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Age is the single most consistent risk factor and it has been estimated that there is a cumulative lifetime risk of one in 40 for developing Parkinson’s disease.100 Loss of pigmented cells in the substantia nigra is the most consistent finding in Parkinson’s disease and normally the quantity of nigral cells diminishes from 425 000 to 200 000 at 80 yr.

In Parkinson’s disease, there is a 30–40% decrease in complex‐1 activity in the substantia nigra pars compacta which may contribute to energy failure and hence predispose the pars compacta to toxic insults and increase its susceptibility to cell death.68 Oxidative stress may be caused by an increase in the number of reactive species including hydrogen ions, superoxide, peroxyl radicals, nitric oxide, and hydroxyl radicals.Genetic mutations may predispose patients to develop Parkinson’s disease if combined with other gene mutations or environmental factors.71 Parkinson’s disease is characterized by the progressive death of selected, but heterogeneous, populations of neurones, including those dopaminergic neurones of the pars compacta of the substantia nigra.The precise mechanisms responsible for cell death are largely unknown and may be due to mitochondrial dysfunction, oxidative stress, the actions of excitotoxins with excess nitric oxide formation, deficient neurotrophic support, or immune mechanisms.57 Although still controversial, the final common pathway appears to be the induction of apoptosis in nigral dopaminergic neurones.1353Mitochondrial dysfunction and oxidative metabolism are major components of many current theories in Parkinson’s disease.Particular anaesthetic problems in patients with Parkinson’s disease are respiratory, cardiovascular, and neurological.Potential drug interactions are described and recommendations are made about suitable anaesthetic techniques.