Dr Robert HauserRobert A. Hauser, MD
Patients with Parkinson disease face a number of challenges from the symptoms of their disease, with motor challenges often topping the list of difficult-to-manage symptoms. Although, a new survey has suggested that perhaps nonmotor symptoms have a further negative impact on patient quality of life than their motor-affecting counterparts.

Conducted by PMD Alliance, the survey polled 700 patients and caregivers and found that 84% reported that these nonmotor symptoms have at least some negative effect on quality of life. Robert A. Hauser, MD, director, Parkinson's and Movement Disorders Center, University of Southern Florida, and coauthors noted that roughly 50% of patients deemed that these impacts were greater than their motor symptoms.

To find out more about the state of Parkinson care and if these symptoms are being approached properly, NeurologyLive spoke with Hauser in an interview. He detailed the medications which are currently available, what still needs to be developed, and what surprised him from the survey findings.

NeurologyLive: Is a collaborative care model ideal for intervening on the symptoms’ impact on things such as sleep and socialization? 

Robert A. Hauser, MD: Of course, I have the perspective of a Parkinson disease physician, so the answer is yes, there's a lot of need for collaboration. We each have our limits to our expertise. Most physicians who have expertise in Parkinson disease will go reasonably far in treating things like depression—sleep is another one, cognition is another one—but when we reach the limits of our abilities, when a person doesn't respond to pretty traditional anti-depressants, then we would refer them to a psychiatrist.

In the same breath, we have medications that treat hallucinations and we have pretty standard anti-hallucination medications. We feel it's under control, but in those patients who have refractory hallucinations, again, we would refer to psychiatry. Sleep is the same thing, many of us know some standards to sleep treatment, but if that's not successful then the sleep doctors are available to help us. Collaboration is very important, but you need to know your limits of where your knowledge is to evaluate and treat and take it as far as you can.

What therapies are currently being used for some of these symptoms?

Well, I will say that we've had 2 recent medications that were approved that are now in our armamentarium that are helpful. One is pimavanserin—trade name Nuplazid—for the treatment of Parkinson disease psychosis, which means hallucinations and delusions, so that's helpful. And in the area of what's called orthostatic hypertension, or neurogenic orthostatic hypertension, we have droxidopa (Northera). That helps raise people's blood pressure for these Parkinson patients who have low blood pressure, which causes lightheadedness. Those are 2 important advances, but probably the most impactful problem is cognition. Although we have some treatments, they're quite inadequate and for many of these other nonmotor things, we really need better treatments.

Many of these things get worse as the disease progresses over time, so that comes back to what we really need desperately: A way to slow disease progression. Ultimately, one day, to a way to diagnose the disease earlier and stop progressions so patients don't get dementia, so patients don't get psychosis, so that they don't get to the bad end points of the disease, where they get that lightheadedness and all these other things we're talking about. 

Are there more agents in the pipeline?

There are medications in the pipeline to potentially treat psychosis and potentially treat orthostatic hypertension. Maybe they'll bring something new to the table, we'll have to see how those clinical trials come out. 

Was anything particularly unexpected or surprising in any way from this survey?

One thing that was interesting was that when patients and care providers were asked how impactful nonmotor symptoms were, if you looked at very much or quite a bit impactful, 66% of the care providers said yes compared to only 33% of patients. Twice as many care providers indicated that these nonmotor symptoms were very much or quite impactful. To me, that was a pretty big difference, suggesting the care providers can see the impact themselves. To get a real assessment of these, other physicians should ask that about the care providers. Health providers should ask this of the care providers, not just the patients.

Transcript edited for clarity.

REFERENCE
Hermanowicz N, Jones SA, Hauser RA. Impact of non-motor symptoms in Parkinson’s disease: a PMDAlliance survey. Neuropysch Dis Treat. 2019;15:2205-2212. doi: 10.2147/NDT.S213917.