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EPDA - European Parkinsons Disease Association EPDA - European Parkinsons Disease Association EPDA - European Parkinsons Disease Association EPDA - European Parkinsons Disease Association EPDA - European Parkinsons Disease Association EPDA - European Parkinsons Disease Association EPDA - European Parkinsons Disease Association EPDA - European Parkinsons Disease Association
EPDA - European Parkinsons Disease Association
LIFE WITH PARKINSON'S
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Frequently asked questions about non-motor symptoms

Non-motor symptoms of Parkinson’s disease are those that are not related to difficulties with movement. Although Parkinson’s is traditionally defined as a movement disorder, it is also associated with a wide range of behavioural/neuropsychiatric and physical symptoms that can severely impact quality of life. These can occur at any point in the disease from the very early stages, even before motor symptoms are recognised, to very late stage Parkinson’s. Non-motor symptoms can eventually come to dominate the condition as it progresses.
The causes of non-motor symptoms are still poorly understood. It is thought that the breakdown of both dopaminergic and non-dopaminergic systems can contribute to their development.1 In Parkinson’s, dopamine-producing nerve cells in several brain areas that regulate behavioural and physical functions degenerate progressively and more abruptly than in the normal course of ageing. Consequently, the amount of dopamine in the brain decreases continuously, creating a shortage. This not only interferes with the body’s movements, but may also affect nerves controlling other bodily functions, such as sleep and the ability to feel pain, leading to the development of certain non-motor symptoms.1
Recently there has also been evidence pointing to the role of other messengers in the brain (i.e. symptoms not related to dopamine), which may lead to other non-motor symptoms such as depression and incontinence.

 

References


  1. Chaudhuri KR, Healy DG, Schapira AH. Nonmotor symptoms of Parkinson’s disease: diagnosis and management. Lancet Neurol 2006;5(3):235-45
Non-motor symptoms can be present at all stages of Parkinson’s and their frequency increases with disease duration. Some symptoms are more common than others. The complexity involved in recognising and understanding non-motor symptoms makes it difficult to establish how common they are.1 Physicians may not recognise non-motor symptoms in up to 50% of cases.1,2 For example pain, one of the more common non-motor symptoms, can affect between 40-75% of people with Parkinson’s. Recent surveys have revealed that close to 90% of people with Parkinson’s have at least one non-motor symptom, with about 10% having up to five non-motor symptoms.3

 

References


  1. Merello MJ, Fernandez HH. Message from your medical editors: September 2008: Movement Disorders Society
  2. Williams DR, Lees AJ. How do patients with Parkinsonism present? A clinicopathological study. Internal Med J 2009;39(1):7-12
  3. Weintraub D, Comella CL, Horn S. Parkinson’s disease--part 1: pathophysiology, symptoms, burden, diagnosis, and assessment. Am J Manag Care 2008;14(2 Suppl):S40-8

In the early stages of Parkinson’s it may be difficult to tell whether an individual symptom is associated with the disease, particularly if there are no apparent motor symptoms. Many other factors, including medication side effects and other medical conditions, may cause symptoms that are similar to the non-motor symptoms of Parkinson’s. If non-motor symptoms as suspected, it is important to consult with a specialist who will be able to investigate this further.
Parkinson’s is, by definition, a movement disorder. Even though non-motor symptoms are an important part of the condition, current diagnostic criteria focus on identifying the classic motor symptoms of Parkinson’s, namely stiffness, resting tremor and slowness of movement.1 Non-motor symptoms such as olfactory abnormalities, sleep disorders (REM sleep behaviour disorder in particular), constipation and depression can often precede the motor symptoms and can act as an early marker that can help lead physicians to a diagnosis of Parkinson’s, but cannot currently be used on their own to make a diagnosis.2

 

References


  1. Parkinson’s disease: national clinical guideline for diagnosis and management in primary and secondary care. National Institute for Health and Clinical Excellence, London, 2006
  2. Poewe W. Non-motor symptoms in Parkinson’s disease. Eur J Neurol 2008;15(Suppl 1):14-20
There is a common misconception that non-motor symptoms occur only at later stages of Parkinson’s. Many symptoms, including olfactory abnormalities (changes in the sense of smell), depression, constipation, certain sleep disorders and erectile dysfunction, can precede motor symptoms and the diagnosis of Parkinson’s by many years.1,2
Symptoms such as dementia, cognitive impairment (slowness in thought, reasoning and perception), orthostatic hypotension (a sudden drop in blood pressure) are more frequently seen in later stages of the disease.1
All non-motor symptoms, regardless of when they first appear, have a tendency to become more severe as Parkinson’s progresses.1

 

References


  1. Antonini A. Non-motor symptoms in Parkinson’s disease. European Neurological Review 2009;4(2):25- 27
  2. Chaudhuri KR. Non-motor symptoms of Parkinson’s disease. Oxford: Oxford University Press, 2009
It is not yet possible to predict which symptoms will affect an individual and the intensity of the symptoms can vary greatly from one person to another. Symptoms can also occur at any stage of Parkinson’s. This, combined with the difficulty in recognising and understanding non-motor symptoms, makes it challenging to establish whether every person with Parkinson’s will experience them. Evidence to date, however, indicates that non-motor symptoms are a universal feature of Parkinson’s.1 It is important for physicians to watch out for all warning signs that might indicate the onset of Parkinson’s and lead to a diagnosis, as early treatment has been shown to be beneficial.2,3

 

References


  1. Poewe W. Non-motor symptoms in Parkinson’s disease. Eur J Neurol 2008;15(Suppl 1):14-20
  2. Olanow CW, Rascol O, Hauser R, Feigin PD, Jankovic J, Lang A et al. A double-blind, delayed-start trial of rasagiline in Parkinson’s disease. N Engl J Med 2009;361(13):1268- 78
  3. Parkinson Study Group. A controlled trial of rasagiline in early Parkinson’s disease. Arch Neurol 2002;59:1937-1943
Non-motor symptoms have a tendency to become increasingly common and established throughout the course of Parkinson’s.1 Symptoms do not generally subside over time, but tend to increase in severity with disease duration.2 It is not yet possible to predict which or when non-motor symptoms will affect a person with Parkinson’s and the severity of symptoms varies from person-to-person.

 

References


  1. Poewe W. Non-motor symptoms in Parkinson’s disease. Eur J Neurol 2008;15(Suppl 1):14-20
  2. Antonini A. Non-motor symptoms in Parkinson’s disease. European Neurological Review 2009;4(2):25- 27
As it is difficult to predict if and when non-motor symptoms will arise, preventing or delaying the appearance of these symptoms is also problematic. Once a symptom is recognised, however, its impact can be reduced with the appropriate available treatment.
Studies have shown that some treatments can help to slow the progression of Parkinson’s. These studies have used the Unified Parkinson’s Disease Rating Scale (UPDRS) as a measure of improvement.1 The UPDRS takes into account the impact of the treatment on both motor and non-motor symptoms and on overall quality of life. The studies have so far shown that these treatments, if administered early, may help slow the progression of the disease as a whole.2,3,4.

 

References


  1. Goetz CG, Tilley BC, Shaftman SR. Movement Disorders Society-sponsored revision of the United Parkinson’s Disease Rating Scale(MDS-UPDRS): scale presentation and clinimetric testing results. Mov Disord 2008;23(15):2129-2170
  2. Olanow CW, Rascol O, Hauser R, Feigin PD, Jankovic J, Lang A et al. A double-blind, delayed-start trial of rasagiline in Parkinson’s disease. N Engl J Med 2009;361(13):1268- 78
  3. Olanow CW, Hauser RA, Jankovic J, Langston W, Lang A, Poewe W et al. A randomized, doubleblind, placebo-controlled, delayed start study to assess rasagiline as a disease modifying therapy in Parkinson’s disease (the ADAGIO study): rationale, design, and baseline characteristics. Mov Disord 2008;23(15):2194-201
  4. Poewe W, Hauser R, Lang A for the ADAGIO investigators. Rasagiline 1 mg/day provides benefits for non-motor symptoms in patients with early Parkinson’s disease. Neurology 2009;72(11 Suppl 3):A321 (P154)
Many symptoms of Parkinson’s, in particular motor but also some non-motor symptoms, are caused by a pathological reduction of dopamine in the brain.1 Most treatments for Parkinson’s act to correct this imbalance.
However, not all non-motor symptoms are dopamine dependent, so each symptom must be treated with appropriate therapies.
Depression in Parkinson’s, for example, can sometimes be treated with antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants, and with non pharmacological therapy. There is not yet, however, sufficient evidence to support the safety and effectiveness of these treatments for depression in Parkinson’s. There are also concerns that some antidepressants may worsen motor symptoms or reduce the effectiveness of other Parkinson’s treatments.2 Similarly, there is little evidence for or against treating pain, excessive daytime sleepiness and dementia in Parkinson’s using standard treatments.
Effective treatment of each symptom must be managed on a case-by-case basis as individuals respond differently to different medications in terms of efficacy and possible side effects.

 

References


  1. Chaudhuri KR, Schapira AH. Non-motor symptoms of Parkinson’s disease: dopaminergic pathophysiology and treatment. Lancet Neurol 2009;8(5):464-74
  2. Parkinson’s disease: national clinical guideline for diagnosis and management in primary and secondary care. National Institute for Health and Clinical Excellence, London, 2006
As some motor and non-motor symptoms stem from the same underlying cause, i.e. the reduction of dopamine in the brain, it is possible that treatment which resolves this imbalance may lead to improvements in both types of symptoms. Some non-motor symptoms are responsive to this type of treatment, namely: fatigue, depression, apathy, anxiety, erectile dysfunction, some urinary abnormalities, pain, constipation, restless legs and periodic limb movements. 1,2,3.
Other symptoms do not respond to and may even be worsened by dopamine replacement therapy. These include: Parkinson hyperpyrexia syndrome (a sudden increase in body temperature), leg oedema (swelling of the legs), heart complications, hallucinations, delusions, excessive daytime sleepiness, insomnia, nausea, diarrhoea, constipation and orthostatic hypotension (a sudden drop in blood pressure).3.
A Parkinson’s specialist physician will be able to advise which treatments are appropriate to manage each person’s individual symptoms.

 

References


  1. Poewe W, Hauser R, Lang A for the ADAGIO investigators. Rasagiline 1 mg/day provides benefits for non-motor symptoms in patients with early Parkinson’s disease. Neurology 2009;72(11 Suppl 3):A321 (P154)
  2. Stocchi F for the ADAGIO investigators. Benefits of treatment with rasagiline in fatigue symptoms in patients with early Parkinson’s disease. Neurology 2009;72(11 Suppl 3):A321(P2559)
  3. Chaudhuri KR, Schapira AH. Non-motor symptoms of Parkinson’s disease: dopaminergic pathophysiology and treatment. Lancet Neurol 2009;8(5):464-74
The sooner symptoms are effectively managed, the less of an impact they will have on quality of life, even when possible side effects are taken into account. People who are not being treated for their Parkinson’s symptoms score lower on quality of life tests.1
There is also a growing body of evidence which suggests that certain treatments for Parkinson’s can help slow disease progression,2,3 allowing a better quality of life for a longer amount of time.4,5 It is hoped that better understanding of the non-motor symptoms may help earlier diagnosis and therefore give earlier access to treatment.

 

References


  1. UK PD Non Motor Group. Report of the fourth meeting of the UK PD Non Motor Group: Non-motor symptoms of PD: what’s new? UK PD Non Motor Group, London,2009
  2. Findley L and Baker MG for European Parkinson’s Disease Association. Impact of Parkinson’s disease on patient participation in daily life: results of an international survey (1999). www.epda.eu.com/pdresources accessed 6th June 2010)
  3. Rahman S, Griffin HJ, Quinn NP, Jahanshahi M. Quality of life in Parkinson’s disease: the relative importance of the symptoms. Mov Disord 2008;23(10):1428- 34
  4. Olanow CW, Rascol O, Hauser R, Feigin PD, Jankovic J, Lang A et al. A double-blind, delayed-start trial of rasagiline in Parkinson’s disease. N Engl J Med 2009;361(13):1268- 78
  5. Olanow CW, Hauser RA, Jankovic J, Langston W, Lang A, Poewe W et al. A randomized, doubleblind, placebo-controlled, delayed start study to assess rasagiline as a disease modifying therapy in Parkinson’s disease (the ADAGIO study): rationale, design, and baseline characteristics. Mov Disord 2008;23(15):2194-201
Exercise and lifestyle changes can improve wellbeing and performance in people with Parkinson’s, for both their motor and non-motor symptoms. Lifestyle changes, such as regular exercise and physiotherapy, are thought to help improve motor symptoms, which in turn may help with feelings of depression and anxiety. Similarly for certain non-motor symptoms, taking steps such as eating a diet rich in fibre may help improve constipation. There has, however, been only a limited amount of research in this field and, with further study, additional non-pharmacological therapies may be uncovered.
Some medications for motor symptoms can induce non-motor symptoms as a side effect. These may include, to varying degrees: Parkinson hyperpyrexia syndrome (a sudden increase in body temperature), leg oedema (swelling of the legs), heart complications, hallucinations, delusions, excessive daytime sleepiness, insomnia, nausea, diarrhoea, constipation and orthostatic hypotension (a sudden drop in blood pressure).1 A combination of different treatments and other factors can contribute to bringing about a particular symptom.2
It is important to read the accompanying patient information leaflet for each medication for further details and to consult a specialist to determine the real underlying cause for each symptom.

 

References


  1. Parkinson Study Group. A controlled trial of rasagiline in early Parkinson’s disease. Arch Neurol 2002;59:1937-1943
  2. Parkinson’s disease: national clinical guideline for diagnosis and management in primary and secondary care. National Institute for Health and Clinical Excellence, London, 2006
There has been growing interest and recognition that non-motor symptoms are an important and significant aspect of Parkinson’s. As a result, there has been a move to increase understanding, with the hope of discovering effective and successful treatments. Research into medicines is being carried out continually. Several new Parkinson’s medications are currently under development1,2,3 as well as new surgical techniques and gene therapy.

 

References


  1. Olanow CW, Rascol O, Hauser R, Feigin PD, Jankovic J, Lang A et al. A double-blind, delayed-start trial of rasagiline in Parkinson’s disease. N Engl J Med 2009;361(13):1268- 78
  2. Poewe W, Hauser R, Lang A for the ADAGIO investigators. Rasagiline 1 mg/day provides benefits for non-motor symptoms in patients with early Parkinson’s disease. Neurology 2009;72(11 Suppl 3):A321 (P154)
  3. Stocchi F for the ADAGIO investigators. Benefits of treatment with rasagiline in fatigue symptoms in patients with early Parkinson’s disease. Neurology 2009;72(11 Suppl 3):A321(P2559)
There are many useful sources of information targeted specifically at non-motor symptoms.
Visit these websites for more information: