A 70-year-old man was referred because his balance had deteriorated in recent months. While he had only occasionally fallen over the previous 3 years, he now described a strong and consistent tendency to fall backward. He planned to retire as soon as possible partly because of this issue, but also because his productivity at work had decreased. His wife noted that he had been uncharacteristically impatient at home, but denied any memory difficulties.

A 72-year-old woman was seen with her husband at the movement disorder clinic. She was referred by her attending neurologist who has been following her for 9 years for Parkinson’s disease (PD). Her symptoms had begun 10 years ago, with a left arm tremor that progressively worsened to affect the left side of her body and her right arm. The tremor was accompanied by generalized slowness of movement and stiffness. She was put on l-3,4-dihydroxyphenylalanine (L-DOPA) 8 years ago with a good initial response. Doses were progressively increased over the years. When seen at the clinic, she was taking L-DOPA/carbidopa (referred to as L-DOPA) 100/25 mg 1.5 pills every 3 hours from 6:00 a.m. to midnight, a total of 10.5 pills daily. Sometimes, she had to take an extra pill at night because of difficulty turning over in bed. She believed the effect of the antiparkinsonian medication was not lasting more than 2.5 hours and felt uncomfortable, with tremor resurgence, about 30 min before taking the next L-DOPA dose. Approximately 1 hour after L-DOPA intake, she would present fidgetiness and mild abnormal movements that were not bothersome but that were noticed by her husband and children. She had a few accidental falls. She sometimes experienced dizziness upon standing up rapidly. Approximately 1 year ago, she began experiencing visual hallucinations (VHs) that were, at times, frightening and prevented the neurologist from increasing L-DOPA doses. Most of the times, the VHs consisted of bugs, but on a few occasions they encompassed faces of unknown people. She had to be put on quetiapine 25 mg a.m. and 50 mg at bedtime to alleviate these VHs. Her husband was also concerned that she had become more forgetful in the past year. She was more apathetic and was not interested in going out anymore. At times, she was going through episodes of confusion. She was also experiencing episodes of daytime sleepiness and would have to nap for at least 1 hour every afternoon.

This 62-year-old former accountant presented to a neurologist with complaints of a right hand tremor, slowness, and gait difficulties. He was diagnosed with Parkinson’s disease (PD) and received pramipexole up to 1.5 mg tid. On this medication, he reported being well for 2 years. After 3 years of evolution, levodopa/carbidopa was introduced because of a worsening of his parkinsonism. His tremor was initially significantly improved by levodopa, but the effect was lost after less than a year. Higher doses caused episodes of hypotension and also spasms of his neck and toes which were treated with clonazepam. At the fifth year, he developed significant freezing of gait and needed a walker to ambulate safely.