Parkinsons Disease: Management of The NonMotor Symptoms

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Parkinsons DiseaseManagement of The Non-Motor
Symptoms

• Dr. Doug MacMahon
• Royal Cornwall Hospitals NHS Trust
• Peninsula Medical School

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Outline

• The importance of non-motor symptoms
• Pre-symptomatic Diagnosis
• Non-motor Questionnaire Scale
• Practical Management

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James Parkinson (1817)
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www.nice.org.uk
NICE Guidelines June 2006
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Sydney Multicentre study Non L dopa responsive
symptoms predominate at 15 years Hely et al 2005
n52
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How Common?

• Constipation
• Community Study MacMahon, Maguire Care of the
  Elderly 75
• Non Motor Survey 50
• When?
• Honolulu Heart study
• gt10 yrs pre Diagnosis of PD

MacMahon DG. Neurology. 199952(7 Suppl
3)S21-5 Chaudhuri KR, et al. The NMSQuest study.
Mov Disord. 2006 Abbott RD, Petrovitch H, White
LR et al. Neurology 2005 65 14421446.
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Combination of idiopathic REM sleep behaviour
disorder and olfactory dysfunction as possible
indicator for a -synucleinopathy demonstrated by
dopamine transporter FP-CIT-SPECT
DaTSCAN INDICATIONS Distinction of ET from
parkinsonism Lewy Body Dementia Presymptomatic
Diagnosis Drug induced pism
K. Stiasny-Kolster, W. H. Oertel et al Brain 2005
128(1)126-37
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Nocturnal Falls90 yr retired, married,
mechanical fall at 0400
TDQ Defending wife by attacking rapist at the
end of the bed
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Aetiology e.g. constipation

• Aging
• Relative immobility
• Drugs
• Lewy bodies in Auerbach's and Meissner's plexuses
• Olfaction - Braak

Wakabayashi K, Takahashi H, Takeda S, Ohama E,
Ikuta F. Parkinson's disease the presence of
Lewy bodies in Auerbach's and Meissner's
plexuses. Acta Neuropathol (Berl).
198876(3)217-221.
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Treated
Unreated
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Parkinsons Disease Not just a motor syndrome
Non Motor Syndrome
Motor Syndrome
Treated
Untreated
Levodopa DDCI Anticholinergics Amantidine DA
Agonists MAOIs COMTIs
GastroIntTract GenitoUrinaryTract CVS Cognition Pa
in Sleep Hypotension Sexual Function Others
Dyskinesias Fluctuations
Bradykinesia Rigidity Tremor Micrographia Gait
problems
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Non motor Questionnaire (available on pds
web-site) http//www.parkinsons.org.uk/for_profess
ionals/resources/non-motor_symptoms_of_ps_qq.aspx
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Non-Motor Scale
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Anxiety Panic Disorder in PD

• Anxiety may precede motor features by 20 years1
• Frequency in established PD 20-402,3
• generalised anxiety disorder gt panic attacks
• comorbidity with depression
• may fluctuate with motor state4
• Assessment
• Hospital Anxiety Depression Scale5
• Management
• treat underlying depression
• reduce OFF periods
• short term benzodiazepines
  (e.g. lorazepam)

1 Shiba 2000 2 Aarsland 1999 3 Stein 1990 4
Maricle 1995 5 Zigmond Snaith 1983
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Depression in PD

• Common - ? 40
• ? Severity
• Rx
• Evidence Free Zone

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DLB PD Dementia A Spectrum
Fluctuating cognition hallucinations
12 months
PD Dementia
DLB
Parkinsonian features
Time
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Dementia in PD

• Common - ? 40
• Evidence of Efficacy Rivastigmine (Emre et al
  2005)

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Dopamine Dysregulation Syndrome

• Self-medication addiction to DRT
• Frequency 2-4
• Characteristic profile
• male (80)
• early onset-disease
• severe but well tolerated dyskinesias
• previous history of mood disorder
• Hypomanic, manic or cyclothymic affective
  syndrome in relation to DRT
• Depression, irritability anxiety on ? DRT

Giovannoni 2000 Lawrence 2003 Pezzella 2005
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Punding

• Complex, prolonged, purposeless stereotyped
  behaviour
• Originally described in amphetamine users

Adapted from Evans 2004
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Pathological Gambling

• Impulse control disorder (DSM-IV)
• Frequently triggered by L-dopa
• Worse in on periods
• Culturally-determined pattern
• Associated with
• pre-morbid alcohol dependence or abuse
• major depression

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Hypersexuality Paraphilias

• Frequency 0.9-3 (male predominant)
• Libido increased but not necessarily potency
• No relation between functional improvement ?
  sexuality1
• Dose dependency between drugs hypersexual
  behaviour1
• Complication of DBS (pallidum gt STN?)2,3
• Reversible transvestic fetishism4
• dopamine agonists selegiline

1 Uitti 1989 2 Burn Tröster 2004 3 Mendez
2004 4 Riley 2002
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Parkinsons Disease Not just a motor syndrome
not just dopaminergic Rx
Non Motor Syndrome
Motor Syndrome
Treated
Untreated
Laxatives Botox Antidepressants Hypnotics Cognitiv
e Enhancers Fludrocort/Midodrine Viagra/Cialis/Ts
terone
Levodopa DDCI Anticholinergics Amantidine DA
Agonists MAOIs COMTIs
GastroIntTract GenitoUrinaryTract CVS Cognition Pa
in Sleep Hypotension Sexual Function Others
Dyskinesias Fluctuations
Bradykinesia Rigidity Tremor Micrographia Gait
problems
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Management of Dopamine-Driven Behaviours

• Explanation to patient family
• Withdraw dopaminergic medication in reverse
  sequence
• short-term prescriptions?
• supervised tablet administration?
• Treat underlying depression (e.g. SSRI)
• Avoid intermittent s/c apomorphine
• Low dose quetiapine for DDS/psychosis?
• Mood stabilizer (e.g. carbamazepine)
• Psychotherapy?

Pezzella 2005 Lawrence 2003
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Multidisciplinary approach
Therefore Refer to appropriate AHP
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And, finally..

• Non-motor problems are common
• May help as diagnostic markers
• Many are treatable
• or at least manageable
• Best managed by Specialist Multidisciplinary
  team/s