Practice Parameter: Treatment of nonmotor symptoms of Parkinson disease [RETIRED]

Abstract

Objective: Nonmotor symptoms (sleep dysfunction, sensory symptoms, autonomic dysfunction, mood disorders, and cognitive abnormalities) in Parkinson disease (PD) are a major cause of morbidity, yet are often underrecognized. This evidence-based practice parameter evaluates treatment options for the nonmotor symptoms of PD. Articles pertaining to cognitive and mood dysfunction in PD, as well as treatment of sialorrhea with botulinum toxin, were previously reviewed as part of American Academy of Neurology practice parameters and were not included here. Methods:A literature search of MEDLINE, EMBASE, and Science Citation Index was performed to identify clinical trials in patients with nonmotor symptoms of PD published between 1966 and August 2008. Articles were classified according to a 4-tiered level of evidence scheme and recommendations were based on the level of evidence. Results and Recommendations:Sildenafil citrate (50 mg) may be considered to treat erectile dysfunction in patients with Parkinson disease (PD) (Level C). Macrogol (polyethylene glycol) may be considered to treat constipation in patients with PD (Level C). The use of levodopa/carbidopa probably decreases the frequency of spontaneous nighttime leg movements, and should be considered to treat periodic limb movements of sleep in patients with PD (Level B). There is insufficient evidence to support or refute specific treatments for urinary incontinence, orthostatic hypotension, and anxiety (Level U). Future research should include concerted and interdisciplinary efforts toward finding treatments for nonmotor symptoms of PD. Neurology The Quality Standards Subcommittee (QSS) of the American Academy of Neurology (AAN) develops scientifically sound, clinically relevant practice parameters to aid in the practice of neurology. This article evaluates treatment options for nonmotor symptoms of Parkinson disease (PD).While PD is considered a disorder characterized by motor symptoms, nonmotor symptoms are an integral part of this syndrome. These symptoms can be as troublesome as motor symptoms and impact activities of daily living, though they are often underrecognized by health care professionals.1,2 The nonmotor symptoms reviewed for this guideline were autonomic dysfunction (gastrointestinal disorders, orthostatic hypotension, sexual dysfunction, urinary incontinence), sleep disorders (restless legs syndrome, periodic limb movements of sleep, excessive daytime somnolence, insomnia, REM sleep behavior disorder), fatigue, and anxiety. Articles pertaining to cognitive and mood dysfunction in PD, as well as treatment of sialorrhea with botulinum toxin, were reviewed as part of previous AAN practice parameters 3,4 and were not included here.

Clinical determinants of primary and secondary fatigue in patients with Parkinson’s disease

“…[44]. This study is also noted in the report of Quality Standards Subcommittee of the American Academy of Neurology on the treatment of non-motor symptoms of PD as the only publication showing improvement of fatigue in PD (evidence level C) [45]. However, due to the stimulant effects of methylphenidate, its use, especially in elderly PD patients with cardiovascular problems, is relatively contraindicated.…”

Modafinil: Parkinson Disease–Related Somnolence

“…[4][5][6][7] Data from open trials and case reports suggest limited benefi t. [8][9][10][11] Several national and international guidelines state that modafi nil should be considered in the management of PD-related somnolence, recognizing that evidence is confl icting with improvement noted in subjective sleep ratings but inconsistent or no benefi t observed in objective sleep parameters. 2,3,12,13 Evaluating the same published clinical data, the Scottish Intercollegiate Guidelines Network does not recommend the use of modafi nil in the management of excessive daytime sleepiness. 14 …”

“…These guidelines also state that there is insuffi cient evidence to support or refute a safety benefi t in patients with PD with EDS who engage in activities where sleepiness poses a potential danger (eg, driving). 12 This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specifi c drug uses that are unapproved by the US Food and Drug Administration.…”

Referral to rehabilitation in Parkinson's disease: who, when and to what end?

“…We reviewed the following evidence-based PD recommendations and guidelines: European Federation of Neurological Societies and Movement Disorder Society (EFNS/MDS-ES) 3 , National Institute for Health and Clinical Excellence (NICE) 4 , American Academy of Neurology (AAN) 5 and Movement Disorder Society (MDS) 6 , concerning non-pharmacological and non-surgical interventions. These were believed to offer an exhaustive, synthetic and up-to-date analysis of the level of evidence of all treatments proposed for PD.…”

“…Current PD guidelines already recognize the potential role of some rehabilitation interventions as a mean to improve patients' functionality and to help patients and their families to cope with the disability and functional limitations due to PD [3][4][5][6] . As for example, the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology recently proposed a set of quality measures for neurology practice 7 that consider PD rehabilitative therapy options as a quality measure for PD care, recommending it to be addressed by clinicians in clinical practice.…”