Pharmacological Options in Parkinson's Disease: A Treatment Guide

Steven E. Lo, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.
Steven J. Frucht, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.

Parkinson’s disease (PD) is a neurodegenerative disorder that can significantly impact older patients’ quality of life. Although there are many pharmacologic options to treat PD, the clinician needs to know the indications and potential adverse effects of new medications in the older patient population. Carbidopa/levodopa remains the gold standard for treatment, and new formulations and levodopa-extenders fill specific niches. This article reviews the pros and cons of these medications in older PD patients, and demonstrates therapeutic strategies through case presentations.
Key words: Parkinson’s disease, treatment, levodopa, COMT inhibitor, aging.

Mutism in the Older Adult

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician, Geriatric Medicine, formerly Blacktown-Mount Druitt Health, Blacktown, New South Wales, Australia.
Gowrie Pavan, MBBS, FRAGP, General Practitioner, The Surgery, Plympton Road, Beecroft, New South Wales, Australia.

Mutism in older adults is not uncommon. It is often confused with severe depression, locked-in syndrome, and persistent vegetative state, but it is important to distinguish among them as the management and prognosis are different. The family physician is the most consulted professional and so is the most helpful in making this distinction. Mutism is a neuropsychological disorder with marked heterogeneity among patients, raising the possibility of conditions such as advanced Alzheimer’s disease, Jacob-Creutzfeldt disease, frontotemporal dementias, and certain psychiatric and psychological conditions. It is both a symptom and a syndrome, and is often associated with akinesia when the term akinetic mutism is used. Akinetic mutism has a number of causes with varied pathology and is characterized by a marked reduction in motor function, including facial expression, gestures, and speech output, with awareness being preserved. All of the disease manifestations can be explained by damage to the frontal lobe or interruption of the complex frontal subcortical circuits and the frontal diencephalic brain stem system by focal lesions or diffuse brain damage.
Key words: mutism, akinetic mutism, frontal-subcortical circuitry, locked-in-syndrome, persistent vegetative state.

Effects of Radiation Therapy on the Older Brain

Barbara-Ann Millar MB ChB, FRCR, Clinical Fellow, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON.

Normand Laperriere MD, FRCPC, Associate Professor, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON

Radiation therapy is commonly used in the management of intracranial malignancies. Although the effects on the developing brain have been extensively documented, the impact of this treatment modality on the older brain requires further investigation. The effect of radiation treatment, the intracranial lesion, and associated comorbidities and medications all influence the individual’s overall outcome. This review looks at the pathophysiology of radiation injury within the brain and its impact on cerebral irradiation in older patients.

Key words: radiotherapy, older brain, tumour, neurocognitive effects.

An Approach to Diagnosis and Management of the Frozen Shoulder

Bob McCormack, MD, FRCSC, Dip Sport Med, Assistant Professor, Head of Division of Arthroscopy and Athletic Injuries, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.

Frozen shoulder, or adhesive capsulitis, is a frustrating condition for both patients and physicians. Pain and a limited range of motion restrict upper extremity function and significantly affect the patient’s quality of life. The goal of this article is to present an organized review of the assessment and management of a frozen shoulder, so the physician can formulate a treatment algorithm. Special considerations for the older patient will be highlighted.

Key words: shoulder, stiffness, capsulitis, older people, treatment.

Introduction
Frozen shoulder is a descriptive term for a clinical syndrome whereby soft tissue contractures cause a limitation of both active and passive range of motion of the glenohumeral joint. The primary role of the shoulder is to place the hand in space; to achieve this, it is necessary to maintain shoulder mobility.

Classification
As outlined in Figure 1, frozen shoulder can be divided into primary and secondary types. The primary, or idiopathic, form is commonly referred to as adhesive capsulitis. Secondary forms are important to identify as they often require a different treatment approach.

Drug-induced Parkinsonism in Older Adults

Joseph H. Friedman, MD, Professor, Clinical Neurosciences, Brown University School of Medicine; Chief, Neurology; Director, Parkinson's Disease and Movement Disorders Center, Memorial Hospital of Rhode Island, Pawtucket, RI, USA.

Drug-induced parkinsonism, an often overlooked condition, is frequently an iatrogenic result of antipsychotic medications, particularly in older adults. Spontaneous features of parkinsonism are common in the community-dwelling older adult as well as in patients with the common dementing illnesses. Parkinsonism is associated with increased mortality and morbidity, and a greater need for support services. This article reviews current knowledge of parkinsonism and stresses the need for diligence. The newer antipsychotics, while reducing the incidence of tardive dyskinesia, are not all completely free of inducing extrapyramidal side effects, with parkinsonism being the most common.
Key words: drug-induced parkinsonism, atypical antipsychotics, extrapyramidal syndromes.