Researchers are appreciating what patients have long known: non-motor symptoms of Parkinson's can be debilitating and difficult to treat. While scientists work on new therapies, doctors use what is on the market today to help manage these symptoms.
Finding the Right Treatment
The long list of Parkinson's non-motor symptoms includes constipation, memory and thinking (cognitive) changes, low blood pressure, depression or anxiety, sleep problems and others. A number of therapies are available to treat Parkinson's disease (PD) non-motor symptoms, but many patients are left wanting — not responding well to therapies or seeing enough relief. Some drugs are approved by the U.S. Food and Drug Administration (FDA) to treat these conditions in people with PD. Most, however, are FDA-approved for the general population but have not been studied in large numbers of people with PD. Still, doctors commonly prescribe them, and people with Parkinson's often find them beneficial.
Here we describe Parkinson's non-motor symptom treatments. With all Parkinson's symptoms, discuss treatment options with your doctor and work together to find a regimen that fits your needs.
Constipation is a decrease in or difficult-to-pass bowel movements. Exercise and diet, as well as lifestyle changes, typically are the first steps in the treatment of constipation. Read more about these recommendations. Today, there are no prescription drugs specifically for Parkinson's-related constipation. But if exercise and lifestyle changes aren't enough, your doctor may recommend over-the-counter or prescription medications, including:
- Fiber supplements: Metamucil (psyllium)
- Stool softeners: Colace (docusate)
These are used if stools are hard and difficult to pass. They can be taken daily for short periods.
- Laxatives: Miralax (polyethylene glycol), Dulcolax (bisacodyl), Senokot (senna)
There are different types of laxatives. Miralax pulls water into the colon to ease constipation; it is fairly gentle. Dulcolax and Senokot, "stimulant" laxatives, cause gut muscle contractions. They can be harsher so are not recommended for daily use.
- Enemas: Different types
These are sometimes recommended for significant constipation. You should use them cautiously and only under the advice of your health care provider.
- Drugs for severe constipation: Linzess (linaclotide), Amitiza (lubiprostone), Trulance (plecanatide)
The FDA has approved several drugs for severe constipation with no known medical cause. When exercise, diet and lifestyle changes, and the above over-the-counter therapies fail, these (and even others) may be considered.
Parkinson's disease dementia (PDD) is when memory or thinking (cognitive) changes interfere with a person's job, daily activities or social interactions.
- Exelon (rivastigmine) is FDA-approved to treat mild to moderate PDD. It increases the amount of the brain chemical acetylcholine, which supports memory and thinking. Exelon is available as a pill, liquid or skin patch.
- Aricept (donepezil) or Razadyne (galantamine) work in the same way but were developed for Alzheimer's.
- Namenda (memantine): approved for Alzheimer's, but sometimes used for Parkinson's dementia, this drug works on the glutamate brain chemical pathway.
Potential benefits of these drugs may include improved memory and thinking; decreased behavioral changes, such as agitation; and delayed need for long-term care facilities. Common side effects may include nausea, vomiting, diarrhea, decreased appetite, weight loss and increased tremor.
Depression and Anxiety
Anxiety and depression can occur in up to half of people with Parkinson's, at any time during the course of their disease. Talk therapy instead of or in addition to medications can be beneficial. Your doctor also may prescribe an antidepressant and/or anti-anxiety medication:
There are many different types of antidepressants. Commonly prescribed ones include SSRIs, such as Paxil (paroxetine), which works on the brain chemical serotonin, and SNRIs, such as Effexor XR (venlafaxine XR), which works on serotonin and norepinephrine to regulate mood. In studies of people with PD who had depression, Paxil and Effexor XR improved depression without worsening motor symptoms. There are other types of SSRIs and SNRIs (and other types of antidepressants) that are commonly prescribed as well..
- Anti-anxiety medications
Antidepressants, especially SSRIs, also may help with anxiety. If anxiety comes on only occasionally or in panic attacks, your doctor may prescribe as-needed medications, such as Ativan (lorazepam) or Xanax (alprazolam). These types of drugs can cause confusion, sleepiness and imbalance.
People with Parkinson's swallow their saliva less often. In later years with PD, this could lead to drooling, which can be embarrassing and isolating. In these situations, doctors may prescribe therapies to treat drooling:
- Injections of botulinum toxin, including Xeomin (incobotulinumtoxinA) and Myobloc (rimabotulinumtoxinB)
- Artane (trihexyphenidyl): Parkinson's medication that can cause dry mouth as a side effect; might help drooling as well as Parkinson's symptoms (it works best for tremor)
- Robinul (glycopyrrolate): a medication that decreases secretions, such as saliva
Because the medications can cause many possible side effects, such as constipation, memory problems and sleepiness, especially in older people, their potential benefits must be carefully weighed against the risks.
People with Parkinson's who experience fatigue often find it difficult to describe, but it's more than drowsiness or extreme tiredness. Fatigue is difficult to treat with medication, so the first steps are behavioral strategies, such as regular exercise and short naps in the early afternoon. Doctors make sure other conditions, such as sleep problems and depression, aren't contributing to the fatigue. If behavioral strategies don't work and fatigue is significant, drugs might be tried:
- Stimulants: Ritalin (methylphenidate)
- Wakefulness-promoting agents: Provigil (modafinil)
Common medication side effects include nausea, anxiety and insomnia.
- Parkinson's medications: Amantadine immediate release, Azilect (rasagiline), selegiline
While not typically prescribed specifically to treat fatigue, some people report a decrease in this symptom (in addition to PD motor symptoms) with these medications.
Low Blood Pressure (Orthostatic Hypotension)
Low blood pressure when changing positions, such as standing from sitting, is called orthostatic hypotension. Dietary and behavioral changes are the first steps to treating orthostatic hypotension. When these aren't enough, your doctor may recommend medication to raise blood pressure.
- Northera (droxidopa)
This drug converts to the chemical norepinephrine, which regulates blood pressure. Side effects may include headache, dizziness and nausea, as well as high blood pressure, especially when lying down at night. Your doctor will have you measure your blood pressure, especially when increasing the dose, to monitor for side effects.
- Florinef (fludrocortisone) or ProAmatine (midodrine)
For some people, doctors may recommend other medications to raise blood pressure. Potential side effects include high blood pressure, especially when lying down at night. Florinef also can cause leg swelling and decrease potassium, so blood levels need to be checked periodically.
- Northera (droxidopa)
Pain is common in Parkinson's. But it can have many different causes (everything from cramping with dystonia to discomfort with constipation) and therefore different treatments. Treatment starts with finding the cause of the pain and making sure motor symptoms are as best controlled as they can be. At the same time, you might use exercise and other non-medication strategies, such as massage, hot or cold therapy, or meditation, to ease your pain. When medication therapy is necessary, it may include:
- Botulinum toxin injections into cramping muscles for dystonia
- Anti-inflammatory medications: ibuprofen
- Pain relievers: Tylenol (acetaminophen) or opioids (narcotics)
Doctors typically recommend opioids only in cases of severe pain because they can cause constipation, confusion and sleepiness.
Psychosis (Hallucinations or Delusions)
Parkinson's disease psychosis causes visual hallucinations (seeing things that aren't there) and delusions (false, often paranoid, beliefs). Hallucinations and delusions are more common in later stages of Parkinson's. When hallucinations and delusions are frightening or upsetting, doctors may recommend medication treatments.
- Nuplazid (pimavanserin) was approved in 2016 by the U.S. Food and Drug Administration (FDA) for hallucinations and delusions associated with Parkinson's disease. It works on the brain chemical serotonin. Nuplazid may improve nighttime sleep and daytime wakefulness as well as lessen a care partner's stress. Side effects may include leg swelling, nausea and confusion.
- Clozaril (clozapine) or Seroquel (quetiapine)
These drugs work on the dopamine and serotonin brain chemical systems. They are approved for mood and thought disorders, such as schizophrenia. Before Nuplazid, these were among the only options for PD psychosis. Because these drugs work on the dopamine system, they can worsen motor symptoms of Parkinson's. Other side effects include sleepiness, weight gain and associated diabetes. Clozaril also can decrease infection-fighting white blood cells, so it requires regular blood monitoring.
All psychosis medications carry a "black box" warning of increased risk of death in elderly people who have dementia. As with any medication, this and all possible side effects need to be carefully considered. Medications to treat psychosis are considered only when symptoms are significant and the potential benefits of treatment outweigh the risks.
Sexual problems are common among people with Parkinson's. They can be complex, involving both physical and emotional issues. Sexual problems also vary from person to person and between men and women.
In men with PD, the most common sexual problem is erectile dysfunction. Many treatments, including medications, are available, but all have a possible side effect of low blood pressure:
- Viagra (sildenafil)
- Cialis (tadalafil)
- Levitra (vardenafil)
In women with Parkinson's, sexual problems can range from decreased sex drive to pain with sexual intercourse. If problems stem from hormonal changes, treatments may include hormone replacement therapy or estrogen cream. Other times, doctors may recommend lubrication for vaginal dryness or medication to boost sex drive.
For insomnia, your doctor will make sure your symptoms and medications aren't contributing to sleep trouble. Behavioral strategies, such as exercising regularly and avoiding naps and caffeine late in the day, are often the first steps in combating insomnia. See the Sleep and Parkinson's Guide for more. When these aren't enough, doctors may recommend sleep medications:
- Sedatives: Lunesta (eszopiclone), Ambien (zolpidem), Sonata (zaleplon)
- Melatonin: an over-the-counter hormonal supplement
- Antidepressants that help with sleep: Silenor (doxepin), Desyrel (trazodone)
When medication is needed for excessive daytime sleepiness (extreme tiredness that makes it difficult to stay awake during the day), doctors may look to:
- Wakefulness-promoting agents: Provigil (modafinil), Nuvigil (armodafinil)
- Stimulants: Ritalin (methylphenidate)
Restless legs syndrome causes an uncomfortable urge to move the legs that goes away only with moving them. Motor symptoms, such as tremor, slowness and stiffness, at or around bedtime might interfere with sleep. Adjustments to Parkinson's medications may help.
Acting out dreams in REM sleep behavior disorder (RBD) may be disruptive or dangerous. A person may, for example, punch, kick and get out of bed unknowingly. Treatment may be necessary:
- Klonopin (clonazepam)
- Melatonin: an over-the-counter hormonal supplement
Sleep medications could potentially worsen Parkinson's symptoms or interact with other medications. Take them only on the advice of your doctor.
People with PD may need to urinate more often and may feel the urge to go almost immediately, which can lead to accidental loss of urine or incontinence. Doctors may recommend a variety of treatments to relax the bladder:
- Botox (botulinum toxin injections) into the bladder muscles
- Ditropan (oxybutynin) or Detrol (tolterodine)
Possible side effects, which may be more likely in older people, are dry eyes and mouth, constipation, sleepiness and confusion.
- Myrbetriq (mirabegron)
Possible side effects include high blood pressure.
Some people with Parkinson's experience the opposite problem, which is not urinating enough. In these situations, a person may need to periodically empty their bladder with a catheter to prevent infection or kidney problems.