How should I manage a >60‑year‑old patient with progressive supranuclear palsy (PSP) for symptom relief, functional preservation, and safety?

Management of Progressive Supranuclear Palsy in Patients Over 60 Years

Progressive supranuclear palsy (PSP) has no disease-modifying treatments available, so management must focus on multidisciplinary symptomatic relief, safety interventions to prevent falls and aspiration, and optimizing quality of life through physical therapy, speech therapy, and environmental modifications. 1, 2

Diagnostic Confirmation and Initial Assessment

• Confirm the diagnosis with a movement disorder specialist, as 41% of PSP patients receive alternative diagnoses (most commonly Parkinson's disease in 67% of cases) before accurate diagnosis 3
• Mean time from symptom onset to PSP diagnosis is 15 months, and consulting a movement disorder specialist expedites accurate diagnosis 3
• The classic clinical finding is supranuclear ophthalmoplegia, though this may not present until late in the illness or at all 4
• Cardinal features include vertical gaze palsy, frequent falls, abnormal gait, postural instability, rigidity, bradykinesia, and cognitive/language/behavioral changes 3, 5

Pharmacological Management: Limited Efficacy

Levodopa Trial

• Trial levodopa for bradykinesia and rigidity, though response is typically poor, negligible, and short-lived in PSP patients 2
• Poor response to levodopa actually forms part of the diagnostic criteria for PSP 2
• Individual patients may occasionally respond, but sustained benefit is rare due to multiple neurotransmitter abnormalities and both pre- and post-synaptic pathology 4

Symptomatic Medications

• Antidepressants are commonly prescribed (87% of patients receive symptomatic medication, most often levodopa and antidepressants), though they are often poorly tolerated due to adverse effects 3, 2
• Avoid acetylcholinesterase inhibitors and N-Methyl-D-aspartate receptor antagonists, as there is limited evidence of effectiveness and risk of adverse effects may outweigh benefits 2
• Avoid atypical antipsychotics for behavioral symptoms, as they are not recommended in the elderly with dementia-associated conditions and will worsen Parkinsonism 2

Focal Symptom Management

• For problematic sialorrhea, use intrasalivary gland botulinum toxin 2
• For dystonia (including blepharospasm), use intramuscular botulinum toxin, baclofen, or benzodiazepines 2
• For myoclonus, use levetiracetam or benzodiazepines 2

Safety Interventions: Critical Priority

Fall Prevention

• Early falls are a hallmark of PSP due to postural instability and gait freezing 1, 5
• Prescribe non-wheelchair walking aids early (mean time from symptom onset to use is 20.8 months) 3
• Prescribe wheelchairs when walking aids become insufficient (mean time from symptom onset to wheelchair use is 39.5 months) 3
• 60% of PSP patients use walking aids and 23% use wheelchairs 3

Dysphagia Management

• Dysphagia is very common at later stages and poses aspiration risk 3, 1
• Refer to speech and language therapists (SALT) for swallowing assessment and strategies 2
• Refer to dieticians for nutritional support and modified diet textures 2

Multidisciplinary Team Approach

Management should focus on optimizing quality of life, relieving symptoms, and assisting with activities of daily living through a multidisciplinary team 2

• Physiotherapists (PT): for gait training, balance exercises, and fall prevention strategies 2
• Occupational therapists (OT): for adaptive equipment and home safety modifications 2
• Speech and language therapists (SALT): for dysarthria and dysphagia management 2
• Dieticians: for nutritional support 2
• Ophthalmologists: for ocular motor impairment management 2
• Psychologists: for cognitive dysfunction and behavioral changes 2
• Palliative care specialists: for end-of-life planning, as mean survival from symptom onset is 7-9 years 4, 1

Prognosis and Counseling

• Mean age of onset is approximately 63 years 4
• Mean survival from symptom onset is 7-9 years 4, 1
• Men are more frequently affected than women 4
• The disease has a relentless course with no disease-modifying treatments currently available 1
• There is an urgent need for disease-modifying agents, as current symptomatic treatments have poor satisfaction 3

Common Pitfalls to Avoid

• Do not delay referral to a movement disorder specialist, as this expedites accurate diagnosis and avoids misdiagnosis as Parkinson's disease 3
• Do not expect significant or sustained benefit from levodopa, as PSP is characterized by poor levodopa response 2
• Do not use atypical antipsychotics for behavioral symptoms, as they worsen Parkinsonism 2
• Do not neglect safety interventions (walking aids, wheelchairs, dysphagia assessment), as falls and aspiration are major causes of morbidity 3, 1, 2