Formulating treatmentmanagement plans

Initial planning In the post-acute phase, there is often great pressure to reduce medication doses radically, but overzealous reductions at this stage are likely to be followed by symptomatic exacerbation. The main task in the early part of this phase is to persuade the patient of the merits of holding the regimen stable while resocialization is being established. As symptomatology begins to settle, those on low-potency regimens are likely to become less tolerant of sedative actions which may compromise resocialization and compliance. A cautious reduction on this basis is certainly justified. With high-potency drugs the problem is more likely to be the apathy and impaired initiative of bradykinesia, which, if not responsive to antiparkinson medication, would also merit dose reduction.

Revision Once the initial steps in resocialization have been achieved, medication can be rationalized. Where multiple drugs continue to be necessary, they should be prescribed at similar times, with as much of the regimen as possible given at night. In addition, the need for adjunctive medications should be re-evaluated.

There is no consensus as to whether or not stopping antiparkinson medication at this stage will result in recrudescence of neurological signs. (5) As it is likely that some patients will not require these treatments, systematic reductions should be started.

If a depot is agreed, this should also be started. Depots are not ideally suited to acute-phase treatment and because of their unusual pharmacokinetics should be commenced 'in parallel' with existing oral medication, which can be discontinued slowly as the depot approaches steady state (i.e. approximately five times the half-life).

The maintenance phase Goals

The boundary between post-acute and maintenance phases is the least defined but is reached when improvements in all the major domains of disorder are felt to be maximal.

The major goals of maintenance are as follows:

1. maximum well being with minimum adverse effects

2. monitoring efficacy/effectiveness and tolerability

3. continuation or completion of rehabilitation and social reintegration.

Attempts to reduce medication should still be cautious during maintenance, but over the longer term, more determined. The major medical task in this phase is monitoring, to include effectiveness, as well as the narrower efficacy. Any long-term therapeutic regimen can only be properly evaluated by balancing efficacy/effectiveness against tolerability. Exploration of neurological tolerability should involve both an enquiry into subjective effects as well as an examination to elicit signs, and should be undertaken regularly.

The final, and to some extent most intensive, aim of maintenance comprises those management techniques geared towards helping patients attain the highest possible level of psychosocial functioning and carers the greatest degree of understanding and skills for coping.

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