Should levodopa be discontinued or continued in an 83-year-old male with advanced Parkinson's disease and Lewy body dementia, focusing on comfort measures, with reduced appetite and intermittent confusion?

Management of Levodopa in Advanced Parkinson's Disease with Lewy Body Dementia Focused on Comfort

For an 83-year-old male with advanced Parkinson's disease and Lewy body dementia who is focusing on comfort measures and experiencing reduced appetite and intermittent confusion, levodopa should be continued but with potential dose adjustment to minimize side effects while maintaining motor symptom control.

Rationale for Continuing Levodopa

Benefits of Continuing Levodopa

• Levodopa remains the gold standard treatment for motor symptoms in Parkinson's disease, even in advanced stages 1
• Discontinuation of levodopa can lead to significant worsening of motor symptoms, potentially causing discomfort and reduced quality of life
• Abrupt reduction or discontinuation of levodopa may lead to hyperpyrexia and confusion, resembling neuroleptic malignant syndrome 1
• Research shows that levodopa does not adversely affect cognitive function in patients with parkinsonism and dementia 2

Considerations for Dose Adjustment

• In patients focusing on comfort measures with advanced disease, medication should be evaluated for potential side effects that may worsen quality of life 3
• Reduced appetite may be exacerbated by medication side effects, and a medication review should be performed 3
• Intermittent confusion could be related to several factors including:
  • Medication side effects
  • Progression of underlying disease
  • Dehydration or nutritional deficiencies

Management Algorithm

Step 1: Medication Review and Optimization

• Reduce levodopa to the minimum effective dose that controls troublesome motor symptoms 4
• Consider simplifying the dosing schedule to improve adherence and reduce fluctuations
• Avoid anticholinergic medications which can worsen confusion in patients with dementia 4
• Monitor for and address side effects that may affect appetite (nausea, vomiting)

Step 2: Nutritional Support

• Regular monitoring of nutritional status is recommended for Parkinson's patients 3
• Address reduced appetite by:
  • Offering smaller, more frequent meals
  • Ensuring adequate hydration
  • Removing unnecessary dietary restrictions 3
  • Considering nutritional supplements if needed

Step 3: Management of Confusion

• Evaluate for potential causes of confusion beyond medication effects
• Consider adding a cholinesterase inhibitor (particularly rivastigmine) which can help with both cognitive symptoms and psychosis in Lewy body dementia 5
• Avoid conventional antipsychotics for management of confusion or psychosis as they can worsen parkinsonism 4

Important Caveats and Considerations

• Monitoring for Adverse Effects: Closely monitor for side effects of levodopa including involuntary movements, gastrointestinal symptoms, and orthostatic hypotension 1
• Gradual Dose Adjustments: Any changes to levodopa dosing should be made gradually to prevent withdrawal symptoms 1
• Individualized Approach: Response to levodopa varies in patients with Lewy body dementia, with approximately one-third showing significant motor improvement 6
• End-of-Life Considerations: In severe or end-stage dementia with limited life expectancy, the focus should shift to comfort rather than optimal symptom control 3

Common Pitfalls to Avoid

1. Abrupt Discontinuation: Never abruptly stop levodopa as this can lead to severe akinesia or neuroleptic malignant syndrome 1
2. Overmedication: Excessive levodopa can worsen confusion and cause hallucinations
3. Ignoring Non-Motor Symptoms: Focus should be on overall comfort, not just motor symptom control
4. Using Inappropriate Medications: Avoid anticholinergics and typical antipsychotics which can worsen symptoms in Lewy body dementia 4

In conclusion, while deprescribing medications is often appropriate in end-of-life care, levodopa should generally be continued in patients with advanced Parkinson's disease and Lewy body dementia, with dose adjustments to optimize comfort and quality of life.