Abstract Body

Parkinson's disease is characterized by verious patterns of progression and disability depending on a number of variables including medications, genetic and underlying pathology. Among factors contributing to loss of independence to perform activities of daily living (ADLs), fluctuating motor and nonmotor symptoms play an importnat role. Advanced Parkinson’s disease (APD) can be defined as a condtion where patients become inadequately controlled by standard oral therapies and in many cases to achieve optimal symptom control APD patients may require more invasive treatment options such as such as deep brain stimulation, subcutaneous apomorphine infusion, and levodopa–carbidopa intestinal gel (LCIG). There is lack of objective and standardized diagnostic criteria to identify APD patients in clinical practice and referral to tertiary centers is often complicated by lack of regional networks and organizational issues.

A combination of three key criteria related to the number of levodopa doses (reflecting efficacy duration) as well duration of off time and dyskinesia has been proposed: i) taking ≥5 doses of oral levodopa, or ii) having ‘off’ symptoms for ≥2 h , or iii) having ≥1 h of troublesome dyskinesia . The functional impact on ADL ohas also been considered leading to a simple screening algorithm ‘5-2-1 positive’.

The number of APD patients considered for device-aided therapies is still small compared with the potential clinical benefit. Overcoming identification and referral challenges and including caregiver and patients in the selection process by improving education and providing quality information represents a critical issue to be addressed more systematically in the near future.