Non-Motor Symptoms

A variety of non-motor symptoms are seen in Parkinson's disease and are especially problematic in late stages of the disease. This is an area where cooperation and co-management between the primary care physician and neurologist is especially helpful.

Anxiety / Restlessness

If associated with "off" periods, anxiety and restlessness can be treated with adjustment of levodopa dosing, or sometimes with medications. Conversely, some patients and families may mistake dyskinesias (abnormal involuntary movements caused by medications) for anxiety. Chronic anxiety in PD is usually a symptom of depression.

Cognitive Problems

Memory and cognitive difficulties are seen in 11-29% of Parkinson's patients. The causes may be cognitive dysfunction from Parkinson's itself, Lewy Body disease, concomitant Parkinson's and Alzheimers, medication side effects, depression (pseudodementia), and medication side effects.

Constipation

Constipation is extremely frequent in PD and is usually best managed by preventative treatment including:

• Regular exercise and walking
• Drinking adequate fluids
• Stool softeners
• Regular dosing of bulk laxatives such as metamucil or regular dosing of lactulose
• Use of dried fruits (dried apricots, prunes)

Also, view these articles on constipation on the Parkinson's Wellness and National Parkinson Foundation web sites.

Depression

Depression is common in PD and is seen in as many as 20-90% of patients. It may be masked because vegetative symptoms of depression are similar to many of the symptoms of PD. Patients usually respond well to medication treatment with antidepressants.

Parkinson's: Speech, Swallowing, and Drooling Problems

Nausea

If levodopa related, try taking the levodopa - carbidopa with meals. Or, if nauseous with meals, try without food.

If not effective, many patients who had been felt intolerant of levodopa can be successfully started on the medication by adding extra carbidopa (Lodosyn®) with each levodopa-carbidopa (Sinemet®) dose.

If still not effective, consider adding Domperidone (Motilium®) - unfortunately it is not available in the USA but can be purchased from Canada. Your Neurologist can discuss these medications further with you and arrange a prescription, if appropriate.

Patients should NOT use any of the "standard" anti-nausea medications (Reglan®, Compazine®, etc) as they will make the Parkinson's symptoms much worse (see medications to avoid).

If nausea is associated with other Parkinson's medications (such as agonists), sometimes this can be managed by withdrawing the newest medication, then slowly re-starting at minimal doses and very slowly increasing.

Orthostatic Hypotension (Low blood pressure with standing)

This may be a later symptom of Parkinson's disease but is especially prominent in Shy Drager (a form of Multiple system atrophy, a Parkinson's variant). We may suspect this if the patient complains of dizziness, fatigue, syncope, or weakness.

• Taper medications used to treat high blood pressure
• Taper non - PD drugs
• Increase salt intake (may use 500mg salt tablets - start with 1-3 per day)
• Compression stockings (you can get a prescription form your doctor)
• Fludrocortisone (Flourinef®) 0.1 - 0.4 mg / day
• Mitodrine (Pro Amatine®) 2.5 - 20 mg /day

Psychosis

May vary from vivid dreams to frank hallucinations and delusional thought. Hallucinations are characteristically visual and if mild and recognized as hallucinations, may not necessitate changes in therapy. However, if they become bothersome or severe, they can often be reduced or eliminated by stopping unnecessary non-PD medications, stopping anticholinergics, amantadine, selegeline, dopamine agonists, and COMT inhibitors (in that order), or changing from CR to standard levodopa/carbidopa. If this is insufficient, reduction of levodopa/carbidopa dose and/or treatment with the medication Quetiapine may be needed.

Restless Leg Syndrome

This is seen more frequently in PD patients and is most effectively treated with night time doses of medications: levodopa, dopamine agonists, benzodiazepines, or narcotics.

Sexual Dysfunction

This may be a later symptom of Parkinson's disease but is especially prominent in Shy Drager (a form of Multiple system atrophy, a Parkinson's variant. Other medical issues may be involved, so discussion with your regular doctor is a good idea.

Sleep Disorders

Excessive daytime sleepiness may be caused by poor sleep at night, be a consequence of medications ( anticholinergics, amantadine, dopamine agonists, or levodopa), or be a symptom of the disease itself. If medication adjustment does not relieve the problem, treatment with mitodrine (provigil) or stimulants may be helpful.

Difficulty sleeping is often due to inability to roll over and move at night or the development of painful "off" dystonias. Because of this, adding a dose of levodopa at night is often helpful. Since depression is common, attention to this and treatment of depression may also be useful, especially with early morning awakening.

Sweating (excessive)

This problem is usually levodopa related and may be seen at either peak or trough drug levels. Treatment options:

• Reduce levodopa dose
• Add dopamine agonist or COMT inhibitor
• Add carbidopa (Lodosyn®)
• Add Beta-blocker

Urinary Incontinence / Frequency

This may be a later symptom of Parkinson's disease but is especially prominent in Shy Drager (a form of Multiple system atrophy, a Parkinson's variant). To manage we typically will:

• Rule out urinary tract infection
• For obstruction or obstructive symptoms: prescribe prazosin or terazosin
• For detrusor hyperactivity (dysynergia) prescribe Oxybutinin (Ditropan®) 5 - 30 mg / day or Probanthaline 7.5 - 15 mg / day
• Precribe Nocturnal DDAVP for nocturnal frequency