Strategies for treating patients with advanced Parkinson's disease with disastrous fluctuations and dyskinesias

Patients with advanced Parkinson's disease often develop severe fluctuations and dyskinesias while receiving long-term levodopa therapy. These complications can prove increasingly difficult to control. Here we review our strategies for coping with such problems. These include establishing the best rational schedule of levodopa treatment, optimizing levodopa absorption, the use of oral dopaminergic agonists, and the use of subcutaneous injections or infusions of apomorphine or lisuride. The problems of severe dyskinesias, sleep disturbances, psychotoxicity, and urinary difficulties also are considered. Finally, the role of new surgical procedures to treat Parkinson's disease is reviewed.