Parkinson's Disease
Quality of Life Issues
Barbara Fitzsimmons, RN, MS
Lisette K. Bunting, RN, MScN



NONMOTOR FEATURES

  Depression

       Depression in PD has been the focus of numerous studies.  Research
indicates
  that 20% to 90% of patients with PD will experience a major depressive
episode as
  compared to 7% of the general population.  Depression accounts for the
majority of
  psychiatric referrals in patients with PD and can be the initial feature
of PD.  It has
  been hypothesized that the shared neurochemistry of these two disorders
accounts
  for the high incidence of depression in PD.(2)
       Depression can be viewed in two ways.  Some patients may become
demora-
  lized with the diagnosis of PD and experience a "reactive depression."
Reactive
  depressions are linked to external events and are short in duration.
Typically the
  patient experiencing a reactive depression is able to resolve the issue
and accept the
  diagnosis.  Individuals experiencing a reactive depression may benefit
from sup-
  portive psychotherapy, however.(2)
       The most typical depression experienced by the patient with PD is
endogenous
  depression.  Endogenous depression is caused by a biochemical imbalance in

the
  brain and can be life-threatening if not treated.  The difficulty in
diagnosing depres-
  sion in patients with PD lies in the shared clinical features of the two
disorders
  (Table 2).

  Dementia



 Sleep Disturbances

      Sleep disorders are a frequent complaint in patients with PD.
Disorders of
 sleep initiation, sleep fragmentation, early morning awakening, excessive
daytime
 somnolence, and parasomnias represent the disorders of sleep seen in PD.  A
 detailed history of the sleep complaint, validated by a bedpartner, is the
best
 method of establishing the cause of sleep disturbances.(11)
      Patients may complain of initiation insomnia as, "I can't get to
sleep." C)nce
 asleep they are able to sleep soundly through the night, however.
Researchers have
 concluded that sleep initiation insomnia in PD is related to anxiety,
agitated de-
 pression, or levodopa therapy.
      The more typical sleep disorders seen in PD are sleep fragmentation
and early
 morning awakening." Sleep fragmentation can be related to the inability to
turn
 over in bed.  Rigidity compounded by the wearing off of medication reduces
pa-
 tients' ability to reposition themselves in bed.  Patients state that they
must wake up
 to change sleeping positions and then are unable to return to sleep.  One
solution to
 this problem is the use of satin sheets to decrease friction and facilitate

turning.
 Early morning awakening typically represents onset of a depressive episode,

and
 the nurse should evaluate the patient for other vegetative symptoms such as
 decreased appetite, psychomotor retardation, and constipation.  Early
morning
 awakening may be related to focal dystonic cramping in the calf and feet,
however.
 Focal dystonia is related to diminished levels of levodopa.(11)
      Excessive daytime somnolence is the most frequent sleep complaint made

by
 family members of PD patients.  In some individuals, daytime somnolence is
related
 to a disturbance in the circadian control of sleep.  These patients are up
at night and
 take multiple naps throughout the day.  Families report that daytime
sonuiolence is
 disruptive to normal family life.  Families should discourage day time
napping in an
 attempt to correct the circadian clock.  Patients who are described as
sleeping all
 day, however, should be screened for metabolic abnormalities that may cause
 disturbances in the sleep-wake cycle.
      Parasomnias are the most debilitating and difficult of the sleep
disorders to
 manage.  Sleep talking, sleep walking, vivid dreams, and nightmares are the

most
 frequently reported parasomnias experienced by patients with PD.  Most
typically,
 these occur as a side effect of levodopa therapy.  Unfortunately, treatment

for
 parasomnias is limited.(11)


 Sexual Dysfunction

      Sexual functioning in patients with PD has received inadequate
attention.  The
   paucity of literature can be attributed to the assumption that patients
with PD are
   elderly and therefore have a diminished interest in sex.  Research
indicates that
   frequency of sexual intercourse decreases with age; however, sexuality
continues to
   play a role in the lives of the elderly.  Sexual dysfunction has a
significant impact on
   patients who are diagnosed with PD in their midadult years when an active

sex life
   is the norm.(1)
       Dysfunction of the autonomic nervous system, depression, medications,

and
   interpersonal issues all play a role in sexual dysfunction in PD.
Autonomic dys-
   function in the urogenital system resulting in impotence is the primary
reason for
   sexual dysfunction in male patients with PD.  Secondary issues affecting
sexual
   function include motor fluctuations, fatigue, medications, sleep
disorders, depres-
   sion, and interpersonal issues.(1)
       The motor fluctuations and fatigue can be related to antiparkinsonian

drugs,
   primarily levodopa.  Patients with PD find that they are better able to
function in
   the morning, after their initial dose of medication, and become more
fatigued with
   greater motor fluctuations as the day progresses.  Numerous reports
document
   hypersexuality with the use of levodopa.  This may result in a problem
when one
   partner has heightened sexual interest that is not shared by the other
partner.  To
   adapt to these changes in their sexual life, couples may need to change
their daily
   routine to accommodate morning sexual activity and take advantage of
optimum
   energy levels and motor functioning.  Unfortunately, sleep disorders
experienced in
   patients with PD may result in bedpartners sleeping in separate beds,
which
   diminishes opportunity for spontaneous sexual activity.(1)
       Depression can also have a significant impact on sexual activity in
patients
   with PD.  As discussed earlier, depression is common in patients with PD
and can
   produce a markedly decreased libido.  Sexual partners may also experience
depres-
   sion and fatigue as they struggle with the caregiving role in the
relationship; thus,
   they also may not have the energy or interest to engage in sexual
activity.  In
   addition, autonon-dc dysfunctions that result in droohn& diaphoresis, and
excessive
   facial oiliness may interfere with perceived attractiveness of the
patient by the
   sexual partner.(1)
       The issues surrounding sexuality in PD are complex.  Patients should
be rou-
   tinely questioned regarding satisfaction of their sexual life.  A
referral to a urologist
   or sex therapist can assist in identifying issues affecting sexuality.
Open conununi-
   cafion regarding sexual issues can be limited by the patient's reduced
facial expres-
   sion and altered speech pattern.  The ability of the couple to
communicate their
   sexual needs within the liniitafions of the disease state can have a
significant impact
   on the couple's marriage and sexual life.(1)