Patient handout

Parkinson Disease (outpatient + chronic)

PRODUCTION

1. Your condition

This handout is for parkinson disease (outpatient + chronic). Your care team identified this based on: unilateral 4-6 hz rest tremor improving with movement (mds 2015 postuma pmid 26474316).

Other reasons your team may use this plan: bradykinesia — decrement / fatiguing on repetitive finger/foot tapping (mds 2015 cardinal feature); asymmetric cogwheel rigidity (mds 2015 supportive); postural instability + recurrent falls (pigd phenotype; falls in first 3 y → consider psp).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
carbidopa-levodopa	25/100 mg PO ½ tab TID with meals; titrate to 1-2 tabs TID over 4 wk	PO	TID-QID	Most efficacious motor agent; LEAP (Mendis NEJM 2019) — early start does NOT worsen course; preferred over DA in older or functionally limited patients per MD 2021 review PMID 30673543
pramipexole	0.125 mg PO TID; titrate weekly to 0.5-1.5 mg TID	PO	TID	Younger patients may favour DA to delay levodopa-induced dyskinesia; CAUTION — ICD risk (gambling/hypersexuality/binge eating) — screen at every visit (QUIP-RS); also OH + somnolence + sleep attacks driving risk
ropinirole	0.25 mg PO TID; titrate weekly to 1-8 mg TID	PO	TID	Alternative non-ergot DA; same ICD/somnolence cautions

Plan: PD motor management — symptom-driven start + advanced motor fluctuation strategy (MDS 2015 + LEAP PMID 30673543)

3. When to call your provider

Contact your care team if any of the following happen:

Acute decompensation (NMS, severe psychosis, aspiration, fall with injury) → ED
Severe motor fluctuations refractory to oral combos → DBS referral or LCIG / Vyalev
Severe psychosis refractory to pimavanserin + quetiapine → clozapine consult
Severe OH with syncope → urgent autonomic workup + droxidopa
ICD positive (QUIP-RS) → reduce/discontinue DA, switch to levodopa
Severe RBD with injury → clonazepam carefully or melatonin escalation
Cognitive decline interfering with function → rivastigmine + driving cessation + caregiver intensification

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

PIGD phenotype — postural instability + gait disorder + freezing predominant; high fall risk; consider PSP if falls within 3 y of onset
MSA suspected — early (within 5 y of motor onset) severe autonomic failure (OH, urinary retention/incontinence, ED), cerebellar features, pyramidal signs, anterocollis, or poor levodopa response (MDS criteria 2015)
PSP suspected — falls within 3 y of onset + vertical (especially downward) supranuclear gaze palsy + axial rigidity + cognitive/behavioral changes (MDS criteria 2015)
CBD suspected — asymmetric apraxia + alien-limb + cortical sensory loss + asymmetric rigidity + myoclonus + poor levodopa response
Advanced PD — wearing-off + dyskinesias + off-time >2 h/day refractory to oral combos; candidate for device-assisted therapy (DBS, LCIG, foslevodopa-foscarbidopa) (MD 2021 review PMID 30673543)
Severe freezing of gait — on or off; refractory to medication adjustments; high fall risk
Severe OH — drop ≥30/15 within 3 min lying-to-standing with recurrent syncope; if EARLY (<5 y) suspect MSA
PD dementia — MoCA <26 with PD ≥1 y after motor onset (MDS criteria Emre 2007); rivastigmine indicated (EXPRESS Emre NEJM 2004 PMID 15590953)
DBS candidate — refractory motor fluctuations + preserved levodopa response + cognition intact + multidisciplinary review (Williams NEJM 2014 PMID 20519680)

5. Follow-up

Annual functional / cognitive / mood / autonomic review; revisit DBS candidacy q12-24 mo if disease progresses; revisit driving safety; goals-of-care for advanced PD; hospice referral when Hoehn-Yahr 5 + bed-bound + dementia + aspiration risk; palliative-care integration earlier (MDS palliative care position 2017)

6. Sources

Guideline: 2015 MDS Clinical Diagnostic Criteria for PD (Postuma, Mov Disord 2015;30:1591-601) + MDS prodromal criteria 2015/2019 (Berg/Heinzel) + MDS criteria validation (Postuma 2018) + AAN-aligned therapy landmark RCTs (LEAP, ADAGIO, Follett STN-vs-GPi DBS, EXPRESS rivastigmine, Cummings pimavanserin) + MSA/PSP/DLB/CBD diagnostic-criteria consensus statements