Often under-recognized; more likely to have anxiety, apathy, anhedonia.

Transcription

1 Appendix 3 (as supplied by the authors): Review and management of non-motor symptoms at all stages of Parkinson disease (PD) Symptom Comments Management Depression Psychosis Dementia Driving in PD Constipation Often under-recognized; more likely to have anxiety, apathy, anhedonia. Later stages (30%) 4 ; may be a side effect of dopaminergic agents; visual hallucinations, usually of people or animals, are most common 80% will be affected at a mean of 11 years; usually after 20 years of disease.after which, the mean survival is 54 months. 6 Impaired secondary to: Visual impairment (can be related to PD or comorbid illness) Reduced motor speed, Attentional deficits, Reaction time deficits Dementia Excessive somnolence/sleep attacks % of PD pts, and may precede the onset of PD by decades. 11,12 Nortriptyline 1, and amitryptiline 2 caution in elderly. pramipexole 1 paroxetine or venlafaxine XR 3 Mirtazapine at night Rule out delirium (i.e. infection, medications) Eliminate low-potency, high side effect anti-pd drugs (anticholinergics, followed by amantadine, monoamine oxidase inhibitors, catechol- O-methyltransferase inhibitors, dopamine agonists; lastly levodopa) Clozapine 1,2 Quetiapine 2 Pimavanserin 5 Rule out delirium (i.e. infection, medications, metabolic, i.e. thyroid, vitamin B12 deficiency) Rivastigmine mg po BID. 1,7 Rivastigmine patch 9.5 mg/24 h may be better tolerated 8, but not covered in all provinces. Donepezil 5-10 mg daily 9 Driving ability: Most early stage patients are safe; if there is uncertainty, we recommend sending for a driving assessment. 10 Insufficient data on treatment Increase water intake Senokot 8.6 mg tab daily for

2 Urinary Dysfunction Urgency, frequency, nocturia and incontinence occur later in the disease. 13 Functional incontinence due to impaired mobility. mild constipation lactulose for moderate to severe constipation. 2,11 Reduce or discontinue drugs with anticholinergic activity. Domperidone 10 mg po TID 2 ; may also help with nausea associated with PD medications. 12 Restorolax 1 packet BID Rule out prostatic hyperplasia/hypertrophy Oxybutinin 5-10 mg po BID or tolterodine 1-2 mg po BID (watch for anticholinergic side effects in elderly) 13 Desmopressin ug nasal/day for severe nocturnal polyuria. 14 Mirabegron (beta-3 agonist) 15 Orthostatic hypotension 30-60% of PD patients 16 Assess antihypertensives, diuretics, levodopa and dopamine agonists as culprits Avoid large meals, alcohol, warm environment Increase water and salt intake Head-up tilt of bed at night Elastic stockings 2,11 Midodrine (peripheral alphaagonist) mg TID- QID; short-lasting effect; may exacerbate supine hypertension. Fludrocortisone mg daily; increases blood volume; modest effect. Domperidone 10 mg TID and mestinon mg QID may be used without worsening supine hypertension; may help with constipation as well. 17,18 Sialorrhea Occurs later in disease in 30% 19 Tactile cues (gum chewing, candy) 20,21 Glycopyrrolate 1 mg po

3 TID 22 Atropine 0.5mg sublingual drops BID 23 (watch for confusion);especially for nocturnal drooling Botulinum toxin (type A and B) Erectile Dysfunction Early or late 27 Sildenafil. 28,29 Caution is advised in those with orthostatic hypotension. Intracavernous injection of prostaglandin E1 may be considered as an alternative treatment. 30 Insomnia Primary: impaired sleep maintenance Secondary: medicationsor motor impairment. Sleep disordered breathing can occur in 48% of patients. 31 Excessive daytime somnolence Rapid eye movement (REM)-sleep behavior disorder (RBD) If early: medication-related If late: disease-related ~50% of pts with PD, and may be an early premotor sign. Rule out medications (especially selegiline or amantadine) Treat motor symptoms/fluctuations (add long-acting levodopa/carbidopa at bedtime) Good sleep hygiene, behavioural therapy. 2 Avoid stimulants, caffeine in the evening Regular sleep pattern Restrict daytime naps Comfortable bedding and room temperature Regular and appropriate exercise Silk sheets or assistive devices, e.g. bed lever or rails, may help with mobility Doxepin 32 Avoid selegiline, antihistamines, H2 antagonists, antipsychotics, sedatives Slow reduction of dopamine agonists Modafinil (modest effect) 33 Consider whether medications are needed. If not, warn about injury and consider bed safety, i.e. bed rails, sleeping alone. Remove medications which

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