Parkinson's Disease in Older Adults

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Target exams

Red flags

• Acute marked deterioration in a stable Parkinson's patient — think intercurrent infection (urinary, respiratory), medication omission (especially in a nil-by-mouth admission), or drug-induced (antipsychotic, antiemetic, GI prokinetic); not disease progression
• Parkinson's disease psychosis — visual hallucinations, paranoid delusions and agitation — predicts nursing-home placement and doubles mortality; treat with pimavanserin (or low-dose clozapine, quetiapine) and avoid first-generation antipsychotics which worsen parkinsonism
• Sudden severe freezing or gait ignition failure with postural instability in a previously mobile patient — consider normal-pressure hydrocephalus, cervical myelopathy, or transition to atypical parkinsonism (progressive supranuclear palsy, multiple system atrophy)
• Aspiration pneumonia — the leading cause of death in advanced Parkinson's; assess swallowing, modify fluid consistency, refer to speech pathology
• Neuroleptic malignant syndrome or parkinsonism–hyperpyrexia syndrome from abrupt levodopa withdrawal — fever, rigidity, rhabdomyolysis, delirium; reinstate dopaminergic therapy immediately and cool the patient
• Orthostatic hypotension from autonomic failure worsened by levodopa and dopaminergic agents — falls, syncope, cognitive fluctuation; reduce culprit drugs and add midodrine or fludrocortisone