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Neurosurgical consultation may be appropriate in patients with tremor, dyskinesias, motor fluctuations, or dystonia refractory to medical treatment. However, patients with dementia or significant psychiatric or behavioral problems are not candidates for current neurosurgical treatments for Parkinson disease.

Psychiatric consultation may be required to control mood disorders and psychiatric symptoms, especially in patients with refractory depression or psychosis.

A urologist is consulted for evaluation and treatment of urinary frequency, urgency, incontinence, or erectile dysfunction.

A physiatrist, physical therapist, or occupational therapist may be able to improve the patient's ability to perform activities of daily living, reduce pain, and avoid fractures and compression neuropathies from falls. Botulinum injections for limb dystonia can be very helpful and are administered by specially trained physiatrists or neurologists.

A nutritionist can help ensure adequate energy intake, particularly when low-protein diets are needed to avoid adverse effects of levodopa.

An otolaryngologist can offer vocal fold bulking procedures in the form of vocal fold injection or Gore-Tex thyroplasty as a possibility in treating refractory true vocal fold bowing. Bilateral injections to medialize the vocal fold can offer improvement, unless the patient is already aphonic due to advanced disease. Bilateral collagen, gel, fat, and hydroxyapatite injections have been used for this purpose. [] Articulatory problems can persist, and the result of surgery can be disappointing.

A gastroenterologist and a speech therapist may be needed to evaluate dysphagia, a common complication in patients with more advanced Parkinson disease. Excessive sialorrhea can be treated with botulinum toxin injections into the salivary glands, usually administered by neurologists or otolaryngologists. In some patients, a gastrostomy may be needed to maintain adequate nutrition.

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Patients with Parkinson disease must have regular follow-up care to ensure adequate treatment of motor and behavioral abnormalities. Once patients are stable on a medication regimen, provide follow-up care at least every 3-6 months, and periodically adjust medication dosages as necessary. Patients also need to be monitored for adverse events, including somnolence, sudden-onset sleep, impulse control disorders, and psychosis. In addition, patients should be evaluated and treated for emergence of clinically relevant nonmotor symptoms, including dementia, psychosis, sleep disorders, and mood disorders.

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Future treatments for Parkinson disease are covered in Future Treatments for Parkinson’s Disease: Surfing the PD Pipeline . This article provides a discussion of new therapies in clinical development that may alleviate motor features or slow disease progression, including A2a antagonists, levodopa formulations, other antiparkinsonian medications, antidyskinesia medications, and gene therapy.

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References

Hauser RA, Grosset DG. [(123) I]FP-CIT (DaTscan) SPECT Brain Imaging in Patients with Suspected Parkinsonian Syndromes. . 2011 Mar 16. .

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This paper explores pragmatic approaches that might be employed to document the behavior of large, complex socio-technical systems (often today shorthanded as “algorithms”) that centrally involve some mixture of personalization, opaque rules, and machine learning components. Thinking rooted in traditional archival methodology — focusing on the preservation of physical and digital objects, and perhaps the accompanying preservation of their environments to permit subsequent interpretation or performance of the objects — has been a total failure for many reasons, and we must address this problem. The approaches presented here are clearly imperfect, unproven, labor-intensive, and sensitive to the often hidden factors that the target systems use for decision-making (including personalization of results, where relevant); but they are a place to begin, and their limitations are at least outlined. Numerous research questions must be explored before we can fully understand the strengths and limitations of what is proposed here. But it represents a way forward. This is essentially the first paper I am aware of which tries to effectively make progress on the stewardship challenges facing our society in the so-called “Age of Algorithms;” the paper concludes with some discussion of the failure to address these challenges to date, and the implications for the roles of archivists as opposed to other players in the broader enterprise of stewardship — that is, the capture of a record of the present and the transmission of this record, and the records bequeathed by the past, into the future. It may well be that we see the emergence of a new group of creators of documentation, perhaps predominantly social scientists and humanists, taking the front lines in dealing with the “Age of Algorithms,” with their materials then destined for our memory organizations to be cared for into the future.

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