ bone mineral density (BMD), as patients with PD tend to have lower BMD,²⁸ a 2-fold increase in the risk of fracture for both men and women,²⁹ and a higher prevalence of vitamin D deficiency.³⁰

One study showed that tai chi, performed for an hour twice weekly, was significantly more effective than the same amount of resistance and strength training at reducing falls.

Also, watch for signs of infection because the most commonly cited cause of death in those with PD is pneumonia rather than a complication of the disease itself.¹¹

End-of-life discussions. As with any potentially life-limiting disease, family physicians should have ongoing discussions with patients and families about goals of care and the importance of completing advanced care directives while the patient is in good health.

CORRESPONDENCE
Michael Mendoza, MD, MPH, MS, FAAFP, 777 South Clinton Avenue, Rochester, NY 14620; Michael_Mendoza@urmc.rochester.edu.