Non-motor Complications of Parkinson’s Disease and

Management

Valerie R. Suski, DOUniversity of Pittsburgh

Department of NeurologyPittsburgh Institute for Neurodegenerative DiseasesUPMC Comprehensive Movement Disorders Clinic

Importance

• Affects quality of life, hospitalization rates, and relationships.

• Correlate with advanced age, duration and severity of the disease

• Under-reported

Insomnia– Sleep fragmentation/Frequent and

early arousals– Causes:

• slowed movements during the night• Changes in sleep/wake cycle• Difficulties turning in bed or adjusting

blankets• Pain, cramps, nocturnal and early

morning dystonia• frequent need to pass urine

– Treatment • Melatonin, sleeping pills• Long acting Parkinson’s meds • Bladder medications• Changing timing of the medications

Restless Leg Syndrome– 12-20% more prevalent

– may be common in off-state in patients with motor fluctuations

– Made worse with• medications: tricyclic antidepressants, selective

serotonin reuptake inhibitors, lithium, caffeine, neuroleptics, H2 blockers

• Diseases/conditions: Kidney disease (particularly end-stage), iron deficiency, neuropathy

– Check serum iron, ferritin, magnesium, B12, folate levels

– Treatment:• Parkinson’s meds, antiseizure meds, tranquilizer,

opiods, supplementation (if deficient)

Excessive Daytime Sleepiness

up to 50% caused by• Medications• Sleep Apnea• Sleep Attacks –

decrease dopamine agonist

• Poor sleep hygiene

REM Sleep Behavioral Disorder

– Preclinical symptom– dream-enacting behaviors

• laughing, talking, shouting, kicking, fighting invisible enemies

– Precipitated or worsened by antidepressants– Treatment

• Medications• Safeguard bedroom, twin beds

Hallucinations– Up to 40%– risk for nursing home placement– What makes you prone to have these?

• infection, medications• Sudden withdrawal of PD meds• Chronic memory problems• Deteriorating vision (macular degeneration,

cataracts)

Managing Altered Mental States

Reduce/eliminate meds:– Anticholinergics – Sedatives– Amantadine – Muscle relaxants– Sleeping pills – Bladder medication

• Reduce dosage of PD meds• Initiate anti-psychotic therapy

FATIGUE• Can be associated with

– Disease progression

– Low blood pressure

– Depression

– Excessive daytime sleepiness, sleep disturbances

• Treatment

– Sleep hygiene

– Antidepressants

– Medications

– Increase water intake, BP management

Depression– 10-45%– Preclinical symptom

• Primary disorder• Secondary disorder

– Treatment• medications• psychotherapy• Stress release• Combination of therapy

Anxiety

– Preclinical symptom– panic attacks, phobias, or generalized anxiety

disorder– Treatment

• Primary anxiety disorder: benzodiazepines• “Secondary anxiety disorder:” Associated with

“off-periods” or low-levodopa levels: adjust levodopa dosing

Memory Loss

Up to 40%progressive clinically characterizedTreatment

• Cholinesterase Inhibitors – may worsen tremors

Orthostatic Hypotension

• Light-headedness, dizziness, fatigue, shoulder or neck pain; blood pressure drops when standing

• Treatment– Frequent orthostatic measurements– Taper anti-hypertensives, non-PD drugs– Increase water/salt intake– Compression stockings– Medication

Constipation

Causes• Slowing down of the GI tract• decreased fluid intake -2 urinary

frequency or incontinence (?)• Decreased activity• Side effect from PD medication

– Anticholinergics– Dopaminergic therapy

Treatment• Stool softeners, increase water intake,

dietary bulk, exercise, laxative, lactulose, in some case enemas

Nausea

Cause/TreatmentLevodopa-related:

take with meals,

add carbidopa,

Add antinausea meds

delayed GI transit time:

more frequent and smaller meals

Bladder

• Urinary Incontinence• Urinary frequency• Urinary hesitancy

• Treatment– Urology consult– Urodynamic study

Sexual DysfunctionReduced drive/Abnormally increased

drive–Testosterone implicated

• Men: attaining and maintaining erections or ejaculation

• Women: difficulty with orgasm

Treatment• Medical screening: depression, anxiety• Endocrine evaluation: prolactin, testosterone,

lutenizing hormone, thyroid screen• Urologic evaluation• medication

Sweating

– Cause:

• Usually levodopa related, and may be seen at:

– peak level

» Reduce levodopa

– trough levels

» add dopamine agonist, COMT inhibitor or levodopa

Drooling

CausesReduced swallowing

Stooped posturing

TreatmentDrying side effects from medicationsGlycopyrrolate Botulinum toxin injectionsAtropine ophthalmic solution mouth rinseScopolamine patch

• Pain– motor fluctuations, early

morning dystonia, Musculoskeletal

– Adjust dopamine therapy

• Smell – Preclinical symptom– Eventually affects up to

90%

Compulsions

• Side effect of Dopamine Agonists– Excessive eating– Pathological gambling

Take Home Points

• Parkinson’s management is individualized

• You are not alone

• Importance of Non-Motor Complications

• Importance of Water

• Medication/Symptoms Lists

• Importance of Timing Symptoms

MEDICATION SIDE EFFECTS

Carbidopa/Levodopa

• Nausea

• Confusion/Hallucinations

• Dyskinesias

• Orthostatic hypotension

Dopamine Agonists

Side EffectsExcessive daytime sleepinessSleep attacksSwelling in the legsHallucinations/confusionCompulsionsOrthostatic hypotension

Amanatadine

RashUrinary RetentionDry MouthConstipationConfusionBlurred Vision

Selegeline/Rasagaline

• Nausea

• Dry mouth

• Constipation

• Confusion/hallucinations

• Insomnia

COMT inhibitors

• Hallucinations

• Diarrhea

• hypotension

• urine discoloration

• With tolcapone, liver toxicity