Managing Parkinsonism and Orofacial Dyskinesia in Elderly Stroke Patients

Parkinson's disease, oromandibular dystonia?

Dear Doctor,
My father has been living with the effects of a stroke for 12 years now.
Approximately 9 years ago, he became reliant on others for care.
Initially, he was able to communicate and eat without issues, but as he aged (he is currently 86 years old), his abilities began to decline.
After being diagnosed with COVID-19 last year, a series of complications became more pronounced, including recurrent urinary tract infections and aspiration pneumonia.
Since April of this year, he has been using a nasogastric tube and a urinary catheter.
After being hospitalized for pneumonia, he returned home but has since become increasingly lethargic and reluctant to speak.

Gradually, although his vital signs have stabilized and his condition is under control, his consciousness and ability to communicate have been inconsistent.
After being discharged in May, he began to exhibit oral and tongue movements at the end of August.
Initially, these movements were sporadic and brief, but they have become more frequent.
His mental state was not very good at first, so he did not speak much.
Currently, he has difficulty expressing himself, and his speech is unclear due to constant tongue movements, which also lead to excessive drooling.
When his tongue is still, he can speak clearly, and his ability to communicate has noticeably improved.
We have been hoping to assist him in transitioning away from the nasogastric tube through speech therapy and swallowing training, but the involuntary movements significantly hinder this process.
With the help of home healthcare, the doctor has indicated that this is due to brain degeneration, resulting in an extrapyramidal syndrome similar to Parkinson's disease, with no other options for assistance available.

We have been using essential oil massages to provide him with temporary relief.
However, since we live on an outlying island, many medical resources are limited, and some diagnostic equipment is unavailable.
Additionally, it is difficult for my father to travel for medical care, and his condition can change suddenly.
We are uncertain about the best ways to assist him effectively in slowing the progression of his condition.

Thank you for taking the time to respond, and we greatly appreciate your help.

Miss Wang, 40~49 year old female. Ask Date: 2023/12/10

Dr. Peng Shiwei reply Neurology

Parkinson's disease is a degenerative disorder that can be managed with medication to slow the progression, but it cannot be cured.
The cause of oromandibular dystonia also requires evaluation by a neurologist.
Due to the inconvenience of going out for medical care, it is recommended to seek advice from a home healthcare physician.
Thank you.

Reply Date: 2023/12/10

More Info

Managing Parkinsonism and Orofacial Dyskinesia in elderly patients, particularly those with a history of stroke, presents unique challenges that require a comprehensive approach. Your father's situation, characterized by the progression of his condition over the years, particularly after a stroke and subsequent health complications, necessitates careful consideration of both medical and supportive interventions.

Understanding Parkinsonism and Orofacial Dyskinesia
Parkinsonism refers to a group of neurological disorders that cause movement problems similar to those seen in Parkinson's disease, including tremors, rigidity, and bradykinesia (slowness of movement). Orofacial dyskinesia, on the other hand, involves involuntary movements of the face and mouth, which can significantly impact communication and swallowing abilities. This condition can arise as a side effect of certain medications or as a result of neurological damage, such as that caused by a stroke.

In your father's case, the combination of his stroke history, advanced age, and recent health issues like COVID-19 and recurrent infections has likely exacerbated his neurological decline. The emergence of orofacial dyskinesia, particularly after a period of hospitalization and recovery, suggests that his neurological status is complex and may require specialized management.

Management Strategies
1. Neurological Evaluation: It is crucial to have a neurologist assess your father’s condition to confirm the diagnosis of Parkinsonism and to evaluate the severity of the orofacial dyskinesia. This evaluation can help tailor treatment options to his specific needs.

2. Medication Review: If your father is on medications that may contribute to or exacerbate dyskinesia, a review and possible adjustment of these medications may be necessary. Medications such as antipsychotics or certain antiemetics can cause or worsen dyskinesia. Discussing alternatives with his healthcare provider could be beneficial.

3. Speech and Swallowing Therapy: Engaging a speech-language pathologist can be invaluable. They can provide targeted exercises to improve communication and swallowing, which may help reduce the impact of orofacial dyskinesia. Techniques such as the Lee Silverman Voice Treatment (LSVT) can be particularly effective for patients with Parkinsonism.

4. Physical Therapy: A physical therapist can work with your father to improve mobility and strength, which may help mitigate some of the movement-related challenges he faces. They can also provide strategies for safe transfers and ambulation, which are critical given his history of stroke.

5. Occupational Therapy: An occupational therapist can assist in modifying his environment to enhance safety and independence. They can recommend adaptive devices that facilitate daily activities and improve quality of life.

6. Supportive Care: Given the complexity of your father’s condition, supportive care is essential. This includes ensuring he has a comfortable and safe living environment, as well as emotional support. Family involvement and education about his condition can also help in managing expectations and improving his quality of life.

7. Alternative Therapies: While not a substitute for medical treatment, complementary therapies such as gentle massage or the use of essential oils may provide comfort and relaxation. However, it’s important to discuss these with his healthcare provider to ensure they are safe and appropriate.

8. Regular Monitoring: Given the fluctuating nature of your father’s condition, regular follow-ups with his healthcare team are essential. This allows for timely adjustments to his treatment plan based on his evolving needs.

Conclusion
Managing Parkinsonism and orofacial dyskinesia in elderly patients, especially those with a complex medical history, requires a multidisciplinary approach. Collaboration among neurologists, therapists, and family caregivers is vital to provide comprehensive care that addresses both the physical and emotional aspects of the patient’s condition. By focusing on tailored interventions and supportive strategies, you can help improve your father's quality of life and manage the challenges he faces.

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