Sexually Active Life Linked to ‘Milder’ Disease Progression in Men with Early Stage Parkinson’s, Study Finds

sexual life and disease

An active sexual life is associated with less severe motor and non-motor disability and a better quality of life in men with early Parkinson’s disease, a study reports.

Its findings are “in line with data showing a close relationship between sexual health and general health both in healthy individuals and in patients with chronic disease,” its researchers wrote, calling on doctors to be watchful of their patients’ sexual life.

The study, “The PRIAMO study: active sexual life is associated with better motor and non‐motor outcomes in men with early Parkinson’s disease,” was published in the European Journal of Neurology.

Because people with Parkinson’s disease have to deal with important changes in sexual function, “achieving a satisfying intimate and sexual relationship is often a challenge.”

Data from previous studies indicate that patients’ sexual performance is affected by their illness, and men with erectile dysfunction, particularly, have worse disease progression.

It is important to stress, however, that an active sexual life — rather than a person’s sexual function — can serve as a general indicator of good health. But little is known about how sexual activity influences the course of Parkinson’s disease.

A team of researchers with the Center for Neurodegenerative Diseases (CEMAND) at the University of Salerno, Italy, analyzed data from a group of 355 people (238 men and 117 women) with early stage Parkinson’s disease who were enrolled in the PRIAMO (PaRkinson dIseAse non MOtor symptoms) study and followed for two years.

Researchers wanted to understand if an active sexual life associates with better outcomes, and how prevalent sexual dysfunction is among sexually active Parkinson’s patients.

Individuals were asked whether they had been sexually active in the past 12 months. Those who responded positively were then questioned about specific issues that arose in the last month, including reduced sexual desire, impotence, loss of erection, or inability to reach an orgasm.

Motor disability, cognitive abilities, and quality of life were measured using validated scales: respectively, the  UPDRS‐III, MMSE, PDQ‐39 and EQ-VAS scales. Depression and other non-motor symptoms were also evaluated.

Early stage Parkinson’s was defined as a score of 2 or lower in the Hoehn and Yahr (H&Y) scale, a five-stage measure of disease progression and disability level, at the study’s start.

Data showed that patients’ sexual activity progressively dropped over time, with 56.3% of patients reporting to be sexually active at the study’s start and 50.8% reporting the same two years later. Men were twice as likely to be active as women.

Nearly half of sexually active men complained about erectile dysfunction (difficulties with erection and impotence) and orgasmic disorders at every time point.

Sexually active men tended to be younger and to have had an earlier onset of symptoms than non-active male patients.

Noticeably, sexually active men were less likely to have gastrointestinal problems and less likely to be affected by apathy (a general lack of motivation and interest) than those not sexually active. The odds of lower chances of these non-motor symptoms were 44% (gastrointestinal problems) and 58% (apathy).

Male patients with an active sexual life were associated with less severe motor disability, better quality of life, and lower depression scores. At two years, they were taking levodopa less frequently and had lesser fatigue as well as attention or memory problems, “reflecting a milder motor impairment and disease progression,” the researchers wrote.

No association between sexual activity and disease symptoms were shown for women, which researchers suggested might be because of gender differences in symptoms and attitudes toward open discussion of sexual drive and difficulties, and the smaller group of female patients in the study.

“The most novel finding of our analysis was that, irrespective of disease severity as evaluated by the H&Y, sexually active men displayed distinctive demographic and clinical features,” the researchers wrote, adding that the findings suggest “that sexual activity might be associated with reduced motor and non‐motor burden and milder disease progression in men with early [Parkinson’s disease].”

They added that, from a “clinician’s perspective, examination of a patient’s sexual life is often neglected during the clinical interview.”

While further studies are needed to confirm such data, they “should prompt movement disorders specialists to periodically inquiry about their patients’ sexual life,” the team concluded.

It is important to note that all correlations between sexual activity and patient outcomes were controlled for patients’ age and disease duration.

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Sleep Deprivation May Amplify Cognitive and Emotional Issues in Parkinson’s, Study Finds

sleep deprivation studied

Not getting enough sleep may cause memory defects and emotional changes in Parkinson’s disease due to changes in dopamine metabolism, according to a study of zebrafish.

The study, “Sleep Deprivation caused a Memory Defects and Emotional Changes in a Rotenone-based Zebrafish Model of Parkinson’s Disease,” was published in Behavioural Brain Research.

Most Parkinson’s patients experience disease-related non-motor symptoms often preceding the onset of hallmark motor signs. Some of Parkinson’s non-motor symptoms include anxiety, apathy, mood changes, cognitive impairment and emotional disorders, which individually or taken together eventually affect patients’ quality of life.

“In addition to cognitive and emotional disorders, sleep abnormalities are also prevalent in [Parkinson’s disease],” the researchers wrote. “The problem of sleep is not only the characteristics of the disease itself, but also related to medication and dyskinesia such as tremor and rigidity.”

Sleep is an essential physiological process, and lack or shortage of sleep time causes fatigue, increase of mood swings, and can affect learning and memory. Some studies have shown that sleep deprivation can result in emotional and cognitive impairments.

Now, a team of Chinese researchers investigated the effects of sleep deprivation on locomotor activity, memory and emotional behavior in a zebrafish model of Parkinson’s disease.

To mimic the neurodegenerative disorder, animals were given rotenone — a pesticide that inhibits function of mitochondria (cells’ powerhouses) — which leads to cellular death and onset of parkinsonian features. People who come in contact with rotenone are at an increased risk of developing Parkinson’s disease.

Zebrafish were deprived of sleep for four weeks by being in an aquarium with around-the-clock lighting. Of note, fish usually are exposed to 10 hours of “lights off” a day. Rotenone-treated and sleep-deprived animals’ results were compared to control animals who were not given rotenone.

Rotenone-treated zebrafish exhibited parkinsonian-like symptoms, particularly slowness of movement. Motor symptoms’ progression was not aggravated by sleep deprivation.

Rotenone treatment alone impaired the zebrafishs’ memories. Compared to control animals, animals treated with rotenone that were sleep deprived had trouble memorizing and discerning similar objects that were presented to them, suggesting sleep deprivation further damages short-term cognitive deficits.

Not getting enough sleep also was found to worsen anxiety and depression-like behavior in the rotenone treated animals.

Scientists then sought to understand if the observed behavioral changes could  be related to the metabolism of dopamine – the chemical messenger that’s in short supply in Parkinson’s disease.

When compared to control animals, those treated with rotenone had lower levels of dopamine in the brain. However, sleep deprivation did not decrease dopamine concentrations any further. DOPAC, the principal metabolite (i.e., product of metabolism) of dopamine, which was reduced after rotenone treatment alone, had its levels restored upon sleep deprivation.

High levels of two types of dopamine receptors (to which dopamine binds), specifically D2 and D3, were observed in rotenone-treated zebrafish, in comparison to the control group. Interestingly, the levels of those same receptors significantly decreased after sleep deprivation.

Dopamine metabolism appears to be altered in rotenone-treated animals and sleep deprivation seems to play a part in such alteration, however there is not a clear understanding as to how this happens yet.

“[Z]ebrafish displayed an anxiety-depressed mood and a decline in memory after [exposure] to Rotenone, and sleep deprivation caused more severe phenotype [disease characteristics] in this model via altering the [dopamine] metabolism and D2 and D3 receptors,” the researchers wrote. “Our studies not only provided the understanding the roles of [sleep deprivation] in PD non-motor dysfunctions, but also provided a useful model for future pathogenesis and therapeutic studies,” they concluded.

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When Facing Darkness, We Must Fight to See the Light


There are days when it feels like we are surrounded by darkness. We live with so many unanswered questions about this illness that it can frustrate us. We often are surprised by so many twists and turns. Sometimes we forget that we must endure and do battle with the dark before we can see or enjoy the light.

When we get swallowed up in the dark places of our disease — the despair, the hopelessness, discouragement, and the depression — it is crucial that we take an active role in fighting it. Sometimes we must face that darkness, take control, and do battle until we see the light. And the light is there. However, we need to be facing in the right direction. Sometimes plowing through the darkness first is the only way to reach that light, or at least get us going on the right path.

We often can become lost in our thinking.

We have told ourselves lie after lie that in order to have a happily ever after, we must always be heading west into the perfect sunset and riding upon an unblemished, white stallion. However, more than likely, Parkinson’s disease will not have that happy ending (if lived out to its fullest) that we’ve been taught to dream about. There will not be a white stallion to ride upon as we gallop away. More than likely, we’ll be plopped into a wheelchair, and if we’re lucky, raced around the halls of a nursing home by a caring, but fun, nursing attendant who, hopefully, has enough smarts to buckle us in first.

Grief over the loss created by this disease may be where you are dwelling right now. The loss of freedom or the ability to do what you used to be able to do. The loss of a loved one to this illness. The loss of a dream because of Parkinson’s. The loss of something tangible, real, and of value — the loss of life as you knew it before you found out you had Parkinson’s disease.

You may be experiencing denial or bargaining with God over this whole “mess.” Perhaps you’re in the pit of depression or feel angry about your current condition. Maybe you’re beginning to see some light in the form of acceptance. That acceptance can be something as small as agreeing to take a new pill in hopes of it working better than the old one. Perhaps you’ve been given the go-ahead for deep brain stimulation and decided to go for it. Maybe you’ve just bought a new shirt that you don’t have to fight to button. 

Wherever you’re at, don’t be afraid of the darkness that often seems to follow you and others with this disease. Face it fighting. Face it determined to win and expect to see the light. 


Note: Parkinson’s News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Parkinson’s News Today or its parent company, BioNews Services, and are intended to spark discussion about issues pertaining to Parkinson’s disease.

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Patients with Bipolar Disorder at Higher Risk of Developing Parkinson’s, Study Suggests

bipolar disorder

Patients with bipolar disorder appear to have a nearly seven times higher risk of developing Parkinson’s disease later in life, according to a nationwide study in Taiwan.

The study, “Bipolar disorder and risk of Parkinson disease: A nationwide longitudinal study,” was published in the journal Neurology.

An association between major depressive disorder and Parkinson’s disease has been suggested in previous studies. But such an analysis has not been conducted in people with bipolar disorder, which is characterized by unusual shifts in mood, energy, and activity levels.

Data from a hospital registry previously showed that people with manic or depressive episodes — both experienced by those with bipolar disorder — had an increased risk of being diagnosed with Parkinson’s, but the temporal link between these two events had not yet been properly assessed.

To address this lack of knowledge, researchers conducted a longitudinal study using Taiwan’s National Health Insurance Research Database. Clinical records from 56,340 patients with bipolar disorder (mean age 40 years) and 225,360 healthy individuals, collected between 2001 and 2009 and followed until 2011, were evaluated. None of the participants had a history of Parkinson’s or related diseases at the start of the study.

Patients with bipolar disorder developed Parkinson’s significantly more often than those in the control group (0.7% vs, 0.1%). These patients also had a shorter time from enrollment to Parkinson’s disease diagnosis (4.2 vs. 6.5 years), and were younger when Parkinson’s was identified (64.2 vs. 73 years).

Use of antipsychotic agents was found to have no impact on these findings. The prevalence of cerebrovascular diseases, traumatic brain injury, hypertension, dyslipidemia (abnormal levels of lipids), and diabetes did not differ between the two groups.

Further analysis revealed that adult bipolar patients were about 6.78 times more likely to develop Parkinson’s than controls, while bipolar patients older than 65 had a 3.87 times higher risk.

Patients with a high frequency of hospital admission (more than two times per year) for psychiatric episodes were found to have 5.62 times higher risk of Parkinson’s than patients admitted less than once a year. Also, two or more psychiatric admissions for manic/mixed or depressive episodes were associated with a greater likelihood of having Parkinson’s.

“Our population-based longitudinal study found that patients with bipolar disease had an increased risk of developing [Parkinson’s] later in life compared to the controls,” the researchers wrote.

“Additional experiments are required to obtain a deeper understanding of the mechanisms involved” in the development of these two disorders,” they said. In addition, “medical practitioners should be aware that the risk of subsequent [Parkinson’s] should be particularly considered in patients with bipolar disease, especially those with multiple psychiatric admissions for mood episodes.”

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Early Involvement of Caudate Brain Region Linked to Worse Prognosis in Parkinson’s Patients, Study Finds

caudate involvement

Almost half of people in the early stages of Parkinson’s disease already have signs of neurodegeneration in a brain region called the caudate, which was previously thought to affect mostly those at advanced disease stages, a study reports.

Early caudate involvement on both sides of the brain, as seen by DaTscan imaging of the brain, appeared to predict the risk for worse outcomes, including cognitive impairment, depression, and gait problems, over a four-year follow-up period.

These findings suggest that caudate involvement detected through DaTscan neuroimaging may serve as an early biomarker to identify patients at a greater risk of faster disease progression in the near future.

The study, “Clinical implications of early caudate dysfunction in Parkinson’s disease,” was published in the Journal of Neurology, Neurosurgery & Psychiatry.

Parkinson’s disease is believed to be caused by the impairment or death of dopamine-producing nerve cells (neurons) in a region of the brain called the substantia nigra, which controls the body’s balance and movement.

When the disease is established, or advanced, the degeneration of dopaminergic neurons and nerve fibers frequently extends to a brain region called the caudate nucleus. This region plays important roles in motor control as well as in various other non-motor tasks, such as learning and sleep.

In fact, the loss of dopaminergic function in this region is known to contribute to the hallmark symptoms of Parkinson’s including cognitive impairment, depression, sleep disorders, and gait problems.

Although less common, caudate dopaminergic dysfunction may also emerge in the early stages of the disease, in which case it could also contribute to the onset of non-motor symptoms. However, the frequency of this specific brain impairment in early Parkinson’s is unknown as are its clinical implications for patients.

To address this lack of knowledge, a team, led by researchers at the University of Milan in Italy and Newcastle University in England, investigated the prevalence of caudate dopaminergic dysfunction in people who were still in the very early stages of Parkinson’s.

By comparing the participants’ state at the beginning of the study and four years later, they also looked for associations between caudate involvement and an increased risk of disease progression.

They analyzed clinical data from 397 patients who had had a Parkinson’s diagnosis for two years or less, and were participating in the Parkinson’s Progression Markers Initiative (PPMI), an ongoing study attempting to identify biomarkers of disease progression. The team compared the collected clinical data from Parkinson’s patients with that of 177 healthy volunteers.

Caudate dysfunction was detected using 123I-FP-CIT single-photon emission computed tomography, commonly known as DaTscan. This is an imaging technique that depicts the levels of dopamine transporters in the brain that is often used to confirm a Parkinson’s diagnosis.

Based on DaTscan imaging data, the participants were divided into three groups: those who had no reduction of dopamine transporters, those who showed reduction in just one side of the brain, and those who had involvement of both sides of the brain.

Initial data showed that 51.6% of the patients had signs of normal caudate dopamine function, while 26% had caudate dopaminergic dysfunction on one side of the brain (unilateral), and 22.4% on both sides (bilateral).

Four years later, the patients who initially had bilateral caudate involvement were found to experience more frequent and worse cognitive impairment and depression, and more severe gait disability.

In general, after four years of follow-up, more patients showed a loss of dopaminergic nerve fibers in the caudate, compared with the study start, affecting 83.9% of patients (unilateral 22.5%, bilateral 61.4%).

“In this study, we have demonstrated a high frequency of early caudate dopaminergic dysfunction in patients with recently diagnosed [Parkinson’s disease],” the researchers wrote.

“Our study suggests that early bilateral caudate dopaminergic dysfunction is associated with an increased frequency of clinically significant depression and to worse depressive symptoms, regardless of age,” they added.

DaTscan parameters used to define the presence of early caudate dysfunction may be a “valid indicator of more rapid onset of such symptoms,” they said, which may help in “identifying patients at risk of clinical progression to cognitive impairment, depression, and gait problems in the near future.”

Assessment of caudate dopaminergic denervation may also assist clinicians in better predicting disease course at an early stage and identifying patients who may benefit the most from early, targeted disease-modifying therapies.

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Empathy Is One Thing, but Apathy Is Quite Another

Empathy and apathy

Two words are often confused with each other in the English language: empathy and apathy. Not only are their meanings different, but they are also quite at opposition with each other. Both terms, however, can relate to Parkinson’s disease.

Empathy deals with being able to understand the thoughts and feelings of others. People with Parkinson’s are empathetic toward other people with the disease because they can understand and relate personally to what they are experiencing. A caregiver can empathize with another caregiver.

Apathy is a whole different ballgame. 

Apathy is not caring about much of anything in life. 

To take it a step further, I once heard someone put it this way: Apathy is not caring about whether or not you care.

It is easy to become apathetic when living and struggling with a chronic illness such as Parkinson’s disease. You may begin to notice that you don’t have the energy to do much of anything, nor do you have the motivation to want to do anything. You don’t have the stamina. With Parkinson’s, it’s easy to feel your staying power begin to fizzle away and your stick-to-itiveness begin to unstick. You feel like quitting. Nothing seems to hold meaning or purpose for you any longer. 

Other people with Parkinson’s would empathize with how you feel. They would understand your lack of motivation, for it can come with the disease. Apathy eats away at you, until getting out of bed, off the couch, or out the door is as tough for a person with Parkinson’s as it is for them to tie their own shoes or button their own shirt. And we know how difficult those things can be! Apathy, however, is even more difficult to deal with. You just quit caring, but not because you want to. 

Apathy sneaks in and tries to rob you of your joy, your motivation, your everything.

Should you begin to notice the signs of apathy in yourself or in a loved one with Parkinson’s disease, it is extremely important that you take measures to deal with it, as it can easily become a downward spiral that can be difficult to stop. Force yourself to get up and get out. Ask a friend to come over. Take a walk. Visit an animal shelter and find a new friend. Talk to your doctor as soon as you can. 

Don’t wait to bring the issue out into the open with someone you trust. Life’s too short to let what you have left slip away to yet another symptom of this chronic disease.


Note: Parkinson’s News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Parkinson’s News Today or its parent company, BioNews Services, and are intended to spark discussion about issues pertaining to Parkinson’s disease.

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Mindfulness Yoga May Reduce Anxiety, Depression in Parkinson’s Patients, Study Suggests

mindfulness yoga

Yoga focused on mindfulness — a mental exercise focused on accepting oneself in the present — could lower anxiety and depression as well as motor impairment in people with mild to moderate Parkinson’s disease, a study says.

The study, “Effects of Mindfulness Yoga vs Stretching and Resistance Trainiang Exercises on Anxiety and Depression for People With Parkinson Disease A Randomized Clinical Trial,” was published in the journal JAMA Neurology.

As many as half of Parkinson’s patients experience anxiety and/or depression, but these psychological effects are often overlooked by researchers.

Previous research has shown that exercising can provide health benefits for people with Parkinson’s. Similarly, mind-body exercises — yoga, dance, tai chi, etc. — have been shown to have benefits for physical health. These exercises also often include a mental or spiritual component, so they could have a positive impact on patients’ psychological health as well.

To study this, researchers recruited people with mild to moderate Parkinson’s at several centers in Hong Kong. All patients were able to stand and walk unaided; those being treated for psychiatric disorders (e.g., patients taking antidepressants) were excluded.

The patients were divided into two groups: 71 participated in a mindfulness yoga program tailored for people with Parkinson’s; and 68 participated in a stretching and resistance training exercising regimen. Both groups, which were similar in terms of demographic characteristics and initial clinical features, met once a week for eight weeks.

Participants in both groups showed comparable improvements in motor function over the course of the study.

Patients who participated in mindfulness yoga, in addition to physical improvements, showed significant reductions in symptoms of anxiety and depression.

“These benefits were remarkable because the participants who received the [yoga] intervention attended [an average] of only 6 sessions,” the researchers wrote.

Those who participated in the resistance training and stretching group showed no change in psychological symptoms.

“These findings suggest that mindfulness yoga is an effective treatment option for patients with PD [Parkinson’s disease] to manage stress and symptoms,” the researchers wrote, adding that “considering that PD is not only a physically limiting condition but also a psychologically distressing life event, health care professionals should adopt a holistic approach in PD rehabilitation.”

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Parkinson’s Patients with Diabetes at Higher Risk of Impulse Control Disorders, Other Issues, Study Suggests

diabetes, Parkinson's

Untreated Parkinson’s patients who also have type 2 diabetes mellitus may be at a higher risk of developing impulse control disorders, severe depression, apathy, and sleep problems, research suggests.

The study, “Preexisting Diabetes Mellitus is Associated with More Frequent Depression and Impulse Control Disorders in Drug Naïve Parkinson’s Disease” will be presented during the 14th​ International Conference on Alzheimer’s and Parkinson’s Diseases and related neurological disorders March 26-31 in Lisbon, Portugal.

Higher doses of dopamine agonists — which act as a substitute for (or mimic) dopamine in the brain — and longer treatment periods have been seen to make Parkinson’s patients more prone to developing impulse control disorders, including gambling, compulsive shopping, over-eating, and compulsive sexual behaviors.

Evidence indicates that type 2 diabetes increases the risk of developing Parkinson’s disease. Interestingly, an association among type 2 diabetes, depression, and impulse control behaviors has also been suggested.

Researchers from the University of Pécs in Hungary sought to study the impact of pre-existing type 2 diabetes mellitus on Parkinson’s-related non-motor symptoms and on impulse control behaviors in people with Parkinson’s not yet taking prescribed antiparkinsonian medications.

The team performed detailed neurological and neuropsychological examinations on 299 newly diagnosed Parkinson’s patients who were not on any medication.

Of these Parkinson’s patients, 77 (25.8%) had pre-existing type 2 diabetes. Diabetic Parkinson’s patients were older, heavier (with a higher body mass index) and included more men. Importantly, and in comparison to non-diabetic Parkinson’s patients, diabetic patients had more severe depression, apathy, sleep problems and more severe non-motor symptoms, measured by the Non-Motor-Experiences of Daily Living part of the Movement Disorders Society-sponsored Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) and the Non-motor Symptoms Scale.

Scientists also reported that 40.3% of Parkinson’s patients with diabetes had impulse control behaviors, which was significantly different from the 22.3% observed in the non-diabetic sample.

Untreated Parkinson’s patients with diabetes were 3.58 times more likely to have impulse control disorders. Due to this, type 2 diabetes mellitus was considered to be an independent predicting factor for the development of these behavior disorders.

Preexisting diabetes may be a risk factor for more frequent impulse control disorders and more frequent and more severe depression, apathy and sleep problems in drug naïve PD patients. However, further prospective longitudinal studies are warranted to study its effects on the disease course,” the researchers concluded.

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Review Study Provides Update on Treatments for Parkinson’s Non-motor Symptoms

non-motor symptoms, Parkinson's

Although there are now more treatment options available for non-motor symptoms in Parkinson’s disease, a lack of evidence on their effectiveness and safety means that more studies and new therapeutic strategies are needed, according to a review study.

The study, “Update on Treatments for Nonmotor Symptoms of Parkinson’s Disease — An Evidence‐Based Medicine Review,” appeared in the journal Movement Disorders.

The International Parkinson and Movement Disorders Society Evidence-Based Committee reviewed research published from 2011 through 2016 on Parkinson’s non-motor symptoms to help physicians select the most effective treatments and provide an update to a 2011 study.

Two online databases were searched, resulting in the inclusion of 37 studies with 20 patients or more. In all of the included studies, treatment lasted a maximum of six months, except for one low-quality safety study, meaning the recommendations do not cover long-term symptom management, the team noted. The studies included pharmacological, surgical, and nonpharmacological interventions, which had to be available in at least one country.

According to their level of evidence, the different approaches were classified as efficacious, likely efficacious, unlikely efficacious, non-efficacious, or with insufficient evidence. To address practice implications, the team also rated the interventions as clinically useful, possibly useful, and unlikely useful, not useful, or investigational.

Christopher G. Goetz, MD, president of the International Parkinson and Movement Disorders Society, noted the differences between this approach and practice guidelines issued by medical associations such as the American Academy of Neurology. In a Neurology Today article written by Susan Fitzgerald, titled “Which are the Most Efficacious Therapies for Nonmotor Parkinson Disease Symptoms?” he said that “guidelines are really culturally based,” and take into account “regulatory issues, access issues, and insurance issues.”

“With evidence-based methodology, we are strictly looking at the published evidence. We don’t tell you whether we recommend it (a specific therapy),” he added.

No clinical trials met the inclusion criteria for the treatment of anxiety disorders, excessive sweating, rapid eye movement behavior disorder, and olfactory or ophthalmologic dysfunction.

Six new studies were reviewed for depression. One addressed venlafaxine, characterized as efficacious, with an acceptable safety risk and no need for specialized monitoring, and clinically useful. This contrasted to amitriptyline, which has insufficient efficacy evidence to treat depression in Parkinson’s patients and was rated as possibly useful. Paroxetine, citalopram, fluoxetine and sertraline, all selective serotonin reuptake inhibitors (SSRIs), were categorized in a similar way.

Rotigotine, marketed as Neupro, was found unlikely efficacious based on the results of one study, and rated as investigational regarding practice implications. Rasagiline, marketed as Azilect, also showed insufficient evidence of efficacy and was classified as investigational as well.

As for nonpharmacological interventions, two studies on repetitive transcranial stimulation showed inconsistent effects on depression. However, its benefits in the general population and in specific measures in people with depression make this approach possibly useful for short-term treatment of Parkinson’s.

Cognitive-behavioral therapy (CBT) could only be rated as likely efficacious and has insufficient safety evidence in the treatment of depression in Parkinson’s due to the lack of replication of its benefits, the investigators cautioned.

Treatments for apathy were also evaluated. Rivastigmine, marketed as Exelon, was found efficacious in one study, but its small group of patients mean that this medication is only possibly useful in the clinic. A similar conclusion was reached for piribedil following deep brain stimulation. In contrast, Neupro was classified as unlikely efficacious based on one trial.

As for the treatment of impulse control disorders, naltrexone, marketed as ReVia, showed insufficient efficacy and safety evidence, while CBT was rated as likely efficacious and possibly useful clinically based on one new study.

Regarding dementia, Aricept (donepezil) and Razadyne (galantamine) still have insufficient efficacy evidence, but were rated possibly useful in clinical practice due to their established benefits outside Parkinson’s.

Both rasagiline and rivastigmine have insufficient efficacy evidence to treat cognitive impairment. A similar conclusion was reached for transcranial direct current stimulation and for cognitive rehabilitation in patients on computer-based cognitive training.

Three new studies were evaluated for psychosis. While olanzapine, marketed as Zyprexa, is not efficacious and therefore not useful from a clinical perspective, Nuplazid (pimavanserin) was characterized as efficacious over six weeks and clinically useful. Seroquel (quetiapine) has insufficient evidence though it is possibly useful in the clinic.

Studies of sleep disorders indicated that Lunesta (eszopiclone) and melatonin have insufficient evidence for the treatment of insomnia, but are possibly useful. Modafinil, marketed as Provigil, is also possibly useful for excessive daytime somnolence and sudden onset of sleep in people with Parkinson’s. Continuous positive airway pressure was considered likely efficacious and possibly useful in lessening daytime sleepiness in patients with obstructive sleep apnea, and Neupro was rated the same for improving sleep quality in Parkinson’s patients.

Assessed treatments of orthostatic hypotension — defined as a drop in blood pressure when standing up — included midodrine and fludrocortisone, marketed as Florinef. Although both have insufficient efficacy evidence, they are classified as possibly useful in the clinic due to benefits seen in clinical trials.

The only trial concerning urinary dysfunction addressed solifenacin, marketed as VESIcare, as a treatment for overactive bladder. It showed that this medication has insufficient evidence on efficacy, but is possibly useful in clinical practice due to benefits observed outside Parkinson’s, while having an acceptable safety risk without specialized monitoring.

One other study addressed erectile dysfunction. Viagra (sildenafil) was considered efficacious and clinically useful, with data in the general population indicating an acceptable safety risk.

Similar efficacy and clinically utility conclusions were presented for botulinum toxin B as a therapy for drooling. Both botulinum toxin type A and B should be administered by well-trained physicians with access to specialized monitoring tools, the researchers emphasized.

Three studies evaluated approaches for gastrointestinal dysfunction. Results of one trial led to lubiprostone, marketed as Amitiza, being considered likely efficacious and possibly useful to treat constipation in people with Parkinson’s. Its safety data in the general and elderly populations indicate that lubiprostone has an acceptable risk in Parkinson’s patients.

Probiotics were categorized as efficacious and clinically useful, which support their over-the-counter use and lack of safety concerns. In contrast, abdominal massages with lifestyle advice have insufficient evidence on safety and efficacy to ease constipation.

Rasagiline was also evaluated as an approach for fatigue, considered efficacious and possible useful based on one small study. One trial analyzed acupuncture in Parkinson’s, but although benefits were found, this approach still has insufficient efficacy evidence.

For pain, prolonged-release oxycodone-naloxone has insufficient evidence, but is possibly useful for Parkinson’s patients with chronic pain, with an acceptable safety risk without specialized monitoring. Rotigotine also has insufficient evidence as a way to lessen pain in Parkinson’s patients, despite benefits seen in one trial.

Overall, despite the substantial growth in the evidence base of approaches for non-motor symptoms in Parkinson’s, this update shows that treatment options remain limited, making the development and testing of new therapies “a top priority,” the team said.

According to Daniel Weintraub, MD, research on Parkinson’s psychiatric and cognitive symptoms is key due to the specificity of the disease compared with the same manifestations found in the general population. He also said this update may help investigators spot areas in need of clinical trials, such as anxiety.

Laura Marsh, MD, a professor of psychiatry and neurology at Baylor College of Medicine, cautioned that although the new review provides “a useful analysis for clinicians to consider,” they still have to practice “the art of medicine.” This involves challenges such as evaluating if dopaminergic therapies for motor function are causing non-motor side effects and what symptom to address first in people with more than one of these complications, she said.

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Apathy and Depression Linked to Sleep Disorder in Parkinson’s Patients, Study Finds


Symptoms of apathy and depression are more frequent and severe in Parkinson’s patients with rapid eye movement sleep behavior disorder (RBD) than in patients without this disorder, according to a study.

Findings also showed that women with Parkinson’s and RBD are more likely to experience apathy than men.

The study, “Apathy in Parkinson’s disease with REM sleep behavior disorder,” was published in the Journal of the Neurological Sciences.

RBD affects up to half of Parkinson’s patients and often appears several years before motor symptoms. People with Parkinson’s and RBD typically experience more non-motor symptoms such as cognitive impairment, daytime sleepiness, and depression than those without RBD.

Apathy is very common in Parkinson’s patients and affects the treatment and long-term outcomes of the disease. Recent evidence showed a high prevalence of apathy in people with RBD and depression, but studies on the association between these disorders in Parkinson’s patients are still lacking.

Researchers at the University of Bern in Switzerland addressed this shortcoming by analyzing the motor function of 64 Parkinson’s patients, using the modified Hoehn & Yahr stage and the Unified Parkinson’s Disease Rating Scale (on and off dopaminergic medication), prior to deep brain stimulation from 2012 to 2016.

Non-motor assessments included the Starkstein apathy scale (SAS), the Hamilton depression rating scale, the Epworth sleepiness scale, and the mini-mental state examination of cognitive impairment. No patient had relevant cognitive deterioration or dementia.

Of the patients, 26 (40%) fulfilled the criteria for RBD (mean age of 62.6 years, Parkinson’s duration of 12.8 years), while 38 did not (mean age of 63 years, disease duration of 11.4 years). Motor function of the two groups only differed in the UPDRS part 2 score, related to daily living activities. This score was higher in patients with RBD when specifically analyzing the periods they were off medication.

Among the patients with RBD, 52% had apathy, defined as a score of 14 or higher on the SAS, while 50% had more symptoms of depression. In the group without RBD, apathy was observed in 42% of patients and depressive symptoms in 20% of them.

Patients with RBD had significantly higher mean apathy and depression scores, indicating greater severity, than those without this disorder. Higher apathy scores were especially seen in women. In contrast, the results of sleepiness and cognitive function were similar between the two groups.

“In [Parkinson’s], RBD is associated with isolated apathy and increased severity of depressive symptoms, independent of medication, motor and other non-motor symptoms,” the researchers wrote.

As for patients without depression, an increased apathy score was found in 53% of those with RBD and 29% of those without RBD. The data also showed that 58% of those with RBD and 64% of those without RBD had increased depressive symptoms but not an increased apathy score.

According to the researchers, this finding means that although their overlap is well-known, “apathy should not be considered as a mere symptom of depression.”

In the group with RBD, women showed more frequent and more severe apathy, as well as more frequent use of antidepressants than men, but these were not statistically significant. However, gender was the only independent predictor of apathy in the group with RBD, with women having a higher risk. No other gender difference was found.

This study suggests that patients with Parkinson’s and RBD “should receive targeted medical attention to improve diagnosis, monitoring and management of neuropsychiatric symptoms and their consequences,” the researchers concluded.

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