A Guide to the Non-Motor Symptoms of
Contents
1. Parkinson s medications can sometimes help 48 Delusions Delusions are false beliefs that are not based on reality or fact Delusions may occur after having hallucinations Suspicions are most often directed at family members Common delusions include cheating spouses or theft Delusions mainly occur in advanced Parkinson s Typically delusions occur in people who also have cogni tive impairment and are therefore part of advanced PD Often Parkinson s medications can make delusions worse Speak to your doctor The same treatments that are used for hallucinations can help delusions decreasing certain Parkin son s medications clonazapine and quetiapine acetylcholines terase inhibitors KEY POINTS e Delusions are uncommon Delusions often include cheating spouses and theft Treatment options Decreasing medications clonazapine and quetiapine 50 Impulse Control Disorders About one in eight people on Parkinson s medications may develop impulsive uncontrolled behaviour Impulsive un controlled behaviours or impulse control disorders ICD can include excessive gambling e hypersexuality e binge eating e compulsive shopping e punding repetitive performance of meaningless tasks You are especially at risk for ICD if you have a history of alcohol abuse gambling or addiction However ICD can happen to anybody with PD 51 ICD symptoms are usually a side effect of medic2. 43 44 Excessive sweating eeeeee 45 46 Double VISION oeenn 47 48 P oco S 49 50 Impulse control disorders se 51 52 INTRODUCTION What is Parkinson s Disease Parkinson s disease PD is an illness which is caused by a slow breaking down or degeneration of nerve cells in the brain Degeneration is a process similar to aging As we age cells in our body begin to work less efficiently Some eventually die When you have Parkinson s disease some areas of your brain are getting older faster than the rest of your body What are the Motor Problems of PD A person with Parkinson s disease gradually loses the ability to have complete control of their body movements You may experience these as changes that appear slowly over time They are also called motor symptoms and can appear in a variety of ways The most important of these are e slowness of movement Movements of the hands legs voice and face are slowed and there is less spon taneous movement e shaking or tremor This often occurs in the hands legs or jaw usually when the limb is resting that is not while you are not using your arms or your legs e stiffness or rigidity Your doctor will detect this during your check up e walking problems This includes slow walking getting stuck or frozen in place and loss of balance Parkinson s disease is a condition that is chronic This means that it
3. and shoulder neck pain can also occur If OH is severe you could black out and fall Certain Parkinson s medications can worsen OH but they do not cause OH OH is part of the disease process itself areas that increase blood pressure with standing degenerate in Parkin son s If you have OH avoid standing up quickly Try elevating the head of the bed when you sleep Slightly increasing salt intake and wearing compression stockings also can help Most people with severe OH will need medications Treat ment options include domperidone see Nausea section fludro cortisone and midodrine The most common side effect of fludro cortisone and midodrine is high blood pressure when lying down Physostigmine is another option which also treats constipation KEY POINTS e One third of people with Parkinson s have orthostatic hypotension Main symptom Feeling light headed when standing up e Other symptoms include Confusion pain headache or blacking out when standing up e Treatment options Domperidone fludrocortisone midodrine or physostigmine Excessive Daytime Sleepiness Excessive daytime sleepiness means feeling sleepy or sleeping too much during the day If you have mild sleepiness you may fall asleep when you are inactive If you have a more se vere case you may have sleep attacks With a sleep attack you will have a sudden desire to sleep This can occur while eating working walking or reading You may ev
4. be aware that certain medications often used for nausea in people without Parkinson s ex dopamine blockers such as Stemetil can make motor symptoms worse and should be avoided If Parkinson s treatment causes nausea your doctor may prescribe domperidone Motilium Domperidone blocks the ef fects of dopamine medications in the stomach without interfering with their benefits in the brain KEY POINTS e Nausea often begins when starting a new Parkinson s drug e This symptom may not persist when related to a new drug e Treatment option Domperidone may help if symptoms do not improve by themselves 14 Constipation Constipation is defined as having less than three bowel movements a week or excessive straining to pass stool It af fects three out of four people with PD Generally constipation is an easy symptom to recognize Other than the difficulty moving your bowels you may also feel that you are unable to completely empty your bowels or that you are unable to completely relax the muscles that prevent bowel movements Although constipation can occasionally be increased by medi cations people usually have this symptom regardless of drug treat ment Constipation is related to degeneration of the nerves in the bowel that control bowel movements That is it is part of the disease itself not caused by Parkinson treatment Constipation can be the first symptom of Parkinson s You may have noticed it years be
5. booklet You may then discuss your answers as well as any questions or concerns that you have with your doctor at your next visit Hefer to the last page of this booklet for a copy of the NMS Quest questionnaire Drooling Drooling occurs when there is a pooling of saliva that re sults in saliva leaking out of the mouth If mild saliva may pool in your mouth however very little will come out If severe you may always have to wipe the sides of your mouth and chin Drooling occurs in half of people with Parkinson s disease Drooling feels like your body is making too much saliva but this is not the case It is in fact caused by decreased mouth move ments and swallowing This results in a build up of saliva in your mouth Chewing gum or sucking on a hard candy can help Hav ing something in the mouth gives an unconscious reminder to swallow and so drooling lessens Although drooling is generally an irritation rather than a dangerous symptom occasionally you might choke on your sa liva If this occurs speak to your doctor Medications taken for motor symptoms of PD often pre vent or decrease drooling These work by improving mouth move ments and swallowing If drooling is still a problem your doctor may recommend atropine A single drop under the tongue decreases the produc tion of saliva People with memory problems or hallucinations need to use atropine carefully Sometimes this drug worsens these sy
6. high blood pres sure or being overweight Women often have less sex drive after menopause Abnormally increased sex drive can be due to an impulse control disorder related to medications see page 51 31 Regular exercise helps develop stamina for sexual inter course Also you may want to consider other forms of intimacy Speak with your partner and decide what is best for your relation ship Some couples are not interested in having sex In that case you may not require any treatment If sex interests you or your partner talk to your doctor Help is available Treatment for men includes sidenafil Viagra for erection problems Testosterone is sometimes used for sex drive prob lems Hormone replacement therapy can increase sex drive in women but this comes with risks Consult your doctor before starting any medications for erectile dysfunction or hormonal replacement therapy KEY POINTS e One half of people with Parkinson s have sexual dysfunction e Sexual dysfunction can include Difficulty with erections men or orgasm women or decreased sex drive both men and women e Treatment option for men Medications such as sildenafil Treatment option for women Hormone replacement therapy with caution Orthostatic Hypotension Orthostatic hypotension OH is a drop in blood pressure when standing The most common symptom is light headedness or dizziness when standing up from sitting Confusion headache
7. therapists or occupational therapists can also help These therapists are specialized in assessment of swallowing problems They typically assess swal lowing with special tests Certain types of food that are easier to swallow may be recommended Proper posture while eating will also be taught KEY POINTS e One half of people with PD have trouble swallowing e Trouble swallowing can result in choking or pneumonia Treatment options Increasing regular PD treatments Swallowing therapists Nausea amp Vomiting Nausea is a sense of unease in the stomach with a feel ing of possible vomiting Sensations of stomach ache and bloat ing also can often occur with Parkinson s The most common cause of nausea is starting a new Parkinson s drug All Parkinson s medications can cause nausea and vomiting but some tend to cause this more than others A feeling of stomach bloating can also be present in Parkinson s usually related to slow stomach movements In this case it may not be related to treatment If nausea and vomiting appear with a new drug these symptoms often go away by themselves even if you stay on the medication Taking your medications with meals or with a small snack may help with these symptoms However this can slightly reduce the absorption of certain medications such as levodopa If nausea is very bothersome it can cause you to stop eat ing if so you must speak with your doctor You should also
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9. However serious memory problems as seen in Alzheimer s are less common and hints or clues are often enough to stimulate memory In most cases dementia in Parkinson s occurs late in the disease as the pathology starts to spread outside of the motor areas and into cognitive areas It usually occurs in older people with Parkinson s it is very rare below age 65 25 There is some preliminary evidence that keeping yourself cognitively active might help prevent dementia Exercise good diet good blood pressure control and prompt treatment of diabe tes or elevated cholesterol may also help prevent dementia Medications are available to help with cognitive function These include the cholinesterase inhibitors such as rivastigmine Exelon and donepezil Aricept These medications help a small or moderate amount Common side effects include nausea vomiting diarrhea and upset stomach Medications used to treat other features of Parkinson s or problems with sleep and anxiety occasionally worsen cogni tive function e g atropine oxybutynin nortryptyline sedatives Therefore make sure your doctor knows all the medications you are taking KEY POINTS e Dementia or cognitive impairment may occur with advanced Parkinson s e Common symptoms include difficulty with planning focussing attention slowing of thought decreased memory e Some forgetfullness can occur normally with aging However it should not interfe
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12. Ronald Postuma Christos Galatas A Guide to the Non Motor O Disease A patient friendly booklet for This booklet is to help you understand Parkinson s Disease and prepare for the treatments ahead Please review it with your family Bring it with you to your clinic appointments Centre universitaire de sant McGill McGill University Health Centre This booklet was prepared by Ron Postuma amp Christos Galatas This booklet was made with the support from the Parkinson Society Canada the Canadian Institutes of Health Research and the Fonds de la recherche en sant Qu bec We would also like to recognize the MUHC Education Portfolio and McGill Molson Medical Informatics for their support throughout the development of this booklet the design and layout as well as for the creation of images February 2012 All rights reserved IMPORTANT PLEASE READ This booklet is intended as a general guide to non mo tor symptoms of Parkinson s disease It is important to realize that everybody is different Therefore you may never experience many of these symptoms and some of the treatments that we discuss may not be ideal for you We list some of the common side effects of treat ments but there are always potential side effects that we do not mention Speak to your treatment team who can help plan the best treatment for you Information provided in this booklet is for educational purposes It is not intended to
13. a tions Dopamine agonists pramipexole Mirapex and ropinirole Requip are the medications that carry the most risk for develop ing ICD Those around you should be made aware of the possibil ity of ICD This way they can contact help as needed If ICD is a problem the most important thing is to inform your doctor Since this is usually a side effect of medications your doc tor will usually reduce your treatment dosage This usually solves the problem When medications are stopped or reduced motor symptoms can become worse so you and your doctor will have to balance side effects with benefits KEY POINTS e One in eight people on certain Parkinson s med ications have an impulse control disorder ICD Excessive gambling and hypersexuality are the most common ICDs e Treatment option Treatment dosage is usually decreased Notes 53 dnour 1010 N UON Gd JeEuoneu19ju eui Aq pejeprjeA pue pedojoeA eg 777 pessnooy Bui eis 10 BulyesjusoUod Aynoug SL 1 o A A T E ana jou eje Aes ajdoad g i2 S HD III DUIS IS MURUFUNM alay JOU ae pjo 15410 yey no oj Guiueddeu aue suy Buinaijag og aJe JO MOU NO yey suru Buneay Jo Bulaas py g NABRRRARTRRARREERARARRRAREESIATEERRASRRRAAERRAAARAAMARRRERSTEERERAES UOISIA ajqnoq 6c g BAENRERRHREESRRRERRRZARREAARRRAAARRAARRER
14. able to smell some dangerous odors ensure that smoke detectors are installed and are in good working order KEY POINTS Almost all people with PD have changes in taste and smell Currently there is no treatment available for this symptom Choking amp Swallowing Difficulties Occasionally patients notice more difficulty in swallow ing generally with food or drink but also with swallowing saliva Swallowing problems usually occur in more advanced disease In mild cases you may be unaware of swallowing problems In Severe cases you may have trouble eating You also may often choke on food Swallowing is a very complex motor activity that requires a high degree of muscle co ordination with a wide range of areas in the brain responsible for it Therefore it is not hard to imagine why swallowing troubles happen In general swallowing troubles are part of more advanced PD 11 It is important to not rush your meals If you choke while eating and talking you may need to ensure your mouth is clear before talking If you are having consistent choking it is very im portant to talk to your doctor Food can go down the wrong pas sage and can end up in the lungs This may result in pneumonia lung infection Treatments that improve motor symptoms of PD can sometimes improve swallowing Your doctor may recommend increasing your current dose or may offer a new Parkinson treat ment Swallowing therapists speech
15. aged with others Exercise particularly while outside may help In some cases you may find it useful to speak with a psychologist or other mental health professional Certain types of psychological therapy the commonest being called cogni tive behavioral therapy have been shown to help depression although they have not yet been proven to help depression in Parkinson s Medications that have been shown to help depression in Parkinson s are nortriptyline and citalopram Celexa Nortripty line has to be used with caution in people with memory problems or hallucinations since it can worsen these symptoms KEY POINTS e One third of people with Parkinson s can experience anxiety and depression e Parkinson s disease affects areas of the brain that control mood Depression and anxiety can begin before motor symptoms e Anxiety can occur in off periods This can be improved by preventing the off times e Treatment options nortriptyline or citalopram sexual Dysfunction With Parkinson s some sexual dysfunction is common In men it can be hard to obtain or maintain an erection Problems with having an orgasm or decreased sex drive can also occur Women can have decreased interest in sex Or they can have problems reaching orgasm Sometimes an increase in sex drive can occur after starting a new drug Many other conditions can cause these symptoms Diffi culty with erection can be caused by diabetes
16. dications It is im portant to note that many other medications conditions affecting the heart etc can also cause leg swelling Therefore it is impor tant to make sure that there is not another cause When leg swelling is caused by Parkinson s it tends not to be dangerous and is usually not treated Some people find com pression stockings helpful these are available at most pharma cies Sitting with your legs up can also help If the leg swelling is bothersome speak to your doctor as it could resolve with medi cation changes KEY POINTS e Some people with Parkin son s have swollen legs e Swelling can be caused by Parkinson s itself or by treat ment e Other conditions can cause leg swelling e g heart dis ease 44 Excessive Sweating Excessive sweating is found in one third of people with Parkinson s With excessive sweating you may find yourself sweating with no exercise or sweating profusely with mild exer cise The exact reason for this symptom is not known Excessive sweating commonly occurs when your muscles are stiff i e during off periods It also occurs during dyskinesia excessive movements as a side effect of medications There is no specific treatment for excessive sweating However you can help limit the amount that you sweat Try these steps e avoid hot or humid environments e avoid strenuous activity in the heat e set the house thermostat lower e wear appropriat
17. e clothing e always keep well hydrated Usually excessive sweating is not a disabling problem and medications are not helpful However it is important to monitor when excessive sweating occurs If it occurs when your medications are wearing off this is important information for the doctor and may result in medication changes particularly with timing of pills KEY POINTS e One third of people with Parkinson s develop excessive sweating e Sweating is often associated with off periods or dyskinesias excessive movement e Some practical tips can help see above Double Vision Double vision is when you see two images of the same object It is an uncommon symptom of Parkinson s Most often double vision with Parkinson s happens while reading There are many other causes for double vision besides Parkinson s In Parkinson s double vision is usually caused by the eye muscles being underactive just like the rest of the mus cles in your body The medications used to treat Parkinson s levodopa pramipexole etc may help with double vision by increasing the muscle activity to the eyes Talk to your doctor about this problem you may need to visit an ophthalmologist eye specialist to rule out other causes KEY POINTS e Double vision is when you see two images of a single object Double vision is fairly uncommon e Many other conditions can cause double vision Treatment option Increasing
18. e to treat insomnia is sleep hy giene Sleep hygiene includes e Bedtime and waking time should be as regular as possible e Do not spend over 8 hours in bed Do not lie in bed for more than half an hour if you cannot sleep Get up and do something relaxing Then try to sleep again later e Bright light in the morning and exercise during the day Use your bed for sleep and sex only e Reduce naps during the day Insomnia can be very difficult to treat Sleeping pills such as triazepam or temazepam may help However sleeping pills have side effects especially feeling sleepy throughout the day Always try sleep hygiene first Then talk about other treatment options with your doctor In many cases it is best to not use medication KEY POINTS e With insomnia you may have difficulty falling and staying asleep e Insomnia contributes to feeling tired during the day e Treatment options Try sleep hygiene or medications rarely REM Sleep Behaviour Disorder REM rapid eye movement sleep is one of the five stages of sleep Most dreaming occurs during this stage Normally there is no movement during REM sleep you are paralyzed If you have REM sleep behaviour disorder RBD this normal paralysis is lost HBD may cause you to act out your dreams You may punch kick shout talk or fall out of bed during this stage You may end up injuring yourself or your bed partner RBD occurs most often in the early morning when peo
19. en have sleep attacks while driving Many factors can make you sleepy For example it is a common side effect of Parkinson s medications Poor sleep at night can also make you sleepy during the day although that is usually not the problem In addition Parkinson s causes chang es in brain areas that control sleep 35 You may wish to try drinking extra coffee or tea during the day Always avoid driving or operating heavy machinery if you feel even slightly sleepy Treatment often begins by reducing medication dosage However this can increase your tremor and slow your move ments Your doctor can also prescribe modatinil This drug in creases alertness Common side effects of modafinil include headaches and nausea KEY POINTS e One half of people with Parkinson s feel sleepy during the day e You may fall asleep while reading talking or working Always think twice about driving even if you are just a little bit tired Treatment options Caffeine adjustment of medications or modafinil Insomnia Insomnia is when you find it hard to fall or stay asleep Most of the time people with Parkinson s have trouble staying asleep more than falling asleep Occasionally PD medications can also cause insomnia Selegiline is the drug most likely to cause insomnia especially if taken in the evening However the main reason for insomnia is changes in the brain caused by Parkinson s The first step you should tak
20. fore you had motor problems 15 Constipation can be treated Make sure you drink enough water Also add fibre to your meals Foods rich in fibre include e bran fibre e whole wheat products e lentils and beans e prunes or prune juice e dried apricots Moderate exercise can help You can also purchase bulking agents Metamucil or stool softeners over the counter However many people need laxatives or enemas to relieve constipation Over the counter laxatives Senokot can help This treatment is available in pill form or as a tea Although constipation is usually not harmful very severe consti pation can cause obstruction of the bowels with medical complications if you have gone a week without a bowel movement take the laxa tives above and talk to your doctor If the above treatments don t help your doctor may recom mend additional prescription laxatives KEY POINTS e Three in four people with PD suffer from constipation This can be an early sign of Parkinson s disease e Treatment options Drink water eat fibre exercise and use bulking agents stool softeners or laxatives 16 Uncontrolled Loss of Stool Loss of stool is not necessarily due to diarrhea which is not very common in PD It refers more to an inability to control bowel movements with incontinence or accidents This is a quite rare feature of PD and is not ever experienced by most patients In mild cases you may be unab
21. ine A rare but dangerous side effect of this drug is low salt levels in the blood If you start taking this drug you will need routine blood tests KEY POINTS One third of people with PD have bladder dysfunction e The bladder is usually over active e Most common symptoms include getting up to urinate at night frequently passing urine and urgency to pass urine Treatment options Anticholinergic medications or desmopressin Unexplained Pain Of course people with Parkinson s can have other con ditions that cause pain such as arthritis lower back pain etc However pain without any explanation may be caused by Parkin son s This pain can feel like stiffness cramps spasms or other muscle pain Many people have different types of pain all at once The legs are the most commonly affected area Usually the pain feels like it is in the muscles One third of people with Parkinson s have such pain 21 The cause of pain in Parkinson s is not always clear Often itis related to muscle rigidity which is a primary motor sign of Parkinson s Often it occurs when medications are wearing off Finally Parkinson s may make you somewhat more sensitive to pain in general Sometimes people will find that stretching the muscles massage or warm baths will help If the problem is still there after speaking with your doctor try over the counter pain medications such as acetaminophen Tylenol Do not take more than the rec
22. l or clozapine Clozaril These medications can some times make you sleepy Other options include cholinesterase in hibitors These are also used for dementia See Cognitive Impair ment amp Dementia section KEY POINTS e One third of people with Parkinson s have hallucinations e Hallucinations are almost always visual you see things that are not there Treatment options Reducing medications clozapine quetiapine rivastigmine or donepezil Depression amp Anxiety If you are depressed you may not be able to experience joy You may stop hobbies that you once enjoyed and you may not want to carry out your daily routine Learning new things may also not interest you Fatigue is commonly linked with depres sion but this is rarely the only symptom fatigue often occurs by itself in Parkinson s Depression can be an early sign of the disease Although living with Parkinson s can certainly cause stress and sadness depression may also be caused by changes in areas of the brain that affect mood Anxiety often occurs with depression in Parkinson s Some people have bursts of anxiety called panic attacks Or you can have excessive worry about everyday things that you cannot con trol As with depression anxiety can be an early sign of Parkin son s Anxiety is also common during off periods 29 One set of important protectors from depression is friends and family as much as you can keep yourself active and en g
23. le to control when you pass gas or you may have only a small amount of leakage Total loss of control occurs in the most severe cases This is rare People with uncontrolled loss of stool usually have uncontrolled loss of urine 17 If the incontinence is caused by inability to move fast to the bathroom on time try to develop a plan to get you there on time It may be useful to schedule a bathroom trip before times that you often have accidents You can find a range of inconti nence products at health supply stores Medications used to treat PD may improve uncontrolled loss of stool both by improving control and helping you get to the bathroom on time KEY POINTS e Rare e PD medications can improve uncontrolled loss of stool Bladder Dysfunction amp Whatis this One third of people experience a bladder related problem with PD The most common problem is an overly active hyperac tive bladder A hyperactive bladder can cause you to e rush to the bathroom or you would be unable to hold it in e urinate frequently less than every two hours e get up multiple times at night to go to the bathroom With PD you may also experience an underactive hy poactive bladder This condition is much LESS common than a hyperactive bladder Symptoms include edifficulty starting urination ea sensation of not completely emptying your bladder eleakage of urine Urinating more frequently can also appear with prostate problem
24. mptoms Your doctor may also suggest injections of Botulinum toxin Botox This is injected into the glands that produce saliva Botu linum toxin reduces the amount of saliva that is formed If you use Botulinum toxin you will need injections every few months KEY POINTS Up to one half of people with PD drool e Saliva pools in the mouth and leaks out e Caused by decreased mouth movements and swallowing Treatment options Atropine or Botulinum toxin Change in Taste amp Smell Smell is altered in almost all people with PD One third of people with PD will have no sense of smell at all Taste can also be affected since smell is directly linked to taste Changes in taste and smell are often unnoticed because the changes are gradual You may notice a decreased overall ability to smell You may have difficulty telling two smells apart Some people notice that their food tastes bland or they always find themselves adding more salt or spice Some cannot smell strong odours that others around them can Loss of smell sensation is part of the process of Parkin son s the degeneration affects areas that are responsible for detecting odours Changes in smell can occur years before changes in movement There is no treatment for changes in taste and smell Generally this is not a dangerous symptom It can result in some loss of appetite it is important to continue eating a full balanced diet Because you may not be
25. ommended dose Severe pain is a clear sign that you should speak with your doctor Pain is often a sign that treatment dosage should be in creased Many people have pain during off periods times when the medication is not working well If this is your case discuss with your doctor ways to decrease off times If pain continues to be a problem your doctor may offer other pain medications KEY POINTS e One third of people with PD have unexplained pain e Muscle aches and leg pains are the most common symptoms Increasing doses of Parkinson s treatments may help Treatment options Over the counter pain medications if pain persists Unexplained Changes in Weight Changes in weight gain or loss can be experienced by people with PD In general weight loss is more common than weight gain The exact reason for changes in weight is not understood Weight loss can be related to nausea from medications It can also be caused by dyskinesia excessive movements Finally it is a com mon feature in advanced PD it is common for people with advanced disease to lose weight despite eating more Appetite is usually not increased in PD However excessive eating and weight gain after starting medications such as pramipexole Mirapex or ropinirole Requip can be due to an impulse control disor der see section on impulse control disorders 23 If nausea vomiting are stopping you from eating there may be treatment
26. ple have the most REM sleep You may have experienced RBD before developing the motor symptoms of Parkinson s 39 If RBD is mild no treatment may be needed If you are having very active and severe movements think about safety in bed bed rails pillows or mattresses beside the bed etc If there are violent movements you may need to sleep apart from your partner until your RBD is treated If RBD becomes a problem the main treatments are mela tonin 3 mg at bedtime or clonazepam Rivotril These medica tions are quite effective and have few side effects in low doses Melatonin is the natural hormone of sleep and is available over the counter KEY POINTS One third of people with Parkinson s have RBD e With RBD dreams are acted out This in cludes screaming kicking punching thrashing etc Injuries may occur Treatment options Melatonin or clonazepam Restless Leg Syndrome Restless leg syndrome RLS is an urge to move the legs often with pain or difficult to describe uncomfortable sensations Generally this is felt when sitting or lying down RLS is worse in the evening and at night Movement provides temporary relief If you have RLS you will feel the need to move your legs in the evening This may cause trouble falling asleep One in ten people with PD will have RLS This is similar to the number in the general population However RLS may be more severe in people with Parkinson s perhap
27. re with your daily routine e Some medications can cause cognitive impairment e Treatment option Cholinesterase Inhibitors like rivastigmine and donepezil can improve cognitive impairment Hallucinations Hallucinations are not vivid dreams disorientation or ab normal beliefs Hallucinations mean hearing or seeing things that are not really there In Parkinson s hallucinations are almost always visual you see something that is not there They commonly begin as minor non threatening visual images For example a spot on the floor or the wall may move Or the spot may look like an insect If hallucinations progress you may see children animals or min iature people At first most people are aware that the hallucina tions are not real Later on what is real may become blurred 2f Hallucinations usually occur after years of having Parkin son s They affect one third of people with the disease They are partially related to medications and partially related to disease affecting areas of the brain involved in interpretation of visual im ages Not all hallucinations need to be treated You might be afraid to talk about your hallucinations However it is important to discuss them with your doctor as they can often be helped If hallucinations are a problem your doctor may try reduc ing some of your medications If this makes motor symptoms worse or does not help your doctor may prescribe quetiapine Seroque
28. replace the advice or in struction of a professional healthcare practitioner or to substitute medical care Contact a qualified healthcare practitioner if you have any questions concerning your care IMI M Portefeuille de l ducation du CUSM The MUHC Education Portfolio Projet d informatique m dicale Molson de McGill McGill Molson Medical Informatics di Parkinson Society Canada Soci t Parkinson Canada 8 Centre universitaire de sante McGill NIC D niversibty Health Centre TABLE OF CONTENTS Introduction T 3 6 OO MR RENE 7 8 Change in taste and smell 9 10 Choking and swallowing difficulties 11 12 Nausea and vomiting ene 13 14 Constipation eesssssee 15 16 Uncontrolled loss of stool 17 18 Bladder dysfunction ueeeeesssssss 19 20 Unexplained pains esseeeeee 21 22 Unexplained changes in weight 23 24 Dementia and cognitive impairment 25 26 Hallucinations RM 27 28 Depression and anxiety aaan 29 30 Sexual dysfunction sssesesss 31 32 Orthostatic hypotension ssesssss 33 34 Excessive daytime sleepiness 35 36 INSOMNIA PA 37 38 REM sleep behaviour disorder 39 40 Restless leg syndrome esee 41 42 Leg swelling
29. s This is a condition that affects men Usually men with prostate problems also notice that the urine stream is slow or hesitant If you are seeing a urologist for your bladder problem make sure he she is aware that you have Parkinson s disease because PD may provide an alternate explanation for the urinary problem Urinary problems related to PD would not improve with surgical operations on the prostate Hyperactive bladder is related to numerous areas of de generation in PD including the nerve cells that control the blad der directly the motor areas affected in PD and sometimes the higher level control of urination in the brain 19 If you are having trouble with hyperactive bladder try to schedule bathroom trips at regular intervals especially if you know a bathroom may not be close by There are several options that decrease the urgency and frequency to urinate Sometimes the medications for the motor symptoms of Parkinson s can help the bladder problem Your doctor may also suggest anticholinergic medications Oxybu tynin Tolteridone or trospium chloride Trosec If you have memory problems or hallucinations and your doctor has pre scribed you an anti cholinergic medication there is a chance that these medications can make these symptoms worse If so stop these immediately and speak with your doctor Desmopressin a nasal spray is often recommended for nighttime urination This drug reduces the formation of ur
30. s see nausea section Also try taking meals during on times times when the medication is working well You will find it easier to use utensils and you may also have less difficulties swallowing No medical treatment is used for weight loss due to PD However you should make sure that you are eating enough If you are losing weight consistently consider using milkshakes or calorie supplements e g Ensure Boost KEY POINTS Unexplained increases or decreases in weight can happen in PD Treatment option Try correcting any underly ing problems e g nausea Also eat during on times 24 Cognitive Impairment amp Dementia Mild cognitive impairment means a problem with memory or concentration that is bothersome but not enough to affect daily life Dementia means a severe loss of memory concentration enough to interfere with usual daily activities Forgetting some in formation sometimes is normal as we age It does not mean you have dementia or that you are cognitively impaired When prob lems in memory and decision making impair your daily routine they need to be addressed Common symptoms of cognitive impairment in Par kinson s include problems with attention and planning Often people are unable to follow a complicated conversation Some notice trouble making decisions It can also take a longer time to formulate thoughts Solving complex problems can be a chal lenge Memory can also be impaired
31. s related to use of medications for Parkinson s Generally it is hard to treat RLS without medications If mild people can find that a brief walk around the room or read ing for a while can help Medications used to treat Parkinson s also treat RLS Levodopa pramipexole Mirapex and ropinirole Requip taken at night may improve RLS If your symptoms occur daily and are more severe one option is gabapentin Neurontin This is not a Parkinson s drug The most common side effect of this drug is feeling sleepy Also try to avoid caffeine nicotine and alcohol at bedtime These make RLS worse in some cases Your doctor may suggest checking your iron levels in the blood since low iron can cause RLS KEY POINTS e One in 10 people with Parkinson s have RLS e With RLS you feel an urge to move legs be cause of uncomfortable or odd feelings RLS tends to be worse at night and affects sleep e Treatment options Levodopa pramipexole ropinirole or gabapentin and avoidance of bedtime caffeine nicotine and alcohol Leg Swelling Leg swelling is a common symptom in people with PD Leg swelling means that the lower part of the legs often become bigger and seem to be filled with water Legs can swell as a side effect of Parkinson s treatments levodopa pramipexole Mirapex and ropinirole Requip cause leg swelling in 2 10 percent of users Parkinson s disease itself can cause your legs to swell even without me
32. will continue over a long period of time It is also progressive which means that it may worsen over time The good news is that we now know a fair amount about the disease Also many of its symptoms are treatable We currently have a number of treatment options available to patients that can ease the prob lems of the disease What is this booklet for While the treatment of the motor problems of Parkinson s disease is important and complex it is not the focus of this book let This booklet is focused on the non motor parts of PD Other than tremor slowness and stiffness you may ex perience other changes with Parkinson s disease These other changes known as non motor symptoms can also impact your quality of life Many patients may also not realize that these other symptoms are linked to Parkinson s disease As a result they go untreated This booklet will help you learn about these symptoms and discuss how you can recognize them It will provide infor mation on treatments and strategies to help you manage these symptoms any serious problems to watch out for as well as when and how to get more help The NMS Quest You will find a non motor symptom questionnaire called the NMS Quest at the end of this guide This question naire is meant to help individuals with Parkinson s disease to identify any non motor problems that they might have You may wish to tear out this questionnaire and complete it as you read through this
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