Managing symptoms and complications of Parkinson disease in palliative care

Motor symptoms of Parkinson disease (bradykinesia, rest tremor, rigidity, loss of postural reflexes, gait freezing) become less responsive to drug therapy as the disease progresses.

Patients with advanced Parkinson disease may develop rigidity from:

• dopaminergic therapy not being administered on time
• antidopaminergic drugs
• inability to swallow medication
• disease becoming less dopamine responsive.

For management of Parkinson disease, including motor complications and advanced disease, see the Neurology guidelines—expert advice is required. For general advice on rationalising drugs for Parkinson disease (including management options for when the patient can no longer swallow), see Rationalising drugs for Parkinson disease in palliative care. In the last days of life, subcutaneous midazolam or sublingual clonazepam may relieve rigidity.

Patients with advanced Parkinson disease can experience a variety of other symptoms including fatigue, depression, anxiety, sleep disturbance, autonomic disturbances (eg constipation, bladder dysfunction, orthostatic hypotension, sexual dysfunction), and pain (which may be related to rigidity). Upper motor neurone changes, cerebellar signs and dementia (see Approach to managing dementia and Dementia in Parkinson disease) are common in advanced disease. Management depends on potential benefits and burdens of treatment, and the patient’s prognosis, preference (including preferred care setting) and goals of care—see also Principles of symptom management in palliative care. When using a drug in patients with Parkinson disease, consider whether the dosage needs modification, or whether an alternative drug is required. Antidopaminergic drugs (eg metoclopramide, haloperidol, prochlorperazine) can aggravate parkinsonian symptoms.