title: Clinical review of treatment options for select nonmotor symptoms of Parkinson's disease.
abstract: BACKGROUND
  Parkinson's disease (PD) is associated with a host of nonmotor symptoms, including psychosis, cognitive impairment, depression, sleep disturbance, swallowing disorders, gastrointestinal symptoms, and autonomic dysfunction. The nonmotor symptoms of PD have the potential to be more debilitating than the motor features of the disorder.
  
  
  OBJECTIVE
  The aim of this article was to review treatment options for the nonmotor manifestations of PD, including pharmacologic and nonpharmacologic interventions.
  
  
  METHODS
  The PubMed and MEDLINE databases were searched for articles published in English between January 1966 and April 2010, using the terms Parkinson's disease, nonmotor, psychosis, hallucination, antipsychotic, cognitive impairment, dementia, depression, sleep disturbance, sleepiness, REM (rapid eye movement) sleep behavior disorder, dysphagia, swallowing disorder, sialorrhea, gastrointestinal, constipation, autonomic dysfunction, orthostatic hypotension, gastroparesis, erectile dysfunction, sexual dysfunction, and urinary dysfunction. Articles were selected for review if they were randomized controlled trials (RCTs), meta-analyses, or evidence-based reviews of treatment of patients with PD, and/or expert opinion regarding the treatment of nonmotor symptoms of PD.
  
  
  RESULTS
  A total of 148 articles, including RCTs, meta-analyses, and evidence-based reviews, were included in this review. The treatment of hallucinations or psychosis in PD should include a stepwise reduction in medications for motor symptoms, followed by the use of quetiapine or clozapine. Dementia may be treated with acetylcholinesterase inhibitors. Evidence is lacking concerning the optimal pharmacologic treatment for depression in PD, with expert opinions indicating selective serotonin reuptake inhibitors as the antidepressants of choice. However, the largest study to date found nortriptyline therapy to be efficacious compared with placebo, whereas paroxetine controlled release was not. A variety of sleep disturbances may plague a person with PD, and treatment must be individualized to the patient's specific sleep disturbance pattern and contributing factors. Swallowing disorders may lead to aspiration and pneumonia, and patients with dysphagia should be referred to a speech therapist for further evaluation and treatment. Orthostasis may be treated with nonpharmacologic interventions as well as pharmacologic treatments (eg, fludrocortisone, midodrine, indomethacin). Other autonomic symptoms are managed in a manner similar to that in patients without PD, although careful attention must be aimed at avoiding dopamine-blocking therapies in the treatment of gastrointestinal dysfunction and gastroparesis.
  
  
  CONCLUSIONS
  Various pharmacologic and nonpharmacologic strategies are available for the management of the nonmotor symptoms of PD. The challenges associated with nonmotor symptoms must not be forgotten in light of the motor symptoms of PD, and treatment of nonmotor symptoms should be encouraged.
authors.affiliation: Elder Services, Spokane, Washington, USA. lindy_wood@wsu.edu
authors.forename: Lindy D
authors.initials: LD
authors.lastname: Wood
authors.forename: Joshua J
authors.initials: JJ
authors.lastname: Neumiller
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Setter
authors.forename: Erin K
authors.initials: EK
authors.lastname: Dobbins
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use; D014150:Antipsychotic Agents / Q000008:administration & dosage / Q000009:adverse effects; D001342:Autonomic Nervous System Diseases / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D018680:Cholinergic Antagonists / Q000008:administration & dosage / Q000009:adverse effects; D002800:Cholinesterase Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D003863:Depression / Q000188:drug therapy / Q000209:etiology / Q000503:physiopathology; D019468:Disease Management; D018450:Disease Progression; D015259:Dopamine Agents / Q000008:administration & dosage / Q000009:adverse effects; D019317:Evidence-Based Medicine; D005767:Gastrointestinal Diseases / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D015201:Meta-Analysis as Topic; D019965:Neurocognitive Disorders / Q000188:drug therapy / Q000209:etiology / Q000503:physiopathology; D010300:Parkinson Disease / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D056888:Patient Positioning / Q000379:methods; D019338:Polypharmacy; D012893:Sleep Wake Disorders / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D014149:Tranquilizing Agents / Q000627:therapeutic use
chemical_list: D000928:Antidepressive Agents; D014150:Antipsychotic Agents; D018680:Cholinergic Antagonists; D002800:Cholinesterase Inhibitors; D015259:Dopamine Agents; D014149:Tranquilizing Agents