Rehabilitation Outcomes and Caregiver Stress in Elderly Patient with End-Stage Parkinson’s Disease

Abstract

The objective was to evaluate the impact of a 3-month comprehensive rehabilitation program on functional outcomes and caregiver burden in a 73-year-old male with end-stage Parkinson’s disease (PD) following pallidotomy. Baseline evaluation included cardiorespiratory, digestive, and neuromusculoskeletal assessments, complemented by a multidomain geriatric assessment: activities of daily living (Barthel Index), cognition (MoCA), nutrition (MNA), mental health (GDS, UCLA Loneliness Scale), sarcopenia (AWGS criteria), frailty (Clinical Frailty Scale), fatigue (FSS), mobility (De Morton Mobility Index), fall risk (Morse Fall Scale), and caregiver burden (Zarit Burden Interview). The patient then underwent a structured 3-month rehabilitation program consisting of strengthening and flexibility training, cardiopulmonary endurance exercise, functional task practice, and psychological and nutritional counseling, with monthly evaluations. At baseline, the patient presented with generalized rigidity, fatigue, low cardiorespiratory endurance, total ADL dependence, malnutrition, sarcopenia, frailty, loneliness, and high caregiver burden, but intact cognition and mood. After rehabilitation, he achieved short distance walking, improved appetite and weight gain, and reduced scores in Zarit Burden, Fatigue Severity Scale, and MNA. Functional independence (Barthel Index) and respiratory capacity (single-breath count) improved, while frailty and sarcopenia remained stable without progression. In advanced PD, comprehensive rehabilitation can yield meaningful gains in mobility, nutrition, and functional independence while alleviating caregiver burden. Frailty and sarcopenia remain strongly associated with disease progression and highlight the need for sustained multidisciplinary care for both patients and caregivers.

1. Introduction

Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder characterized by motor symptoms such as tremor, rigidity, bradykinesia, and postural instability, and a wide spectrum of non-motor manifestations. These symptoms profoundly impair activities of daily living (ADL) and reduce quality of life, particularly in older adults who may also face age-related comorbidities. In addition to physical disability, psychological challenges such as depression, anxiety, and social isolation are highly prevalent and further complicate disease management [1,2].

Among geriatric patients with PD, frailty and sarcopenia are particularly important determinants of functional decline. Sarcopenia, defined as loss of muscle mass and strength, and frailty, a multidimensional syndrome of decreased physiological reserve, increase vulnerability to falls, hospitalization, and dependency. These conditions interact with PD-related motor deficits to accelerate disability and make rehabilitation outcomes more uncertain [3].

While no curative therapy exists for PD, symptomatic treatment is pursued through pharmacological and surgical approaches. Levodopa remains the standard pharmacologic therapy, but long-term use is associated with motor fluctuations and dyskinesias [4]. In selected patients with severe, medication-refractory symptoms, surgical intervention may be indicated [5].

Patients with end-stage PD often experience emotional disturbances. However, this burden extends beyond patients to their caregivers. Caregivers frequently assume responsibility for mobility assistance, ADL support, medication management, and emotional care. Inadequately addressed caregiver stress may negatively affect both caregiver well-being and patient outcomes [6]. Given the complex interplay of motor, non-motor, geriatric, and caregiver-related challenges, rehabilitation for end-stage PD requires a holistic, multidisciplinary approach. Integrating physical therapy, occupational therapy, nutritional support, psychological counseling, and caregiver education is critical to prevent further decline and to sustain quality of life [7].

This case report presents an elderly patient with end-stage Parkinson’s disease who underwent a comprehensive rehabilitation program addressing frailty, sarcopenia, ADL dependency, and gastrointestinal complications, while also evaluating caregiver burden, an aspect rarely explored in the rehabilitation of advanced PD patients. The integration of caregiver stress assessment alongside geriatric and functional rehabilitation provides a novel, holistic perspective that is seldom discussed in existing literature.

2. Case Presentation

A 73-year-old man with PD presented with progressive stiffness in all extremities, predominantly on the left side, and persistent right-sided neck rigidity. His symptoms began in 2007 with bradykinesia, hypomimia, micrographia, and resting tremor, for which he was diagnosed with PD and started on levodopa 0.5 mg three times daily. The dose was gradually escalated to 1 mg three times daily (2008–2017) due to worsening rigidity and tremor.

In 2017, after becoming immobile in all extremities, he underwent pallidotomy, followed by an increase in levodopa to 1.5 mg three times daily, which improved stiffness and tremors, restoring independence in ADL. By 2019, the levodopa dose was increased to 2 mg three times daily. However, in 2020–2021 he self-reduced the dose to 1 mg three times daily, leading to worsening rigidity, stooped posture, bradykinesia, and tremor, though he remained ADL-independent at that time.

In 2021, he was diagnosed with obstructive ileus and subsequently underwent colostomy. Since then, he gradually declined, becoming partially dependent for ADL, particularly transfers, toileting, and lower body dressing. By 2022, he required full caregiver assistance for mobility and stoma care. Previously, he had been able to ambulate up to one kilometer without aids.

Nutritionally, his appetite decreased in the past three months, worsened by edentulism after denture loss. He consumed three small meals daily, mostly porridge with vegetables and protein, and experienced a 3 kg weight loss over two months.

On December 2023, the patient was admitted to the medical rehabilitation center. He was alert, able to answer simple questions, and follow instructions. Examination revealed generalized rigidity, limited joint mobility (particularly in the neck and left extremities), resting tremor, bradykinesia, and postural instability. Muscle strength was largely preserved but restricted by contractures, with intact reflexes. Cardiorespiratory assessment showed fatigue and vital sign changes during postural transitions, while swallowing difficulties due to edentulism contributed to malnutrition and underweight status. Functional mobility was limited to lying, supported side-lying, and supported sitting. Comprehensive geriatric assessment further demonstrated severe physical dependence, sarcopenia, frailty, and markedly limited mobility, necessitating full assistance for activities of daily living and placing him at high risk of falls and related complications. Social isolation and caregiver burden were evident, although cognition and mood remained preserved. Notably, the primary caregiver is his 73-year-old wife, whose advanced age contributes to caregiver burden. Despite extensive physical limitations, the absence of pain and depression provided some comfort, supporting his overall quality of life. The summary of the patient’s examination findings is presented in

Table 1. Summary of patient’s examination findings and comprehensive geriatric assessment.

Function	Items	Result
Mental Function
Orientation, attention, memory function	MoCA-Blind	18/22 (mild cognitive impairment)
Sleep function	ISI	10/28 (subthreshold insomnia)
Emotional function	GDS-15	4/15 (no depression)
	UCLA-3 Item	3/9 (some degree of loneliness)
	EQ-5D-3L	Mobility 3 (extreme problem), self-care 3 (extreme problem), usual activities 3 (extreme problem), pain/discomfort 1 (no problem), anxiety/depression 1 (no problem)
Sensory Function
Seeing function	Visual Acuity	Uncorrected presbyopia
Cardiorespiratory and Respiratory Function
Respiratory function	Depth of respiration	Limited chest expansion
Respiratory muscle function	Additional respiratory function	Single Breath Count Test: 6 Inadequate cough ability
Exercise tolerance function	General physical endurance	Able to sit with support for >30 min. Unable to sit without support for more than 1 min due to weakness, fatigue, poor dynamic and static balance.
	Fatigability	Borg scale 12/0/0 after sitting without support for less than 1 min FSS: 39/63 (significant fatigue)
Digestive Function
Swallowing	Oral Swallowing	Prolonged oral phase for solid consistency due to edentulism
	Pharyngeal swallowing	GUSS: 20/20
Defecation Function	Elimination of feces	Via Stoma
	Fecal consistency	Bristol stool type 5–6
Weight maintenance functions	MNA	13.5/30 (malnutrition)
	BMI	18.2 kg/m2 (underweight)
Neuromusculoskeletal and Movement Functions
Mobility of joint functions	Neck	Limitation in all direction
	Upper extremities	Limitation on bilateral shoulder, elbow and wrist; left phalangeal flexion contracture
	Lower extremities	Limitation on bilateral hip flexion, knee flexion and ankle
Muscle power function	Upper extremities	Muscle weakness on bilateral shoulder, elbow, forearm and wrist
	Lower extremities	Muscle weakness on left hip, knee, ankle and toes
Involuntary movement reaction functions	Hughes criteria	Present resting tremor, rigidity, bradykinesia, and postural instability
Sarcopenia screening	AWGS	Possible sarcopenia (calf circumference 26 cm, SARC-F 8/10, SARC-calf 18/20)
Activity and Participation
Mobility	DEMMI	0/100 (immobile)
	MFS	75/125 (high fall risk)
Self Care	Barthel Index	10/100 (total dependent)
Community life	SSII	2/5 (socially isolated)
Environmental Factors
Support and relationship	ZBI	25/88 (mild to moderate caregiver burden)
	CFS	7 (severe frailty)
	PPS	40% (mainly in bed, unable to do most activities, extensive disease, self-care mainly assistance required, normal or reduced intake, full or drowsy consciousness)
	PPI	3.5 (median survival >6 weeks)

MoCA-Blind: Montreal Cognitive Assessment—Blind version, 0–22; ≥19 = normal, 13–18 = mild cognitive impairment, ≤12 = moderate–severe impairment. ISI: Insomnia Severity Index, 0–28; 0–7 = no insomnia, 8–14 = subthreshold, 15–21 = moderate, 22–28 = severe. GDS-15: Geriatric Depression Scale, 15-item, 0–15; 0–4 = normal, 5–8 = mild depression, 9–11 = moderate depression, 12–15 = severe depression. UCLA-3 Item: University of California Los Angeles 3-Item Loneliness Scale, 3–9; higher = greater loneliness. EQ-5D-3L: EuroQol-5 Dimension 3-Level. Domains (5): mobility, self-care, usual activities, pain/discomfort, anxiety/depression. Levels (3): 1 = no problems, 2 = some/moderate problems, 3 = extreme. FSS: Fatigue Severity Scale, 9–63; 9–35 = no/mild fatigue, 35–44 = significant fatigue, ≥45 = severe fatigue. GUSS: Gugging Swallowing Screen, 0–20; 0–9 = severe dysphagia, 10–14 = moderate dysphagia, 15–19 = mild dysphagia, 20 = normal swallowing. MNA: Mini Nutritional Assessment, 0–30; <17 = malnutrition, 17-23.5 = risk of malnutrition, 24–30 = normal nutritional status. BMI: Body Mass Index; <18.5 = underweight, 18.5–24.9 = normal weight, 23.0–24.9 = overweight, ≥25.0 = obese. AWGS: Asia Working Group for Sarcopenia; calf circumference <34 cm, SARC-F ≥4, or SARC-CalF ≥11 = possible sarcopenia. DEMMI: De Morton Mobility Index, 0–100; higher = better mobility. MFS: Morse Fall Scale; 0–24 = low risk, 25–44 = moderate, ≥45 = high fall risk. Barthel Index, 0–100; 0–20 = total dependent, 21–60 = severe dependent, 61-90 = moderate dependent, 91–99 = slight dependent, 100 = independent. ZBI (Zarit Burden Interview, 22-item): 0–88; 0–20 = little/no burden, 21–40 = mild–moderate, 41–60 = moderate–severe, 61–88 = severe. SSII: Steptoe Social Isolation Index; score 0 on ≥2 items = socially isolated. CFS: Clinical Frailty Scale, 1–9; 1–3 = very fit, 4 = vulnerable, 5–6 = mild–moderate frailty, 7 = severe frailty, 8 = very severe frailty, 9 = terminally ill. PPS: Palliative Performance Scale, 0–100%; a lower score = a greater degree of functional decline. PPI: Palliative Prognostic Index; ≤4 = >6 weeks survival, 4.1–6 = 3–6 weeks, >6 = <3 weeks.

.

Based on these findings, a rehabilitation program was designed and is shown in

Table 2. Rehabilitation management program.

Problems	Target	Programs
Mobilization Disturbance	Prevent complications (osteoporosis, contracture, ulcers)	Program: Sitting endurance, isotonic open-chain exercise for all extremities. Education: Immobilization effects, energy conservation. Follow programs for fatigue, ADL, joint stiffness, malnutrition, frailty, sarcopenia.
Joint Stiffness	Increase ROM in neck, upper/lower extremities	Program: Cervical orthosis, flexibility exercise for neck, shoulder, hip, knee, ankle (daily, 10 reps × 2 sets with 5 s hold).
Fatigue—Cardio pulmonary	Reduce FSS < 36	Program: Deep breathing, cardiopulmonary exercise (3×/week, 30–40% HRR, 10–30 min using arm ergo cycle with support). Education: Immobilization effects, energy conservation. Incorporate malnutrition, frailty, sarcopenia programs.
Cardiopulmonary Disturbance	Reduce FSS < 36	Program: Cardiopulmonary training (3×/week, 30–40% HRR, 10–30 min), deep breathing exercises. Education: Immobilization effects, energy conservation. Home Program: Gradual walking, large muscle exercise.
Psychosocial Disturbance—Loneliness	Decrease UCLA < 2, caregiver burden	Program: Psychologist consult, social engagement activities, and discussions for companionship.
ADL Disturbance	Partial dependence improvement	Program: ADL self-care in sitting
Malnutrition	Improve MNA > 17.5, better mobility, psychological state, appetite, posture	Program: Nutritional education on food composition (protein, fluids), increase meal frequency, proper sitting position, prosthodontist/nutritionist consult, and psychological support.
Postural Disturbance	Prevent further stooped posture, avoid falls	Program: Include exercises for joint stiffness, psychological support, caregiver burden, and fatigue.
Communication Disturbance	Increased volume	Program: Address fatigue through targeted activities.
Sarcopenia and Frailty	Maintain scores	Program: Include malnutrition and mobilization programs.
Parkinson’s Disease Management	Maintain PPI < 4, increase mobility	Palliative Care: Advanced care planning, social worker assessment, fall prevention (home modifications), spiritual support.

. The plan prioritized prevention of physical complications, nutritional optimization, and frailty management, while strengthening social and caregiver support systems. Interventions were tailored to the patient’s preserved cognitive function and stable socioeconomic status to promote adherence and sustainability of outcomes.

Over the three-month rehabilitation program, as shown in Figure 1, gradual improvements were observed. After rehabilitation, he achieved short-distance walking, as well as improved appetite and weight gain, and showed reduced scores in the Zarit Burden Interview, Fatigue Severity Scale (FSS), and improved Mini Nutritional Assessment (MNA). Functional independence (Barthel Index) and respiratory capacity (single-breath count) improved slightly, while frailty and sarcopenia remained stable without progression. Overall, caregiver burden decreased substantially, highlighting the positive impact of the program.

3. Discussion

This case illustrates the complex interplay of motor progression, treatment resistance, comorbidities, and caregiver burden in an elderly patient with end-stage PD. The patient demonstrated rapid decline in motor function despite early initiation of levodopa, requiring progressive dose escalation. Within the first year of therapy, he exhibited poor responsiveness, likely due to gastrointestinal dysfunction that impairs levodopa absorption [8]. Over the following decade, escalating doses provided only transient benefit, ultimately resulting in severe immobility and necessitating pallidotomy targeting the globus pallidus to relieve rigidity, tremor, and dyskinesia. At the time of surgery in 2017, deep brain stimulation (DBS) was not feasible due to financial and logistical limitations. Although DBS is now the preferred approach, pallidotomy remains a relevant alternative in resource-limited settings, offering meaningful symptom relief and valuable insight into the long-term rehabilitation challenges of such patients [5]. However, pallidotomy does not halt disease progression, and post-surgical rehabilitation remains essential to maintain function and independence, particularly in older adults with frailty and sarcopenia [9,10].

Following the procedure, the patient temporarily regained partial independence in daily activities, with notable reduction in bradykinesia. Over time, however, his functional capacity declined due to obstructive ileus requiring colostomy, further compounded by frailty, sarcopenia, and nutritional deficits. Frailty and sarcopenia, which are common in elderly PD patients, exacerbated functional decline and fatigue [3]. Gastrointestinal dysfunction is common in advanced PD and may result from autonomic impairment and medication side effects, leading to malnutrition, fatigue, and further functional deterioration [11]. Prolonged immobility, social withdrawal due to stoma care, and reduced oral intake related to edentulism worsened his overall condition, placing him at high risk of further decline and institutionalization. This situation also contributed to elevated caregiver burden, negatively affecting both patient outcomes and caregiver well-being.

Comprehensive geriatric assessment played a pivotal role in identifying the patient’s multifactorial problems and guiding an individualized rehabilitation strategy. By integrating management of frailty, sarcopenia, and nutrition, the rehabilitation program aimed to preserve remaining function and prevent further complications. Equally important was the inclusion of caregiver support as part of the intervention, recognizing that caregiver burden directly influences patient adherence, emotional stability, and long-term care sustainability. This holistic perspective underscores that rehabilitation in advanced PD must extend beyond physical therapy to encompass psychosocial and family dynamics.

The three-month program focused on strengthening and flexibility to reduce rigidity, cardiopulmonary training to improve endurance, functional task practice to support ADL, and psychological counseling combined with caregiver education to reduce stress and promote engagement. Evidence supports such multimodal rehabilitation: resistance and functional training improve motor symptoms, fatigue, balance, and ADL performance in PD patients [12,13,14,15]. Over the course of therapy, the patient demonstrated measurable improvement, including reduced fatigue, improved nutritional status, and lower caregiver burden.

These outcomes suggest that even in end-stage PD complicated by frailty and sarcopenia, comprehensive rehabilitation can stabilize functional status and enhance quality of life for both patients and caregivers. The findings reinforce the clinical value of combining geriatric assessment, targeted rehabilitation, and caregiver involvement as a unified strategy to optimize care in advanced PD.

4. Conclusions

An integrated and multidisciplinary rehabilitation program can meaningfully improve mobility, nutrition, psychosocial well-being, and caregiver burden in elderly patients with end-stage PD. Even when functional gains are modest, targeted rehabilitation remains clinically valuable in reducing fatigue and caregiver stress, thereby supporting quality of life for both patients and families.