Patient 1

Mr. Tan (not his real name) is a 65-year-old man who has been suffering from Parkinson's Disease (PD) for about seven years. Initially, he did well with Madopar (250 mg) 1/2 tablet three times a day. With such a low dose of medications, his stiffness and tremor almost completely disappeared. His legs felt strong enough to enable him to walk for 30 minutes everyday. He could even drive his car.

However, for the past two years, he slowed down. His hands started trembling again, to the extent that he spilt the soup on his shirt when he had dinner. While sleeping, he could no longer turn his body to the side. Even waking up in the morning was tough. He needed his wife to pull him up from the bed and help him to stand up. He fell down often at home, as his legs could not "listen" to him anymore. Due to his weakness and falls, he was too scared to leave his home.

When I saw him in my clinic, I explained to him that the first five years of his illness was the "honeymoon period", during which his illness responded well to just small total daily dose of medications. And what happened over the past two years (his recent deterioration) was merely due to the progression of his PD, which all Parkinson's patients experience. In order to solve his recent problem, I suggested that he increase his total daily dose of Madopar, to one tablet three times a day.

Despite my explanation, he was initially reluctant to take a higher dose of medications. "I am worried that if I keep on increasing the dose of my medications, I will run out of options soon," he replied.

But finally, after much persuasion, Mr. Tan increase the dose of his medications. Yesterday, when he came back to my clinic, he was back to almost normal again, while taking four tablets of Madopar daily. He could do everything on his own again, without needing any help. And he did not have to bother his wife again whenever he woke up in the morning.

Patient 2

Mrs. Lee (not her real name) is a 67-year-old lady who has been having PD for five years. She had started taking Madopar (250 mg) one tablet three times a day right from the early stage of her illness. Even though she did well initially, for the past one year she had experienced "violent trembling" of her legs about one hour following each dose of Madopar. She also noticed that she started feeling stiff and slow about two hours after each dose of Madopar.

Despite this, she could still walk round the house, albeit feeling unsteady. To her family's surprise, she could still do some household work and carry out daily activities on her own, in spite of the "violent trembling".

All along, Mrs. Lee had been a very active housewife. Even though she had a maid, she was determined to be as independent as possible. As such, she increased the dose of Madopar to six times a day, in order to "keep going". Despite this, she still could not get rid of the "violent trembling" which she thought was the "off" period tremor, i.e. periods of inadequate medications. Following this, she took a total of ten tablets of Madopar a day (which was a rather high dose). Again, the "violent trembling" of her legs did not disappear, but instead it became worse. That was when she consulted me.

I discovered that the "violent trembling" of her legs was actually "dyskinesia", (involuntary movement caused by medications) which suggested that she was taking a bit too much medications. I cut down her Madopar to just 1/2 tablet five times a day. Over the next week, she got better - the dyskinesia was reduced significantly.

Discussion

This is very common dilemma faced by many Parkinson's patients. How much total daily dose of medications is considered adequate (just nice) or too little or too much?

It is important to know that the ultimate aim of medical treatment of PD is to enable or help Parkinson's patients to attain a relatively normal quality of life, i.e. to carry out daily activities as normal as they wish.

As such, the adequate or optimal total daily dose of medications depends on the following factors, which should be seriously considered in every Parkinson's patients' treatment;

a) The disease duration

This refers to the total number of years of illness. The longer is the disease duration, the higher is the total daily dose of medications required. This is a peculiar nature of PD - it progresses relentlessly despite optimal medications. Every one or two years, the total daily dose of medications needs to be increased in order to keep the patient going.

b) The concept of "quality of life"

This certainly varies among individuals. I think it depends on how optimistic or pessimistic a person is in life.

Some people desire to continue working, driving or playing games jut like any other healthy people. There are Parkinson's patients who are still working despite having the illness for ten years or so. As such, they need to take a higher total daily dose of medications (say, six tablets of Madopar a day plus other types of medications) to maintain their daily physical activities.

For those who live sedentary life, i.e. housewives or pensioners who seldom leave home, a smaller total daily dose of medications is sufficient (say, three tablets of Madopar a day). However, having said this, it is also important to make sure that the "small dose" of medications is enough to help the patient to carry out daily activities independently. There is no point in minimizing the total daily dose of medications to the extent of being almost "crippled", as Patient 1.

Mr. Tan (Patient 1) has minimized his total daily dose of medications due to a common misconception - that if the dose of medications is increased to the maximum too early, then there will be no more medications left to be used in the late stage of PD. The truth is, this is a wrong statement.

In this day and era, there are many new medications for PD (there are, in fact, many options). And even if patients have reached a late stage of illness when the medications are no longer that effective, there is another option left - brain surgery. The currently available surgical technique (Deep Brain Stimulation, DBS) helps Parkinson's patients to have a relatively good quality of life for another seven years or so. And after the effect of DBS has worn off, there will be newer medications or surgical techniques. Thus, the issue of "running out of options" in the treatment of PD is no longer relevant nowadays.

In other words, Patient 1 did not have to minimize his total daily dose of medications.

On the other hand, Mrs. Lee (Patient 2) took an excessive total daily dose of medications. She was unrealistic - taking ten tablets of Madopar a day despite being able to carry out her daily activities. She expected too much from her treatment. She did not need to take such a high dose of Madopar.

It is important to now that the aim of treatment in PD is not to help patients completely get rid of their symptoms (which is not possible, even with the latest treatment). On and off, even the well-treated Parkinson's patients cannot avoid having a bit of tremor or dyskinesia each and every day in their life.

c) The presence of dyskinesia

The development of dyskinesia is an inevitable phenomenon in every Parkinson's patients. Dyskinesia, a side effect of medications (levodopa in Madopar or Sinemet), is the "swinging" body movement which is seen in 50% of Parkinson's patients after 3-5 years of these medications. It typically occurs after about one hour after each dose of medications.

As dyskinesia is provoked by a relatively high dose of medications, it is treated by reducing the dose of medications. In contrast, tremor (signifying inadequate dose of medications) is treated by increasing the dose of medications. Thus, it is vital that Parkinson's patients know the difference between dyskinesia and tremor (this will be discussed again in the future article).

In other words, if the medications are too much, the dyskinesia becomes severe. On the other hand, if the medications are too little, Parkinson's patients become slow and stiff. Thus, there has to be a correct and precise adjustment in total daily dose of medications - the real challenge in the treatment of PD.

d) The presence of side effects

It is just natural that whenever any patient experience side effect due to medications, the dose of medications has to be reduced.

Conclusions

The adequate or optimal total daily dose of medications varies among individuals. There is no hard and fast rule - there is no best dose of medications which applies to each and every Parkinson's patients. The most important principle in managing PD is to tailor the treatment according to individual needs - every Parkinson's patient is different from each other. Whatever the correct total daily dose of medications is, the aim of treatment is to help Parkinson's patients achieve a relatively normal quality of life. It is not enough if the medications can merely reduce the symptoms (e.g. tremor), but cannot help a Parkinson's patient to walk unassisted at home.