A 66 year old man with early Parkinson’s disease had mild right-sided hand tremor and bradykinesia. Rasagiline 1 mg was prescribed.

a) Discuss the mechanism of action and adverse effects of rasagiline, and dietary advice. (3 marks)

b) Rasagiline could not reduce his hand tremor. Benzhexol (Artane) 1 mg twice Daily was prescribed. List TWO common adverse effects associated with the use of Benzhexol. (2 marks)

c) The patient did not tolerate Benzhexol for treatment of tremor. Name ONE alternative medication and list TWO common adverse effect.  (3 marks)

d) The patient was prescribed increasing dosage of levodopa as the Parkinson‘s disease progressed, he experienced marked nausea. What dietary advice can alleviate his gastrointestinal (“GI”) upset? Name ONE medication that can help reduce nausea. (2 marks)

e) After five years of levodopa treatment the patient experienced frequent ineffective periods, the “off” symptom. Discuss FOUR pharmacotherapeutic strategies for motor fluctuations. (4 marks)

f) After 15 years of diagnosis of Parkinson’s disease, the patient experienced psychotic features with auditory hallucination and confused speech which could be due to the use of high dose dopaminergic medications. He was advised to stop some of the parkinsonian medications. Name ONE rare but severe complication that may occur during abrupt stopping of dopaminergic medications. (1 mark)

g) His psychotic symptoms persisted despite reducing dose of dopaminergic medications. Atypical antipsychotic was prescribed. Discuss with explanation whether quetiapine or risperidone is a better treatment option. (2 marks)

h) The patient also experienced significant postural hypotension. Name TWO non-pharmacological management to orthostatic hypotension. Name ONE adverse effect with fludrocortisone. (3 marks)