Motor symptoms, treatment

The treatment of non-motor symptoms should be based on whether they are worse during an off state or if they could be related to other neurotransmitter dysfunction. 

The treatment of non-motor symptoms, such as psychological conditions, sleep disorders, and autonomic dysfunction, should include both pharmacologic and nonpharmacologic approaches. Patients should be given suggestions for maintaining ADLs, a positive self-image, family communication, and a safe environment. 

Preclinical studies of ziprasidone indicate that it also has a low propensity to induce EPS, which was confirmed in subsequent phase II and III studies. Furthermore, the motor symptoms evoked by ziprasidone were seldom sufficiently troublesome to warrant anticholinergic medication. In one phase III trial, not more than 25% of patients receiving 160 mg/day were prescribed an anticholinergic at any time during the 6-week treatment period. These results indicate that therapeutic doses of ziprasidone not only induce a low incidence of acute EPS, but when they occur, they are often mild and do not require antiparkinsonian medication (137). 

Controversy exists as to when specific anti-Parkinson drugs should be employed.1,16 Much of the debate focuses on when levodopa therapy should be initiated. Without question, levodopa is the most effective pharmacological treatment for reducing the motor symptoms of Parkinson disease. As mentioned previously, however, long-term use of levodopa poses several risks, and the effectiveness of this drug seems to diminish after several years of use. Consequently, some practitioners question whether levodopa therapy should be withheld until the parkinsonian symptoms become severe enough to truly impair motor function. In theory, this saves the levodopa for more advanced stages of this disease, when it would be needed the most.48... 

Agitation, which may occur in patients with dementia, can be treated with anti-psycho tics agents, mood stabilizing anticonvulsants, trazadone and anxiolytics (Doody et al., 2001). The atypical anti-psychotic medications are the treatment of choice for psychotic symptoms, such as hallucinations or delusions, particularly in those with Parkinsonism in whom dopamine receptor blockage is contraindicated due to the potential to worsen motor symptoms. In these patients, clozapine, which may reduce tremor in addition to its anti-psychotic effects, is particularly effective. However, rare cases of agranulocystosis necessitate weekly blood counts, and so limit its utility. Que-tiapine may be the next agent of choice because it appears to have fewer adverse motor effects than the other medications... 

Absence status epilepticus is a condition of impaired consciousness, perhaps including mild motor symptoms, that lasts from 30 minutes to 12 hours. It can be distinguished from ongoing seizures because of organic or toxic causes by the spike-and-wave EEC pattern that is characteristic of absence seizures. The usual pharmacological treatment of absence status employs diazepam or lorazepam, followed by ethosuximide. 

Juvenile Huntington disease with acute onset of motor symptoms coincident with initiation of treatment with methylphenidate has been reported [74 ]. 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Response fluctuations occur with disease progression as the patient s dopamine reserves are depleted in the brain and as a complication of PD treatment. Motor fluctuations include delayed peak response, early wearing off, random unpredictable on-off, and freezing. Dyskinesias include chorea, dystonia, and diphasic dyskinesia. Wearing off can be visualized by imagining the therapeutic window of dopamine narrowing over time. The therapeutic window is defined as the minimum effective concentration of dopamine required to control PD symptoms (on without dyskinesia) and the maximum concentration before experiencing side effects from too much dopamine (on with dyskinesia). Early in the disease, a dose of... 

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