September 1, 2016

Parkinson's Nonmotor Symptoms

Earlier today, I shared a terrific article from September‘s Mayo Clinic Health Letter, which provided an excellent overview of Parkinson’s disease (PD). I was especially interested in the information about the "support drugs” that might enhance the effectiveness of carbidopa-levodopa (Sinemet), the current gold standard med for treating PD.

As a follow-up, I want to share another Mayo piece about the flip side of PD -- its nonmotor complications. I’ve written often about this subject, especially how the serotonin-boosting over-the-counter supplement 5-HTP has helped me deal with three common nonmotor issues people with Parkinson’s often experience: depression, insomnia, and constipation.

Here’s that article.

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When most people think of Parkinson’s disease, the signs and symptoms that come to mind are movement (motor) related, such as tremor, slowed movement and rigid muscles.

However, there’s another side of Parkinson’s symptoms — nonmotor symptoms. It’s increasingly recognized that nonmotor symptoms or complications may be as prominent as movement-related symptoms in the effect Parkinson’s has on your life. The good news is that many of these nonmotor symptoms are treatable or manageable. Treating them can have a major impact on how active and independent you can remain as you manage the progression of Parkinson’s disease.

Taking Action
It’s important for your doctor to determine if nonmotor symptoms may be related to dopamine drugs used to control movement symptoms. If so, fine-tuning your dopamine drug regimen may be an option for improving many nonmotor symptoms. Sometimes, this works with no unwanted effects.

However, there’s a balance point where benefits of adjustments must be weighed against the downside of possible decreased movement control.

Additional treatments for nonmotor symptoms are specific to problems such as: 
  • Constipation — Adequate fluid and dietary or supplemental fiber intake can be a helpful foundation for improvement. Polyethylene glycol (MiraLAX), methylcellulose (Citrucel, others) and psyllium (Metamucil, others) are among several laxative choices that may be helpful. Anticholinergic drugs used to treat tremor often aggravate constipation.
  • Excessive saliva from reduced swallowing — Chewing gum or sucking on hard candy can help encourage swallowing to reduce saliva. Frequently, salivary gland injections of botulinum toxin are used to reduce saliva production. Select anticholinergic drugs — such as glycopyrrolate (Cuvposa, Robinul) — may be taken orally or as a liquid drop in the mouth. However, side effects may worsen constipation or cause confusion in older adults.
  • Difficulty swallowing — Avoiding foods that are difficult to swallow, taking smaller bites and proper posture may help, but often referral to a speech or physical therapist is needed for more individualized therapy.
  • Lightheadedness when standing due to low blood pressure (orthostatic hypotension) — If you take a drug to lower blood pressure, an adjustment in dose may help. Other steps may include drinking adequate amounts of water; possibly increasing your salt intake, if your doctor recommends it; eating frequent, small meals; using compression stockings; and shifting slowly from lying down to standing.
  • Hallucinations — Parkinson’s drugs are often the cause of hallucinations, and simple doctor reassurance is sometimes enough for hallucinations that aren’t troubling.   If hallucinations or delusions are bothersome, dose adjustment of the Parkinson’s drugs you’re taking or small doses of the antipsychotic drug quetiapine (Seroquel) may help. A new drug — pimavanserin (Nuplazid) — has been shown to reduce hallucinations and delusions without affecting movement symptoms.
  • Depression — Parkinson’s diseaserelated damage to parts of the brain that govern mood are the main cause of depression with Parkinson’s. Depression is very common. Treating depression can often improve movement symptoms and quality of life. Counseling can be helpful, but carefully selected antidepressant medications are the mainstay of treatment.
  • Anxiety — Medication side effects or a disease other than Parkinson’s disease — such as depression or a thyroid problem — can contribute to anxiety. Counseling, exercise, and relaxation or meditation techniques are also helpful. Anti-anxiety medications such as benzodiazepine may have side effects such as confusion or balance issues that can make them difficult to tolerate. Antidepressant drugs in the selective serotonin reuptake inhibitor (SSRI) class may be a better choice. 
  • Pain management — Techniques include careful use of pain medications, physical therapy, massage, exercise and stretching, counseling, and alternative therapies such as acupuncture.
  • Difficulty sleeping — Basic sleep hygiene such as a regular bedtime, a cool, quiet sleep environment, and reserving the bedroom for sleep and sex are a good foundation. Addressing sleep-interrupters such as the need to urinate at night, restless legs syndrome or sleep apnea also is important. In addition, a bedtime dose of dopamine medication can be helpful if Parkinson’s symptoms interfere with sleep. Antidepressants can sometimes help with sleep, and for those who act out dreams, the supplement melatonin or the benzodiazepine drug clonazepam (Klonopin) may be prescribed. If daytime fatigue is a significant problem despite addressing sleep issues listed above, the drug methylphenidate (Metadate, Ritalin, others) may be worth a cautious trial.
  • Cognitive decline — This is typically minor until the later stages of Parkinson’s disease. Getting regular exercise, eating a healthy diet and taking other heart and brain-healthy steps such as controlling blood pressure and cholesterol levels are all ways to potentially reduce the risk or pace of cognitive decline. If dementia has advanced to a problematic level, mild to moderate improvements in cognition may be achieved with use of a class of drugs called cholinesterase inhibitors, but side effects can be an issue. 

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