NWPF

Non-Motor Symptoms

The following information highlights the most common non-motor symptoms associated with Parkinson's. More information on these problems is available in the treatment section and on the blog. 

COGNITIVE CHANGES
 Executive Dysfunction and Dementia

BrainpuzzleChange in cognition is not uncommon with executive functions and less commonly memory declines.  This can present as slowness in thinking speed (referred to as bradyphrenia) and difficulties with multitasking. The reductions in speed affect word finding, keeping up with conversations, and performing complex tasks, and dividing one’s attention and concentration. Memory abilities with Parkinson’s may be less efficient, but are usually not affected as much as Alzheimer’s patients are affected. People affected by Parkinson’s benefit from reminders and memory prompts.  

Common cognitive changes include:

  • Slowed thinking speed- give yourself time to complete a task.
  • Word finding difficulties- this is sometimes described as finding the right word or name for an object or person. Don’t let anxiety make this worse.
  • Trouble with multitasking- focus on one important task at a time rather than trying to do two things at once.
  • Difficulty organizing complex tasks, steps or instructions- try to keep tasks simple when possible.
  • Memory problems- appointment reminders, alarms, task organizers and task or event calendars help you remember important information.
Dementia

Dementia occurs in approximately 20 to 30% of people with PD. Cognitive problems in dementia have progressed to the point where an individual has more trouble completing or carrying out everyday activities or tasks, begins to require supervision and/or confusion/ Dementia with Parkinson's disease is generally divided into two types:

  1. Parkinson's dementia- Cognitive problems begin many years after PD is diagnosed. 
  2. Lewy body dementia (LBD) - Cognitive difficulties begin at or near the time of diagnosis. Common features of LBD include:

The major symptoms of LBD include change in a person’s cognitive abilities and behavior. These changes significantly impact daily living and are listed below:

  • Changes in alertness and attention – this is often described as a changing or fluctuating level of alertness or ability for a person throughout the day. Clues to the presence of fluctuations include excessive daytime drowsiness (if nighttime sleep is adequate) or daytime sleep longer than 2 hours, staring into space for long periods, and episodes of disorganized speech. Hallucinations, confusion, and agitation – these symptoms can be caused by medications such as typical antipsychotics and other medicines that affect brain function.
  • Problems with movement and posture. These symptoms may be similar to Parkinson’s movement problems.
  • Confusion
  • Cognitive problems similar to executive dysfunction seen in Parkinson’s disease. Memory is affected but usually less severe early in the course than that seen with Alzheimer’s disease.
  • Vivid dreaming, active dreaming or a condition called REM Sleep Disorder

Dementia can be mixed, that is, caused by more than one problem. Examples of mixed dementia include:

  • Alzheimer's disease
  • Vascular or dementia secondary to stroke.
BEHAVIORAL CHANGES
Depression

StressDepression is a mood disorder that affects how we think and feel. Depression can replace hope, joy, positivity, self-confidence, and possibilities with hopelessness, sadness, insecurity, and impossibilities. Depression can ‘color our world with shades of gray'. 

Many people with Parkinson’s experience depression. In fact, research studies report that up to 50% of people with Parkinson’s experience symptoms of depression. Depression can begin before the movement symptoms of Parkinson’s have become obvious otherwise termed a preclinical symptom. Some of the symptoms of depression could be:

  • Sad mood
  • Irritability
  • Change in sleep
  • Change in appetite
  • Loss of enjoyment
  • Apathy
  • Negative perception of one's performance
  • Sedation
  • Decreased interest in sex

The cause of depression in Parkinson’s is thought to occur from:

  • Biochemical changes (serotonin, dopamine, and norepinephrine) in brain regions that influence mood seen with Parkinson's.
  • A long-term problem that co-exists with Parkinson's
  • Circumstances and frustrations such as a reaction or response to your Parkinson’s diagnosis, life worries, social isolation, loneliness, or secondary to chronic frustrations when symptoms cause problems with everyday tasks.

Depression can occur:

  • Generalized
  • Non-motor flucutation-Present at end of medication dose
  • In the setting of other life stressors or frustration. Depression can be present at all times, as a reaction to having a bad day or when Parkinson’s medications start to wear off just before the next dose of medicine is due.
Anxiety

Anxiety can be experienced as nervousness, worrying, 
feeling jittery, having an unsettled mind or inability to concentrate or stop thoughts that interfere with daily activities or sleep. Common physiologic changes associated with anxiety include:

  • Palpitations, racing pulse,
  • Sweatiness,
  • Jitteriness,
  • Dizziness,
  • Atypical chest pain,
  • Nausea,
  • Loss of appetite,
  • Muscle tightness (especially in the neck, shoulder and trunk), and headache.
  • Worsening movement0 especially tremor, dyskinesia and freezing of gait

Anxiety can be part of your ‘worries’ about diagnosis, your future, or other life concerns. In addition, anxiety can be a symptom of Parkinson’s. It can be constant or change with your changing movement symptoms. For example, feelings of anxiousness can occur when Parkinson’s medications wear off usually prior to when the next dose is due. Certain movement symptoms can increase or worsen with anxiety, especially tremor and gait freezing. When anxiety is coupled to your movement problems, one problem can worsen the other, like a snowball effect. This is familiar to you if you have tremor as you may have noticed tremor increases at times of stress or anxiety and the increased tremor, in turn, increases anxiety. In addition to tremor, anxiety can worsen off states, dyskinesia, and motor initiation or freezing. Anxiety can cause or worsen restlessness, sleeplessness, fatigue, pain, bladder urgency, and even increase your sensitivity to medicines and their side effects. All in all anxiety can rob you of much needed energy.

Impulsivity control

Impulsivity-control problems are experienced in some individuals with Parkinson’s disease.  Impulse-control behaviors include a reduced ability to resist impulses and an increase in behaviors that impair social or occupational functioning. A person will continue these activities even with awareness of how these behaviors negatively impact your life, relationships and daily activities. Impulse control problems can be caused by all dopamine medicines but are more common with dopamine agonists (see treatment section.) Common behaviors include an increase in: 

  • Risk-taking activities
  • Compulsive gambling
  • Binge and overeating
  • Compulsive shopping or overspending
  • Hyper-sexuality
  • Hoarding 

Repetitive behaviors, such as compulsive manipulating or sorting of common objects, are referred to as “punding” when they are driven by a sense of desire or when the possibility of pleasure is associated with the activity. These behaviors are similar to ritualistic behaviors performed to reduce anxiety, as seen in obsessive-compulsive disorder.

Apathy

Apathy is a loss of interest or motivation for completing daily tasks, chores or activities that you are able to otherwise perform. Apathy can show itself as:

  • Cognitive- blunted 
  • Behavioral- lack of motivation for daily activities
  • Emotional- blunted mood

Apathy can be present with or without depression.  Medicines are not typically effective when depression is not present so a multifaceted approach is needed including help from friends, a structured schedule and occupational therapy.

Hallucinations 

Hallucinations are a side effect associated with dopaminergic medicines used to treat Parkinson’s disease motor symptoms. Hallucinations are an altered perception of how our brain interprets information it receives about our environment, surroundings, senses and/or body sensations. Hallucinations can be visual, auditory or tactile. The most common type of hallucinations in PD are visual in nature. They may range from the experience of a simple illusion such as ‘seeing’ a spot on the wall turn into a well formed object such as a spider or they me be more complex and actual visions that do not exist. Sights of people and animals are common hallucinations. A person can have insight into and reason through the fact that a hallucination is not indeed real. In more advance cases, insight is lost and hallucinations are interpreted as real without the ability to reason that they are not grounded in reality.

The risk of experiencing hallucinations if you have Parkinson’s disease increases with the following:

  • High levels of dopaminergic medicines. Specific medicines such as dopaminergic agonists, anticholinergic medicines and amantadine are associated with a higher risk of this problem.
  • Additive effect of other brain active medicines such as sedatives, sleeping aids, muscle relaxants, narcotic pain medicines and some bladder medicines.
  • Cognitive problems, confusion and dementia increases risk of hallucinations associated with Parkinson’s medicines.
  • Visual problems such as cataracts, glaucoma and reduced night vision can increase the risk of developing hallucinations especially at night. (Hallucinations are not directly caused by eye problems but reflect how the brain interprets sensory information. However, poor vision does exacerbate this problem in susceptible individuals.)
  • Stress can increase the risk – whether emotional, physical or the stress on your body from a medical condition or surgery.
Fatigue

Fatigue can be present throughout the day. Common causes of fatigue include:

  • Inadequate sleep
  • Anxiety and depression
  • Increased energy exertion secondary to movement problems
  • Reduced stamina and deconditioning
  • Secondary to medicines for movement, pain, mood 
  • A primary symptom of the disease itself
SLEEP
General sleep problems

SleepSleep problems are a very common complain. There are so many reasons why sleep is difficult. General sleep problems associated with Parkinson's include fragmented sleep. In this scenario, deep stages of sleep are reduced leading to earlier and more frequent awakening. Other problems that can affect fragmented sleep include:

  • Movement problems- Pain from muscle spasm or dystonia, wearing off of medicine effect, tremor and difficulty turning in bed/getting out of bed.
    • Dystonia or muscle cramps- Dystonia is an involuntary condition of the muscle that leads to muscle contractions causing cramping, pain and unwanted movement. Dystonia can be an off related problem occurring at times when medication is low.  This is why it can be a problem at night. Calf and foot dystonia (toes bending, curling or foot pulling) are common problems at night.  Treatment sometimes requires a slow release form of dopaminergic medicine given at night or medication dosing in the middle of the night.  Botulinum toxin is also helpful in some cases.
  • Bed Mobility and Comfort, i.e. difficulty turning in bed
  • Bladder problems- frequent and urgent urination (see next section)
  • Anxiety and worries
REM Sleep disorder (RBD)

This problem occurs during REM or dream sleep. Dreams are described as vivid, often physical. In this condition, patients do not lose muscle tone as normally occurs in this sleep stage allowing them to act out of dreams. This symptom can precede initial movements. Symptoms or problems include:

  • Punching, Kicking
  • Talking and Screaming
  • Getting out of bed while dreaming
  • Risk of injury to the patient and/or their care partner 
Sleep Apnea

Sleep apnea is a condition where a person fails to breath (termed apnea) sometimes for a long enough period of time to cause a drop in blood oxygenation.  Some people with sleep apnea, especially obstructive sleep apnea, snore loudly and awaken gasping for air. Up to 20% of people with Parkinson’s have sleep apnea. A sleep study may be needed for diagnosis. There are 2 types:

  • Central- the brain does not send the appropriate nerve signals to initiate and control regular breathing leading to long pauses while sleeping.
  •  Peripheral or Obstructive- caused by the block of airflow through the nose, mouth and breathing pathways.  Obstructive sleep apnea increases in people who are overweight and more fatty tissue leading to blockage of air passages.

Problems worsened by sleep apnea

  • Depression
  • High blood pressure
  • Increased heart disease and stroke risk
  • Confusion
  • Sedation
  • Headache 
LOSS OF SMELL

Olfactory BulbReduced sense of smell can be one of the earliest symptoms of Parkinson's disease sometimes beginning many years before diagnosis. Loss of smell can reduce sense of taste and/or interest in eating.

AUTONOMIC DYSFUNCTION
veggiesConstipation

Constipation is caused by slow movement of digested food through the intestine. Average number of bowel movements per week will vary for individuals and not everyone has a bowel movement every day. For some it is a minor nuisance well controlled by change in diet and activity. For others it can be a serious problem causing discomfort, use of stool softeners and supplements. Severe constipation, left untreated, can cause colon obstruction, dilation and in rare cases perforation. 

Weak abdominal wall muscles, pelvic and sphincter muscle dystonia can also cause problems with elimination.

Constipation is caused by dysfunction in the autonomic nervous system, a branch of the nervous system that regulates organ and body functions. Other causes include

  • Diet low in fiber from fruits, vegetables, grains, seeds and nuts
  • Dehydration or limited fluid intake
  • Decreased exercise
  • Certain medicines such as amantadine, anticholinergics, narcotics, sedatives and muscle relaxants 
Bladder problems

Bladder problems are common and can be caused by a combination of factors including Parkinson's associated changes bladder control by the autonomic nervous system referred to as neurologic bladder, and non-Parkinson's problems such as prostate disease in men and anatomical changes and weakness in women (often caused by changes from child birth.) Often a urology evaluation and testing of bladder function called urodynamic is needed to define what type of problem(s) you are having. Most common PD problems are:

  • Nocturia- frequently nighttime urination
  • Urinary urgency (also called overactive bladder) - sudden, intense feeling of needing to urinate due to over active bladder muscles.
  • Dyssynergica- difficulty urinating and slow bladder emptying with the urge

Stress incontinence- urination during coughing, laughing, sneezing, or exercising. This is quite common in women after childbirth or men after prostate cancer surgery and is often the cause of anatomical body changes and overactive bladder.   

Sexual Dysfunction

Problems with sexual function could include:

  • Disinterest in sex
  • Loss of intimacy due to physical symptoms, pain, fatigue
  • Difficulty maintaining an erection
Lightheadedness or Dizziness

ciculatorysystem (1)The term dizziness is often used to describe different feelings or sensations:

  • Dizziness is sometimes used to describe a feeling of imbalance or insecurity when standing. Dizziness on standing can have multiple causes including those below:
  • Lightheadedness from low blood pressure
  • Imbalance or postural instability  when standing causing you to feel dizzy or unstable
  • Anxiety
  • Confusion or sedation often described as feeling ‘dizzy inside my head”
  • Vertigo or inner ear problems

Dizziness from low blood pressure most commonly, is due to a condition called orthostatic hypotension, which is a drop in blood pressure that occurs when you move from a lying or sitting position into a standing position. This causes symptoms of lightheadedness or near fainting.

As Parkinson’s advances, the risk of orthostatic hypotension increases. Additional causes of this problem include:

  • Dehydration
  • Some medicines including dopamine medicines
  • Heart disease
  • Anemia 

Other problems caused by low blood pressure include:

  • Fatigue
  • Reduced stamina
  • Decreased mental alertness
 PAIN 

calfPain has many sources in Parkinson's including neurologic, muscular and skeletal. Pain associated with Parkinson's can be present at any time or as an off or end of dose related syndrome. The following problems or syndromes can cause pain or discomfort: 

  • Muscular pain due to muscle tightness, overuse, dystonia or excessive muscle contraction. This pain is sometimes described as a 'charley horse.'
  • Skeletal- arthritic pain is common with aging. Muscle weakness, change in posture, change in gait mechanics, restricted flexibility at a joint, dystonia and repetitive movements such as tremor or dyskinesia can increase joint pain. 
  • Neurologic changes can also cause pain. Examples include:
    • Abdominal pain unrelated to GI function
    • Off related pain - often described as burning in the limbs
    • Restless leg syndrome
VISION

SnellenchartLike other problems vision changes are often a combination of Parkinson's and non-Parkinson’s problems and aging. Glaucoma, cataracts, acuity changes with aging and macular degeneration are examples of non-PD problems. Vision problems associated with Parkinson’s include:

  • Motor- eye muscles lose their ability to move in coordination causing double or blurry vision.
  • Eye Opening- This has two causes
    • Blepharospasm of eye muscle closure
    • Opening apraxia or trouble initiating eye opening
  • Vision- contrast sensitivity and depth perception can be altered leading to problems with night or low light vision and gauging movement in space
  • Perceptions- referring to how are brain mis- interprets information from our environment ranging from perception of a presence in our peripheral vision,  illusions (i.e. spot on the ground is seen as a bug) or well-formed hallucinations described above.) Although not a problem with the eye itself, eye and vision problems can increase the risk for these problems.

Monique L. Giroux, MDMonique L. Giroux, MD
Medical Director, Northwest Parkinson's Foundation