Non-motor Complications of Parkinson’s Disease and Management

1. Valerie R. Suski, DO University of Pittsburgh Department of Neurology Pittsburgh Institute for Neurodegenerative Diseases UPMC Comprehensive Movement Disorders Clinic Non-motor Complications of Parkinson’s Disease and Management

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

3. 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

4. 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)

5. Excessive Daytime Sleepiness up to 50% caused by • Medications • Sleep Apnea • Sleep Attacks – decrease dopamine agonist • Poor sleep hygiene

6. 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

7. 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)

8. 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

9. 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

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

11. 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

12. Memory Loss Up to 40% progressive clinically characterized Treatment • Cholinesterase Inhibitors – may worsen tremors

13. 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

14. 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

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

16. Bladder • Urinary Incontinence • Urinary frequency • Urinary hesitancy • Treatment • Urology consult • Urodynamic study

17. 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

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

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

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

21. Compulsions • Side effect of Dopamine Agonists • Excessive eating • Pathological gambling

22. 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

24. MEDICATION SIDE EFFECTS

25. Carbidopa/Levodopa • Nausea • Confusion/Hallucinations • Dyskinesias • Orthostatic hypotension

26. Dopamine Agonists Side Effects Excessive daytime sleepiness Sleep attacks Swelling in the legs Hallucinations/confusion Compulsions Orthostatic hypotension

27. Amanatadine Rash Urinary Retention Dry Mouth Constipation Confusion Blurred Vision

28. Selegeline/Rasagaline • Nausea • Dry mouth • Constipation • Confusion/hallucinations • Insomnia

29. COMT inhibitors • Hallucinations • Diarrhea • hypotension • urine discoloration • With tolcapone, liver toxicity