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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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Introduction to non-motor symptoms

  • Chandni Chandiramani MSc
    Kings College and Institute of Psychiatry, London, UK
  • Kartik Logishetty BSc
    Kings College London, London, UK
  • K Ray Chaudhuri FRCP, MD, DSc
    Kings College and Institute of Psychiatry, and National Parkinson Foundation Centre of Excellence, Kings College Hospital and University Hospital Lewisham, London, UK
Non-motor symptoms

Parkinson’s is a slowly progressive neurodegenerative disease and it is now recognised that motor symptoms of the disease are associated with a number of non-motor symptoms.

There is a wide spectrum of non-motor symptoms ranging from neuropsychiatric (including depression, confusion and dementia), sleep-related (including excessive daytime sleepiness, restless legs and insomnia), autonomic (including bladder disturbances and sexual dysfunction), to gastrointestinal symptoms (including nausea, constipation and dribbling of saliva). Some people also suffer from pain, weight loss or gain, or dysfunctions in vision or smell. Non-motor symptoms are highly prevalent across all stages and disease durations and the number of individual symptoms experienced by each person increases with age, disease duration and severity.1,2 They can dominate both the early and later stages of Parkinson’s, significantly affecting health-related quality of life (HRQoL). They can also bring on hospitalisation1–4 resulting in an increase in healthcare utilisation and an escalation of economic burden.5

Some non-motor symptoms may develop years before motor symptoms and before a diagnosis of Parkinson’s disease is made.6 Post-mortem studies by Braak and colleagues suggest that the manifestation of non-motor symptoms may reflect a six-stage progression of the disease from ‘induction sites’ much lower in the brain than the substantia nigra, where dopamine is produced.7 Early disease – stage one – is associated with degeneration of the olfactory area and results in dysfunction of the sense of smell. Impaired olfaction has been shown to affect up to 90% of people with Parkinson’s and is one of the earliest and most common non-motor symptoms.8,9 Stage two reflects the progression of the pathological process to the lower brainstem nuclei, which are thought to be key areas mediating non-motor symptoms such as olfaction, sleep control, depression and cognition, pain, constipation and central autonomic control. Several of these symptoms are now recognised as possible pre-motor features of Parkinson’s. The typical clinical motor symptoms of Parkinson’s (tremor, rigidity and slowness of movement) emerge at stages three and four with the involvement of the substantia nigra and other deep nuclei of the mid- and forebrain.1 This concept however, remains controversial.

Post-mortem studies by Braak and colleagues suggest that the manifestation of non-motor symptoms may reflect a six-stage progression of the disease from ‘induction sites’ much lower in the brain than the substantia nigra, where dopamine is produced.

As the average life expectancy of the population increases, the management of non-motor symptoms will become increasingly important.10,11 A holistic approach to the treatment of Parkinson’s must therefore include the early recognition and assessment of non-motor symptoms. The non-motor symptom complex is frequently unrecognised by healthcare professionals. This may be because of a tendency to focus on motor aspects or perhaps due to a lack of awareness between seemingly unrelated non-motor symptoms and the disease.1,2,12  The recent work by the Parkinson’s Disease Non-Motor Group (PDNMG) has led to the availability of validated tools for the assessment of non-motor symptoms (NMS) in Parkinson’s, which include the NMS Questionnaire (NMSQuest – completed by the person with Parkinson’s) and the NMS Scale (NMSS – completed by a healthcare professional). The latter is one of the most critically validated tools after being applied and tested in an international population of over 700 patients. A third reason why non-motor symptoms may not be recognised early was highlighted by a recent report using the NMSQuest. People may not discuss a number of non-motor symptoms – particularly dribbling of saliva, difficulties swallowing, sexual problems and pain – either because of embarrassment or because they are unaware of their relevance to Parkinson’s.13 Missed non-motor symptoms can lead to increased economic burden and may also have therapeutic and social implications. Therefore, screening for non-motor symptoms using the NMSS and NMSQuest is fundamental to symptom recognition and, subsequently, improving quality of life and reducing disability and the cost of care.1,14 Indeed, non-motor symptom features, such as olfactory dysfunction and REM sleep behaviour disorder, are potential preclinical markers of Parkinson’s and could be used to identify a population ‘at risk of Parkinson’s disease’. This will be particularly important for early treatment with disease-modifying agents.

Hidden Face

The management of Parkinson’s requires a holistic, patient-centred approach, robust assessment and multidisciplinary input (see the article on the multidisciplinary approach to the management of Parkinson’s on pages 18–23 of this booklet). Although non-motor symptoms are largely believed not to have a dopaminergic basis, evidence from a handful of trials suggests that depression, restless legs, bladder disturbances, fatigue and constipation may be alleviated by dopaminergic treatment.1,2,14 In addition, people with cognitive decline, psychosis, excessive daytime sleepiness, erectile dysfunction or drooling may benefit from symptom-specific medications. Some non-motor symptoms respond poorly to traditional dopaminereplacement therapies such as levodopa.

While dopaminergic therapy has long been the mainstay of treating motor symptoms of Parkinson’s, it may precipitate some non-motor symptoms such as dopamine dysregulation syndrome and orthostatic hypotension, hallucinations and sleep disturbances. People on long term levodopa treatment can experience the “wearing off” phenomena which may be associated with non-motor symptoms such as anxiety, pain or fatigue. They may benefit from continuous dopaminergic stimulation such as extended release/24 hour formulations, infusions, skin patches or even deep brain stimulation.2

In conclusion, delayed detection of nonmotor symptoms may lead to disability, poor quality of life and increasing the cost of care of Parkinson’s disease in the society. Non-motor symptoms such as visual hallucinations, dementia and falls are a major source of hospitalisation and institutionalisation and the main cost-drivers in Parkinson’s care. Recognition of these symptoms is therefore essential for the management of Parkinson’s and earlier access to treatment. Finally, the importance of a multidisciplinary approach, including support for carers, cannot be overemphasised.15

 

References


Kristina Löfdahl måsar
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