By Aaron Haug, M.D., Blue Sky Neurology

Tremor gets the most attention. It is often the resting tremor that first brings Parkinson disease (PD) to someone’s attention. It may be that people with Parkinson’s (PWP) ask their physicians about it, or their physicians may be the first to notice it, but resting tremor is often the symptom that leads to the diagnosis of PD.

Because tremor is the most obvious symptom for many PWP, it can sometimes remain the center of attention for too long. While tremor and other motor symptoms certainly can cause functional disability and should be treated optimally, it is often the nonmotor symptoms of PD that cause a significant portion of the discomfort and disability for PWP.

Nonmotor symptoms can affect a wide range of bodily functions. This two-part article will present some of the most common symptoms and their treatments. Not everyone will experience all of these symptoms! It can be overwhelming to see all of these symptoms listed one after the other, but it is important for PWP and their loved ones to be aware of these symptoms so that treatments can be considered.

Sleep Symptoms.

REM Sleep Behavior Disorder (RBD). Normally, a person’s body is paralyzed during sleep. In some PWP this safety mechanism is lost, and they can unknowingly act out their dreams. This is often noted by the bed partner as kicking or punching behavior. Treatment with clonazepam, a benzodiazepine, can be very effective.

Restless legs syndrome (RLS). RLS is described as a creepy-crawly, achy, tight, or restless feeling in the legs, which is usually worse in the evening and briefly relieved by moving the legs. Many of the medicines that are used to treat tremor and motor symptoms (levodopa, pramipexole, ropinirole, rotigotine) are effective for RLS, and clonazepam can also be effective. Opiate or opioid-like medicines (such as hydrocodone, oxycodone, or tramadol) are sometimes used in more severe cases.

Insomnia. Difficulty falling asleep or staying asleep is common in PWP. An important part of treating insomnia is good sleep hygiene. This includes behaviors such as setting a regular bedtime; not drinking caffeine after noon; and not drinking alcohol in excess. If one has been in bed for more than 15 minutes and is not falling asleep, it is advisable to get out of bed, do something boring (like read the phone book), and then try again. As far as medicines, melatonin is a supplement available over-the-counter that can be very effective in PWP. Prescription medicines such as clonazepam and Ambien can be effective but are not meant to be used long-term. Medicines that contain diphenhydramine (i.e. Benadryl, which is an ingredient in medicines such as Tylenol PM or Advil PM) should generally be avoided as they can cause confusion in older patients, and this problem can be more prominent in PWP.

Excessive Daytime Sleepiness. First, try to improve nighttime sleep with the strategies above. If sleepiness persists, brief naps can be very helpful. If these measures are not enough, medicines such as methylphenidate (Ritalin), modafinil (Provigil), or armodafinil (Nuvigil) are often used.

Behavioral Symptoms.

Anxiety and Depression. These symptoms are both common in Parkinson disease. This is partly because levels of brain chemicals involved in mood, such as serotonin and norepinephrine, are decreased in PD along with dopamine. Counseling and talk therapy can be helpful and are worth considering before prescription medicines. Benzodiazepines, such as clonazepam, can be helpful for anxiety. There are many medicines that can be helpful with depression as well as anxiety: fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), buproprion (Wellbutrin), venlafaxine (Effexor), desvenlafaxine (Pristiq), mirtazapine (Remeron), vilazodone (Viibryd), and  trazodone.

Dementia. Memory loss and changes in thinking can occur in PWP. Cholinesterase inhibitors can improve thinking and memory in some PWP; these include donepezil (Aricept), rivastigmine (Exelon, Exelon patch), and galantamine (Razadyne). Occasionally PWP with dementia can become agitated or have hallucinations. Quetiapine (Seroquel) and clozapine (Clozaril) can be helpful for these symptoms. Other antipsychotic medications, such as haloperidol (Haldol), risperidone (Risperdal), aripiprazole (Abilify), olanzapine (Zyprexa), and ziprasidone (Geodon) should be avoided as they can make the motor symptoms of PD worse. 

In the next issue, autonomic nonmotor symptoms such as orthostatic hypotension, overactive bladder, erectile dysfunction, and gastrointestinal symptoms will be discussed.  Again, although not everyone will experience these symptoms, it is important to be aware of them so that treatment options can be considered and discussed.