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Advanced Parkinson's disease — SCE Neurology MCQ

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HardMovement DisordersAdvanced Parkinson's diseaseSCE Neurology

A 59-year-old man with Parkinson's disease has severe wearing-off and peak-dose dyskinesia despite optimised oral levodopa, rasagiline and entacapone. He has no dementia, psychosis or uncontrolled depression. Examination during an off period shows marked bradykinesia; MRI is unremarkable. What is the most appropriate management?

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Correct answer: C — Refer for device-aided therapy assessment

Refer for device-aided therapy assessment is the best answer. Disabling motor fluctuations despite optimised medication in a cognitively suitable patient should prompt assessment for device-aided therapies such as DBS, apomorphine or levodopa intestinal gel. Abrupt levodopa withdrawal is unsafe; olanzapine and haloperidol worsen parkinsonism; physiotherapy helps function but does not address severe fluctuations. Clinical pearl: Advanced therapy referral should occur before disability and comorbidity make options impossible.

Reference: NICE NG71; ABN advanced Parkinson's disease guidance