non motor complications of parkinson s disease and management
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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. Importance.

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non motor complications of parkinson s disease and management

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
importance
Importance
  • Affects quality of life, hospitalization rates, and relationships.
  • Correlate with advanced age, duration and severity of the disease
  • Under-reported
insomnia
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
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
Excessive Daytime Sleepiness

up to 50% caused by

  • Medications
  • Sleep Apnea
  • Sleep Attacks – decrease dopamine agonist
  • Poor sleep hygiene
rem sleep behavioral disorder
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
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
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
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
Depression
  • 10-45%
  • Preclinical symptom
    • Primary disorder
    • Secondary disorder
  • Treatment
    • medications
    • psychotherapy
    • Stress release
    • Combination of therapy
anxiety
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
Memory Loss

Up to 40%

progressive

clinically characterized

Treatment

  • Cholinesterase Inhibitors – may worsen tremors
orthostatic hypotension
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
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
Nausea

Cause/Treatment

Levodopa-related:

take with meals,

add carbidopa,

Add antinausea meds

delayed GI transit time:

more frequent and smaller meals

bladder
Bladder
  • Urinary Incontinence
  • Urinary frequency
  • Urinary hesitancy
  • Treatment
    • Urology consult
    • Urodynamic study
sexual dysfunction
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
sweating
Sweating
  • Cause:
    • Usually levodopa related, and may be seen at:
      • peak level
        • Reduce levodopa
      • trough levels
        • add dopamine agonist, COMT inhibitor or levodopa
drooling
Drooling

Causes

Reduced swallowing

Stooped posturing

Treatment

Drying side effects from medications

Glycopyrrolate

Botulinum toxin injections

Atropine ophthalmic solution mouth rinse

Scopolamine patch

slide20
Pain
    • motor fluctuations, early morning dystonia, Musculoskeletal
    • Adjust dopamine therapy
  • Smell
    • Preclinical symptom
    • Eventually affects up to 90%
compulsions
Compulsions
  • Side effect of Dopamine Agonists
    • Excessive eating
    • Pathological gambling
take home points
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
carbidopa levodopa
Carbidopa/Levodopa
  • Nausea
  • Confusion/Hallucinations
  • Dyskinesias
  • Orthostatic hypotension
dopamine agonists
Dopamine Agonists

Side Effects

Excessive daytime sleepiness

Sleep attacks

Swelling in the legs

Hallucinations/confusion

Compulsions

Orthostatic hypotension

amanatadine
Amanatadine

Rash

Urinary Retention

Dry Mouth

Constipation

Confusion

Blurred Vision

selegeline rasagaline
Selegeline/Rasagaline
  • Nausea
  • Dry mouth
  • Constipation
  • Confusion/hallucinations
  • Insomnia
comt inhibitors
COMT inhibitors
  • Hallucinations
  • Diarrhea
  • hypotension
  • urine discoloration
  • With tolcapone, liver toxicity
ad