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


    Non motor complications of parkinson s disease and management

    • 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