Title: Parkinsons Disease: Management of The NonMotor Symptoms
1Parkinsons DiseaseManagement of The Non-Motor
Symptoms
- Dr. Doug MacMahon
- Royal Cornwall Hospitals NHS Trust
- Peninsula Medical School
2Outline
- The importance of non-motor symptoms
- Pre-symptomatic Diagnosis
- Non-motor Questionnaire Scale
- Practical Management
3James Parkinson (1817)
4www.nice.org.uk
NICE Guidelines June 2006
5Sydney Multicentre study Non L dopa responsive
symptoms predominate at 15 years Hely et al 2005
n52
6How Common?
- Constipation
- Community Study MacMahon, Maguire Care of the
Elderly 75 - Non Motor Survey 50
- When?
- Honolulu Heart study
- gt10 yrs pre Diagnosis of PD
MacMahon DG. Neurology. 199952(7 Suppl
3)S21-5 Chaudhuri KR, et al. The NMSQuest study.
Mov Disord. 2006 Abbott RD, Petrovitch H, White
LR et al. Neurology 2005 65 14421446.
7Combination of idiopathic REM sleep behaviour
disorder and olfactory dysfunction as possible
indicator for a -synucleinopathy demonstrated by
dopamine transporter FP-CIT-SPECT
DaTSCAN INDICATIONS Distinction of ET from
parkinsonism Lewy Body Dementia Presymptomatic
Diagnosis Drug induced pism
K. Stiasny-Kolster, W. H. Oertel et al Brain 2005
128(1)126-37
8Nocturnal Falls90 yr retired, married,
mechanical fall at 0400
TDQ Defending wife by attacking rapist at the
end of the bed
9Aetiology e.g. constipation
- Aging
- Relative immobility
- Drugs
- Lewy bodies in Auerbach's and Meissner's plexuses
- Olfaction - Braak
Wakabayashi K, Takahashi H, Takeda S, Ohama E,
Ikuta F. Parkinson's disease the presence of
Lewy bodies in Auerbach's and Meissner's
plexuses. Acta Neuropathol (Berl).
198876(3)217-221.
10Treated
Unreated
11 Parkinsons Disease Not just a motor syndrome
Non Motor Syndrome
Motor Syndrome
Treated
Untreated
Levodopa DDCI Anticholinergics Amantidine DA
Agonists MAOIs COMTIs
GastroIntTract GenitoUrinaryTract CVS Cognition Pa
in Sleep Hypotension Sexual Function Others
Dyskinesias Fluctuations
Bradykinesia Rigidity Tremor Micrographia Gait
problems
12Non motor Questionnaire (available on pds
web-site) http//www.parkinsons.org.uk/for_profess
ionals/resources/non-motor_symptoms_of_ps_qq.aspx
13Non-Motor Scale
14Anxiety Panic Disorder in PD
- Anxiety may precede motor features by 20 years1
- Frequency in established PD 20-402,3
- generalised anxiety disorder gt panic attacks
- comorbidity with depression
- may fluctuate with motor state4
- Assessment
- Hospital Anxiety Depression Scale5
- Management
- treat underlying depression
- reduce OFF periods
- short term benzodiazepines
(e.g. lorazepam)
1 Shiba 2000 2 Aarsland 1999 3 Stein 1990 4
Maricle 1995 5 Zigmond Snaith 1983
15Depression in PD
- Common - ? 40
- ? Severity
- Rx
- Evidence Free Zone
16DLB PD Dementia A Spectrum
Fluctuating cognition hallucinations
12 months
PD Dementia
DLB
Parkinsonian features
Time
17Dementia in PD
- Common - ? 40
- Evidence of Efficacy Rivastigmine (Emre et al
2005)
18Dopamine Dysregulation Syndrome
- Self-medication addiction to DRT
- Frequency 2-4
- Characteristic profile
- male (80)
- early onset-disease
- severe but well tolerated dyskinesias
- previous history of mood disorder
- Hypomanic, manic or cyclothymic affective
syndrome in relation to DRT - Depression, irritability anxiety on ? DRT
Giovannoni 2000 Lawrence 2003 Pezzella 2005
19Punding
- Complex, prolonged, purposeless stereotyped
behaviour - Originally described in amphetamine users
Adapted from Evans 2004
20Pathological Gambling
- Impulse control disorder (DSM-IV)
- Frequently triggered by L-dopa
- Worse in on periods
- Culturally-determined pattern
- Associated with
- pre-morbid alcohol dependence or abuse
- major depression
21Hypersexuality Paraphilias
- Frequency 0.9-3 (male predominant)
- Libido increased but not necessarily potency
- No relation between functional improvement ?
sexuality1 - Dose dependency between drugs hypersexual
behaviour1 - Complication of DBS (pallidum gt STN?)2,3
- Reversible transvestic fetishism4
- dopamine agonists selegiline
1 Uitti 1989 2 Burn Tröster 2004 3 Mendez
2004 4 Riley 2002
22 Parkinsons Disease Not just a motor syndrome
not just dopaminergic Rx
Non Motor Syndrome
Motor Syndrome
Treated
Untreated
Laxatives Botox Antidepressants Hypnotics Cognitiv
e Enhancers Fludrocort/Midodrine Viagra/Cialis/Ts
terone
Levodopa DDCI Anticholinergics Amantidine DA
Agonists MAOIs COMTIs
GastroIntTract GenitoUrinaryTract CVS Cognition Pa
in Sleep Hypotension Sexual Function Others
Dyskinesias Fluctuations
Bradykinesia Rigidity Tremor Micrographia Gait
problems
23Management of Dopamine-Driven Behaviours
- Explanation to patient family
- Withdraw dopaminergic medication in reverse
sequence - short-term prescriptions?
- supervised tablet administration?
- Treat underlying depression (e.g. SSRI)
- Avoid intermittent s/c apomorphine
- Low dose quetiapine for DDS/psychosis?
- Mood stabilizer (e.g. carbamazepine)
- Psychotherapy?
Pezzella 2005 Lawrence 2003
24Multidisciplinary approach
Therefore Refer to appropriate AHP
25And, finally..
- Non-motor problems are common
- May help as diagnostic markers
- Many are treatable
- or at least manageable
- Best managed by Specialist Multidisciplinary
team/s