Palliative Prescribing in
Parkinson's Disease:
Evidence and
Recommendations
A comprehensive guide to symptom management and quality of life
improvement for patients with advanced Parkinson's disease.
by Soumil Sarna
The Palliative Needs of Parkinson's Patients
What is Palliative Care in Unique Challenges Non-Motor Symptom
PD? Burden
Complex symptom management with
Specialized care focused on relieving disease progression. Patients face Over 90% of patients experience non-
suffering and improving quality of life motor and non-motor symptoms that motor symptoms. These often cause
for people with advanced Parkinson's worsen over time. more distress than motor symptoms.
disease.
Motor Symptoms Management
Levodopa Adjustments
More frequent, smaller doses may reduce motor fluctuations. Limited by
diminishing efficacy and side effects in advanced disease.
Dopamine Agonists
Help smooth "on-off" transitions. Must monitor for impulse control disorders
and hallucinations.
MAO-B & COMT Inhibitors
Extend levodopa duration. Especially useful for wearing-off symptoms and
predictable fluctuations.
Managing Dyskinesia
May require reducing levodopa or adding amantadine. Balance between
mobility and dyskinesia control is essential.
Managing Psychiatric Symptoms
Depression & Anxiety Psychosis Cognitive Impairment
SSRIs like sertraline are first-line First, reduce PD medications that may Rivastigmine shows modest benefit in
treatments. SNRIs (venlafaxine, trigger hallucinations. Quetiapine is PD dementia. Consider memantine for
duloxetine) may help with both mood preferred for hallucinations and moderate-to-severe cognitive decline.
and pain. delusions.
Simplify medication regimens as
Avoid tricyclic antidepressants due to Clozapine is effective but requires blood cognitive function declines. Focus on
anticholinergic effects. CBT provides monitoring. Pimavanserin is specifically quality of life over complicated
non-pharmacological support. approved for PD psychosis. treatments.
Managing Autonomic Symptoms
Orthostatic Hypotension
Constipation
Midodrine (2.5-10mg TID) raises blood
pressure. Fludrocortisone (0.1mg daily) Polyethylene glycol daily as first-line.
increases volume. Non-drug: compression Increase fluid and fiber intake. Consider
stockings, elevate head of bed. probiotic supplements.
Urinary Issues
Sialorrhea
Oxybutynin (2.5-5mg BID) for urgency.
Glycopyrrolate (1-2mg TID) reduces
Mirabegron may have fewer cognitive side
secretions. Botulinum toxin injections into
effects. Intermittent catheterization for
salivary glands last 3-6 months.
retention.
Managing Pain in Parkinson's Disease
Opioids
For severe pain unresponsive to other treatments
NSAIDs & Adjuvants
Anti-inflammatories, gabapentin for neuropathic pain
Acetaminophen
First-line for musculoskeletal pain
PD pain has multiple origins. About 85% of patients experience pain, often under-recognized and undertreated. Non-pharmacological
approaches include physical therapy, heat/cold therapy, and mindfulness.
End-of-Life Considerations
Recognize End-Stage Signs
Inability to stand/walk, dependence for ADLs, difficulty swallowing,
recurrent infections, and cognitive decline indicate disease progression.
Advanced Care Planning
Discuss preferences early. Document decisions about feeding tubes,
ventilation, and resuscitation while capacity remains.
Managing Terminal Symptoms
Morphine for dyspnea (2.5-5mg subcutaneously). Midazolam for agitation
(2.5-5mg subcutaneously). Glycopyrrolate for secretions.
Alternative Medication Routes
Subcutaneous, rectal, and sublingual routes bypass swallowing
difficulties. Consider medication patches when appropriate.
Ethical and Legal Considerations
Ethical Principles Capacity Assessment
Respect autonomy while balancing beneficence and non- Regularly evaluate decision-making capacity. Cognitive
maleficence. Ensure equitable access to palliative services fluctuations in PD require ongoing assessment. Identify
regardless of location. surrogates early.
Documentation Palliative Sedation
Clearly document discussions about goals of care. Ensure Reserved for intractable symptoms at end of life. Follow
advance directives are accessible. Update preferences as institutional protocols. Maintain distinction from euthanasia.
disease progresses.
Recommendations for Palliative
Prescribing
Individualize Treatment Plans
Tailor medications to each patient's specific symptoms. Consider disease stage,
comorbidities, and patient preferences.
Regular reassessment is crucial as needs change with disease progression.
Interdisciplinary Approach
Engage neurologists, palliative specialists, nurses, therapists, and social
workers. Coordinate care across settings.
Hold regular team meetings to address complex symptoms and psychosocial
needs.
Family Support
Educate caregivers about medication administration and monitoring.
Provide resources for caregiver burden.
Include family in treatment decisions when appropriate.
Improving Quality of Life in Parkinson's Disease
50% 90% 3X
Symptom Reduction Patient Preference Quality of Life
Proper palliative prescribing can reduce Most patients prefer comfort-focused care Palliative interventions can triple quality of
symptom burden by half. in advanced stages. life scores.
By focusing on individualized symptom management through evidence-based prescribing, we can dramatically improve quality of life.
Palliative care is not about giving up, but about living well with Parkinson's disease.