Symptom prevalence and pharmacological management of late-stage Parkinson's disease (LSPD): a cross-sectional, multinational survey.

Late-stage Parkinson's disease (LSPD) presents with disabling motor and non-motor symptoms, the latter becoming dominant in the late stage. There is limited information on LSPD. This study aimed to identify common symptoms and common drug treatments of LSPD. We conducted an online survey of physicians treating patients with Parkinson's disease in specialized palliative care across Austria, Germany and Switzerland, followed by a two-round Delphi survey involving movement disorder specialists. Consensus was defined as ≥ 75% agreement. 118 participants of 1252 contacted institutions completed the survey. In the Delphi process, eight experts out of 19 participated. Most frequently reported symptoms were dysphagia (94%), rigidity (78%), speech disorder (70%), bradykinesia (61%), dementia (74%) and constipation (64%). Most frequently used medications for motor symptom control at admission to palliative care were levodopa (96%) and rotigotine (48%). Similarly, levodopa (64%) and rotigotine (49%) were most frequently reported to be prescribed until the end of palliative care. Delphi experts agreed on the importance of oral and intestinal levodopa as well as rotigotine for the palliative care phase. Levodopa therapy should be maintained until end of life. Regarding non-motor symptom control, Delphi panelists concluded that laxatives, antipsychotics and medications for hypersalivation should be administered until end of life. Macrogol (70%) and sodium picosulfate (71%) were the most favored laxatives. Among antipsychotics quetiapine was most recommended for psychosis (76%) and delirium (59%) management. However, Delphi panelists agreed on clozapine for psychosis management and quetiapine for delirium management. For hypersalivation, consensus was reached on botulinum toxin injection. harmacological treatment of LSPD should be based on a symptom-oriented and stage-based approach. Therapy encompasses levodopa and non-dopaminergic treatments for non-motor symptom control.