Research Article

Compliance with National and International Guidelines in the Treatment of Nonmotor Symptoms in Late-Stage Parkinson’s Disease

Table 3

Pharmacological treatment of nonmotor symptoms in late-stage PD in relation to the recommendations of the priority rating in the Swedish National Board of Health and Welfare’s guidelines and in the Swedish Movement Disorder Society’s guidelines (n = 107).

Total cohortSymptom presenta(n, %)Symptomatic individualsb(n, %)

Depressive symptomsc
 No antidepressant medication, n (%)56 (52%)23 of 37 (62%)26 of 63 (41%)
 Antidepressant medication, n (%)51 (48%)14 of 37 (38%)37 of 63 (59%)
  SNRI (venlafaxine)6 of 51 (12%)1 of 37 (3%)5 of 63 (8%)
  TCA1 of 51 (2%)1 of 37 (3%)0 of 63 (0%)
  NaSSANo prio (mirtazapine)23 of 51 (45%)7 of 37 (19%)16 of 63 (25%)
  SSRI21 of 51 (41%)5 of 37 (14%)16 of 63 (25%)
Anxietyd
 Anxiolytics15 (14%)5 of 34 (15%)1 of 17 (6%)
Psychotic symptomse
 Antipsychotics29 (27%)
  Clozapine9 of 29 (31%)
  Quetiapine20 of 29 (69%)
 Hallucinations
  Antipsychotics16 of 49 (33%)9 of 18 (50%)
   Clozapine6 of 49 (12%)2 of 18 (11%)
   Quetiapine10 of 49 (20%)7 of 18 (39%)
 Delusions
  Antipsychotics12 of 27 (44%)5 of 13 (38%)
   Clozapine6 of 27 (22%)3 of 13 (23%)
   Quetiapine6 of 27 (22%)2 of 13 (15%)
Cognitive impairment
 Dementiaf
(MMSE ≤ 23, n = 60/≤18, n = 27)
 Acetylcholinesterase inhibitors
  Rivastigmine, n (%)15 (14%)14 of 60 (23%)9 of 27 (33%)
  Donepezil, n (%)4 (4%)3 of 60 (5%)1 of 27 (4%)
 Memantine, n (%)23 (22%)22 of 60 (37%)10 of 27 (37%)
Autonomic dysfunction
 Orthostatic hypotensiong
 Antihypotensives27 (25%)
  Midodrine16 (15%)
  Fludrocortison6 (6%)
  Others12 (11%)
   Droxidopa1 (1%)
   Etilefrin7 (7%)
 Lightheadedness
 Antihypotensives20 of 54 (37%)11 of 19 (58%)
  Midodrine10 of 54 (19%)7 of 19 (37%)
  Fludrocortison4 of 54 (7%)3 of 19 (16%)
  Others9 of 54 (17%)4 of 19 (21%)
   Droxidopa00
   Etilefrin6 of 54 (11%)2 of 19 (11%)
 Fainting
 Antihypotensives12 of 21 (57%)7 of 8 (88%)
 Midodrine7 of 21 (33%)5 of 8 (63%)
 Fludrocortison3 of 21 (14%)0
 Others4 of 21 (19%)2 of 8 (25%)
  Droxidopa00
  Etilefrin3 of 21 (14%)2 of 8 (25%)
 Sialorrheah
 Botulinum toxin, n (%)4 (4%)2 of 65 (3%)2 of 42 (5%)
Constipationi
 Laxatives, n (%)54 (50%)33 of 58 (57%)19 of 35 (54%)
Urinary urgency/frequency/nocturiaj
 Peripheral anticholinergics
  Detrusitol000
  Emselex000
  Vesicare1 (1%)1 of 91 (1%)1 of 71 (1%)
  Betmiga3 (3%)2 of 91 (2%)2 of 71 (3%)
 Botulinum toxin injection bladderNAvNAvNAv
Sleep disturbances/disorders
 Insomniak
  Hypnotics/sedative/insomnia drugs, n (%)28 (26%)7 of 31 (23%)4 of 16 (25%)
 Daytime sleepinessl
  Psychostimulant drugs, n (%)1 (1%)1 of 63 (2%)1 of 29 (3%)
Behavioral disorders
 Dopaminergic dysregulation syndrome
 Impulse control disorder
  NaltrexoneNAvNAvNAv

PD, Parkinson’s disease; q1–q3, first and third quartiles; NMSS, Nonmotor Symptoms Scale (0–360, higher = worse); D, domain (severity × frequency of each item of the domain are added together; each item is scored 0–12 (higher = worse), 2 missing. MMSE, Mini-Mental State Examination (0–30, higher = better), 4 missing; GDS-30, geriatric depression scale (0–30, higher = worse), 7 missing; SSRI, selective serotonin reuptake inhibitor; NaSSA, noradrenergic and specific serotonergic antidepressants; SNRI, serotonin-norepinephrine reuptake inhibitors; TCA, tricyclic antidepressants. NAv, information nonavailable. aSymptom present, individuals with score ≥1 on item of the NMSS scored 0–12 (higher = worse), if nothing else is stated. bSymptomatic individuals include those who score above the cutoff of ≥6 (moderate–severe) on item of the NMSS, if nothing else is stated. cDepressive symptoms based on GDS-30 cutoff for depression (≥10 points): symptom present 1–9 points, symptomatic individuals ≥10 points. dAnxiety score refer to (NMSS item 9) feel nervous, as no other specific data for anxiety was collected. ePsychotic symptoms scores refer to item 13 (hallucinations) and item 14 (delusions) of the NMSS. fDementia as assessed by the MMSE, cutoffs cognitive impairment ≤23/dementia ≤18 MMSE. gOrthostatic hypotension based on item 1 (lightheadedness) and item 2 (fainting) of the NMSS. hSiallorhea based on item 18 of the NMSS. iConstipation based on item 21 of the NMSS. jUrinary urgency/nocturia based on domain 7 of the NMSS. kInsomnia based on item 5 of the NMSS. lDaytime sleepiness based on item 3 of the NMSS. Priority according to the Swedish national guidelines (the Swedish National Board of Health and Welfare’s guidelines and the Swedish movement disorder society’s guidelines on diagnosis and treatment of PD): Priority 1–4 (recommended/should be used), Priority 5–7 (can be used), Priority 8–10 (can be used as an exception), research and education (Swedish FoU): should be used only in the frame of clinical studies, non-do: should not be used.