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Classes of medication

There are many different drugs for Parkinson’s. Each one belongs to a class of medications, that is a wider group of drugs that work in the same way.

Levodopa

Levodopa is always given combined with either benserazide or carbidopa. It can be used at all stages of Parkinson’s.

The development of levodopa

Levodopa was the first breakthrough in the treatment of Parkinson's. Its development was based on the discovery that people with Parkinson's experience a severe loss of dopamine in the brain. It is still the most widely used treatment for Parkinson's, and almost everyone requires levodopa at some point during the course of their Parkinson’s.

During the first few years of levodopa clinical use, large amounts of levodopa were needed to be effective. These large doses were associated with side-effects such as nausea and vomiting due to the rapid breakdown of levodopa in the body by enzymes.

One of the main enzymes involved in this breakdown of levodopa is peripheral dopa-decarboxylase (DDC). It was quickly realised that by inhibiting this enzyme using a DDC inhibitor, it was possible to reduce the levodopa dose by 70%, thereby reducing the severity of side-effects. This combination is so effective that, today, levodopa is almost always given with a DDC inhibitor, either carbidopa or benserazide. However, when DDC is inhibited another enzyme, catechol-O-methyl transferase (COMT), takes over the breakdown of levodopa. Consequently, COMT inhibitors were recently developed as a way of further improving the delivery of levodopa to the brain.

How levodopa works

Dopamine is a chemical messenger made in the brain. The symptoms of Parkinson’s are caused by a decrease in the levels of dopamine, due to the death of the nerve cells in the brain that make it.

Unfortunately, taking dopamine as a drug treatment would not help you, because it cannot cross into your brain where it’s needed. Doctors can get around this by using levodopa.

Levodopa is a chemical building-block that your body converts into dopamine. Levodopa already occurs naturally in your body, and taking it as a medication boosts the supply. The nerve cells in your brain then have more of this ingredient and so can make more dopamine. Levodopa is given either with benserazide or carbidopa as this prevents levodopa breaking down before it reaches the brain.

How levodopa is used

Levodopa has been used to treat Parkinson’s since the 1960s. Later, it was found that adding benserazide or carbidopa could allow more levodopa to get into the brain and make it work better.

Levodopa can be used at all stages of Parkinson’s. However, it can have side effects that build up over time. One side effect of levodopa is ‘off ’ periods, when your body becomes so stiff and slow that you are unable to move. Another side effect that can happen with long-term use of levodopa is involuntary movements (dyskinesia).

Although levodopa may be taken at any stage of the condition, based on current scientific evidence, there is no particular time to start taking it that is right for everyone. You and your specialist, or Parkinson’s nurse if you have one, will need to discuss this and agree what is the best choice for you at this time.

Treatment will usually start with a low dose and this is gradually increased until you and your specialist or Parkinson’s nurse agree that your symptoms are under control.

If you have problems with swallowing, this may determine the form of drug you will take. There may be a suitable option that is easier to swallow, if you can’t easily take tablets. There are some options that release active ingredients slowly (controlled or prolonged release capsules or tablets). These allow you to take fewer tablets in a day. However, these will not be suitable for everyone who takes levodopa.

Available forms

Several different forms are available:

1. Tablets

These come in different strengths, depending on the dose your specialist or Parkinson’s nurse thinks you need.

Controlled release (CR) or prolonged release (PR) capsules or tablets

These let the levodopa enter your body slowly instead of all at once. Involuntary movements (dyskinesia can be a side effect of taking high doses of levodopa. Controlled release options can sometimes reduce the number of times you experience dyskinesia. They can also be taken before going to bed to reduce stiffness during the night.

Dispersible tablets

This form can be mixed with water to make a drink. It takes effect more quickly than capsules because it doesn’t need to be broken down in your stomach to release the active ingredient. It can also be used if you have trouble swallowing tablets or capsules. If you are prescribed non-dispersible tablets or capsules, these should not be crushed or put into water.

2. Intestinal gel

This option is only suitable for a very small number of people, whose symptoms cannot be controlled with the more common forms of treatment. The medication is pumped continuously through a tube that is surgically inserted in the intestine. If you are prescribed this option you are less likely to experience involuntary movements. You might also have fewer ‘off’ periods. It may also help to control your symptoms at night.

Advantages

Levodopa is seen as the most effective treatment for Parkinson’s symptoms. When taking it, you may experience a big improvement in your symptoms, especially with stiffness and slowness of movement. It can also improve non-motor symptoms such as speech, swallowing, sleep and depression and so can enhance wellbeing.

Disadvantages

1. Becomes less effective after time

After a while, you may have a less predictable response to levodopa. You may get ‘off’ periods when you feel weak and cannot move well. The effect of the dose may wear off more quickly, maybe even before your next one is due or has begun to work. When this happens, your specialist or Parkinson’s nurse will sometimes change or increase your dose, change the form of medication or how often you take it. They may add other Parkinson’s medications to take alongside levodopa. This will help it to be more effective in treating your Parkinson’s symptoms.

2. Movement problems

One of the main problems with levodopa is a side effect called dyskinesia. These are spasms or muscle movements that happen when you don’t want them to. Dyskinesia can increase over time, although not everyone will have this side effect.

See also Dyskinesia.

Over time you may also find your symptoms re-emerge or become noticeably worse before it is time to take your next dose of levodopa. This is known as 'wearing-off'’ with periods of time when certain symptoms such as tremor, rigidity and bradykinesia (slow movement) are no longer effectively controlled.

See also ‘wearing off’.

3. Sleepiness and fainting

Levodopa treatment can make you feel very sleepy. Sometimes this happens quite suddenly and without warning. Levodopa can also make you faint or feel dizzy.

4. Other side effects

Other common side effects that can happen with levodopa include: nausea and vomiting, hypotension (low blood pressure), loss of appetite, psychological problems, hallucinations (seeing, hearing, feeling and smelling things that aren’t there), and sleep problems.

Levodopa and diet   

Taking levodopa with food can sometimes help to reduce feelings of sickness. However, for some people, protein (which is found mainly in meat, fish, eggs, cheese and beans) seems to interfere with the way levodopa works, by affecting how well the medication is absorbed by the body.

Protein is needed by the body so it is important not to stop eating protein. However, some people may benefit from taking their medication at least 30 minutes before eating. Your specialist or Parkinson’s nurse can advise you on timing your doses and this should be discussed with them when you are first prescribed the medication. They may also refer you to a dietician for advice.

See also Eating well.

Impulsive and compulsive behaviour

A small number of people taking levodopa have problems with impulsive or compulsive behaviour. This can also be called impulse control disorder. It affects a much smaller percentage of people taking levodopa than those taking dopamine agonists, but it is still a possible side effect.

Impulsive behaviour is when a person can’t resist the temptation to carry out activities that could lead them to harm themselves or others. In many cases, this behaviour is out of character.

Compulsive behaviour is when a person has an overwhelming drive or urge to act in a certain way, often repetitively, to reduce the worry or tension that they get from that urge. Both of these can have a devastating impact on the person with Parkinson’s and those around them.

Some examples are gambling, becoming a ’shopaholic’, binge eating, and a focus on sexual feelings and thoughts, which may get in the way of everyday life. Other behaviour may include punding, which is repetitive collecting and sorting of objects.

Another potential problem is dopamine dysregulation syndrome, where someone with Parkinson’s might be tempted to take more of their Parkinson’s medication than they are prescribed.

If you think this is happening to you or the person you are caring for, tell your GP, specialist or Parkinson’s nurse right away.

It is important that all people with Parkinson’s are assessed for any potential risk of impulsive and compulsive behaviour before they start taking their medication.

There are certain factors that may mean you’re more likely to experience this behaviour: a family history of gambling or alcohol abuse, a personal history of addictive behaviour, being male, being a younger person with Parkinson’s, being a smoker, or single and living alone.

Even if you do not fit any of these categories, treatment should be monitored over time. People with Parkinson’s, their carers, friends and family members should work with healthcare professionals to monitor any changes in behaviour.

See also Impulsive & compulsive behaviour.

Withdrawal syndrome with levodopa

Research has shown that withdrawal symptoms can happen when someone very suddenly stops taking levodopa, perhaps because they are experiencing impulsive and compulsive behaviour. It can lead to symptoms including depression, anxiety and pain. Any withdrawal from Parkinson’s medications needs to be done gradually, under the supervision of a health professional, to avoid the risk of developing this syndrome.

Dopamine agonists

Dopamine agonists may be given on their own or prescribed alongside levodopa or other drugs.

Unlike other dopamine agonists, apomorphine is usually reserved for late Parkinson’s when symptoms are severe and levodopa is not working well all the time.

How dopamine agonists work

Dopamine is a chemical messenger made in the brain. The symptoms of Parkinson’s are caused by a decrease in the levels of dopamine, due to the death of the nerve cells in the brain that make it.

One treatment option is to use levodopa, which is converted into dopamine in the brain. Another possible approach is to use dopamine agonist medications, which act like dopamine to stimulate your nerve cells. Dopamine agonists mimic the action of dopamine rather than boosting the inadequate supply of dopamine in the way levodopa does.

How dopamine agonists are used

Dopamine agonists are used at all stages of Parkinson’s. You might take them alone when treatment is being started, or alongside levodopa to help the levodopa work better.

Treatment with dopamine agonists has to be started carefully to minimise the risk of side effects, with the dose gradually increasing until you and your specialist or Parkinson’s nurse are happy that your symptoms are under control.

Some dopamine agonists are now being made as ‘one a day’ tablets. These can be a better option for the body and may help both movement and other symptoms of Parkinson’s.

Available forms

Several different forms are available:

1. Tablets and capsules

These come in different strengths, depending on the dose your specialist or Parkinson’s nurse thinks you need.

2. Prolonged release tablets

These can be taken less frequently and they work longer in the body, compared to normal capsules and tablets.

3. Skin patch

A dopamine agonist patch is also available. This may be helpful if you have trouble swallowing tablets, as well as for those who have problems with drooling and gastritis. It might also reduce stomach upsets. The patch should be held in place for 30 seconds. Once in place it lasts for 24 hours. The patch may cause a skin reaction, such as reddening or itching, but this is usually mild or moderate, will only affect the area the patch has been and will normally disappear after a few hours when you remove the patch. Moving the patch to a different site every day will help to avoid irritation. The patch should be stored in a refrigerator.

4. Injection or infusion

Apomorphine is a dopamine agonist that is given by injection or infusion pump. It is the strongest known dopamine agonist. It is reserved for more advanced Parkinson’s that does not respond as well to oral medication or when most oral (taken through the mouth) Parkinson’s drugs becomes less effective or do not work. If you continue to have sudden and unpredictable changes in your symptoms that aren’t controlled by other Parkinson’s medications, apomorphine may help.

You may need to have injections of apomorphine between doses of your usual tablets, or you may need apomorphine more often. In this case, you can use a portable, battery-driven pump, which gives the medication through a needle under the skin. However, this is not commonly used, and is only suitable in certain cases.

Ideally, apomorphine will be started in hospital, under the guidance of a specialist or Parkinson’s nurse. Once you are settled on this treatment, you and your carers (if relevant) can be trained in how to use it or, depending on where you live, community nurses may be able to visit your home.

Advantages

Delaying levodopa treatment

Scientific studies suggest that dopamine agonists can be effective treatments for several years when used alone. However, this will not be the case for everyone.

Fewer movement problems

Your symptoms may be controlled during the day for longer than is usually the case with levodopa. Where this happens, you may be less prone to long-term side effects such as the ‘on/off'effect’ and dyskinesia (movements that you can’t control).

Helping levodopa work better

Dopamine agonists can also be taken with levodopa, at all stages of Parkinson’s. They can help when the effect of levodopa wears off or doesn’t always work so well. Dopamine agonists may help to smooth out the ‘on/off’ effect that you may have with levodopa.

Fewer tablets to take (in some cases)

There are now some once-daily preparations that could make a big difference by reducing the number of tablets you take. But this option may not suit everyone.

Positive effects on non-motor symptoms

Dopamine agonists have recently been shown to have a good effect on the symptoms of Parkinson’s not related to movement, including sleep problems, pain and mood.

Disadvantages

1. Heart problems

Some of the older dopamine agonists increase the risk of heart problems. As a group, these are known as the ‘ergot’ types and they include: bromocriptine, pergolide and cabergoline. Because of this risk, these Parkinson’s medications are only used when other dopamine agonists do not work well. All newer dopamine agonists are non-ergot in type. These are apomorphine, pramipexole, ropinirole and rotigotine. They have not been associated with an increased risk of heart damage. Doctors prefer to use these if possible.

2. Sleepiness and fainting

Dopamine agonists can make you feel very sleepy, faint or dizzy. This is most likely to happen when you start taking the medication. Once a stable dose is reached, this effect often wears off. In a few people, sleepiness happens quite suddenly. Sudden sleep onset, without any warning, has been reported. If this happens, it’s important that you tell your specialist or Parkinson’s nurse.

3. Other side effects

We can’t list all the possible side effects. However, some of the most common side effects that can happen with dopamine agonists include: nausea, constipation, low blood pressure, headaches, psychological problems, hallucinations (seeing, hearing, feeling and smelling things that aren’t there), movement problems, swollen limbs, a stuffy nose and a dry mouth. Sight problems can include blurred vision, so it’s important to have regular eye checks.

Impulsive and compulsive behaviour

Some people taking dopamine agonists have problems controlling compulsive or impulsive behaviour. It can also affect people taking levodopa, but it more frequently affects people taking dopamine agonists.

Impulsive behaviour is when a person can’t resist the temptation to carry out certain activities that could lead them to harm themselves or others. In many cases, this behaviour is out of character.

Compulsive behaviour is when a person has an overwhelming drive or urge to act in a certain way, often repetitively, to reduce the worry or tension that they get from their drive or urge. Both of these can have a devastating impact on the person with Parkinson’s and those around them.

Some examples are gambling, becoming a ’shopaholic’, binge eating, and a focus on sexual feelings and thoughts, which may get in the way of everyday life. Other behaviour may include punding, which is repetitive collecting and sorting of objects.

If you think this is happening to you or the person you are caring for, tell your GP, specialist or Parkinson’s nurse right away so they can help.

It is important that all people with Parkinson’s are assessed for any potential risk of impulsive and compulsive behaviour before they start taking their medication.

There are certain factors that may mean you’re more likely to experience this behaviour: a family history of gambling or alcohol abuse, a personal history of addictive behaviour, being male, being a younger person with Parkinson’s, being a smoker, or single and living alone.

Even if you do not fit any of these categories, treatment should be monitored over time. People with Parkinson’s, their carers, friends and family members should work with healthcare professionals to monitor any changes in behaviour.

See also Impulsive & compulsive behaviour.

Dopamine agonist withdrawal syndrome

Recent research has discovered dopamine agonist withdrawal syndrome, which can happen when someone very suddenly stops taking dopamine agonists, perhaps because they are experiencing impulsive and compulsive behaviour. It can lead to symptoms including depression, anxiety or pain . Any withdrawal from Parkinson’s medications needs to be gradual, under the supervision of a health professional, to avoid the risk of this syndrome.

Apomorphine can cause severe short-term nausea and sickness, so an anti-sickness medication called domperidone (Motilium) will also be given two to three days before this treatment is started and continued for at least two weeks or more, once your treatment is underway.

Injections of apomorphine are taken in a similar way to insulin for diabetes. There is a ready-to-use injection pen that works within 10 minutes and is often used as a ‘rescue’ measure. This is very useful if you have a sudden ‘off’ period.

Soreness or nodules can develop where the needle enters your skin. If this happens, do not stop the treatment and quickly seek advice from your specialist or Parkinson’s nurse. It is important to change injection site to minimise scarring or infection. Simple massage, silicone gel patches or ultrasound can help to reduce any nodules that form.

COMT (catechol-O-methyl transferase) inhibitors

Dopamine is a chemical messenger made in the brain. The symptoms of Parkinson’s are caused by a decrease in the levels of dopamine, due to the death of the nerve cells in the brain that make it.

In late Parkinson’s, COMT inhibitors are used alongside levodopa to help it work more smoothly.

How COMT inhibitors work

Unfortunately, taking dopamine as a drug treatment for Parkinson’s would not help you, because it could not cross into your brain where it’s needed. However, you can boost the supply in your brain by taking levodopa, a medication that acts as a chemical building-block to help your body produce more dopamine.

COMT inhibitors can block an enzyme that breaks down levodopa.

Two main COMT inhibitors have been developed to date: entacapone and tolcapone.

How COMT inhibitors are used

These medications are used alongside levodopa, to help it work more smoothly. They can be tried if your dose of levodopa is not working for long enough or it ‘wears off’.

COMT inhibitors do not help Parkinson’s on their own – they have to be used with levodopa.

COMT inhibitors come as tablets. There is also a combined tablet that includes levodopa, carbidopa (one of the ‘helper’ medications that are always given alongside levodopa) and the COMT inhibitor entacapone.

Advantages

1. Helping levodopa work more smoothly

COMT inhibitors can help when levodopa is not working long enough and starts to wear off between your doses. It can help to reduce the ‘off’ time when you have more trouble with your Parkinson’s symptoms and it can increase the amount of ‘on‘ time when your symptoms are better controlled.   

2. Taking less levodopa (in some cases)

In many cases, levodopa can be taken less often and at a lower dose.

Improving Parkinson's symptoms

Sometimes, adding a COMT inhibitor to your medication regime can help your Parkinson’s symptoms.    

Disadvantages

1. Liver damage

With tolcapone, there is a risk of liver damage that can be fatal. It is rare, but for this reason, it is a second choice, only used if you can’t take another COMT inhibitor. If you take this medication, you will need regular blood tests to check the health of your liver.

This risk has not been seen with the other available COMT inhibitor, entacapone.

2. Worse levodopa side effects

Because COMT inhibitors strengthen levodopa, the side effects of levodopa, including unwanted movements and sickness, can get worse, too. If this happens, your specialist or Parkinson’s nurse can help you reduce the dose of levodopa.

3. Other side effects

We can’t list all the possible side effects. However, some of the most common side effects that can happen with COMT inhibitors include: sleeping problems, loss of appetite, diarrhoea, dizziness, fainting, falls, hallucinations (seeing, hearing, feeling and smelling things that aren’t there), headache, confusion, dry mouth, chest pain, sleepiness and getting flu or having flu-like symptoms. These medications can also discolour your urine.

MAO-B (monoamine oxidase B) inhibitors

Dopamine is a chemical messenger made in the brain. The symptoms of Parkinson’s are caused by a decrease in the levels of dopamine, due to the death of the nerve cells in the brain that make it.

Monoamine oxidase B (MAO-B) inhibitors are sometimes used alone in early Parkinson’s, or with levodopa and sometimes other drugs in late Parkinson’s.

How MAO-Bs work

Unfortunately, taking dopamine as a drug treatment for Parkinson’s would not help you, because it could not cross into your brain where it’s needed.

MAO-B inhibitors can help your nerve cells to make better use of the dopamine that it does have. They do this by blocking an enzyme called monoamine oxidase type B (MAO-B), which breaks down dopamine in your brain. This helps to increase the amount of dopamine that the brain can use, which helps to relieve the symptoms of Parkinson’s.

Two main MAO-B  inhibitors have been developed to date: rasagiline and selegeline.

How MAO-B inhibitors are used

A MAO-B inhibitor can be used on its own in early Parkinson’s, or in combination with other medications at all stages of Parkinson’s. These medications are mainly available as tablets. There is also a form that dissolves on the tongue and a liquid preparation. These may help if you have trouble swallowing.

Advantages

1. Improving Parkinson's symptoms

On its own, a MAO-B inhibitor can help with some Parkinson’s symptoms, but it can become less effective over time.

2. Not all have to be increased gradually

Many medications for Parkinson’s have to be started gradually, with the dose slowly being increased over time. Rasagiline can be started on the full dose, but selegiline cannot.

3. Delaying levodopa treatment

By taking a MAO-B inhibitor at an early stage of Parkinson’s, you might be able to delay starting levodopa until your symptoms become more difficult to manage.

4. Helping levodopa work better

When you have been taking levodopa for a while, you may find that its effects wear off too quickly. When taken with levodopa, these drugs can help it work better.

A MAO-B inhibitor can help with this. Taking a MAO-B inhibitor may also reduce the dose of levodopa you need and lengthen the time between your doses of levodopa.

Disadvantages

1. Combination with antidepressants

If you’re taking some types of antidepressant, you might not be able to take MAO-B inhibitors, as these medications can interact with each other to raise blood pressure to a dangerous level.

2. Combination with decongestants

Decongestants or cold remedies can affect some types of MAO-B inhibitor. If you need to use one of these products, check with your pharmacist which one is safest to use.

3. Worse levodopa side effects

Because MAO-B inhibitors strengthen levodopa, the side effects of levodopa, including unwanted movements and sickness, can get worse, too. If this happens, your specialist or Parkinson’s nurse can help you reduce the dose of levodopa.

Dietary precautions

Your specialist or Parkinson’s nurse may advise you to avoid certain foods, such as cheese, broad beans, yeast extracts or fermented soya bean (tofu).

Other side effects

We can’t list all the possible side effects. However, some of the most common side effects that can happen with MAO-B inhibitors include headache, aching joints, indigestion, flu-like symptoms and depression.

Amantadine

Amantadine is usually used with other Parkinson’s medication and has an effect on tremor and stiff muscles.

How Amantadine works

Exactly how this medication works for Parkinson’s isn’t known yet. It may modify levels of certain chemicals in the brain.

How Amantadine is used

Amantadine can be used to treat tremor and stiff muscles. It isn’t used very often and it is unlikely to be prescribed alone. It is usually given with other medications for Parkinson’s and can be used at all stages of Parkinson’s.

It is started at a lower dose and the amount is stepped up gradually. It is available as capsules and syrup.

Advantages

Fewer movement side effects

It is generally agreed that there is not enough scientific evidence to support amantadine as a first choice in early Parkinson’s. But for some people, amantadine may reduce dyskinesia (involuntary movements) caused by your other Parkinson’s medications, without making your Parkinson’s symptoms worse.

Disadvantages

1. Limited effects on Parkinson's

Amantadine is not a first choice for the treatment of Parkinson’s and it may have only a mild effect. Over time, amantadine can become less effective.

Blurred vision, fainting, confusion or dizziness

If you have these side effects, it is not safe to drive or use machinery.

2. Other side effects

We can’t list all the possible side effects. However, some of the most common side effects that can happen with a glutamate antagonist include: feeling nervous, anxious or overexcited, poor concentration, headache, hallucinations (seeing, hearing, feeling and smelling things that aren’t there), movement problems, sleep problems such as insomnia, fast or irregular heartbeat, loss of appetite, nausea and vomiting, constipation, sweating, swollen hands and ankles, and skin reactions.

Anticholinergic medication

Anticholinergics are not used very often for Parkinson’s but sometimes they are used for reducing tremor and stiff muscles.

How anticholinergics work

These medications block the action of acetylcholine, a chemical messenger (neurotransmitter) that is found in your body. Acetylcholine helps to send messages from your nerves to your muscles.

In the brain, there is normally a balance between the activity of dopamine and the activity of acetylcholine. But in Parkinson’s a deficiency in the brain of the neurotransmitter dopamine causes over-activity of acetylcholine. Anticholinergics work by blocking acetylcholine’s activity to restore this balance and help reduce your Parkinson’s symptoms.

How anticholinergics are used

These medications are older and are not used very often for Parkinson’s today. Sometimes they are prescribed for reducing tremor and muscle stiffness. They can be used on their own, especially in the early stages of your Parkinson’s when symptoms are mild, before levodopa is prescribed.

Anticholinergics can also be used with levodopa or a glutamate antagonist. They are taken as tablets or as a liquid.

Advantages

1. Possible effect on mild movement symptoms

Older medical studies found some benefit with Parkinson’s symptoms. Anticholinergics can be effective for younger people in the early stages of Parkinson’s when symptoms are mild.

2. Possible effect on other Parkinson's symptoms

Anticholinergics may also be used to reduce saliva production if you have a problem with drooling.

Oxybutynin is an anticholinergic that is used in people without Parkinson’s to reduce bladder contractions that can cause a strong, frequent urge to urinate. It is only used very cautiously in people with Parkinson’s.

Disadvantages

1. Limited effect on movement symptoms

It is generally agreed that the limited improvement in movement symptoms do not outweigh the disadvantages of using anticholinergics.

2. Memory problems

Anticholinergics are not very often given to people with Parkinson’s because they can cause memory problems or make them worse. If you’re taking anticholinergics, your specialist or Parkinson’s nurse must closely monitor your situation.

3. Side effects

Another reason these drugs are not seen as a first choice is their side effects. We can’t list all the possible side effects. However, some of the most common side effects that can happen with anticholinergics include: dry mouth, blurred vision, upset stomach, constipation, dizziness and trouble urinating. Confusion, hallucinations (seeing, hearing, feeling and smelling things that aren’t there), forgetfulness and psychological problems are less common, but they can also happen with these medications.  Anticholinergics are not recommended for older people because of the increased risk of confusion.

Acknowledgement

Our thanks to Parkinson's UK for permission to use the following source(s) in compiling this information:

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