Table Of ContentParkinson’s Disease and Nonmotor Dysfunction
C C N
U R R E N T L I N I C A L E U R O L O G Y
Daniel Tarsy, , S E
MD ERIES DITOR
Parkinson’s Disease and Nonmotor Dysfunction, edited by Ronald F. Pfeiffer
and Ivan Bodis-Wollner, 2005
Thrombolytic Therapy for Acute Stroke, Second Edition, edited
by Patrick D. Lyden, 2005
Movement Disorder Emergencies: Diagnosis and Treatment,edited by Steven J. Frucht
and Stanley Fahn, 2005
Inflammatory Disorders of the Nervous System: Pathogenesis, Immunology,
and Clinical Management,edited by Alireza Minagar and J. Steven Alexander, 2005
Neurological and Psychiatric Disorders: From Bench to Bedside,edited by
Frank I. Tarazi and John A. Schetz, 2005
Multiple Sclerosis: Etiology, Diagnosis, and New Treatment Strategies,edited
byMichael J. Olek, 2005
Seizures in Critical Care: A Guide to Diagnosis and Therapeutics,edited
byPanayiotis N. Varelas, 2005
Vascular Dementia: Cerebrovascular Mechanisms and Clinical Management,
edited by Robert H. Paul, Ronald Cohen, Brian R. Ott, Stephen Salloway, 2004
Atypical Parkinsonian Disorders, edited by Irene Litvan, 2005
Handbook of Neurocritical Care, edited by Anish Bhardwaj, Marek A. Mirski,
and John A. Ulatowski, 2004
Handbook of Stroke Prevention in Clinical Practice, edited by Karen L. Furie
and Peter J. Kelly, 2004
Clinical Handbook of Insomnia, edited by Hrayr P. Attarian, 2004
Critical Care Neurology and Neurosurgery, edited by Jose I. Suarez, 2004
Alzheimer’s Disease:A Physician’s Guide to Practical Management, edited
byRalph W. Richter and Brigitte Zoeller Richter, 2004
Field of Vision: A Manual and Atlas of Perimetry, edited by Jason J. S. Barton
and Michael Benatar, 2003
Surgical Treatment of Parkinson’s Disease and Other Movement Disorders, edited
byDaniel Tarsy, Jerrold L. Vitek, and Andres M. Lozano, 2003
Myasthenia Gravis and Related Disorders, edited by Henry J. Kaminski, 2003
Seizures:Medical Causes and Management, edited by Norman Delanty, 2002
Clinical Evaluation and Management of Spasticity, edited by David A. Gelber
and Douglas R. Jeffery, 2002
Early Diagnosis of Alzheimer's Disease, edited by Leonard F. M. Scinto
and Kirk R. Daffner, 2000
Sexual and Reproductive Neurorehabilitation, edited by Mindy Aisen, 1997
Parkinson’s Disease
and Nonmotor Dysfunction
Edited by
Ronald F. Pfeiffer,
MD
Department of Neurology, University of Tennessee Health Science Center,
Memphis, TN
and
Ivan Bodis-Wollner, ,
MD DSc
Departments of Neurology and Ophthalmology, State University of New York,
Downstate Medical Center, Brooklyn, NY
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Library of Congress Cataloging-in-Publication Data
Parkinson's disease and nonmotor dysfunction / edited by Ronald F. Pfeiffer
and Ivan Bodis-Wollner.
p. ; cm. -- (Current clinical neurology)
Includes bibliographical references and index.
ISBN 1-58829-316-5 (alk. paper)
1. Parkinson's disease.
[DNLM: 1. Parkinson Disease--complications. 2. Autonomic Nervous System
Diseases--etiology. 3. Behavioral Symptoms--etiology. 4. Sensation
Disorders--etiology. 5. Sleep Disorders--etiology. WL 359 P24654 2005] I.
Pfeiffer, Ronald. II. Bodis-Wollner, Ivan, 1937- III. Title. IV. Series.
RC382.P2577 2005
616.8'33--dc22
2004025976
Series Editor’s Introduction
Parkinson’s Disease and Nonmotor Dysfunction fills a major gap in the current rapidly growing
body of knowledge concerning Parkinson’s disease. Drs. Pfeiffer and Bodis-Wollner have correctly
perceived that many nonmotor features of Parkinson’s disease are given insufficient attention in the
medical literature. Unfortunately, they are often also given insufficient attention by the practicing
neurologists who see these patients. As recently pointed out, there is clearly much more to Parkinson’s
disease than depletion of the nigrostriatal dopamine system (1). Parkinson’s disease (not just mul-
tiple system atrophy) is a multisystem disorder, both pathologically and in its clinical manifestations.
This is clearly true for the various motor system abnormalities, which are not fully corrected by
dopamine replacement therapy strategies, but also for the nonmotor system abnormalities that are the
subject of this volume.
Although recently there has been increased awareness of the cognitive, psychiatric, and sleep
disorders commonly associated with Parkinson’s disease, many of their manifestations remain
under-recognized and their importance in managing patients is underestimated. Even less attention is
paid to the myriad of other nonmotor disturbances that plague these patients. For example, among the
autonomic disorders, although orthostatic hypotension is well recognized, it is usually attributed to
dopaminergic medications rather than to effects of the underlying disease. Urologic disorders are
also very familiar in these patients, but may not be properly understood or well managed. Beyond
this, there is much less awareness of the less common and less obvious autonomic disorders which
are herein reviewed chapter by chapter. Their link to Parkinson’s disease is usually unappreciated
and there is frequently an unfortunate tendency to attribute the symptoms they produce to advancing
age. Finally, unusual sensory and painful phenomena, dysphagia, fatigue, and visual deficits are
other less common features of this remarkably varied disease that readers of this book may become
acquainted with as signs of Parkinson’s disease for the first time.
This book highlights the fact that management of Parkinson’s disease requires a multidisciplinary
approach. This may not always require referral to a consultant but at least requires awareness of the
spectrum of nonmotor symptoms. Some of these symptoms may be more subtle than others. Under-
standably, many will not be forthcoming in the typical initial encounter in which more troublesome
motor symptoms usually dominate the visit. Some need to be elicited by careful inquiry on the part of
the medical caregiver. Symptom questionnaires may be especially useful in gathering symptoms that
can be returned to in subsequent visits. Knowledge and understanding of Parkinson’s disease is grow-
ing exponentially. This volume establishes the baseline of current knowledge and undoubtedly will
stimulate further fruitful inquiry in the field.
1. Lang AE, Obeso JA. Challenges in Parkinson’s disease: restoration of the nigrostriatal dopam-
ine system is not enough. Lancet 2004; 3:309–316.
Daniel Tarsy, MD
Parkinson’s Disease & Movement Disorders Center
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
v
Preface
The idea that Parkinson’s disease (PD) is characterized only by such motor features as tremor,
rigidity, bradykinesia, and postural instability is deeply embedded not only in the minds of patients
and their family members, but also in the training and practice of many physicians. However, even a
quick perusal of the amazingly perceptive clinical description that James Parkinson put to paper in
1817 reveals that from the beginning, various features not reflective of motor dysfunction were
recognized and described as being part of PD. It has only been relatively recently that attention has
been refocused on these nonmotor features, and the realization has grown that nonmotor features are
frequently present in PD and can be the source of considerable discomfort and disability for affected
individuals. In fact, it is not at all infrequent that these nonmotor features play a dominant role in the
clinical picture.
The growing recognition that nonmotor features are an important component of PD has, in turn,
led to the realization that these aspects of the condition have often received insufficient attention in
the current medical and lay literature. This volume on Parkinson’s Disease and Nonmotor Dysfunc-
tion is an attempt to at least partially correct that deficiency and provide a source of detailed informa-
tion describing and explaining these nonmotor features that can be readily accessed by the practicing
physician. To this end, a truly outstanding group of experienced researchers and clinicians has been
assembled to provide this in-depth review of nonmotor dysfunction in PD, which has been subdi-
vided into five diverse domains.
Behavioral abnormalities are problems encountered in the management of PD, particularly in
individuals with more advanced disease, which are both distressingly frequent and frequently dis-
tressing. They may be intrinsic components of the disease process itself (depression and dementia),
treatment-induced complications (psychosis and postsurgical behavioral changes), or a combination
of both (anxiety, obsessionality). Whatever their derivation, behavioral abnormalities can seriously
impact and impair quality of life for both patients and family members.
Autonomic dysfunction is often mistakenly considered to be a feature of multiple system atrophy
and not PD. In reality, individuals with PD can, and frequently do, display various features indicative
of autonomic dysfunction. Gastrointestinal, urogenital, cardiorespiratory, thermoregulatory, and other
aspects of autonomic function may become impaired in PD, not simply as consequences of medica-
tion-induced derangements, but as part of the disease process itself. These autonomic features often
develop in the later stages of the illness but may also appear early, occasionally even before the
classic motor components become evident.
Sleep-related dysfunction can be a source of considerable consternation, not only to patients but
also to their family members, who often suffer the indirect, and sometimes the direct (at least in the
setting of rapid eye movement sleep behavior disorder), consequences of the patient’s sleep distur-
bance. As with behavioral and autonomic dysfunction, sleep-related disturbances can be either dis-
ease-related or medication-induced and may occur both early and later in the course of PD.
Sensory dysfunction is perhaps the least well-known or recognized and also the most purely
nonmotor facet of nonmotor dysfunction in PD. Abnormalities of primary sensory function (vision
and olfaction) occur, as do more complex sensory phenomena, as exemplified by the visuo-cognitive
deficits and the various pain syndromes and disorders of sensation that may plague the patient with
PD.
Finally, a section of this volume is devoted to several problems (oculomotor dysfunction and
fatigue) that tread on, or perhaps cross over, the line between motor and nonmotor dysfunction in PD.
However, they are included here because they often are not covered extensively in the more tradi-
tional discussions of the motor features of PD.
vii
viii Preface
It is our hope that this collection of contributions by a truly tremendous contingent of authors will
serve to increase awareness of the contributions that nonmotor features may make to the collective
clinical picture experienced by the patient with PD. Early recognition of these features will lead, we
hope, to more prompt and effective treatment of them, a goal that can be firmly shared and appreci-
ated by both patient and physician alike.
Ronald F. Pfeiffer, MD
Ivan Bodis-Wollner, MD,DSc
Contents
Series Editor’s Introduction.............................................................................................................v
Preface................................................................................................................................................vii
Contributors.......................................................................................................................................xi
Part I. Behavioral Dysfunction in Parkinson’s Disease
1 Depression.................................................................................................................................3
William J. Burke, Steven P. Wengel, and Daryl Bohac
2 Anxiety.....................................................................................................................................13
Hubert H. Fernandez and Tanya Simuni
3 Obsessionality.........................................................................................................................25
Marie-Andrée Bruneau
4 Dementia..................................................................................................................................35
Patricia Kavanagh and Karen Marder
5 Psychosis..................................................................................................................................49
Eric S. Molho and Stewart A. Factor
6 Postsurgical Behavioral Changes........................................................................................75
Laurie M. Rilling, John A. Lucas, and Ryan J. Uitti
Part II. Autonomic Dysfunction in Parkinson’s Disease
7 Dysphagia................................................................................................................................95
Norman A. Leopold
8 Gastric Dysfunction.............................................................................................................105
Tanya Gurevich, Amos D. Korczyn, and Nir Giladi
9 Intestinal Dysfunction.........................................................................................................115
Ronald F. Pfeiffer
10 Impaired Sexual Function...................................................................................................127
Cheryl Waters and Janice Smolowitz
11 Urological Dysfunction.......................................................................................................139
Carlos Singer
12 Cardiovascular Autonomic Dysfunction.........................................................................149
David S. Goldstein
13 Thermoregulatory Dysfunction.........................................................................................159
Mark S. LeDoux
14 Respiratory Dysfunction.....................................................................................................173
Holly A. Shill
Part III. Sleep-Related Dysfunction in Parkinson’s Disease
15 Insomnia.................................................................................................................................181
Maria L. Moro-de-Casillas and David E. Riley
16 Rapid Eye Movement Sleep Behavior Disorder.............................................................191
Suzanne Stevens and Cynthia Comella
ix
x Contents
17 Excessive Daytime Sleepiness............................................................................................199
David Hardesty, Daryl Victor, and Steven J. Frucht
18 Sleep Apnea...........................................................................................................................209
Cheryl M. Carlucci and Robert A. Hauser
Part IV. Sensory Dysfunction in Parkinson’s Disease
19 Visual Dysfunction ..............................................................................................................223
Robert L. Rodnitzky
20 Primary Visual and Visuocognitive Deficits...................................................................233
Ivan Bodis-Wollner and Andrea Antal
21 Olfactory Dysfunction.........................................................................................................245
Sarah Furtado and Zbigniew K. Wszolek
22 Pain Syndromes and Disorders of Sensation..................................................................255
Blair Ford and Ronald F. Pfeiffer
Part V. Sensorimotor Dysfunction in Parkinson’s Disease
23 Oculomotor Dysfunction....................................................................................................271
Parashkev Nachev and Christopher Kennard
24 Fatigue....................................................................................................................................281
Carol Ewing Garber and Joseph H. Friedman
Index.................................................................................................................................................295
