Non-motor symptoms affect overall quality of life in Parkinson Disease (PD) as much as motor symptoms.

• Almost 85% of PD patients report pain. Musculoskeletal pain from limitations in mobility is the most commonly reported pain type. NSAIDs, acetaminophen, physical rehabilitation, and low dose opioids are commonly utilized analgesic strategies. Dystonia is a prolonged involuntary muscle contraction which often leads to foot cramping, muscle spasms, and a sensation of muscles twisting. In addition to the analgesics listed above, skeletal muscle relaxants and botulinum toxin injections may be warranted. Neuropathic pain is a less common pain. Gabapentin, pregabalin, duloxetine, venlafaxine, and/or interventional strategies (e.g. spinal cord stimulator or a nerve block) are preferred over tricyclic antidepressants (TCAs) due to the risk for delirium and falls in PD patients.

• Approximately 40 % of patients with advanced disease experience neuropsychiatric symptoms, most commonly visual hallucinations. The assessment and treatment are similar to delirium in general with a few considerations:
- Several PD medications are associated with psychosis: amantadine; monoamine oxidase type B (MAOB) inhibitors, catechol-O-methyl transferase inhibitors (e.g. entacapone); and dopamine agonists (e.g. pramipexole). Before initiating new pharmacotherapies, reduce or discontinue these medications as appropriate.
- Neuroleptics such as haloperidol, risperidone, and olanzapine should be avoided as they may worsen motor symptoms by blocking dopamine and raise mortality risk. Quetiapine is the preferred pharmacologic treatment because it seems to have the least effect on motor symptoms. Clozapine has the most compelling evidence of all anti-psychotics for treating PD-related psychosis.

• Excessive daytime somnolence is common. Therapeutic issues:
- Nocturnal sleep hygiene practices
- AM intake of caffeine or methylphenidate twice a day or modafinil once a day.
- About 85% of patients have a sleep disorders such as rapid eye movement behavior sleep disorder, restless leg syndrome, and obstructive sleep apnea as have a sleep disorder - refer to a sleep specialist when appropriate.
- Sudden bouts of excessive daytime drowsiness or sleep (“sleep attacks”) can be common and hazardous - if present, patients should avoid driving.

• Depression. Duloxetine, venlafaxine, bupropion, sertraline, and escitalopram are preferred over mirtazapine and TCAs which have higher anticholinergic activity.

• The only approved treatment for PD-related dementia is rivastigmine; but its anticholinergic properties can worsen PD symptoms and its efficacy in preventing progression of cognitive impairment is limited

• Hypotension. Nonpharmacologic interventions like increased fluid/salt intake and compression stockings are first-line treatments as are a reduction of antihypertensive medications if appropriate. Fludrocortisone or midodrine can be added in refractory cases.

• Sialorrhea and drooling are common because of the reduced oromotor control and autonomic dysfunction. Chewing gum or hard candy may encourage swallowing and reduce drooling in mild cases. It has also been described the use of glycopyrrolate by mouth three times a day; atropine 1% ophthalmic solution sublingual once to twice a day; ipratropium spray, or botulinum toxin injections into salivary glands.

See reference for more information.

Adapted from Estupinan D et al. Parkinson’s disease: part 2 palliation for common non-motor symptoms. Palliative Care Network of Wisconsin. Fast facts and concepts #362. Internet. Accessed on December 27, 2018.