Evaluation and management of the non-motor features of Parkinson's disease.

Parkinson's disease (PD) is traditionally viewed as a motor disorder with a characteristic triad of tremor, rigidity and bradykinesia. There is now increasing awareness that PD is a complex systemic disorder with many nonmotor symptoms (NMS) which include autonomic dysfunction, sleep disorders, sensory and neuropsychiatric features. NMS become more common in severity and frequency with advancing disease when neuropsychiatric features such as cognitive impairment and psychosis dominate the clinical picture. NMS are strongly correlated with quality of life for patients and their families as well as institutional care placement. Despite their importance, NMS are poorly recognized by clinicians and often undeclared by patients. Use of a validated screening tool NMSQuest followed by specific symptom assessment instruments strengthens the recognition and holistic management of NMS in PD. Some NMS such as mood disturbance, anxiety, pain and insomnia may be improved by optimization of dopaminergic therapy. Conversely, psychosis, excess daytime somnolence or impulse control disorder (ICD) may be triggered by dopaminergic drugs. Other NMS such as dementia and severe depression may be unresponsive to dopaminergic treatment and may reflect perturbations in cholinergic, serotonergic or noradrenergic neurotransmitter function. These symptoms are more challenging to manage but may be ameliorated to some extent by agents such as acetylcholinesterase inhibitor or antidepressant drugs. This contribution reviews the evidence for the evaluation and management of key NMS in PD (apathy, anxiety, depression, psychosis, dementia, ICD, sleep disturbance, autonomic dysfunction, pain) and highlights the urgent need for both novel therapies and more controlled trials for current therapeutic strategies.