Autonomic Dysfunction in Parkinson's Disease
by Dr. Ehsan Hadi, MD, Dignity Health
Parkinson’s disease (PD) is the second most common neurodegenerative disorder, after Alzheimer’s disease, with a prevalence of 0.5–3% as the age advances. Parkinson’s disease is a slowly progressive brain condition, which manifests with both motor and non-motor symptoms. Parkinson’s disease falls into the category of neurodegenerative conditions that are called Synucleinopathies, which means there is abnormal accumulation in the brain of misfolded proteins called α-synuclein (αSyn). PD can also affect the autonomic nervous system (ANS), which is the part of our nervous system that regulates body functions including the heart, gut, sexual functions, urinary bladder, etc. Involvement of the ANS in PD can be asymptomatic or lead to some of the most debilitating symptoms affecting quality of life. Some of the common features of autonomic dysfunction reported in PD are below.
ORTHOSTATIC HYPOTENSION (OH): Defined as a fall in systolic blood pressure of 20 mm Hg or more and diastolic pressure of 10 mm Hg or more, when lying supine and then standing. OH can be asymptomatic, though symptoms can include light headedness, tiredness, thinking difficulty, passing out, neck and shoulder discomfort “coat hanger pain”, etc. Management includes minimizing/stopping blood pressure lowering medications, dietary modification (lowering intake of alcohol, reserving it to evening time, multiple small meals/reducing carbohydrates and sugar intake), maintaining adequate hydration/salt intake, compression stocking, etc. If response from above conservative measure remains inadequate, medications such as Fludrocortisone, Midodrine and Droxidopa can be tried.
DELAYED GASTRIC EMPTYING AND CONSTIPATION: Deposition of Alpha synuclein in the gastrointestinal system has also been noted and can lead to a variety of symptoms such as excessive drooling (Sialorrhea), nausea, delayed gastric emptying (Gastroparesis), difficulty swallowing, abdominal distention, constipation, etc. Reducing meal size, low fat diet, eating slowly, adding thickeners are helpful strategies for some of these symptoms though more specifically, for drooling medication like Glycopyrolate and Botulinum toxin can be tried. Additionally, constipation can be addressed by avoiding aggravating medications (opioids/anticholinergics), maintaining adequate hydration, regular exercise, increased dietary fiber, stool softeners, laxative
URINARY ABNORMALITIES: Bladder dysfunction occurs due to PD related changes that take place in the brain, commonly leading to bladder muscle contraction abnormalities i.e. over/under activity. Symptoms can include increased urinary frequency, urinary urgency or waking up frequently at night to urinate. Treatment includes behavioral modification i.e. timed bladder emptying, medications that relax bladder over activity such as Mirabegron, Solifenacin, botulinum toxin injection, etc. Additionally, a urology consult should also be considered.
SEXUAL DYSFUNCTION: Sexual dysfunction symptoms include erectile dysfunction, ejaculation problems, difficulty achieving orgasm, and hyper-sexual drive in males, whereas in women symptoms can include lack of lubrication, reduced sexual drive etc. Factors that may contribute to sexual dysfunction include depression/anxiety, excessive alcohol, smoking, medications such as Hydrochlorthiazide, Beta-blockers, Selective Serotonin inhibitors, etc. and previous prostate surgery. Treatment should emphasize lifestyle modification and discontinuing offending medications. Additional therapeutic options include PDE–5 inhibitors, vacuum pump, surgical placement of spinal prosthesis etc. Treatments of female sexual dysfunction are limited and include vaginal lubrication, hormonal therapy and psychotherapy. Depending on the symptoms — urology referral is typically recommended.
TEMPERATURE DYSREGULATION: Different areas of the brain are involved in maintenance of core body temperature, though loss of temperature regulation is thought to be due to peripheral nerve involvement. ANS dysfunction has been attributed to a variety of temperature related changes such as excessive or inadequate sweating. At times these symptoms can also occur in the setting of involuntary movements (dyskinesia) or PD medication wearing off and may benefit from PD medication optimization.
Secondary causes should also be investigated such as medications (antidepressants, anticholinergics), endocrine abnormalities (thyroid disorders, diabetes), etc.
by Dr. Ehsan Hadi, MD, Dignity Health
Parkinson’s disease (PD) is the second most common neurodegenerative disorder, after Alzheimer’s disease, with a prevalence of 0.5–3% as the age advances. Parkinson’s disease is a slowly progressive brain condition, which manifests with both motor and non-motor symptoms. Parkinson’s disease falls into the category of neurodegenerative conditions that are called Synucleinopathies, which means there is abnormal accumulation in the brain of misfolded proteins called α-synuclein (αSyn). PD can also affect the autonomic nervous system (ANS), which is the part of our nervous system that regulates body functions including the heart, gut, sexual functions, urinary bladder, etc. Involvement of the ANS in PD can be asymptomatic or lead to some of the most debilitating symptoms affecting quality of life. Some of the common features of autonomic dysfunction reported in PD are below.
ORTHOSTATIC HYPOTENSION (OH): Defined as a fall in systolic blood pressure of 20 mm Hg or more and diastolic pressure of 10 mm Hg or more, when lying supine and then standing. OH can be asymptomatic, though symptoms can include light headedness, tiredness, thinking difficulty, passing out, neck and shoulder discomfort “coat hanger pain”, etc. Management includes minimizing/stopping blood pressure lowering medications, dietary modification (lowering intake of alcohol, reserving it to evening time, multiple small meals/reducing carbohydrates and sugar intake), maintaining adequate hydration/salt intake, compression stocking, etc. If response from above conservative measure remains inadequate, medications such as Fludrocortisone, Midodrine and Droxidopa can be tried.
DELAYED GASTRIC EMPTYING AND CONSTIPATION: Deposition of Alpha synuclein in the gastrointestinal system has also been noted and can lead to a variety of symptoms such as excessive drooling (Sialorrhea), nausea, delayed gastric emptying (Gastroparesis), difficulty swallowing, abdominal distention, constipation, etc. Reducing meal size, low fat diet, eating slowly, adding thickeners are helpful strategies for some of these symptoms though more specifically, for drooling medication like Glycopyrolate and Botulinum toxin can be tried. Additionally, constipation can be addressed by avoiding aggravating medications (opioids/anticholinergics), maintaining adequate hydration, regular exercise, increased dietary fiber, stool softeners, laxative
URINARY ABNORMALITIES: Bladder dysfunction occurs due to PD related changes that take place in the brain, commonly leading to bladder muscle contraction abnormalities i.e. over/under activity. Symptoms can include increased urinary frequency, urinary urgency or waking up frequently at night to urinate. Treatment includes behavioral modification i.e. timed bladder emptying, medications that relax bladder over activity such as Mirabegron, Solifenacin, botulinum toxin injection, etc. Additionally, a urology consult should also be considered.
SEXUAL DYSFUNCTION: Sexual dysfunction symptoms include erectile dysfunction, ejaculation problems, difficulty achieving orgasm, and hyper-sexual drive in males, whereas in women symptoms can include lack of lubrication, reduced sexual drive etc. Factors that may contribute to sexual dysfunction include depression/anxiety, excessive alcohol, smoking, medications such as Hydrochlorthiazide, Beta-blockers, Selective Serotonin inhibitors, etc. and previous prostate surgery. Treatment should emphasize lifestyle modification and discontinuing offending medications. Additional therapeutic options include PDE–5 inhibitors, vacuum pump, surgical placement of spinal prosthesis etc. Treatments of female sexual dysfunction are limited and include vaginal lubrication, hormonal therapy and psychotherapy. Depending on the symptoms — urology referral is typically recommended.
TEMPERATURE DYSREGULATION: Different areas of the brain are involved in maintenance of core body temperature, though loss of temperature regulation is thought to be due to peripheral nerve involvement. ANS dysfunction has been attributed to a variety of temperature related changes such as excessive or inadequate sweating. At times these symptoms can also occur in the setting of involuntary movements (dyskinesia) or PD medication wearing off and may benefit from PD medication optimization.
Secondary causes should also be investigated such as medications (antidepressants, anticholinergics), endocrine abnormalities (thyroid disorders, diabetes), etc.
COVID-19: There is still limited information about the effects of COVID-19 specifically regarding Parkinson’s disease, having said that, given the frailty associated with Parkinson’s disease, it would be prudent to be cautious, prepared and follow the precautions recommended by public health departments/ CDC. During these challenging times, it cannot be emphasized enough the need for all, PD community specifically and the
community at large, to reach out to each other, offer support and assistance to those most vulnerable and share our resources.
community at large, to reach out to each other, offer support and assistance to those most vulnerable and share our resources.