Parkinson’s Disease (PD) is a degenerative central nervous system disorder which disproportionately affects the motor system leading to asymmetric muscle rigidity, bradykinesia, and a resting “pill-rolling” tremor. It involves a section of the midbrain called the substantia nigra which leads to a depletion of the neurotransmitter dopamine. Dopamine derivatives (levo-dopa) and agonists are pharmacologic mainstays for the motor symptoms.

Typical PD has a longer prognosis and progresses slower with less nonmotor symptoms and cognitive impairment early in the disease course compared with atypical PD which includes a variety of disorders such as multisystem atrophy, corticobasal degeneration, and Lewy body dementia.

While the progression of functional impairment and disability is quite variable, typically PD progresses over many years.
- Within 5 years patients begin to have levodopa related treatment complications such as dyskinesia, psychosis, and dystonia
- Within 12 years patients have issues with falls, gait disturbance, and balance
- Within 15-20 years issues with either hallucinations or dementia are common.

The symptom burden from the motor and non-motor symptoms of PD has been shown to be comparable to metastatic cancer. The slow erosion of functional capacity and the increased dependence on caregivers leads many patients to suffer from a diminished sense of personhood and identity. This can lead to significant caregiver distress, financial hardship, and consequently a high utilization of nursing home placement in the last years of life.

Late-term PD complications.
• Dementia in approximately 40% patients.
• Delirium and visual hallucinations.
• Extrapyramidal symptoms (muscle rigidity and dyskinesia)
• Dysphagia from progression of motor symptoms or dementia

End-of-life care medication management: many experts recommend continuing levo-dopa derivatives and agonists as long as the patient is able to swallow pills. Abrupt discontinuation of these medications can be associated with intense and uncomfortable muscle rigidity.

See reference for more information.

Adapted from Estupinan D et al. Parkinson’s disease: part 1 disease trajectory. Palliative Care Network of Wisconsin. Fast facts and concepts #361. Internet. Accessed on January 5, 2019.