The Treatment of Older Patients with Parkinson's Disease

There are approximately 150 000 persons over age 80 in Germany who suffer from Parkinson's disease. Eighty percent of patients develop dementia during the course of this disease. Older patients with Parkinson's disease often suffer from the multimorbidity typically seen in this age group. Comorbidities affect the options for treating Parkinson's disease. Older patients are markedly underrepresented in most trials of antiparkinsonian drugs.

In this narrative review, we propose practical ways to simplify the treatment regimen of older patients with Parkinson's disease to lessen side effects and make treatment more manageable for these patients and the persons caring for them.

The mainstay of treatment is levodopa in combination with a dopa decarboxylase inhibitor, taken during the day as a standardrelease or dispersible formulation and at night in extended-release form; along with a catechol-O-methyltransferase inhibitor if neces - sary. Antiparkinsonian drugs with other mechanisms of action should be used sparingly, if at all. Treatment options for patients with severe fluctuations in efficacy and long "off" (akinetic) phases include a jejunal levodopa pump and the subcutaneous administration of foslevodopa. Parkinson's disease dementia should be treated with rivastigmine, a cholinergic anti-dementia drug (approved in capsule form for this indication). Otherwise intractable psychosis should be treated with quetiapine (off-label) or clozapine (evidence-based; weekly blood tests required). Other neuroleptic drugs should not be given to patients with Parkinson's disease. Physiotherapy and speech therapy are evidencebased components of therapy with proven efficacy in every stage of the disease.

Further randomized controlled trials tailored to this patient population are needed to provide a better evidence base for the treatment of older patients with Parkinson's disease.