NWPF

Advanced Stage Treatment

PD Stages

Therapy in advanced stage PD includes the following focus:

  • Treatment of motor symptoms still responsive to medicine such as wearing off and dyskinesia
  • Non-medical therapies of dopaminergic non-responsive symptoms of postural instability, freezing of gait, speech, swallowing.
  • Medicine simplification to reduce side effects
  • Quality of life focus continues throughout each stage but deserves particular attention here with focus on social engagement, cognitive health
  • Rehabilitation, Life Planning andCaregiver support
Medications
Levodopa continues to help motor symptoms such as rigidity, bradykinesia and tremor. Some medicines such as dopamine agonists, amantadine and selegiline cause increasing problems of concern in advanced stage due to higher risk of these side effects:
  • Confusion and memory problems
  • Hallucinations
  • Sedation
  • Lightheadedness

Levodopa, entacapone (Stalevo) and rasagiline have similar side effects but with lower risk and are often used preferentially in this stage.

It is important not to overmedicate for symptoms that are bothersome yet will not respond to medicines. This only leads tomore side effects. 

DEEP BRAIN STIMULATION (DBS)

DBS is a surgical treatment often described as a brain pacemaker in which electrical stimulation or impulses are applied to specific areas of the brain involved in motor control.  For Parkinson’s, these brain regions are the globus pallidus internus (Gpi) or the subthalamic nucleus (STN). 

DBS is especially helpful in midstage PD since this surgery can treat:

  • Tremor
  • Reduce Off Time
  • Reduce Dyskinesia

On a case by case basis, DBS can be considered in advancing stages but must be considered only too treat symptoms noted above and not the dopaminergic non-responsive symptoms that define advanced disease.  Careful consideration is needed given increased surgical risk in advanced disease. For instance, DBS is not performed:

  • To treat posture, balance, speech and swallowing problems
  • If confusion/dementia is present
  • As a treatment of 'last resort'
PERSONALIZING YOUR THERAPY
  • comforthand (2)A motor diary can help you and your doctor tailor medicine doses to time of day that you are having the most trouble and reduce un-necessary medicine. 
  • Medication Side Effects. Be sure you are not overusing medicines for symptoms that will not respond.
  • Learn about medicine side effects to monitor before adding additional medicine.
  •  Ask for rehabilitation therapy such as physical therapy, occupational therapy and speech therapy in the Comprehensive Care Worksheet in  My Medical Chart can help.  
  • Rehabilitation is especially helpful to 
    • Reduce fall risk
    • Maintain independence when appropriate
    • Educate and guide caregiving needs
    • Reduce pain
    • Recommend adaptive or assistive strategies
    • Timing and selection of a walker or wheelchair
    • Promote social, emotional and cognitive activities
    • Assess home care environment and needs
    • Life planning education
    • Enhance nutrition, modify diet and reduce aspiration risk
    • Focus on life quality 
      • A motor diary can help you and your doctor tailor medicine doses to time of day that you are having the most trouble. 
      • Learn about medicine side effects that you can monitor before adding additional medicine.
      • Review DBS therapy with your health care provider. DBS does not treat all movement problems so be sure to review the DBS section, Expectations, before considering this therapy.
      •  Ask for rehabilitation therapy such as physical therapy, occupational  therapy and speech, the Comprehensive Care Worksheet  can help.
Find these and other helpful forms in My Medical Chart.

Monique L. Giroux, MDMonique L. Giroux, MD
Medical Director, Northwest Parkinson's Foundation