Transcript Non-motor Complications of Parkinson`s Disease and Management

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
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
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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?
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infection, medications
Sudden withdrawal of PD meds
Chronic memory problems
Deteriorating vision (macular degeneration,
cataracts)
Managing Altered Mental States
Reduce/eliminate meds:
– Anticholinergics
– Amantadine
– Sleeping pills
– Sedatives
– Muscle relaxants
– 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
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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 characterized
Treatment
• Cholinesterase Inhibitors – may worsen tremors
Orthostatic Hypotension
• Light-headedness, dizziness, fatigue, shoulder
or neck pain; blood pressure drops when
standing
• Treatment
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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/Treatment
Levodopa-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 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
– Cause:
• Usually levodopa related,
and may be seen at:
– peak level
» Reduce levodopa
– trough levels
» add dopamine
agonist, COMT
inhibitor or
levodopa
Drooling
Causes
Reduced swallowing
Stooped posturing
Treatment
Drying side effects from medications
Glycopyrrolate
Botulinum toxin injections
Atropine ophthalmic solution mouth rinse
Scopolamine 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
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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
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Nausea
Confusion/Hallucinations
Dyskinesias
Orthostatic hypotension
Dopamine Agonists
Side Effects
Excessive daytime sleepiness
Sleep attacks
Swelling in the legs
Hallucinations/confusion
Compulsions
Orthostatic hypotension
Amanatadine
Rash
Urinary Retention
Dry Mouth
Constipation
Confusion
Blurred Vision
Selegeline/Rasagaline
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Nausea
Dry mouth
Constipation
Confusion/hallucinations
Insomnia
COMT inhibitors
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Hallucinations
Diarrhea
hypotension
urine discoloration
With tolcapone, liver toxicity