Continuous and advanced treatment strategies in the old to very old parkinsonian population

Abstract

Parkinson's disease (PD) is a neurodegenerative disorder with an incidence and a prevalence increasing with age, predicted to increase drastically in the next 10 years among the geriatric population aged above 80 in France. There are two distinct groups of patients in which therapeutic issues are different. On the one hand, old to very old patients in which PD started at a late age above 80. These patients present with a more severe PD with earlier onsets of cognitive defects and dopa-resistant axial signs, and more comorbidities needing to be taken into account while treating them. Because of their limited life expectancy, these patients would not likely need second line treatments over their disease course. On the other hand, patients presenting with advanced PD, in which fluctuations and dyskinesia induced by dopamine replacement therapy and dopa-resistant axial symptoms impede patient's daily life. These patients are often treated with multiple antiparkinsonian medications, sometimes at high doses. Some patients will also be treated with advanced therapies such as continuous subcutaneous apomorphine infusion, continuous levodopa-carbidopa intestinal gel or, more rarely, even subthalamic or pallidal deep brain stimulations. Because of the specificities of the old to very old parkinsonian patients, tolerance and efficacy of these treatments can be decreased. What is at stake is to aim for the best motor state possible while limiting iatrogenic adverse events. New emerging, potentially less invasive, techniques, such as gamma knife thalamotomy or high-intensity focused ultrasound thalamotomy or sub-thalamotomy, are also discussed here.