What is the next best step for an elderly patient with Parkinson's Disease (PD) who has shown minimal improvement on Sinemet (Carbidopa-Levodopa) and is experiencing frequent falls?

From the Guidelines

For an elderly patient with Parkinson's disease (PD) who is experiencing minimal improvement on Sinemet and having frequent falls recently, the most appropriate next step is to discuss the possibility of Deep Brain Stimulation (DBS). When a patient with PD shows limited response to levodopa therapy (Sinemet) and develops frequent falls, this suggests advancing disease that may benefit from surgical intervention rather than medication adjustments. DBS involves implanting electrodes in specific brain regions to modulate abnormal neural circuits responsible for motor symptoms. This approach is particularly beneficial for patients with medication-refractory symptoms or those experiencing significant motor fluctuations and dyskinesias. Simply increasing the Sinemet dose or changing administration timing would be unlikely to help a patient already showing minimal response to the medication, and might worsen side effects without improving fall risk. Additionally, frequent falls in advanced PD often reflect axial symptoms and postural instability that respond poorly to dopaminergic therapy. DBS, particularly targeting the subthalamic nucleus or globus pallidus interna, can provide more consistent symptom control and potentially reduce fall risk in appropriate candidates, making it the most appropriate next step in management 1.

Some key considerations in the management of PD patients with frequent falls include:

• The potential for weight changes, with weight loss being a common feature of PD, and the importance of monitoring nutritional status and considering supplementation with vitamins such as vitamin D 1.
• The role of levodopa in contributing to weight loss and metabolic changes, and the potential for DBS to induce weight gain, particularly in the abdominal region 1.
• The importance of monitoring for and managing potential complications of PD and its treatment, including osteoporosis, fractures, and hyperhomocysteinemia 1.

Overall, the decision to proceed with DBS should be made on a case-by-case basis, taking into account the individual patient's symptoms, medical history, and potential risks and benefits of the procedure. However, for patients with advanced PD and frequent falls who have shown minimal response to levodopa therapy, DBS is a potentially effective treatment option that can improve symptom control and reduce fall risk.

From the FDA Drug Label

Patients taking carbidopa and levodopa tablets alone or with other dopaminergic drugs have reported suddenly falling asleep without prior warning of sleepiness while engaged in activities of daily living (includes operation of motor vehicles).

The management of NMS should include: 1) intensive symptomatic treatment and medical monitoring and 2) treatment of any concomitant serious medical problems for which specific treatments are available

The next best step for an elderly patient with Parkinson's Disease (PD) who has shown minimal improvement on Sinemet (Carbidopa-Levodopa) and is experiencing frequent falls is to:

• Reassess the patient's treatment plan and consider alternative therapies, as the current treatment is not effective and may be contributing to the falls.
• Monitor the patient closely for symptoms of neuroleptic malignant syndrome (NMS) and other adverse effects, especially if the dosage of carbidopa and levodopa is reduced or discontinued.
• Consider consulting a specialist, such as a neurologist, to evaluate the patient's condition and develop a new treatment plan.
• Advise the patient to exercise caution while driving or operating machines during treatment with carbidopa and levodopa tablets, and to avoid these activities if they experience somnolence or sudden sleep onset 2.

From the Research

Next Best Steps for Elderly Patient with Parkinson's Disease

The patient in question has shown minimal improvement on Sinemet (Carbidopa-Levodopa) and is experiencing frequent falls. Considering this, the following options can be explored:

• Adjustment of Medication: According to 3, the combination of carbidopa and levodopa is the most effective treatment for Parkinson's disease. However, the patient's minimal improvement on Sinemet suggests that alternative or adjunctive therapies may be necessary.
• Adjunctive Therapy: Studies 4, 5 suggest that adjunctive therapy with a dopamine agonist, a monoamine oxidase-B inhibitor, or a catechol O-methyltransferase inhibitor can improve motor symptoms and functional status in patients with Parkinson's disease.
• Deep Brain Stimulation (DBS): DBS is an effective treatment option for patients with advanced Parkinson's disease who have poorly controlled symptoms despite optimal medical therapy 4, 6.
• Levodopa-Carbidopa Intestinal Gel Infusion (LCIG): LCIG has been shown to have comparable effects to DBS on motor function for advanced Parkinson's disease, with acceptable tolerability 6.
• Rehabilitative Therapy: Occupational, physical, and speech therapy can improve patient function and are recommended as part of a comprehensive treatment plan 4, 5.

Considerations for Frequent Falls

• Assessment of Fall Risk: It is essential to assess the patient's fall risk and identify potential contributing factors, such as postural instability, orthostatic hypotension, or medication side effects.
• Modification of Environment: Modifying the patient's environment to reduce fall hazards, such as removing tripping hazards and installing handrails, can help prevent falls.
• Physical Therapy: Physical therapy can help improve the patient's balance, strength, and mobility, reducing the risk of falls.

Treatment of Motor Complications

• Management of Wearing Off: Strategies for managing wearing off, such as adjusting levodopa dosing or adding adjunctive therapies, can help improve motor symptoms and reduce the risk of falls 7.
• Treatment of Dyskinesias: Treatment options for dyskinesias, such as amantadine or deep brain stimulation, can help reduce the severity of these symptoms and improve the patient's quality of life 7.