# Presentation: 276675

## MANAGEMENT OF ADVANCED

- PARKINSON’S DISEASE:Non-Motor Complications

- Eugene C. Lai, M.D., Ph.D.
- Houston VA Medical Center
- Baylor College of Medicine

## NON-MOTOR COMPLICATIONS IN PARKINSON’S DISEASE

- Neuropsychiatric manifestations
- Cognitive impairment
- Sleep disturbances
- Autonomic dysfunctions
- Sensory phenomena

## CLINICAL PROFILE

- OF PATIENTS WITH
- NON-MOTOR COMPLICATIONS

- 85 patients:
- Mean age			66.2 (38-85)
- Mean age at onset		58.9 (31-83)
- Mean disease duration	  7.8 (0.5-33)
- Median H & Y		  	  2.2 (1-5)
- 84.7% with motor fluctuations, all experienced one or more non-motor symptoms
- 47.2% with neuropsychiatric manifestations
- 84.7% with autonomic disturbances
- 69.4% with sensory phenomena

- Gunal DI et al.  Can J Neurol Sci 2002;29:61-64.

## RISK FACTORS FOR

- NON-MOTOR COMPLICATIONS

- Early age of disease onset
- Longer duration of disease
- Higher doses of levodopa
- Age of patient
- Presence of motor fluctuations

## MOST FREQUENT NON-MOTOR FLUCTUATIONS

| NMF | FREQUENCY % | FREQUENCY DURING OFF % |
| --- | --- | --- |
| Anxiety | 66 | 88 |
| Drenching sweat | 64 | 59 |
| Slowness of thinking | 58 | 83 |
| Fatigue | 56 | 75 |
| Akathisia | 54 | 63 |
| Irritability | 52 | 88 |
| Hallucinations | 49 | 25 |

- Witjas T et al. Neurology, 2002;59:408-413.

## INFORMATION NECESSARY TO MAKE DECISIONS IN THERAPY

- Medication regimen
- Response to medication dosing throughout the day
- Side-effects from medications
- Daily activities
- Dietary habits
- Sleep patterns
- Emotional state
- History of response to pharmacologic therapy

## NEUROPSYCHIATRIC MANIFESTATIONS INPARKINSON’S DISEASE

- NEUROPSYCHIATRIC MANIFESTATIONS INPARKINSON’S DISEASE

- Depression
- Hallucination / delirium
- Behavioral fluctuation	-Anxiety / panic		-Agitation

## DEPRESSION IN

- PARKINSON’S DISEASE

- Affects 40-50% of patients
- Characterized by:
- Feeling of guilt
- Lack of self esteem
- Loss of initiative
- Helplessness, remorse, sadness
- Causes may be endogenous, exogenous,       	or both

## FREQUENCY OF NEUROPSYCHIATRIC SYMPTOMS

| SYMPTOM | FREQUENCY % |
| --- | --- |
| Anxiety | 66 |
| Fatigue | 56 |
| Irritability | 52 |
| Hallucinations | 49 |
| Self-withdrawal | 44 |
| Euphoria | 42 |
| Lassitude/weariness | 42 |
| Sadness | 38 |

- Witjas T et al. Neurology, 2002;59:408-413.

## TREATMENT OF NEUROPSYCHIATRIC PROBLEMS IN PARKINSON’S DISEASE

- Reduce / discontinue medications
- Treat underlying medical illness
- Antidepressants
- Atypical neuroleptics
- Anxiolytics
- Keep active / exercise
- Educate caregivers
- Psychological counseling

## COGNITIVE IMPAIRMENT INPARKINSON’S DISEASE

- COGNITIVE IMPAIRMENT INPARKINSON’S DISEASE

- Affects up to 40% of patients
- Late feature of PD
- Differential diagnosis: PDD vs AD vs DLB
- Frontal-executive dysfunction, impairments of visuo-spatial abilities, temporal ordering, memory and attention
- Increases caregiver burden

## TREATMENT OF

- COGNITIVE IMPAIRMENT
- IN PARKINSON’S DISEASE

- No proven medical therapy
- Cholinesterase inhibitor?
- Avoid offending medications
- Symptomatic behavioral treatment
- Caregiver education

## SLEEP DISTURBANCES IN PARKINSON’S DISEASE

- Insomnia
- REM behavior disorder
- Nightmares
- Obstructive sleep apnea
- Excessive daytime sleepiness

## TREATMENT OF SLEEP DISTURBANCES IN PD

- Treat depression / anxiety
- Add controlled-release levodopa at bedtime
- Sleep hygiene program
- Short-acting sedative hypnotics
- Minimize nocturia
- Clonazepam for REM Behavior Disorders
- Discontinue tricyclic drugs and MAO inhibitors
- Avoid stimulants in evening
- Evaluate sleep disorder
- Judicious use of stimulants for EDS

## DYSAUTONOMIAS IN PARKINSON’S DISEASE

- Constipation
- Urinary problems
- Orthostatic hypotension
- Sexual problems
- Impaired thermoregulation
- Dysphagia
- Siarrhea/drooling

## TREATMENT OF CONSTIPATION IN PD

- Dietary modification
- Increase physical activity
- Stop anticholinergics
- Stool softener
- Bulk fibers
- Lactulose
- Mild laxative
- Education

## TREATMENT OF URINARY PROBLEMS IN PD

- Nocturia, frequency, urgency
- Reduce evening fluid intake
- Elevate head of bed
- Medication (oxybutynin, tolterodine)
- Consider urologic evaluation

## TREATMENT OF ORTHOSTATIC HYPOTENSION IN PD

- Eliminate antihypertensives, if possible
- Behavior modification
- Increase salt and fluid intake
- Support stockings
- Elevate head of bed
- Medications (fludrocortisone, midodrine)

## SENSORY PHENOMENA IN PARKINSON’S DISEASE

- Rigidity / cramps
- Dystonic pain
- Musculoskeletal pain associated    	with immobility
- Heaviness in limbs
- Restless leg syndrome

## TREATMENT OF SENSORY PHENOMENA IN PD

- Stretching exercises
- Medication adjustment
- Physical therapy
- Baclofen
- NSAIDs
- Botulinum toxin injection
- Rule out rheumatologic, orthopedic, radicular and neuropathic causes

## PARKINSON’S DISEASERESEARCH, EDUCATION, AND CLINICAL CENTERHOUSTON VA MEDICAL CENTER

- PARKINSON’S DISEASERESEARCH, EDUCATION, AND CLINICAL CENTERHOUSTON VA MEDICAL CENTER