Parkinson's Disease

Last updated 1 Jun 2026 · Geriatric medicine

📋 Key Information Summary

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Parkinson's disease (PD) is a progressive neurodegenerative disorder caused by loss of dopaminergic neurons in the substantia nigra, with prevalence rising sharply after age 65 — affecting approximately 1–2% of Australians over 65 years.
Diagnosis remains primarily clinical: the MDS Clinical Diagnostic Criteria (2015) require bradykinesia plus rest tremor and/or rigidity, with supportive features (levodopa response, olfactory loss, REM sleep behaviour disorder).
Motor features include tremor (resting, pill-rolling), rigidity (lead-pipe/cogwheel), bradykinesia, postural instability and gait freezing; non-motor features (depression, constipation, anosmia, REM sleep behaviour disorder, cognitive decline) often precede motor symptoms by years.
Levodopa/carbidopa (Sinemet®) remains the most effective symptomatic therapy; initiating levodopa does NOT need to be delayed — early treatment improves quality of life and the "wear-off" phenomenon is a disease feature, not solely drug-induced.
Dopamine agonists (pramipexole, ropinirole, rotigotine) and MAO-B inhibitors (selegiline, rasagiline, safinamide) are alternatives or adjuncts, especially in younger-onset disease; impulse control disorders are a key risk with dopamine agonists.
Amantadine (PBS-listed) may help levodopa-induced dyskinesias; anticholinergics are reserved for tremor-dominant disease in younger patients due to cognitive side-effects in the elderly.
Non-motor symptom management is as important as motor control: depression (SSRIs/SNRIs, not TCAs in elderly), psychosis (pimavanserin, quetiapine — avoid typical antipsychotics), constipation (macrogol, fibre), and orthostatic hypotension (midodrine, fludrocortisone).
Falls are the leading cause of morbidity — multifactorial risk assessment, physiotherapy, home hazard modification, and medication review are cornerstones of prevention.
Dysphagia affects up to 80% of advanced PD; speech pathology assessment, texture-modified diet, and deep brain stimulation (DBS) consideration in selected patients are essential.
Autonomic dysfunction (constipation, orthostatic hypotension, urinary urgency, erectile dysfunction) requires proactive screening and management.
Advanced therapies — deep brain stimulation (DBS), levopa–carbidopa intestinal gel (LCIG/Duodopa®), and subcutaneous apomorphine infusion — should be considered when motor complications become disabling despite optimised oral therapy.
Aboriginal and Torres Strait Islander Australians face barriers to timely diagnosis and specialist access; culturally safe, community-based models of care with multidisciplinary team involvement are essential to improve outcomes.

Introduction & Australian Epidemiology

Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease, characterised by the progressive loss of dopaminergic neurons in the substantia nigra pars compacta and the accumulation of α-synuclein-containing Lewy bodies. It is the most common movement disorder encountered in geriatric medicine, and its management requires careful balancing of motor symptom control against the risks of cognitive decline, autonomic dysfunction, falls, and polypharmacy in older adults.

In Australia, an estimated 150,000–200,000 people live with PD, with a prevalence of approximately 1–2% in those aged over 65 years and rising to 3–5% in those aged over 85 years. The incidence increases markedly with age, peaking in the seventh to eighth decades. Men are approximately 1.5 times more likely to develop PD than women. The economic burden to the Australian health system is substantial, with direct costs estimated at over AUD

.1 billion annually (Deloitte Access Economics, 2014), encompassing hospital admissions, residential aged care, medications and allied health services.

Australia's ageing population means the number of people with PD is projected to double by 2040. The disease disproportionately affects quality of life in later years, contributing to falls, hip fractures, aspiration pneumonia, dementia and premature residential aged care admission. Timely diagnosis, proactive multidisciplinary management and advance care planning are therefore critical components of geriatric care.

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Diagnostic delay: The median time from symptom onset to diagnosis in Australia is 1–3 years. Up to 20% of patients initially diagnosed with PD are reclassified at follow-up (often to essential tremor, vascular parkinsonism or drug-induced parkinsonism). Early referral to a movement disorder specialist improves diagnostic accuracy and long-term outcomes.

Risk factors for PD include advancing age (strongest), male sex, family history (first-degree relative confers 2–3× risk), certain genetic variants (LRRK2, GBA, SNCA, PARK2), pesticide exposure (rotenone, paraquat), rural living, head trauma, and possibly dairy consumption. Protective factors include caffeine intake, physical activity, and possibly urate levels. Cigarette smoking shows an inverse association, though this is not a recommendation for smoking.

Motor Features and Diagnosis

Cardinal Motor Features

The motor features of PD are characterised by the triad of bradykinesia, rigidity, and rest tremor. Postural instability is a fourth cardinal feature but typically emerges later in the disease course (Hoehn & Yahr stage 3+).

Motor Feature	Characteristics	Clinical Assessment
Bradykinesia	Slowness of initiation, progressive decrement in amplitude and speed of repetitive movements. Required for diagnosis.	Finger tapping, hand opening/closing, pronation–supination, toe tapping, heel tapping. Look for amplitude decrement and arrest.
Rest tremor	4–6 Hz, pill-rolling, typically asymmetric at onset. Suppresses with voluntary movement. Present at rest, may re-emerge with posture holding.	Observe hands at rest, during distraction (serial 7s, walking). Check for re-emergent tremor during sustained posture.
Rigidity	Velocity-independent increase in tone. Lead-pipe (continuous) or cogwheel (with superimposed tremor). Often asymmetric.	Passive range of motion at wrist, elbow, neck. Reinforcement manoeuvre — ask patient to perform task with contralateral hand.
Postural instability	Impaired postural reflexes; tends to pull to one side (retropulsion). Usually appears after ≥5 years of disease.	Pull test: stand behind patient, pull shoulders briskly. Positive if ≥2 steps retropulsion without recovery. MDS-UPDRS Part III.
Gait disturbance	Shuffling, reduced arm swing (often asymmetric), freezing of gait (especially on initiation and turning), festination.	Observe gait over 10 m, turning, dual-task walking, narrow corridor. Freezing of gait questionnaire (FOG-Q).

MDS Clinical Diagnostic Criteria (2015)

The Movement Disorder Society (MDS) criteria require:

Absolutely necessary: Bradykinesia, defined as slowness of movement with progressive decrement in amplitude or speed of repetitive actions.
Plus at least one of: Muscular rigidity, 4–6 Hz rest tremor.
Supportive criteria (≥2 strongly support PD): Clear and dramatic beneficial response to dopaminergic therapy, presence of levodopa-induced dyskinesia, rest tremor of a limb, positive olfactory loss or cardiac sympathetic denervation on MIBG scintigraphy.
Absolute exclusion criteria (any one rules out PD): Cerebellar abnormalities, downward supranuclear gaze palsy, frontotemporal dementia or primary progressive aphasia within 5 years, parkinsonism restricted to lower limbs for >3 years, treatment with a dopamine-blocking agent consistent with drug-induced parkinsonism, and others.
Red flags (≥2 make PD uncertain): Rapid gait impairment requiring wheelchair within 5 years, absence of motor progression over 5 years, early severe dysphonia, early severe dysarthria, early severe dysphagia, inspiratory dysfunction, and others.

Differential Diagnosis

Condition	Key Distinguishing Features	Investigations
Essential tremor	Postural/kinetic tremor, bilateral, family history, improves with alcohol, no bradykinesia	Clinical diagnosis; DaTSCAN normal
Vascular parkinsonism	Stepwise onset, lower-body predominance, vascular risk factors, poor levodopa response	MRI brain showing extensive small vessel disease
Drug-induced parkinsonism	Symmetric onset, dopamine-blocking agents (metoclopramide, haloperidol, antipsychotics)	Medication review; DaTSCAN typically normal
Progressive supranuclear palsy (PSP)	Early falls, vertical supranuclear gaze palsy, axial rigidity, poor levodopa response	MRI "hummingbird sign"; DaTSCAN abnormal
Multiple system atrophy (MSA)	Early autonomic failure, cerebellar or parkinsonian features, poor levodopa response	MRI "hot cross bun sign" (MSA-C); autonomic testing
Dementia with Lewy bodies (DLB)	Cognitive decline before or within 1 year of motor symptoms, visual hallucinations, fluctuating cognition	Neuropsychological testing; DaTSCAN abnormal

Investigations

Essential Clinical assessment using MDS-UPDRS Validated rating scale for motor and non-motor features. Part III (motor) scored during "on" and "off" states. MBS item 110 (neurology consultation).

Available DaTSCAN (¹²³I-ioflupane SPECT) Demonstriates presynaptic dopaminergic deficit. Useful to differentiate PD from essential tremor or drug-induced parkinsonism. Available at major Australian tertiary centres (MBS item 61433). Medicare-rebatable when clinical doubt exists. NOT required if clinical picture is classic.

Available MRI Brain Not diagnostic of PD but essential to exclude structural causes (stroke, hydrocephalus, tumour). Recommended for atypical presentations or age <50 at onset. MBS item 63087.

Referral Neuropsychological assessment Baseline cognitive testing (MoCA, ACE-III) at diagnosis and serially. Essential when cognitive decline is suspected. Refer to clinical neuropsychologist. MBS item 110.

Referral Autonomic function testing Tilt-table test, formal autonomic screen. Refer when orthostatic hypotension or autonomic symptoms are prominent. Available at major centres.

Specialist Genetic testing Consider in young-onset PD (<50 years) or strong family history. LRRK2, GBA, SNCA, PARK2 panels. Referral to genetic counselling recommended. Available through Australian Genomics.

Hoehn & Yahr Staging

Stage 1

Unilateral involvement

Symptoms on one side only. Minimal or no functional impairment. Often diagnosed here.

Setting: GP-led, community

Stage 2

Bilateral, no balance impairment

Both sides affected. Minimal disability. Posture and gait still normal.

Setting: GP + neurologist

Stage 3

Mild to moderate bilateral disease

Impaired postural reflexes, early balance problems. Still physically independent. Falls begin.

Setting: Neurologist + MDT

Stage 4

Severe disability

Still able to stand and walk but requires assistance. Motor fluctuations and dyskinesias common.

Setting: Specialist + MDT + consideration of advanced therapies

Stage 5

Wheelchair-bound or bedridden

Requires constant care. Severe motor and non-motor complications. Aspiration pneumonia risk high.

Setting: Residential aged care / specialist palliative care

Non-Motor Symptoms

Non-motor symptoms (NMS) affect virtually all patients with PD and are often more disabling than the motor features. They may precede motor symptoms by 10–20 years (prodromal PD) and significantly impact quality of life, carer burden and institutionalisation rates. Systematic screening using the Non-Motor Symptoms Questionnaire (NMSQuest) or MDS-UPDRS Part I is recommended at every review.

Neuropsychiatric Symptoms

Symptom	Prevalence	Management
Depression	40–50%	SSRIs (sertraline, citalopram) or SNRIs (venlafaxine). Pramipexole has antidepressant effect. Avoid TCAs in elderly (anticholinergic burden). Psychological therapies (CBT) effective. Screen with PHQ-9.
Anxiety	30–40%	Often related to "off" periods — optimise dopaminergic therapy first. SSRIs/SNRIs. CBT. Avoid benzodiazepines in elderly (falls risk).
Psychosis / hallucinations	20–40%	Stepwise: (1) reduce anticholinergics, polypharmacy; (2) reduce/amend PD medications (anticholinergics → amantadine → dopamine agonists → MAO-B inhibitors → levodopa); (3) quetiapine 12.5–100 mg (PBS authority required for psychosis); (4) pimavanserin 34 mg daily (PBS authority required, limited availability). Avoid typical antipsychotics (haloperidol) and olanzapine — worsen parkinsonism.
Cognitive decline / PD dementia	30–80% over disease course	Rivastigmine 1.5 mg BD, titrate to 6 mg BD (Exelon® — PBS authority required for PD dementia). Rivastigmine transdermal patch 4.6 mg/24 h, titrate to 9.5 mg/24h or 13.3 mg/24h. Donepezil and galantamine may be used. MoCA/ACE-3 monitoring. Minimise anticholinergic load.
Impulse control disorders	15–20% on dopamine agonists	Pathological gambling, hypersexuality, compulsive shopping/eating. Screen at every review (QUIP-RS questionnaire). Reduce or cease dopamine agonist (taper gradually). Warn patients and carers at initiation.
Apathy	20–40%	Distinguish from depression. Rotigotine patch may help. Structured activity programmes, physiotherapy, goal-setting. Rivastigmine if cognitive component present.

Sleep Disorders

REM sleep behaviour disorder (RBD): Dream enactment, vocalisation, injury. Present in 30–50% of PD; a strong prodromal marker. Safety measures (bed padding, bed rails, partner safety). Clonazepam 0.5–2 mg nocte (PBS-listed) or melatonin 2–10 mg (PBS-listed for adults ≥55 with primary insomnia).
Excessive daytime somnolence: Assess for sleep apnoea, medication-related sedation. Modafinil 100–200 mg (off-label, not PBS-listed for PD) may be considered. Reduce sedating PD medications. Driving assessment required.
Insomnia: Related to nocturnal akinesia, nocturia, pain, RBD. Controlled-release levodopa (Sinemet CR® — PBS-listed). Sleep hygiene, melatonin, address nocturia.
Restless legs syndrome: 20–30%. Dopamine agonists or gabapentin enacarbil (off-label in PD). Iron studies — supplement if ferritin <75 µg/L.

Sensory and Other Non-Motor Symptoms

Anosmia / hyposmia: Present in >90% of patients. Often the earliest symptom. May precede motor features by years. Not usually treatable but aids diagnosis. Screen with Sniffin' Sticks or Brief Smell Identification Test.
Pain: Musculoskeletal, dystonic, central/nociceptive. Multimodal management: optimise dopaminergic therapy, physiotherapy, duloxetine, gabapentin/pregabalin (PBS-listed for neuropathic pain). Avoid opioids if possible in elderly.
Fatigue: Prevalence 30–50%. Address contributing factors (depression, sleep, anaemia, thyroid). Exercise programmes beneficial. Modafinil (off-label).
Drooling (sialorrhoea): Due to reduced swallow frequency, not overproduction. Botulinum toxin type A (Botox® — PBS authority required) to parotid/submandibular glands. Glycopyrrolate 1 mg BD (off-label, anticholinergic — caution in elderly). Atropine 1% eye drops sublingually (off-label).

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Never use metoclopramide or prochlorperazine in PD: These dopamine-blocking anti-emetics will acutely worsen parkinsonism. Use domperidone (Motilium® — PBS-listed, but note QTc prolongation risk) or ondansetron instead. Always review the medication list for hidden dopamine antagonists.

Levodopa and Dopaminergic Therapy

Pharmacological management of PD aims to improve motor function and quality of life while minimising adverse effects, particularly in older adults who are vulnerable to cognitive side-effects, hallucinations, orthostatic hypotension and falls. The choice of initial therapy depends on symptom severity, patient age, cognitive status and patient preference.

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Key principle — do not delay levodopa: There is no evidence that delaying levodopa is neuroprotective or alters disease progression. In patients aged ≥70, or those with cognitive impairment, levodopa/carbidopa is first-line. Starting with a dopamine agonist in elderly patients increases the risk of hallucinations, oedema, and impulse control disorders with less motor benefit.

First-Line Therapy — Levodopa/Carbidopa

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Levodopa/Carbidopa (Sinemet®)

Sinemet 100/25, 250/25 · Intestinal gel: Duodopa® · Dopaminergic

Adult dose Start 50/12.5 mg (half tablet) TDS, titrate by 50 mg levodopa every 3–7 days. Maintenance 100/25 mg TDS–QID; typical range 300–1000 mg/day levodopa in divided doses.

Route Oral (immediate-release or controlled-release). Duodopa: jejunal PEG-J infusion (specialist only).

Renal adjustment No specific adjustment; use lower starting doses if eGFR <30 mL/min (reduced clearance). Monitor closely.

Hepatic adjustment Use with caution in hepatic impairment; start low, titrate slowly.

Key adverse effects Nausea (take with food), postural hypotension, dyskinesias (dose-related), hallucinations (elderly), drowsiness, impulse control (rare with levodopa alone).

PBS status ✔ PBS General Benefit (Sinemet) Authority Required (Duodopa LCIG)

Second-Line — Adjunct Therapy for Motor Fluctuations

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Pramipexole (Sifrol®)

Sifrol 0.088 mg, 0.18 mg, 0.7 mg · Non-ergot dopamine agonist

Adult dose Start 0.088 mg (as base) TDS, titrate weekly. Target 0.54–1.1 mg TDS (as base). Extended-release: 0.375 mg nocte, titrate to 3.15 mg daily.

Key adverse effects Nausea, oedema, somnolence, hallucinations, impulse control disorders (gambling, hypersexuality). Higher risk in elderly and those with cognitive impairment.

Renal adjustment Reduce dose if CrCl 20–50 mL/min; avoid if CrCl <20 mL/min. Extended-release: avoid if CrCl <30.

PBS status ✔ PBS General Benefit

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Ropinirole (Requip®)

Requip 0.25 mg, 1 mg, 2 mg, 5 mg · Non-ergot dopamine agonist

Adult dose Start 0.25 mg TDS, titrate weekly. Target 3–9 mg TDS. Modified-release: 2 mg nocte, titrate to 24 mg daily.

Key adverse effects Similar to pramipexole. Impulse control disorders, somnolence, nausea, oedema, postural hypotension.

Renal adjustment No dose adjustment required for mild–moderate renal impairment.

PBS status ✔ PBS General Benefit

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Rotigotine (Neupro®)

Neupro transdermal patch 2 mg/24 h, 4 mg/24 h, 6 mg/24 h, 8 mg/24 h · Non-ergot dopamine agonist

Adult dose Start 2 mg/24 h patch once daily, titrate weekly by 2 mg/24 h. Maintenance 4–8 mg/24 h.

Key advantage Continuous transdermal delivery reduces motor fluctuations. Useful in patients with dysphagia. Apply to clean, dry, intact skin; rotate sites.

Key adverse effects Application site reactions (up to 30%), nausea, somnolence, peripheral oedema, impulse control disorders.

PBS status ✔ PBS General Benefit

MAO-B Inhibitors

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Rasagiline (Azilect®)

Azilect 1 mg · Irreversible MAO-B inhibitor

Adult dose 1 mg once daily (monotherapy or adjunct to levodopa). No dose titration needed.

Renal adjustment No adjustment required. Caution in severe renal impairment.

Key interactions Avoid concomitant SSRIs/SNRIs, tramadol, meperidine, St John's wort — serotonin syndrome risk. Mild dietary restrictions (avoid excessive tyramine).

PBS status ✔ PBS General Benefit

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Safinamide (Xadago®)

Xadago 50 mg, 100 mg · Reversible MAO-B inhibitor with glutamatergic modulation

Adult dose 50 mg once daily for 2 weeks, then 100 mg once daily. Adjunct to levodopa in mid-to-late stage PD with motor fluctuations.

Key advantage May reduce "off" time and dyskinesia severity. Fewer dietary restrictions than irreversible MAO-B inhibitors.

Renal adjustment No adjustment for mild–moderate. Avoid in severe hepatic impairment.

PBS status Restricted Benefit — Authority Required

Other Adjunct Therapies

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Amantadine (Symmetrel®)

Symmetrel 100 mg · NMDA antagonist

Adult dose 100 mg BD (morning and midday). Extended-release (Gocovri® — not PBS-listed): 137 mg nocte, titrate to 274 mg nocte.

Indication Levodopa-induced dyskinesias. Also has mild antiparkinsonian effect.

Key adverse effects Livedo reticularis, ankle oedema, hallucinations, confusion (caution in elderly), insomnia, anticholinergic effects.

Renal adjustment Reduce to 100 mg daily if eGFR 30–60; avoid if eGFR <30. Largely renally cleared.

PBS status ✔ PBS General Benefit

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Apomorphine

Apomorphine injection / sublingual film · Potent dopamine agonist

Subcutaneous rescue 2 mg SC injection for "off" episodes; titrate to effective dose (2–6 mg). Onset 10–20 min. Pre-treat with domperidone 10–20 mg TDS (at least 2 days prior) to reduce nausea.

Continuous infusion For severe motor fluctuations. 1–4 mg/hour SC via pump. Specialist initiation (movement disorder clinic).

Key adverse effects Nausea/vomiting (almost universal — domperidone mandatory), injection site nodules, somnolence, haemolytic anaemia (rare), QTc prolongation.

PBS status Authority Required (Specialist)

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Entacapone (Comtan®)

Comtan 200 mg · COMT inhibitor

Adult dose 200 mg with each dose of levodopa/carbidopa (maximum 8 doses daily = 1600 mg).

Indication "Wearing-off" phenomenon. Extends levodopa duration of action by ~1 hour per dose.

Key adverse effects Diarrhoea (most common, may require discontinuation), urine discolouration (orange-brown), dyskinesias (reduce levodopa dose by 10–30% on initiation).

PBS status ✔ PBS General Benefit

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Levodopa/Carbidopa/Entacapone (Stalevo®)

Stalevo 50/12.5/200, 100/25/200, 150/37.5/200, 200/50/200

Adult dose One tablet with each levodopa dose, matched to current levodopa dose. Simplifies regimen vs separate entacapone.

PBS status ✔ PBS General Benefit

Motor Complications — Recognition and Management

Wearing-off

End-of-dose deterioration

Motor and non-motor symptoms return before next levodopa dose. <4 hours benefit per dose. Predictable pattern.

Management: Add entacapone, COMT inhibitor, MAO-B inhibitor, or switch to more frequent lower-dose levodopa. Consider dopamine agonist adjunct.

Peak-dose dyskinesia

Choreiform movements at peak levodopa effect

Most common form. Occurs when levodopa levels are highest. Usually begins as mild head/trunk, progresses to limbs.

Management: Reduce individual levodopa dose, increase dosing frequency, add amantadine, consider COMT inhibitor to smooth levels.

Diphasic dyskinesia

Dyskinesia at onset and end of dose

Less common. Occurs at the beginning and end of each dose cycle. Often ballistic/hyperkinetic.

Management: Increase levodopa dose (paradoxical), add dopamine agonist, consider continuous infusion therapies.

"Off" periods / freezing

Predictable or unpredictable "off" states

Sudden loss of mobility. May occur unpredictably. Freezing of gait on initiation, turning, doorways. High fall risk.

Management: Apomorphine rescue SC, sublingual apomorphine, optimise oral regimen, consider DBS or LCIG if refractory.

When to Refer for Advanced Therapies

Optimise oral therapy

Ensure maximum tolerated levodopa with adjuncts (COMT, MAO-B, dopamine agonist, amantadine). Address adherence and timing. Diet: high-protein meals may impair levodopa absorption — consider protein redistribution.

Specialist review

Movement disorder neurologist assessment for motor fluctuations, dyskinesias, or functional impairment ≥2 hours/day "off" time despite optimised oral therapy.

Consider device-aided therapies

Deep brain stimulation (DBS), levodopa–carbidopa intestinal gel (LCIG/Duodopa®), or continuous subcutaneous apomorphine infusion. Selection depends on age, cognition, comorbidities, patient preference and availability.

Advanced Therapy	Patient Selection	Key Considerations	Australian Availability
Deep brain stimulation (DBS)	Age typically <70, good cognitive function, good levodopa response (≥30% improvement), no active psychiatric disease, no significant cerebrovascular disease.	STN or GPi targeting. Improves motor fluctuations, dyskinesias, tremor. Does NOT improve gait freezing or cognitive decline. Requires programming expertise. MRI-conditional devices now standard.	Available at major tertiary centres (Royal Melbourne, RPA Sydney, Royal Brisbane, Royal Adelaide, Fiona Stanley Perth). PBS authority required. Long waiting lists in public system.
LCIG (Duodopa®)	Severe motor fluctuations not controlled by oral therapy. May be suitable for patients not eligible for DBS (older age, cognitive impairment).	Continuous jejunal infusion via PEG-J. Significant reduction in "off" time. Risks: tube complications (dislocation, obstruction, stoma infection), weight loss, polyneuropathy (monitor B12, methylmalonic acid). Requires community nursing support.	PBS authority required. Initiated at specialist centres. Home delivery and community nursing arranged through Duodopa service providers. Available in all capital cities.
Apomorphine continuous SC infusion	Severe motor fluctuations. Younger, more mobile patients who can manage the pump device. Trial of acute response required.	Portable pump with subcutaneous cannula. Domperidone pre-treatment mandatory. Monitor for QTc prolongation, haemolytic anaemia (rare). Subcutaneous nodules manageable with rotation.	PBS authority required via specialist. Available through movement disorder services.

Falls, Swallowing, Autonomic Dysfunction and Advanced Care

Falls Prevention

Falls are the leading cause of morbidity in PD, with 60–70% of patients falling annually. Hip fractures from falls are a major cause of hospitalisation and mortality. Falls in PD are multifactorial — combining postural instability, freezing of gait, orthostatic hypotension, visual impairment, cognitive impairment, medication side-effects, and environmental hazards.

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Falls prevention is a medical emergency in PD: A single fall doubles the risk of hip fracture and nursing home admission. Every PD patient should be asked about falls at every consultation. The Timed Up and Go (TUG) test, Mini-BESTest, and Falls Efficacy Scale-International (FES-I) should be performed at least annually.

Physiotherapy: PD-specific physiotherapy (LSVT-BIG, PWR!Moves, tai chi) improves balance, gait speed, and reduces falls. Minimum 2 sessions/week recommended. Funded under MBS chronic disease management plans (GP Management Plan — MBS item 721, Team Care Arrangements — MBS item 723) providing up to 5 allied health sessions per calendar year.
Exercise programmes: Regular aerobic and balance exercise (≥150 minutes/week) is associated with slower motor decline and fewer falls. Exercise physiology, community falls prevention classes (e.g., Stepping On programme — available in all Australian states).
Home hazard assessment: Occupational therapy home visit. Remove loose rugs, install grab rails, improve lighting, address flooring, bathroom safety. Funded through My Aged Care (Commonwealth Home Support Programme or Home Care Package).
Medication review: Reduce polypharmacy. Minimise sedatives, antihypertensives (especially at night), anticholinergics, and opioids. Consider deprescribing under clinical guidance.
Vitamin D supplementation: 1000 IU daily if vitamin D <50 nmol/L (common in PD). Evidence for falls reduction is modest but supplementation is low-risk and addresses common deficiency. PBS-listed for patients at risk of deficiency.
Orthostatic hypotension management: (See Autonomic Dysfunction below).
Freezing of gait strategies: Auditory cueing (metronome, rhythmic music), visual cues (laser cane, floor lines), cueing apps, stepping sideways. Refer for PD-specific gait rehabilitation.
Hip protectors: Consider in high-risk patients in residential aged care. Evidence is mixed but may reduce fracture severity.

Dysphagia and Swallowing

Dysphagia affects 35–80% of PD patients and increases with disease duration. Silent aspiration is common and leads to aspiration pneumonia — the leading cause of death in PD. Both oral and pharyngeal phases are affected, with reduced lingual control, delayed swallow reflex, and residue in the valleculae and piriform sinuses.

Screening: Ask about coughing/choking during meals, wet/gurgly voice after eating, unexplained weight loss, recurrent chest infections. Use the Eating Assessment Tool (EAT-10). Refer to speech pathology if any concerns.
Speech pathology assessment: Clinical swallowing examination and instrumental assessment (videofluoroscopy or fibreoptic endoscopic evaluation of swallowing — FEES). Available at public hospitals (MBS item 110 for specialist consultation, or bulk-billed speech pathology through hospital outpatient services).
Management strategies: Chin tuck, effortful swallow, supraglottic swallow techniques, modified diet textures (IDDSI framework), thickened fluids as indicated. LSVT-LOUD and SPEAK OUT!® voice programmes may improve swallow function.
Medication administration: Levodopa tablets may be crushed and administered via enteral tubes. Controlled-release formulations should NOT be crushed. Rotigotine patch bypasses swallowing issues entirely. Duodopa (LCIG) via PEG-J is a definitive solution for advanced dysphagia.
PEG tube consideration: Percutaneous endoscopic gastrostomy may be considered for medication delivery and nutrition in advanced PD. However, it does NOT prevent aspiration (aspiration occurs from oral secretions above the PEG). Shared decision-making with patient, family and palliative care team is essential.

Autonomic Dysfunction

Autonomic dysfunction is an intrinsic feature of PD (related to α-synuclein deposition in autonomic nuclei) and may predate motor symptoms by years. It becomes increasingly prevalent and troublesome as the disease progresses.

Autonomic Domain	Features	Management
Orthostatic hypotension	≥20 mmHg systolic or ≥10 mmHg diastolic drop on standing. Symptomatic: dizziness, syncope, falls. Worsened by dopaminergic therapy, dehydration, deconditioning.	Non-pharmacological: rise slowly, adequate hydration (1.5–2 L/day), salt loading (6–10 g/day if no contraindication), compression stockings (waist-high), avoid large meals, elevate head of bed 10–15°. Pharmacological: midodrine 2.5–10 mg TDS (PBS authority required), fludrocortisone 50–300 µg daily (PBS-listed — monitor for supine hypertension, hypokalaemia, oedema). Droxidopa (northera) — not currently PBS-listed in Australia. Avoid antihypertensives if possible; review morning antihypertensives.
Constipation	Affects 60–80%. Precedes motor symptoms. Reduces levodopa absorption. Risk of ileus and faecal impaction.	Dietary fibre (25–30 g/day), adequate fluid intake, regular exercise. Macrogol 3350 (Movicol® — PBS-listed for palliative care, otherwise general sale). Osmotic laxatives: lactulose 15–30 mL BD (PBS-listed). Stimulant laxatives: senna, bisacodyl for refractory constipation. Prucalopride 1–2 mg daily (Resotran® — PBS authority required for chronic constipation refractory to other laxatives). Avoid anticholinergic agents (including tricyclics).
Urinary dysfunction	Frequency, urgency, nocturia, urge incontinence (detrusor overactivity). Post-void retention less common.	Fluid management, bladder training, reduce evening fluids. Mirabegron 50 mg daily (Betmiga® — PBS-listed for overactive bladder) — fewer anticholinergic effects than oxybutynin. Solifenacin 5–10 mg daily (Vesicare® — PBS-listed) — use cautiously in elderly due to cognitive effects. Desmopressin intranasal for nocturia (off-label; monitor sodium). Avoid oxybutynin in elderly (cognitive impairment risk).
Sexual dysfunction	Erectile dysfunction (50–80% of men), reduced libido. May be disease-related or medication-related (dopamine agonists may increase libido). Hypersexuality as impulse control disorder — screen for this.	Sildenafil 25–100 mg (Viagra® — PBS authority required for erectile dysfunction). Tadalafil 5–20 mg (Cialis® — PBS authority required). Address medication contributions. Counselling for relationship/psychological aspects. Consider safety in the context of impulse control disorders.
Sweating abnormalities	Hyperhidrosis (excessive sweating), anhidrosis (reduced sweating). Can be a wearing-off symptom. Impaired thermoregulation.	Optimise dopaminergic therapy (wearing-off-related). Clothing adaptation, cooling strategies. Oxybutynin 2.5–5 mg (off-label for hyperhidrosis — caution in elderly). Glycopyrrolate (off-label). Botulinum toxin for focal hyperhidrosis (PBS authority required).

Advanced Disease and Palliative Care

Parkinson's disease is a life-limiting condition with a median survival of 10–15 years from diagnosis, though this varies substantially. Advance care planning should be initiated early and revisited regularly, particularly when cognitive decline emerges. Palliative care is appropriate at any stage but is especially important in Hoehn & Yahr stages 4–5.

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Anticipate end-of-life symptoms: In the final days of life in PD, swallowing and consciousness decline, making oral levodopa impossible. Subcutaneous, transdermal and rectal routes should be considered. Rotigotine patch and subcutaneous apomorphine provide continuous dopaminergic stimulation. Levodopa can be administered via NG tube. Anticipate and treat aspiration pneumonia, pain, agitation, and secretions proactively. Involve palliative care early.

Advance care planning

Initiate at diagnosis. Document preferences regarding resuscitation, hospital transfer, artificial nutrition/hydration, and level of care. Use state-based Advance Care Directives (e.g., NSW: Advance Care Directive, Victoria: Advance Care Plan). Register with My Health Record.

Multidisciplinary team

Neurologist, GP, geriatrician, physiotherapist, occupational therapist, speech pathologist, dietitian, social worker, psychologist/psychiatrist, continence nurse, Parkinson's nurse specialist. Parkinson's Australia and state-based Parkinson's organisations provide support and information.

Palliative care integration

Refer to specialist palliative care when: rapid decline, significant pain/symptom burden, dysphagia limiting medications, recurrent aspiration, severe hallucinations, patient/family distress. Palliative care is NOT only for the dying phase — early integration improves quality of life.

Carer support

Carer burden in advanced PD is extremely high. Screen carers for depression and burnout. Respite care, Carer Gateway (1800 422 737), My Aged Care referrals. Education on disease progression and what to expect.

Special Populations

👴

Elderly (≥75 years)

Preferred first-line: Levodopa/carbidopa at lowest effective dose. Dopamine agonists carry higher risk of hallucinations, oedema, somnolence and impulse control disorders in this age group.

Anticholinergic burden: Avoid anticholinergics (benztropine, trihexyphenidyl) — high risk of confusion, urinary retention, constipation, falls. Use anticholinergic burden scales (e.g., Anticholinergic Cognitive Burden Scale).

Cognitive monitoring: Baseline and 6-monthly MoCA/ACE-3. Rivastigmine if PD-MCI or PD dementia develops.

Falls risk: Medication review, physiotherapy, home assessment. Minimise polypharmacy.

Residential aged care: Ensure Parkinson's-specific care plans. Parkinson's nurse specialist visit where available. Medication timing is critical — delays in medication administration in RACFs are a major quality issue.

When ≥75 years, start levodopa — do not use dopamine agonists as monotherapy. Lower starting dose (25/100 mg half tablet TDS) and slower titration.

👶

Young-Onset PD (≤50 years)

Diagnostic consideration: Higher likelihood of genetic aetiology (LRRK2, GBA, PARK2). Consider genetic testing and counselling.

Initial therapy: MAO-B inhibitors or dopamine agonists may be preferred to delay levodopa-related motor complications. However, if symptoms are functionally significant, levodopa should not be withheld.

Impulse control disorders: Higher risk with dopamine agonists. Screen rigorously with QUIP-RS. Advise patients and families.

Employment and family planning: Occupational therapy, workplace adjustments. Women: discuss dopaminergic therapy effects on pregnancy (dopamine agonists suppress lactation). Levodopa is relatively safe in pregnancy but evidence is limited.

Device-aided therapies: DBS is well-suited to younger patients with preserved cognition and good levodopa response. Consider early referral.

Young-onset PD has a slower disease course but longer disease duration. Long-term medication planning and early advance care discussions are appropriate.

🫘

Renal Impairment

Levodopa: No specific dose adjustment, but lower starting doses if eGFR <30 mL/min. Monitor for increased adverse effects.

Pramipexole: Significant renal adjustment — dose reduction required if CrCl 20–50; avoid if CrCl <20.

Amantadine: Accumulates in renal impairment — reduce dose or avoid if eGFR <30.

Entacapone: No adjustment required but use cautiously in severe impairment.

COMT inhibitors: No significant renal adjustments for entacapone or opicapone.

Dialysis: Levodopa is partially dialysable. Consider post-dialysis dose. Adjust medication timing around haemodialysis sessions.

🛡️

Immunocompromised / Frail

Infection risk: Aspiration pneumonia is the leading cause of death. Ensure influenza and pneumococcal vaccination. COVID-19 vaccination recommended.

Frailty screening: Use Clinical Frailty Scale or Fried criteria. Frailty predicts poor outcomes after falls, infections and hospitalisation.

De-prescribing: Regular medication review. Consider whether each PD medication still provides functional benefit. Avoid adding new medications without removing others where possible.

Antipsychotic caution: Never use haloperidol, droperidol, metoclopramide or olanzapine. Use quetiapine (lowest dose) for psychosis if required.

In the frail elderly, the goal of PD therapy shifts from motor optimisation to maintaining comfort, independence and quality of life.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience neurological disorders, including parkinsonism, at potentially higher rates than non-Indigenous Australians, though specific PD prevalence data in First Nations populations are limited. The burden of comorbidities (diabetes, cardiovascular disease, chronic kidney disease), earlier onset of age-related conditions, and barriers to specialist access create unique challenges in diagnosis and management.

⚠️

Underdiagnosis risk: Parkinson's disease and other parkinsonian syndromes may be underdiagnosed in Aboriginal and Torres Strait Islander communities due to reduced access to neurologists and movement disorder specialists, cultural differences in symptom reporting, and competing health priorities (chronic disease burden). Community-based health workers and ACCHOs (Aboriginal Community Controlled Health Organisations) play a vital role in early recognition and referral.

Specialist access

Remote and very remote Aboriginal and Torres Strait Islander communities have limited or no access to neurologists or movement disorder clinics. Telehealth (MBS items 99200–99215 for specialist video consultations) is essential but requires reliable internet and culturally appropriate platforms. Outreach neurology services through state health departments and organisations like Purple House (renal, but model applicable to neurology) should be expanded.

Medication access and adherence

PBS medications are available through Section 100 (S100) Remote Area Aboriginal Health Services with no co-payment for eligible patients. Close the Gap PBS co-payment measure ensures no out-of-pocket costs for PBS medicines for Aboriginal and Torres Strait Islander patients with a chronic disease management plan. Medication adherence support through Aboriginal health workers, blister packs, and community pharmacy Remote Delivery programs (NT, WA, QLD) is critical. Levodopa timing is important — consider rotigotine patch for patients who may have difficulty with multiple daily dosing.

Cultural considerations

Health literacy varies; educational materials should be culturally appropriate and available in local languages where possible. Sorry Business, cultural obligations, and connection to Country may affect appointment attendance and care planning. Use the Australian Indigenous Doctors' Association (AIDA) cultural safety framework. Male health workers may be needed for discussions about sexual dysfunction in male patients; gender sensitivity in all consultations. "Shame" and stigma associated with movement disorders and cognitive decline may delay help-seeking.

Falls and injury prevention

Environmental hazards differ in remote communities (uneven terrain, limited indoor lighting, community housing design). Falls prevention must account for community living arrangements and outdoor mobility needs. Hip fracture management requires rapid evacuation from remote communities — aerial retrieval services (Royal Flying Doctor Service) and forward triaging at remote clinics are essential.

Aged care in community

Many Aboriginal and Torres Strait Islander Elders prefer to remain on Country rather than enter residential aged care. Flexible aged care packages (My Aged Care — Aboriginal and Torres Strait Islander-specific assessment teams), multi-purpose health service models, and Aboriginal-specific aged care facilities support culturally safe care. The Aged Care Royal Commission (2021) recommended increased investment in culturally appropriate aged care for First Nations Australians.

Advance care planning

Advance care planning discussions must respect cultural protocols around death and dying, family decision-making structures, and obligations to Country. End-of-life care preferences may include preference to return to Country. Work with Aboriginal health workers and liaison officers to facilitate these conversations. The National Palliative Care Strategy includes specific actions for Aboriginal and Torres Strait Islander communities.

Key Resources

Parkinson's Australia: Information resources — www.parkinsons.org.au (limited culturally specific materials; advocacy for more is ongoing).
Aboriginal Community Controlled Health Organisations (ACCHOs): NACCHO member organisations provide primary care, chronic disease management, and referral pathways. Link patients to their local ACCHO.
Close the Gap PBS co-payment measure: Ensures PBS medicines are available at no cost for eligible Aboriginal and Torres Strait Islander patients with chronic conditions.
My Aged Care Aboriginal and Torres Strait Islander Access: Dedicated assessment pathway for First Nations older Australians. Call 1800 200 422.
Rural and Remote Health (RHDAustralia): Resources for managing chronic neurological conditions in remote settings.

📚 References

1. Postuma RB, Berg D, Stern M, et al. MDS clinical diagnostic criteria for Parkinson's disease. Mov Disord. 2015;30(12):1591–1601. doi:10.1002/mds.26424
2. Bloem BR, Okun MS, Klein C. Parkinson's disease. Lancet. 2021;397(10291):2284–2303. doi:10.1016/S0140-6736(21)00218-X
3. Fox SH, Katzenschlager R, Lim SY, et al. International Parkinson and Movement Disorder Society evidence-based medicine review: Update on treatments for the motor symptoms of Parkinson's disease. Mov Disord. 2018;33(8):1248–1266. doi:10.1002/mds.27372
4. Seppi K, Ray Chaudhuri K, Coelho M, et al. Update on treatments for nonmotor symptoms of Parkinson's disease — An evidence-based medicine review. Mov Disord. 2019;34(2):180–198. doi:10.1002/mds.27602
5. Deloitte Access Economics. Parkinson's Disease in Australia — Prevalence, Costs and Future Burden. Melbourne: Deloitte; 2014.
6. Australian Institute of Health and Welfare (AIHW). Dementia in Australia. Cat. no. DEM 7. Canberra: AIHW; 2023.
7. Parkinson's Australia. National Parkinson's Plan: A Framework for Action. Canberra: Parkinson's Australia; 2019.
8. Titova N, Padmakumar C, Lewis SJG, Chaudhuri KR. Parkinson's disease: Defining the non-motor profile. Expert Rev Neurother. 2017;17(2):123–134. doi:10.1080/14737175.2016.1212664
9. DeMaagd G, Philip A. Parkinson's disease and its management: Part 1 — Disease entity, risk factors, pathophysiology, clinical presentation, and diagnosis. P T. 2015;40(8):504–532.
10. DeMaagd G, Philip A. Parkinson's disease and its management: Part 2 — Initiation of motor complications, prevention, and management strategies. P T. 2015;40(8):533–546.
11. Royal Australian College of General Practitioners (RACGP). Management of Parkinson's disease in general practice — Clinical guide. Melbourne: RACGP; 2022.
12. Coelho M, Ferreira JJ. Late-stage Parkinson disease. Nat Rev Neurol. 2012;8(8):435–442. doi:10.1038/nrneurol.2012.126
13. National Institute for Health and Care Excellence (NICE). Parkinson's disease in adults — NG71. London: NICE; 2017 (updated 2024).
14. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
15. Movement Disorder Society Task Force on Rating Scales for Parkinson's Disease. The Unified Parkinson's Disease Rating Scale (UPDRS): Status and recommendations. Mov Disord. 2003;18(7):738–750. doi:10.1002/mds.10473

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).