Management of High-Grade Encephalopathy

Monitoring and Sedation

Consider regular monitoring with transcranial Doppler ultrasound rather than invasive ICP devices for patients with high-grade encephalopathy, as recommended by the Anaesthesia society 1
Avoid benzodiazepines in patients with high-grade encephalopathy, as they can worsen encephalopathy, and consider using dexmedetomidine with caution due to hepatic metabolism, as recommended by the Anaesthesia society 1

For patients with cognitive concerns, consider GPi deep brain stimulation rather than STN DBS, as recommended by the American Academy of Neurology 2
For patients with depression risk, pallidal stimulation is preferred over STN stimulation, according to the American Academy of Neurology 2
When medication reduction is the goal, STN DBS is recommended over GPi DBS, as suggested by the American Academy of Neurology 2
For patients with "on" medication dyskinesias without anticipated medication reduction, target the GPi, as recommended by the American Academy of Neurology 2

Melatonin (3-12mg) is recommended as the first-line treatment for REM Sleep Behavior Disorder, showing significant improvement with fewer side effects than Clonazepam, as recommended by the American Academy of Sleep Medicine 3
Rivastigmine may decrease dream enactment in adults with mild cognitive impairment, and cholinesterase inhibitors like rivastigmine may improve dementia symptoms, as suggested by the American Academy of Sleep Medicine 4

Pregabalin is a first-line treatment for Parkinson's disease, with Level A evidence, according to the American Academy of Physical Medicine and Rehabilitation 5
Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids, and capsaicin are considered second-line options for Parkinson's disease, with Level B evidence, as recommended by the American Academy of Physical Medicine and Rehabilitation 5
Mirtazapine (7.5-30 mg at bedtime) may be beneficial in treating depression and stimulating appetite, with moderate evidence, while olanzapine (5 mg/day) may be considered for patients with psychosis and weight loss, with low evidence 6
Megestrol acetate is not recommended as an appetite stimulant due to potential worsening of motor symptoms and lack of safety evidence, as recommended by the American College of Clinical Nutrition 7

Gait training, balance exercises, and flexibility work are essential components of physical therapy, as recommended by the American Physical Therapy Association 8, 9
Occupational therapy can improve activities of daily living and provide adaptive equipment recommendations, according to the American Occupational Therapy Association 8, 9
Speech therapy can address communication difficulties and provide swallowing assessment and management, as suggested by the American Speech-Language-Hearing Association 8, 9
A Mediterranean diet rich in vegetables, fruits, and low-fat dairy products is recommended, with high evidence, and reduce sodium intake to <100 mmol/day if hypertension is predominant, as recommended by the European Society of Cardiology 10
Avoid excessive alcohol consumption, as recommended by the European Society of Cardiology, with high evidence 10
Both endurance and resistance exercises can slow disease progression and improve quality of life, as recommended by the American Geriatrics Society, with moderate evidence 9

Regular assessment of motor symptoms and medication response is crucial, with periodic neurologic evaluations for seizures and movement disorders, as recommended by the American Academy of Sleep Medicine and the American Academy of Neurology 4, 8
Evaluate gastroparesis with solid-phase gastric emptying studies if symptoms are suggestive, as recommended by the American Gastroenterological Association 11
Regular monitoring of nutritional status and body weight is essential, as recommended by the Clinical Nutrition guidelines, with moderate evidence 9
Target a systolic BP of 120-129 mmHg if tolerated, and a diastolic BP of <80 mmHg, but not <70 mmHg, as recommended by the European Society of Cardiology, with high evidence 10
For older patients (≥65 years), target a systolic BP range of 130-139 mmHg, as recommended by the European Society of Cardiology, with high evidence 10

Angiotensin receptor blockers (ARBs) like losartan are recommended as first-line antihypertensive agents, with high evidence, according to the American College of Cardiology 10, 12
Losartan can be safely used with Sinemet (carbidopa/levodopa), with moderate evidence, and start with a low dose (25-50 mg daily) and titrate gradually, especially in elderly patients, with moderate evidence 10, 13
Monitor for orthostatic hypotension, and diagnose if systolic BP drops ≥20 mmHg or diastolic BP drops ≥10 mmHg within 3 minutes of standing, with moderate evidence, and avoid combining losartan with ACE inhibitors, with high evidence 10
Midodrine, droxidopa, fludrocortisone, pyridostigmine, and octreotide can be used to manage neurogenic orthostatic hypotension, as recommended by the American Heart Association, with moderate evidence 14
Acute water ingestion (≥240-480 mL) can provide temporary relief, with peak effect at 30 minutes, as recommended by the American Heart Association, with low evidence 14