Management of associated problems

Patients with Parkinson's disease (PD) often problems other than the movement disorder, including:

• pain:
  • pain may be associated with periods of under or over treatment - in these cases the therapeutic regimen should be adjusted accordingly
  • dysaesthesiae may respond to tricyclic antidepressants
    
    
• postural hypotension:
  • may be due to the medication and the disease process
  • if a person with Parkinson's disease has developed orthostatic hypotension, review the person's existing medicines to address possible pharmacological causes, including:
    • antihypertensives (including diuretics)
    • dopaminergics
    • anticholinergics antidepressants. [2017]
  • midodrine should be considered for people with Parkinson's disease and orthostatic hypotension, taking into account the contraindications and monitoring requirements (including monitoring for supine hypertension)
  • if midodrine is contraindicated, not tolerated or not effective, consider fludrocortisone (taking into account its safety profile, in particular its cardiac risk and potential interactions with other medicines)
    
    
• constipation:
  • dietary intervention may be helpful
    
    
• anxiety:
  • benzodiazepines may help patients with advanced disease who often become anxious
    
    
• depression:
  • responds to standard anti-depressant drugs and ECT
    
    
• psychotic symptoms (1,2)
  • people with PD and psychosis should receive a general medical evaluation and treatment for any precipitating condition
  • consideration should be given to withdrawing gradually antiparkinsonian medication that might have triggered psychosis in people with PD
    • reduce the dosage of any Parkinson's disease medicines that might have triggered hallucinations or delusions, taking into account the severity of symptoms and possible withdrawal effects. Seek advice from a healthcare professional with specialist expertise in Parkinson's disease before modifying therapy (1)
  • typical antipsychotic drugs (such as phenothiazines and butyrophenones) should not be used in people with PD because they exacerbate the motor features of the condition
  • do not treat hallucinations and delusions if they are well tolerated by the person with Parkinson's disease and their family members and carers (as appropriate)
  • consider quetiapine to treat hallucinations and delusions in people with Parkinson's disease who have no cognitive impairment
  • if standard treatment is not effective, offer clozapine to treat hallucinations and delusions in people with Parkinson's disease. Be aware that registration with a patient monitoring service is needed
  • be aware that lower doses of quetiapine and clozapine are needed for people with Parkinson's disease than in other indications
  • do not offer olanzapine to treat hallucinations and delusions in people with Parkinson's disease
    
    
• daytime hypersomnolence
  • modafinil may be considered for daytime hypersomnolence in people with PD
  • advise people with Parkinson's disease who have daytime sleepiness and/or sudden onset of sleep not to drive (and to inform the DVLA of their symptoms) and to think about any occupation hazards. Adjust their medicines to reduce its occurrence, having first sought advice from a healthcare professional with specialist expertise in Parkinson's disease
  • at least every 12 months, a healthcare professional with specialist expertise in Parkinson's disease should review people with Parkinson's disease who are taking modafinil
    
    
• rapid eye movement sleep behaviour disorder
  • take care to identify and manage restless leg syndrome and rapid eye movement sleep behaviour disorder (RBD) in people with Parkinson's disease and sleep disturbance
  • clonazepam or melatonin should be considered to treat RBD if a medicines review has addressed possible pharmacological causes
    
    
• nocturnal akinesia
  • levodopa or oral dopamine agonists should be considered to treat nocturnal akinesia in people with Parkinson's disease. If the selected option is not effective or not tolerated, offer the other instead
  • consider rotigotine if levodopa and/or oral dopamine agonists are not effective in treating nocturnal akinesia (2)
    
    
• parkinson's disease dementia (1)
  • offer a cholinesterase inhibitor[6] for people with mild or moderate Parkinson's disease dementia
  • consider a cholinesterase inhibitor for people with severe Parkinson's disease dementia
  • consider memantine for people with Parkinson's disease dementia, only if cholinesterase inhibitors are not tolerated or are contraindicated
    
    
• drooling of saliva
  • only consider pharmacological management for drooling of saliva in people with Parkinson's disease if non-pharmacological management (for example, speech and language therapy is not available or has not been effective
  • glycopyrronium bromide should be considered to manage drooling of saliva in people with Parkinson's disease
  • consider referral to a specialist service for botulinum toxin A iif treatment for drooling of saliva with glycopyrronium bromide is not effective, not tolerated or contraindicated (for example, in people with cognitive impairment, hallucinations or delusions, or a history of adverse effects following anticholinergic treatment)
  • only consider anticholinergic medicines other than glycopyrronium bromid to manage drooling of saliva in people with Parkinson's disease if their risk of cognitive adverse effects is thought to be minimal. Use topical preparations if possible (for example, atropine) to reduce the risk of adverse events
    
    
    
    
    
    

Reference:

• NICE (January 2018). Age-related macular degeneration
• Senard JM et al. Orthostatic hypotension in patients with Parkinson's disease: pathophysiology and management. Drugs Aging. 2001;18(7):495-505.