What is the recommended symptomatic treatment plan for a 65‑year‑old patient with progressive supranuclear palsy presenting with early gait instability, frequent falls, axial rigidity, vertical gaze palsy, dysarthria, dysphagia, and cognitive impairment?

Symptomatic Treatment of Progressive Supranuclear Palsy

For this 65-year-old patient with PSP, prioritize multidisciplinary supportive care over pharmacological interventions, as no disease-modifying treatments exist and medication responses are typically poor and short-lived. 1

Pharmacological Management

Levodopa Trial

• Attempt a levodopa trial despite limited expectations, as it may provide modest, temporary improvement in bradykinesia and rigidity in a minority of PSP patients 1
• Recognize that poor levodopa response is a diagnostic criterion for PSP, with benefits often negligible and short-lived when present 1
• Discontinue if no meaningful benefit after adequate trial, as continued use without response adds medication burden 1

Symptomatic Medications by Target

For sialorrhea/drooling:

• Intrasalivary gland botulinum toxin injections are the most effective intervention for problematic drooling 1

For dystonia and blepharospasm:

• Intramuscular botulinum toxin is first-line for focal dystonia including blepharospasm 1
• Baclofen serves as an alternative or adjunct for dystonia management 1
• Benzodiazepines may reduce dystonic symptoms 1

For myoclonus (if present):

• Levetiracetam is preferred for myoclonic symptoms 1
• Benzodiazepines serve as alternative agents 1

For depression and behavioral symptoms:

• Antidepressants may help with depression and behavioral manifestations, though adverse effects often limit tolerability 1
• Avoid atypical antipsychotics as they are not recommended in elderly patients with dementia-associated conditions and will worsen parkinsonism 1

For cognitive impairment:

• Do not use acetylcholinesterase inhibitors or memantine, as evidence for efficacy in PSP is limited and risks outweigh potential benefits 1

Essential Multidisciplinary Interventions

Fall Prevention and Mobility (Highest Priority)

• Implement walking aids early (mean time to use is 20.8 months from symptom onset), as this patient already has gait instability and frequent falls 2
• Recognize that PSP patients characteristically fall backwards, not forwards, which requires specific safety counseling 3
• Early falls within the first year predict shorter survival and warrant aggressive fall prevention strategies 4
• Physical therapy should focus on axial rigidity, postural instability, and backward fall prevention 1
• Consider wheelchair evaluation (typically needed around 39.5 months from symptom onset) 2

Dysphagia Management

• Prioritize speech and language therapy evaluation immediately, as dysphagia is very common at presentation and early dysphagia predicts shorter survival 2, 4
• Dietician involvement is essential for nutritional optimization and aspiration prevention 1
• Early dysphagia management may potentially prolong survival, as pneumonia is the most common cause of death in PSP 4

Dysarthria Support

• Speech and language therapy for communication strategies and augmentative devices as speech deteriorates 1

Ocular Symptoms

• Ophthalmology consultation for vertical gaze palsy management and visual compensation strategies 1
• Address blepharospasm with botulinum toxin as noted above 1

Cognitive and Behavioral Support

• Psychology services for cognitive strategies and behavioral management 1
• Occupational therapy to maintain activities of daily living as long as possible 1

Palliative Care

• Early palliative care involvement given median survival of 5.6 years from onset 4
• Address advance care planning, particularly regarding aspiration risk and pneumonia management 4

Critical Prognostic Factors

This patient's early falls are particularly concerning, as onset of falls during the first year predicts shorter survival time 4. Additional poor prognostic indicators include early dysphagia and incontinence 4. Age at onset, sex, early dementia, vertical supranuclear palsy, and axial rigidity do not affect survival prognosis 4.

Common Pitfalls to Avoid

• Do not persist with levodopa if no response after adequate trial, as "poor levodopa response" is a diagnostic criterion for PSP 1
• Avoid antipsychotics for behavioral symptoms, as they worsen parkinsonism and carry significant risks in elderly patients with dementia 1
• Do not delay mobility aids waiting for medication response, as pharmacological options are limited and falls occur early 2, 4
• Do not overlook dysphagia screening, as it directly impacts survival through aspiration pneumonia risk 4
• Recognize that fractures occur in 25% of PSP patients and are not necessarily related to fall severity, requiring proactive bone health management 4