Should levodopa be discontinued or continued in patients with Parkinson's disease (PD) and Lewy body dementia (LBD) at the end of life during palliative care?

Continuing Levodopa During End-of-Life Palliative Care for Parkinson's Disease with Lewy Body Dementia

Levodopa should be continued during end-of-life palliative care for patients with Parkinson's disease and Lewy body dementia to maintain quality of life and prevent significant worsening of motor symptoms.

Rationale for Continuing Levodopa

Levodopa remains the most effective medication for managing motor symptoms in Parkinson's disease, even in advanced stages with dementia. Abrupt discontinuation can lead to:

• Significant worsening of motor function
• Increased rigidity and immobility
• Potential neuroleptic malignant-like syndrome
• Decreased comfort and quality of life

The Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (2020) specifically recommends that cholinesterase inhibitors should not be discontinued in individuals who have clinically meaningful symptom reduction, even if there is evidence of cognitive and functional decline 1. This principle applies similarly to levodopa in advanced Parkinson's disease.

Benefits of Continuing Levodopa in End-of-Life Care

1. Symptom Management: Even in end-stage disease, levodopa helps control rigidity and akinesia, which can:

   • Reduce pain from rigidity
   • Facilitate nursing care and repositioning
   • Prevent pressure ulcers
   • Maintain minimal mobility

2. Quality of Life: Levodopa continues to provide symptomatic relief that improves quality of life, which remains the primary goal in palliative care 2, 3.

3. Comfort Maximization: The European Association for Palliative Care emphasizes that "improving quality of life, maintaining function and maximizing comfort" are key objectives of palliative care for people with dementia 1.

Dosing Considerations in End-of-Life Care

When continuing levodopa in end-of-life care:

• Simplify medication regimen when possible
• Consider reducing dose only if side effects (dyskinesias, hallucinations) are problematic
• Maintain regular dosing schedule to prevent wearing-off symptoms
• Switch to liquid formulations if swallowing difficulties develop

When to Consider Dose Reduction or Discontinuation

According to the Canadian Consensus guidelines, discontinuation should only be considered if 1:

1. There has been clinically meaningful worsening despite treatment
2. No benefit was observed at any time during treatment
3. The patient has developed intolerable side effects (severe nausea, vomiting, psychosis)
4. Medication adherence is poor and precludes safe use

Monitoring Response

Monitor for:

• Changes in rigidity and mobility
• Signs of discomfort that may indicate wearing-off symptoms
• Emergence of hallucinations or confusion
• Swallowing difficulties that may require medication form changes

Nutritional Considerations

The ESPEN guideline notes that levodopa use is associated with nutritional challenges 1:

• Monitor for weight loss, especially in advanced disease
• Be aware that higher levodopa doses may be associated with increased risk for malnutrition
• Consider vitamin B supplementation (B6, B12, folate) as levodopa can cause hyperhomocysteinemia

Conclusion

While many medications may be appropriately discontinued during end-of-life care, levodopa represents a special case in Parkinson's disease with Lewy body dementia. The benefits of continued treatment in terms of comfort, quality of life, and symptom management typically outweigh the risks of discontinuation. The focus should remain on maximizing comfort and quality of life rather than on reducing medication burden.