Parkinson's%20disease%20-and-%20parkinson's%20disease%20dementia Management

Parkinson’s Disease Dementia (PDD)

• Stop current drug that may aggravate the condition
  • Anticholinergic drugs used for treating motor symptoms of Parkinson’s disease may worsen cognition as well as psychotic symptoms
  • Dementia is a relative contraindication in the use of dopamine agonists

• Rivastigmine is the only cholinesterase inhibitor approved for Parkinson's disease dementia
  • Acts by inhibiting both acetylcholinesterase and butyrylcholinesterase
  • Has significant effects in cognitive symptoms and global function in patients with Parkinson's disease dementia
  • May improve behavior and activities of daily living

• Donepezil may be considered in Parkinson's disease dementia
• Use of cholinesterase inhibitors has a potential risk of exacerbating motor symptoms
• Memantine, an N-methyl-D-aspartate receptor antagonist, may be given for the treatment of parkinsonism and central spasticity

Psychosis

• Often drug-induced
  • Reduce the dose or stop offending drug

• Clozapine may be added to current therapy
• Quetiapine, but not Olanzapine, may also be considered
• Pimavanserin has been recently approved for the treatment of hallucinations & delusions associated with Parkinson’s disease psychosis

Depression

• Optimize current drug therapy
• Selective serotonin reuptake inhibitors (SSRI) or selective serotonin-norepinephrine reuptake inhibitor (SNRI) may be added to therapy
  • Venlafaxine, a SNRI, is clinically useful for the treatment of depression in Parkinson’s disease
• Pramipexole was found to be an effective treatment of depressive symptoms

Orthostatic Hypotension

• Avoid factors that may trigger or worsen the condition (eg large meals, alcohol intake, warm environment, diuretics, antihypertensive drugs)
• In symptomatic patients, increase salt intake
• Use of elastic stockings, head-up tilt at night may be advised
• Peripheral alpha-adrenergic agonist may increase the standing blood pressure
• May consider Fludrocortisone, since it enhances renal sodium reabsorption and has alpha-adrenoreceptor sensitizing properties

Urinary Incontinence

• Avoid coffee and limit water intake before bedtime
• Peripherally acting anticholinergic drug may be added to current therapy

Gastrointestinal Motility Problems

• Patients with Parkinson's disease commonly develop constipation and reduced gastric motility
  • Advise patient on diet, use of laxatives and other measures to improve gastrointestinal motility

• Patients on dopaminergic therapy frequently experience gastrointestinal adverse effects (eg anorexia, nausea and vomiting)
• Reduce dose or stop current drugs with anticholinergic effects
• May add Domperidone to current therapy

Erectile Dysfunction

• May consider use of Sildenafil