Treating advanced Parkinson disease

Advanced therapies (ie surgery and pump-delivered dopaminergic therapy) for Parkinson disease are provided in specialised movement disorders units.

Increasingly, surgery is used to treat Parkinson disease—high-frequency deep brain stimulation is preferred. Surgery is most successful in patients with severe motor fluctuations and dyskinesias. However, surgery does not alleviate cognitive deficits, nonmotor complications and some motor effects (especially postural instability, falls, dysarthria and on-period gait freezing).

Surgery is contraindicated when the patient has:

• a major psychiatric illness
• cognitive impairment
• a major medical illness
• a cardiac pacemaker that is not compatible with magnetic resonance imaging (deep brain stimulation is not possible)
• levodopa-resistant parkinsonism, except when tremor is the main symptom.

Advanced age is a relative contraindication for surgery.

Continuous dopaminergic therapy via portable, programmable pumps is available for older patients or when surgery is unsuitable. Levodopa+carbidopa intestinal gel is administered continuously through a permanent tube, directly into the duodenum or upper jejunum. Apomorphine is delivered subcutaneously. For both drugs, adjusting infusion rates and giving bolus doses helps smooth out motor fluctuations and dyskinesias.