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• Response to levodopa before deep brain stimulation is a good indicator of better outcome following DBS.

Treatment of Parkinson's patients is highly individualized and is based on many criteria. These include:

• Level of disability
• Stage of the disease
• Age of the patient
• Presence of comorbid conditions (e.g., dementia, hypertension)

Evaluation of these parameters helps determine when to introduce drug therapy and which classes of drugs to employ. Though there are no standard guidelines that are applicable for all patients, there are certain principles that seem to be widely accepted. These include:

• If the patient is below the age of 70, they will usually be given dopamine agonists as the initial therapy because motor complications from levodopa are a significant issue for these patients and the dopamine agonists reduce the incidence of motor complications.

• If the patient is above 70 years of age, they will usually be started on levodopa because:

  • older patients are less likely to be affected by motor complications from levodopa
  • levodopa is less likely to cause problems for people with comorbid conditions
  • levodopa is better tolerated than most other classes of Parkinson's disease drugs in terms of both cognitive and behavioral side effects
  • levodopa is usually used as the initial treatment for any patient who has cognitive impairment

Beyond these general principles, there is a great deal of variation in how patients are medicated. It is crucial for the patient to be under the care of a doctor who has extensive knowledge and experience in the diagnosis and treatment of Parkinson's disease. The decisions to add medications, and to raise or lower doses, are made very carefully and must be monitored by a medical professional who is intimately familiar with the nuances of the progression of Parkinson's disease as well as controlling side effects.

As the disease and level of disability progress, there are several options to manage motor complications that arise. These include:

• Smaller and more frequent doses of levodopa
• Adding or increasing dopamine agonists to levodopa
• Adding MAO-B or COMT inhibitors in order to increase the half-life of levodopa
• Adding amantadine or selegiline to reduce dyskinesia

Neuroprotective Therapy for Parkinson's Disease

The goal of neuroprotective therapy is to prevent disease progression by treating the mechanisms involved in causing Parkinson's disease. There are many studies being conducted to evaluate various agents that may possibly slow the progression of Parkinson's disease. Some of these agents include:

• Coenzyme Q10 (ubidecarenone)- an antioxidant
• Certain dopamine agonists - so far the indications are that the only dopamine agonist that might do so is pramipexole and possibly ropinirole. However, the current evidence is inconclusive and no definitive conclusions have been reached.
• MAO-B inhibitors (selegiline, rasagiline)

A Practice Parmater published by the American Academy of Neurology (AAN) indicated that no treatment to date has been shown to be neuroprotective. To read more about the conclusions of the AAN regarding neuroprotective agents and Parkinson's disease, please click on the following link:

http://aan.com/professionals/practice/guidelines/Neuroprotective_PD.pdf