non-motor complications of parkinson’s disease and management
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
Non-motor Complications of Parkinson’s Disease and
Management
Valerie R. Suski, DOUniversity of Pittsburgh
Department of NeurologyPittsburgh Institute for Neurodegenerative DiseasesUPMC Comprehensive Movement Disorders Clinic
Importance
• Affects quality of life, hospitalization rates, and relationships.
• Correlate with advanced age, duration and severity of the disease
• Under-reported
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– 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
up to 50% caused by• Medications• Sleep Apnea• Sleep Attacks –
decrease dopamine agonist
• Poor sleep hygiene
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– 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
Reduce/eliminate meds:– Anticholinergics – Sedatives– Amantadine – Muscle relaxants– Sleeping pills – Bladder medication
• Reduce dosage of PD meds• Initiate anti-psychotic therapy
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– 10-45%– Preclinical symptom
• Primary disorder• Secondary disorder
– Treatment• medications• psychotherapy• Stress release• Combination of therapy
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
Up to 40%progressive clinically characterizedTreatment
• Cholinesterase Inhibitors – may worsen tremors
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
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
Cause/TreatmentLevodopa-related:
take with meals,
add carbidopa,
Add antinausea meds
delayed GI transit time:
more frequent and smaller meals
Bladder
• Urinary Incontinence• Urinary frequency• Urinary hesitancy
• Treatment– Urology consult– Urodynamic study
Sexual DysfunctionReduced 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
– Cause:
• Usually levodopa related, and may be seen at:
– peak level
» Reduce levodopa
– trough levels
» add dopamine agonist, COMT inhibitor or levodopa
Drooling
CausesReduced swallowing
Stooped posturing
TreatmentDrying side effects from medicationsGlycopyrrolate Botulinum toxin injectionsAtropine ophthalmic solution mouth rinseScopolamine patch
• Pain– motor fluctuations, early
morning dystonia, Musculoskeletal
– Adjust dopamine therapy
• Smell – Preclinical symptom– Eventually affects up to
90%
Compulsions
• Side effect of Dopamine Agonists– Excessive eating– Pathological gambling
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
MEDICATION SIDE EFFECTS
Carbidopa/Levodopa
• Nausea
• Confusion/Hallucinations
• Dyskinesias
• Orthostatic hypotension
Dopamine Agonists
Side EffectsExcessive daytime sleepinessSleep attacksSwelling in the legsHallucinations/confusionCompulsionsOrthostatic hypotension
Amanatadine
RashUrinary RetentionDry MouthConstipationConfusionBlurred Vision
Selegeline/Rasagaline
• Nausea
• Dry mouth
• Constipation
• Confusion/hallucinations
• Insomnia
COMT inhibitors
• Hallucinations
• Diarrhea
• hypotension
• urine discoloration
• With tolcapone, liver toxicity