Non-motor Complications of Parkinson

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Non-motor Complications of Parkinsons Disease
and Management

• Valerie R. Suski, DO
• University of Pittsburgh
• Department of Neurology
• Pittsburgh Institute for Neurodegenerative
  Diseases
• UPMC Comprehensive Movement Disorders Clinic

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Importance

• Affects quality of life, hospitalization rates,
  and relationships.
• Correlate with advanced age, duration and
  severity of the disease
• Under-reported

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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 Parkinsons meds
• Bladder medications
• Changing timing of the medications

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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
• Parkinsons meds, antiseizure meds, tranquilizer,
  opiods, supplementation (if deficient)

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Excessive Daytime Sleepiness

• up to 50 caused by
• Medications
• Sleep Apnea
• Sleep Attacks decrease dopamine agonist
• Poor sleep hygiene

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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

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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)

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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

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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

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Depression

• 10-45
• Preclinical symptom
• Primary disorder
• Secondary disorder
• Treatment
• medications
• psychotherapy
• Stress release
• Combination of therapy

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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

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Memory Loss

• Up to 40
• progressive
• clinically characterized
• Treatment
• Cholinesterase Inhibitors may worsen tremors

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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

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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

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Nausea

• Cause/Treatment
• Levodopa-related
• take with meals,
• add carbidopa,
• Add antinausea meds
• delayed GI transit time
• more frequent and smaller meals

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Bladder

• Urinary Incontinence
• Urinary frequency
• Urinary hesitancy
• Treatment
• Urology consult
• Urodynamic study

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Sexual Dysfunction

• Reduced 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

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Sweating

• Cause
• Usually levodopa related, and may be seen at
• peak level
• Reduce levodopa
• trough levels
• add dopamine agonist, COMT inhibitor or levodopa

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Drooling

• Causes
• Reduced swallowing
• Stooped posturing
• Treatment
• Drying side effects from medications
• Glycopyrrolate
• Botulinum toxin injections
• Atropine ophthalmic solution mouth rinse
• Scopolamine patch

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• Pain
• motor fluctuations, early morning dystonia,
  Musculoskeletal
• Adjust dopamine therapy
• Smell
• Preclinical symptom
• Eventually affects up to 90

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Compulsions

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

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Take Home Points

• Parkinsons management is individualized
• You are not alone
• Importance of Non-Motor Complications
• Importance of Water
• Medication/Symptoms Lists
• Importance of Timing Symptoms

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MEDICATION SIDE EFFECTS
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Carbidopa/Levodopa

• Nausea
• Confusion/Hallucinations
• Dyskinesias
• Orthostatic hypotension

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Dopamine Agonists

• Side Effects
• Excessive daytime sleepiness
• Sleep attacks
• Swelling in the legs
• Hallucinations/confusion
• Compulsions
• Orthostatic hypotension

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Amanatadine

• Rash
• Urinary Retention
• Dry Mouth
• Constipation
• Confusion
• Blurred Vision

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Selegeline/Rasagaline

• Nausea
• Dry mouth
• Constipation
• Confusion/hallucinations
• Insomnia

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COMT inhibitors

• Hallucinations
• Diarrhea
• hypotension
• urine discoloration
• With tolcapone, liver toxicity

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