What is the treatment for an 80-year-old male with bradykinesia (slow movements)?

Treatment of Bradykinesia in an 80-Year-Old Male

The most critical first step is determining whether this bradykinesia represents Parkinson's disease, drug-induced parkinsonism, or another etiology, as this fundamentally determines treatment—with carbidopa-levodopa being the gold standard for Parkinson's disease and medication discontinuation being essential for drug-induced causes. 1, 2, 3

Initial Diagnostic Evaluation

Essential History Components

• Medication review: Identify any dopamine-blocking agents (antipsychotics, metoclopramide, prochlorperazine) that could cause drug-induced parkinsonism 3
• Symptom characteristics: Determine if bradykinesia is accompanied by resting tremor (4-6 Hz, present at rest, reduced with voluntary movement) and rigidity, which strongly suggest Parkinson's disease 1, 2
• Temporal pattern: Drug-induced symptoms typically emerge within weeks to months of medication initiation, while Parkinson's disease has insidious onset 3
• Cognitive status: Use the Mini Mental State Examination to assess for dementia, as cognitive impairment affects treatment decisions and prognosis 4

Physical Examination Priorities

• Postural blood pressure: Measure supine and standing blood pressure to exclude orthostatic hypotension as a contributor to movement difficulties 4
• Gait and balance assessment: Observe for shuffling gait, reduced arm swing, and postural instability with eyes open and closed 4
• Neurological examination: Assess for cogwheel rigidity, bradykinesia in finger tapping, and asymmetry of symptoms (Parkinson's disease is typically asymmetric initially) 1, 2

Treatment Algorithm

If Drug-Induced Parkinsonism is Identified

Immediately discontinue or reduce the offending medication 3

• If antipsychotic therapy must continue, switch to an atypical antipsychotic (quetiapine or clozapine have lowest extrapyramidal symptom risk) 3
• Symptoms typically improve within weeks to months after discontinuation, though may persist in some cases 3
• Do not initiate carbidopa-levodopa for drug-induced parkinsonism, as this addresses the wrong underlying pathophysiology 3

If Parkinson's Disease is Diagnosed

Pharmacological Treatment (First-Line)

Initiate carbidopa-levodopa combination therapy, which is the most effective symptomatic treatment for bradykinesia in Parkinson's disease 1, 2

Dosing approach for elderly patients:

• Start with low doses due to increased risk of adverse effects in the elderly 4
• Carbidopa-levodopa reduces the levodopa dose needed by approximately 75% and decreases nausea/vomiting 1, 2
• Titrate gradually over weeks, monitoring for orthostatic hypotension, confusion, and hallucinations 4
• The half-life of levodopa increases from 50 minutes to 1.5 hours when combined with carbidopa 1, 2

Important considerations:

• High protein meals can impair levodopa absorption as it competes with amino acids for gut transport 1, 2
• Advise taking medication 30-60 minutes before meals or 1 hour after meals 1, 2
• Monitor standing blood pressure regularly, as elderly patients are at higher risk for orthostatic hypotension 4

Non-Pharmacological Interventions (Adjunctive)

Progressive resistance training (2-3 days per week) 4

• One set of 10-15 repetitions at low intensity (40% of 1-repetition maximum)
• One set of 8-10 repetitions at moderate intensity (41-60% of 1-repetition maximum)
• Emphasize muscle power (speed of contraction) rather than strength alone, as this better preserves functional capacity 4
• Progress weight when 15 low-intensity repetitions feel "somewhat difficult" (Borg RPE 12-14) 4

Aerobic exercise (3-7 days per week) 4

• 20-60 minutes of continuous or intermittent exercise (minimum 10-minute episodes)
• Target heart rate for 80-year-old: 80-120 beats per minute (50-75% of maximum) 4
• Walking, swimming, or dancing are appropriate modalities 4

Balance training to prevent falls 4

• Static exercises (standing on one leg with hand support as needed)
• Dynamic exercises (walking with directional changes)
• Particularly important given that elderly patients with bradykinesia have 20-50% prevalence of gait and balance instability 4

Critical Pitfalls to Avoid

Do not confuse Parkinson's disease bradykinesia with functional movement disorders 4

• Functional movement disorders may present with variable slowness that improves with distraction
• These require completely different treatment approaches focused on physical therapy and retraining normal movement patterns 4
• Carbidopa-levodopa will not help functional disorders and may reinforce illness beliefs 4

Do not use beta-blockers for parkinsonian tremor 5

• Beta-blockers are effective for senile tremor (present during movement and maintained posture, often affecting head and upper extremities asymmetrically) 5
• Parkinsonian tremor is present at rest and reduced by voluntary movement—requires dopaminergic therapy 5

Do not prescribe typical antipsychotics or metoclopramide to elderly patients with existing bradykinesia, as these will worsen symptoms 3

Monitor for "wearing off" phenomena as disease progresses, which may require dose adjustments or addition of other Parkinson's medications 1, 2