Clinical aspects of palliative care in advanced Parkinson’s disease

Parkinson's disease (PD) is one of the most common neurodegenerative disorders of the elderly population with an average age of onset of 60 years of age [1]. PD affects 17.4 per 100,000 of individuals between the ages of 50-59 and 93.1 people per 100,000 of individuals between the ages of 70-79 [2,3]. The average patient lives 15 years from the time of diagnosis until death [4]. PD is currently assessed as more of a systemic brain disease with many different dysfunctional or dying neuronal cell systems thus affecting different transmittor substances and not only a loss of specific dopaminergic neurons in the substantia nigra. As PD progresses, there is a also presence of Lewy bodies within the cytoplasm of the affected dopaminergic neurons and a hierarchical spread of these within the brain from the medulla oblongata through the substantia nigra to the cortex. The PD course could be described as passing through a trajectory of phases starting with a “honey-moon” phase with an almost complete symptom relief due to pharmacological treatment, followed by a motor complication phase, neuropsychiatric phase, and ending up in the palliative phase. However, this is only a way to describe the inevitable progression of the disease as many symptoms may occur during all stages of the disorder. Unfortunately, few therapeutic options are available for PD patients who have progressed to more advanced disease [5]. There are several therapeutic options for advanced PD patients including intraduodenal levodopa infusion, apomorphine infusion and deep brain stimulation. They have different profiles and are addressing different PD phenotypes. However, end-stage PD patients, especially if they are cognitively impaired as they often are, exclude them from these therapies. Medical interventions are largely ineffective in preventing the inevitable progression of PD since there is always also a possibility of an intercurrent illness. Additionally, there is a high probability of PD patients t