Key takeaways
- Parkinson’s affects far more than movement. Symptoms like mood changes, sleep problems, constipation, dizziness, urinary issues, pain, and thinking changes are common—and often more disruptive to daily life than tremor or stiffness. The good news: most are treatable when you name them early and build a plan with your care team. (Parkinson’s Foundation)
- Screen routinely. Simple tools like the Non‑Motor Symptoms Questionnaire (NMSQuest) and the MDS Non‑Motor Rating Scale (MDS‑NMS) make it easier to spot problems you might not think to mention. Bring a completed checklist to visits. (Movement Disorders Society, PMC)
- Match treatment to the symptom. From cognitive‑behavioral therapy (CBT) for depression/anxiety to melatonin or clonazepam for REM sleep behavior disorder (RBD), midodrine or droxidopa for low blood pressure on standing, and rivastigmine or pimavanserin for thinking and psychosis—there are targeted options with evidence behind them. Always individualize and check for drug interactions. (PMC, JCSM, FDA Access Data)
What are “non‑motor” symptoms?
Non‑motor symptoms (NMS) are changes not directly about movement, such as mood, sleep, bowel/bladder, blood pressure, pain, and cognition. They can precede diagnosis by years (e.g., loss of smell, constipation, RBD) and often drive quality‑of‑life concerns for patients and families. Name them; treat them. (Parkinson’s Foundation)
A practical first step: Download a PD non‑motor checklist (e.g., NMSQuest), circle anything you’ve noticed in the last month, and bring it to your next visit. Clinicians can use the MDS‑NMS to track severity over time. (Parkinson’s UK, Movement Disorders Society)
Mood and thinking
Depression & anxiety
What it feels like: persistent sadness, loss of interest, worry, irritability, low energy, poor sleep or appetite.
What helps:
- CBT (including tele‑CBT) improves depression and anxiety in PD and is often as impactful as medication, without drug interactions. Ask for CBT tailored to chronic illness or PD. (PMC, American Academy of Neurology)
- Antidepressants: High‑quality trials show paroxetine (SSRI) and venlafaxine XR (SNRI) improve depression in PD without worsening motor symptoms. Other SSRIs/SNRIs are commonly used based on broader evidence and tolerability. (PMC)
- Medication safety note for clinicians: Use caution when combining MAO‑B inhibitors (rasagiline, safinamide) with serotonergic antidepressants because of serotonin‑syndrome warnings on FDA labels; coordinate dosing and monitoring if co‑prescribing. (FDA Access Data)
Urgent help: If you or your loved one has thoughts of self‑harm, call local emergency services or a crisis line immediately.
Cognitive change & psychosis (hallucinations/delusions)
What it feels like: slowed thinking, attention or memory problems; seeing things others don’t; false beliefs.
What helps:
- Rivastigmine (Exelon® patch) is FDA‑approved for Parkinson’s disease dementia and can support attention, daily function, and behavior; the patch often causes fewer stomach side effects than capsules. (FDA Access Data, PMC)
- For hallucinations/delusions that persist after optimizing PD meds and ruling out triggers (infection, dehydration, vision/hearing issues), pimavanserin (Nuplazid®)—a non‑dopaminergic antipsychotic—is FDA‑approved for Parkinson’s disease psychosis. Quetiapine is commonly used; avoid olanzapine (worsens motor symptoms). Clozapine is effective but requires blood monitoring. (FDA Access Data, NICE)
Sleep and alertness
Insomnia & fragmented sleep
- CBT‑I (cognitive‑behavioral therapy for insomnia) is effective and safe in PD; even computerized/brief formats can help. Embed sleep hygiene, stimulus control, and regular rise times. (PMC, Wiley Online Library)
REM sleep behavior disorder (RBD)
Acting out dreams can cause injury.
- Follow AASM 2023–2025 guidelines: first ensure bedroom safety (pad corners, move lamps, consider separate beds temporarily). Melatonin and clonazepam are standard options; tailor to fall risk and cognition. (PubMed, AASM)
Restless legs syndrome (RLS)
- Newer guidelines favor gabapentin enacarbil or pregabalin first‑line and de‑emphasize chronic dopamine agonists because of “augmentation” (worsening and spread of symptoms). Check and replenish iron if ferritin is low. (JCSM)
Obstructive sleep apnea (OSA) & daytime sleepiness
- OSA is common in PD; CPAP improves sleepiness and health outcomes in adults with OSA and is workable for people with PD. Screen if loud snoring, witnessed apneas, or morning headaches. (JCSM, MDPI)
- Modafinil can reduce subjective daytime sleepiness in some patients; evidence is mixed, so address sleep disorders and medications first. (PubMed)
Autonomic symptoms
Lightheadedness when standing (neurogenic orthostatic hypotension, nOH)
Try first: hydrate (target ~2–2.5 L/day if not restricted), liberalize salt if safe, small frequent meals, compression stockings/abdominal binder, rise slowly, elevate head of bed 10–20°. (PMC)
Medications: Midodrine or droxidopa improve standing blood pressure; fludrocortisone can help but monitor for edema and low potassium. Watch for supine hypertension. (AAFP, PMC)
Constipation & GI symptoms
- Start with water, fiber, movement, timed toileting. For persistent symptoms, osmotic laxatives (polyethylene glycol/PEG) are first‑line; lubiprostone or lactulose can be added as needed. Treat pelvic‑floor dyssynergia if present. (e-JMD, PubMed)
Urinary urgency/nocturia
- Behavioral strategies: caffeine/alcohol reduction, fluid timing, bladder training, pelvic‑floor therapy.
- Medications: Consider mirabegron (β‑3 agonist)—effective and less likely to impair cognition than antimuscarinics in older adults; use antimuscarinics cautiously in PD and in consultation with neurology/uro‑geriatrics. (American Urological Association, BioMed Central)
Sexual health
- Common and treatable. For erectile dysfunction, PDE5 inhibitors are first‑line unless contraindicated (e.g., nitrates; use caution with low blood pressure). Address mood, sleep, and relationship factors; consider lubricants, positioning, and scheduled intimacy. (Frontiers)
Drooling (sialorrhea)
- Start with speech‑language therapy (swallowing cues, posture, sugar‑free gum). If needed, glycopyrrolate (less brain‑penetrant anticholinergic) or sublingual atropine drops may help, though anticholinergics can worsen thinking in older adults. Botulinum toxin injections into salivary glands (incobotulinumtoxinA/Xeomin® or rimabotulinumtoxinB/Myobloc®) are FDA‑approved and often very effective. (PubMed, Michael J. Fox Foundation)
Pain, fatigue, and apathy
- Pain in PD is multifactorial. Combine physical therapy/exercise, posture and mobility work, and if needed neuropathic pain agents (gabapentin/pregabalin, duloxetine) while optimizing dopaminergic therapy. Consider specialty pain referral when persistent. (PMC)
- Fatigue improves with treating sleep disorders, mood, exercise, and energy conservation. Pharmacologic options have mixed evidence; a trial of modafinil may help selected patients after sleep/OSA are addressed. (PubMed)
- Apathy responds best to structured routine, exercise, and goal‑focused behavioral strategies; medication evidence is limited, though cholinesterase inhibitors may help in some cases with co‑existing cognitive symptoms. (PMC)
Safety & interactions: a few high‑yield reminders for clinicians
- MAO‑B inhibitors (rasagiline, safinamide) + SSRIs/SNRIs/tricyclics: review FDA warnings; if co‑prescribing is necessary, use the lowest effective doses, educate families on red‑flag serotonin‑syndrome symptoms (fever, agitation, tremor, clonus), and coordinate follow‑up. (FDA Access Data)
- Anticholinergics (for bladder or drooling) can worsen confusion, constipation, and dry mouth; prefer mirabegron for overactive bladder and botulinum toxin for sialorrhea when cognition is vulnerable. (American Urological Association, Michael J. Fox Foundation)
- Psychosis: check for UTI, dehydration, vision/hearing problems and medication triggers; when an antipsychotic is needed, pimavanserin (PD psychosis indication) or quetiapine/ clozapine (with ANC monitoring) are options; avoid olanzapine in PD. (FDA Access Data, NICE)
Build your personal non‑motor plan (patients & families)
- List what’s bothering you most (use NMSQuest—free, one page). Bring it to every visit. (Parkinson’s UK)
- Pick 1–2 priorities for the next 90 days (e.g., “sleep through the night” or “no near‑falls on standing”).
- Match one action per priority:
- Schedule follow‑up to review what changed and adjust.
Clinician corner (quick references)
- Depression in PD: CBT ± SSRI/SNRI (paroxetine or venlafaxine XR have Class I data). Screen drug interactions (MAO‑B inhibitors). (PMC, FDA Access Data)
- RBD: safety + melatonin or clonazepam per AASM guideline (2023). (PubMed)
- nOH: non‑pharmacologic bundle → midodrine/droxidopa; monitor supine BP. (PMC)
- Urge incontinence/overactive bladder: behavioral therapy → mirabegron (cognition‑sparing) → consider antimuscarinic if necessary and cognition permits. (American Urological Association, BioMed Central)
- PDP (psychosis): rule out delirium; pimavanserin first; quetiapine/clozapine alternatives; avoid olanzapine. (FDA Access Data, NICE)
- PDD: rivastigmine patch (FDA‑approved). (FDA Access Data)
- Sialorrhea: speech therapy → glycopyrrolate or sublingual atropine (caution in cognitive impairment) → botulinum toxin (Xeomin®, Myobloc®). (PubMed, Michael J. Fox Foundation)
Conversation starters for your next appointment
- “I filled out the NMS questionnaire—can we review the top three items?” (Parkinson’s UK)
- “My partner says I act out dreams—how do we make the bedroom safer, and should we try melatonin?” (PubMed)
- “Standing makes me dizzy—can we try a stepwise plan for orthostatic hypotension?” (PMC)
- “I’m up four times a night to urinate—would mirabegron be safer for my memory than an anticholinergic?” (American Urological Association)
- “What’s the best option for drooling that won’t cloud my thinking?” (Michael J. Fox Foundation)
We’re here to help
At Aqualane Research, we’re committed to patient‑centered care and advancing treatments for Parkinson’s—including non‑motor symptoms that often go under‑treated. If you’re interested in learning about or participating in clinical studies, we can help you pre‑screen and connect with appropriate trials.
Sources & further reading
- Parkinson’s Foundation: overview of non‑motor symptoms and patient guides. (Parkinson’s Foundation)
- MDS Non‑Motor tools: NMSQuest and MDS‑NMS (clinician rating scale). (Movement Disorders Society)
- AASM clinical guideline for RBD management. (PubMed)
- MDS Evidence‑Based Medicine update on non‑motor treatments. (Movement Disorders Society)
- Orthostatic hypotension consensus & primary care review. (PMC, AAFP)
- Depression in PD—CBT and antidepressants evidence. (PMC)
- PDP treatment (pimavanserin FDA label) and NICE psychosis recommendations. (FDA Access Data, NICE)
- PDD (rivastigmine FDA label). (FDA Access Data)
- Urinary symptoms and cognition‑sparing options. (American Urological Association, BioMed Central)
- Sialorrhea options, including botulinum toxins. (Michael J. Fox Foundation)