Autonomic and Other Problems

Drooling may be accompanied by speech problems and dysphagia. Anticholinergics, botulinum toxin injections, and sublingual atropine can decrease drooling. Speech therapists perform swallowing studies to assess the risk of aspiration, and nutritionists optimize diet. Patients at high risk of aspiration or poor nutrition may require placement of a percutaneous endoscopic gastrostomy tube. Nausea improves if patients take their PD medications with meals or pharmacologic therapy (domperidone [in Canada] or trimethobenzamide). Sexual dysfunction or urinary problems may require a urolo-gic evaluation. Adjustment of PD therapy to increase on time, removal of drugs that decrease sexual response, and pharmacologic therapy (sildenafil or yohimbine) may help treat sexual dysfunction. Patients with urinary frequency may find a bedside urinal along with a decrease in evening fluids helpful. Improvement in PD symptom control can improve urinary frequency, but worsening symptoms may require cath-eterization or pharmacologic measures (oxybutynin, tolterodine, propantheline, imi-pramine, hyoscyamine, or nocturnal intranasal desmopressin). Anticholinergic drugs could cause urinary retention and constipation. Constipation can be improved by increased fluid intake, a fiber-rich diet, and physical activity. Patients should generally avoid cathartic laxatives and use stool softeners, osmotic or bulk-forming laxatives, glycerin suppositories, or enemas. Dyskinesia-related sweating may respond to PD therapy adjustment or ^-blockers. Orthostasis may respond to removal of offending drugs (tricyclic antidepressants, PD medications, alcohol, and antihypertensives) increasing carbidopa doses, or addition of salt or fluids to the diet, compression stockings, fludrocortisone, indomethacin, or mitodrine. Seborrhea usually responds to over-the-counter dandruff shampoos or topical steroids.2,6-8,11,12,46,47

Treatment of Response Fluctuations

© As the disease progresses, most patients develop response fluctuations. Treatment is based on optimizing the pharmacokinetic and pharmacodynamic properties of Parkinson s disease medications.

Treatment includes adjusting or adding medications to maximize the patient's on time, minimize the time on with dyskinesia, and minimize off time (Table 32-2). Use various dosage plans to minimize suboptimal or delayed peak levodopa concentrations by adding longer-acting medications to minimize wearing-off periods, adding or adjusting medications to stop an unpredicted off period, and providing treatments that decrease freezing episodes. It also involves adjusting or adding medications to decrease chorea, dystonia, diphasic dyskinesias, or akathisia. Patients should schedule activities when they are on. Patients can also keep an extra dose of medication with them when they are away from home in case their medication wears off.2,6,15,16,46-48

Table 32-2 Management of Motor Complications in Advanced PD

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