1. Balance Control Improves Following Replacement of Paroxetine with Venlafaxine and Levodopa in a Case of Microvascular Dementia The American Journal of Geriatric Pharmacotherapy 2011;9: 133-137 Jaime McDonald, Philippe Corbeil, Emmanuelle Porcher Presented By: Deepa Patel Doctor of Pharmacy Candidate, 2012 Mercer University COPHS July 8, 2011

2. Postural Instability Common complaint in geriatric patients Can be due to several disease states, including Parkinsons disease, microvascular dementia, in addition to numerous neurological disorders Falls may lead to decreased quality of life and increased mortality

3. Study Design Case study of a single patient Funding by NSERC (Natural Sciences and Engineering Research Council of Canada) Study authors were fully involved in every aspect of the trial and publication and received contracts from the drug manufacturers

4. Patient Case 86 y/o female with a 6 month history of frequent falls without injury and Parkinson- like syndrome of the lower limbs secondary to microvascular dementia Bilateral rigidity Left-sided akinesia Diminshed postural adjustment reflexes No signs of deconditinoing Moderate ischemic leukopathy of the paraventricular white susbtance Atropy of cerebral subcortical and cerebellar regions Current Medications Atorvastatin 40 mg daily ASA 81 mg daily Pantoprazole 40 mg daily Paroxetine 20 mg daily Vision, BP and HR normal Ruled out: hypothyroidism, peripheral neuropathy, arterial insufficiecy

5. Microvascular Dementia Usually attributed to diseases that may lead to ischemia such as diabetes mellitus and dyslipidemia Neurotransmitters implicated in gait disorders include Serotonin Norepinephrine Dopamine

6. Serotonin Involvement in balance control is postulated as SSRI withdrawal has detrimental effects on balance

7. Norepinephrine Involvement in balance control is attributed to regulation of the mental processes of attention and concentration

8. Dopamine Highly debated relationship with balance control, but evidence of postural instability in Parkinsons disease strengthens the hypothesis that dopamine contributes, particulary when patients have eyes open

9. Intervention 6 months: Venlafaxine 27.5 mg at bedtime + Levodopa/carbidopa 100/25 mg, 1.5 tablets TID 3 months: Venlafaxine 37.5 mg at bedtime (reduced dose due to intolerability) Venlafaxine 37.5 mg twice daily Pt initially on Paroxetine 20 mg daily (tapered over 3 weeks)

10. Results Primary outcome: Center of Pressure (CoP) measured over 20 seconds, average of three trials per treatment intervention performed

11. Conclusion Most improvement in balance control when using combination therapy of Venlafaxine (SNRI) and Levodopa Author suggests that for geriatric patients on antidepressants, addition or switching medications with differing mechanisms of action may be an effective option for helping alleviate balance control issues

12. Commentary Strengths of Study Did not use medications on the Beers list Dosing was appropriate for disease state and patient age Tapering of medication was appropriate Weaknesses of Study Single patient study Most patients with microvascular dementia present with numerous concomitant disease states including diabetes mellitus and hypertension, however this patient did not report such illnesses