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Neurodegenerative Diseases Parkinson’s Disease
Non-motor Symptoms in Parkinson’s Disease
Angelo Antonini
Physician, Parkinson Institute, Milan, Medical Co-ordinator for Information Technology and Clinical Research, Department of Neuroscience,
Hospital ‘Istituti Clinici di Perfezionamento’, Milan, and Professor of Neurology, University of Milan-Bicocca
Abstract
Parkinson’s disease (PD) is the second most common neurodegenerative disorder after Alzheimer’s disease and is responsible for
significant morbidity and costs. Non-motor manifestations of PD can be as disabling as the classic motor symptoms. Moreover, medications
used to treat PD motor symptoms may have variable effects on these non-motor domains.
Keywords
Parkinson’s disease, autonomic function, cognition, dementia, urinary function, sexual dysfunction
Disclosure: The author has no conflicts of interest to declare.
Received: 26 August 2009 Accepted: 14 September 2009
Correspondence: Angelo Antonini, Parkinson Institute, Istituti Clinici di Perfezionamento, 20126 Milan, Italy. E:
angelo3000@yahoo.com
Non-motor symptoms (NMS) in Parkinson’s disease (PD) have gained psychiatric disorders, daily somnolence and autonomic dysfunction
relevance in recent years due to their impact on patient quality of (primarily postural hypotension).
life and their contribution to institutionalisation at an advanced
disease stage.
1,2
NMS are present at disease onset and some, such The prevalence of cognitive impairment over the course of PD is
as psychiatric and sleep disorders, may even precede motor difficult to quantify, with reported rates ranging from 8 to 93%
symptoms.
3,4
The pathophysiology of NMS is still poorly understood – depending on the population screened and the tests used.
8
Reported
dysfunction of both dopaminergic and non-dopaminergic systems rates of dementia also vary greatly, but it appears that PD dementia
contribute to their development. (PDD) develops in approximately 30–40% of PD patients. This means
that people with PD have a five- to six-fold increased risk of dementia
NMS include cognitive and psychiatric dysfunction, disorders of compared with healthy adults.
9,10
The risk of PDD increases with age
mood and affect, sensory dysfunction, sleep disturbances and and disease duration: PDD was diagnosed in 80–90% of patients by
various symptoms of autonomic dysfunction (see Table 1). the 90 years of age in one study, and in a cohort of patients living
Dopaminergic therapy can induce non-motor side effects such as with the disease for 20 years 83% were diagnosed with dementia.
11
orthostatic hypotension, hallucinations, somnolence and insomnia.
5
Braak and colleagues
6
suggested that degeneration in nuclei Cognitive dysfunction in PD primarily involves impaired working
involving non-motor domains, primarily the lower brainstem and memory and poor performance on visuo-spatial and executive tests;
olfactory systems, may occur before pathology begins in the however, memory and language problems may also be observed.
dopamine nigro-striatal system. This hypothesis has inspired studies
to determine whether olfactory changes and changes in sleep Psychiatric Features –
patterns may serve, in the future, as pre-clinical markers for PD. Psychosis and Depression
While the Braak hypothesis is intriguing in terms of our Psychiatric features are common in PD at all disease stages and
understanding of the pathological course of PD, NMS remain a major depression may even precede motor disability. Depression affects
factor in determining quality of life, progression of disability and approximately 40% of patients, with some reports as high as 70%,
nursing home placement. although only 4–6% of patients fulfil the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition (DSM-IV) criteria for major
Cognitive Impairment and Dementia depression.
12,13
There is no clear relationship between the degree
Cognitive dysfunction is quite common in PD patients, while only of motor symptoms (disease severity), age at onset, family history of
30–50% develop a clinically relevant dementia during the disease mood disorders or even past history of depression, and there does
course.
7
This is different from dementia with Lewy bodies (DLB), not appear to be a correlation with the development of depression in
where the onset of dementia coincides with Parkinsonian motor PD. Suicide is unusual, although it has been reported in patients who
symptoms. Cognitive dysfunction in PD is a subtle, slowly have undergone deep brain stimulation (DBS) surgery.
progressing process, although some cognitive impairment is often
noted much earlier in the course of PD. Additional clinical features Psychosis in PD affects roughly 40% of patients who are receiving
observed in cognitively impaired PD patients include hallucinations, dopaminergic therapy and may affect up to 10% of patients who are
© TOUCH BRIEFINGS 2009 25
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