Non-motor complications in late stage Parkinson’s disease: recognition, management and unmet needs

Abstract

Introduction:The burden of non-motor symptoms (NMS) is a major determinant of health-related quality of life in Parkinson's disease (PD), particularly at its late stage. Areas covered: The late stage is usually defined as the period from unstable advanced to the palliative stage, characterized by a combination of emerging treatment-resistant axial motor symptoms (freezing of gait, postural instability, falls and dysphagia), as well as both non-dopaminergic and dopaminergic NMS: cognitive decline, neuropsychiatric symptoms, aspects of dysautonomia, pain and sleep disturbances (insomnia and excessive day-time sleepiness). Here, the authors summarize the current knowledge on NMS dominating the late stage of PD and propose a pragmatic and clinically focused approach for their recognition and treatment. Expert opinion: The NMS progression pattern is complex and remains under-researched. While dopamine-dependent NMS may improve with dopamine replacement therapy, non-dopamine dependent NMS worsen progressively and culminate at the late stages of PD. Furthermore, some PD specific features could interact negatively with other comorbidities, multiple medication use and frailty -the evaluation of these aspects is important in the creation of personalized management plans in the late stage of PD.

Personalized Care in Late-Stage Parkinson’s Disease: Challenges and Opportunities

“…The management of NMS is based on the application of the clinical evidence available for earlier PD stages [ 13 ] and herein summarized in Figure 1 (right panel) [ 9 , 14 ] (see also BOX, Case S1 ). Nevertheless, the dose therapeutic response, tolerance, and AEs profile may be distinct in LSPD, limiting its applicability.…”

Parkinson's disease and Covid-19: Is there an impact of ethnicity and the need for palliative care

“…People with Parkinson's Disease (PD, PwP) may experience a substantial burden of motor and non-motor symptoms, both major determinants of the health-related quality of life (QoL), that may not be sufficiently tackled by a traditional model of care (a chronic illness model focused on motor symptoms and delivered through a patient–physician dyad) ( Boersma et al, 2016 ; Chaudhuri et al, 2021 ; Rukavina et al, 2021 ). Gaps have also been indentified specially related to mental health issues unmasked during the Covid-19 pandemic ( Subramanian et al, 2021 ).…”

“…Among numerous accessible assessment tools (scales and questionnaires) that may capture and quantify distinctive NMS, the 30-item NMS Questionnaire (NMSQuest) is a simple and time-efficient, patient-completed outcome measure, which may be applied remotely to flag up the presence of certain NMS, and allows for a staging of the overall NMS burden ( Chaudhuri et al, 2006 ; Rukavina et al, 2021 ).…”

“…In terms of pharmacological treatment, continuing the exact personalized medication regimen is crucial ( Gerlach, Winogrodzka, & Weber, 2011 ). In addition, medication should be carefully reviewed and, where appropriate, an anticholinergic load should be reduced, perhaps using the Anticholinergic cognitive burden scale as a guidance ( Rukavina et al, 2021 ). The agents with the least anti-parkinsonian efficacy, which might potentially contribute to delirium should be discontinued (Proposed order: 1.…”

The impact of COVID-19 on palliative care for people with Parkinson’s and response to future pandemics

“…Of note, a detailed discussion on interventions for optimal treatment of particular NMS is beyond the scope of this paper; an International Parkinson and Movement Disorders Society Evidence-based Medicine (MDS-EBM) Task Force guidelines should be followed [16]. In addition, management of non-motor complications in a late stage PD has been extensively reviewed recently [17].…”